Impact

The impact of our research spans from the bench to the bedside and into practice. Our research is of direct relevance to the NHS, social care, the third sector, and health policy within the region, nationally and on the international stage. We deliver research with impact beyond the University across three main clinical areas: rehabilitation, cancer, and dementia. These are linked by four overarching subject and methodological strengths: implementation research, health economics, evidence syntheses, and evaluating health technologies and complex interventions. This activity is embedded in the Schools of Healthcare, Medical, and Biological Sciences. Engagement with service users and the public is at the core of all our activities, facilitated by our unique approach to bilingualism.

The primary beneficiaries of our research are those in health, ranging from individuals, e.g. patients, carers, nurses, doctors, allied health professionals, and managers, through to organisations and leaders in public and charitable health settings (e.g. The Alzheimer’s Society, Age UK, Tenovus, Arthritis UK, Cancer Research UK), advisory groups (e.g. National Institute for Health & Care Excellence [NICE], All Wales Medicines Strategy Group, Wales Cancer Implementation Group, UK National Cancer Survivorship Initiative) and government (e.g. Department of Health, Welsh Government, Home Office, the International Cancer Benchmarking Programme).

We demonstrate two main types of impact:

Impacting on practice and service delivery by collaborating in variety of ways with partners to deliver real-world solutions to real world problems. This includes the design and delivery of national screening programmes, tools and practices to promote more effective service delivery, and the creation of new innovations for use in practice.

Impacting on policy making and improving societal health by engaging with government, service user groups, other agencies, and with the general public, we provide and communicate the underlying knowledge needed to improve policy making and its implementation. This includes the production of evidence that is included in national guidance and the strategies which could be used for implementation, thus supporting the transfer and exchange of research findings to different settings and countries.

Impact of Health Economics Research at Bangor University:

Value-based assessment

Value-based assessment is the system by which new medicines will be evaluated by NICE from 2014. We were the first to conduct a study of the public’s preferences for a range of criteria for NHS spending priorities on new medicines [1]. We used a choice-based format in which 4,118 adult members of the general public were asked to express their preferred way for the NHS to allocate resources between competing hypothetical populations. With explicit consideration of the opportunity cost, respondents were asked to select from a range of resource configurations ranging from all money to be spent on one population, to all money to be spent on the alternative population.

We identified clear preferences for 3 criteria proposed for the value based pricing scheme: 60% of respondents would prioritise a treatment for a severe disease compared with a moderately severe disease, all else being equal. Treatments which address an unmet need were prioritised by 57% of respondents, and medicines associated with wider societal benefits, in the form of reducing patients’ reliance on carers, were prioritised by 50%.

This study “provided an important corroboration and reference point which complemented and enhanced the work directly commissioned by the Department to understand societal valuation of treatments”. “It improved the confidence in the evidence base underlying the system of value-based assessment”, and has made “a really valuable contribution to development of value-based assessment”. Our research findings supported the notion underlying the burden of illness weighting of health outcomes, which has consequently become a central component of the methods for value-based assessment.

Cancer Drugs Fund

The Cancer Drugs Fund was established in England in 2011 to ring-fence £200M per annum for cancer drugs that are judged by NICE to be cost-ineffective. The Lancet called it the “product of political opportunism and intellectual incoherence”, prompting us to test the public’s preferences empirically [1]. We found no preference for cancer treatments – 64% expressed a preference for equal allocation between cancer and non-cancer treatments – nor for treatments (usually for cancer) that extend life, at the end-of-life.

The decision by the Welsh Government not to establish a Cancer Drugs Fund (May 2012) was linked to our research which demonstrated that the public does not support the premium pricing of treatments for cancer over other, equally serious conditions. Referring to our work, the Welsh Health Minister said: “This research clearly shows the public supports our evidence-based approach to providing excellent, high quality care for cancer patients in Wales. That is why we have rejected the notion of a Cancer Drugs Fund in Wales” [2]. This research was also cited by Scotland’s Cabinet Secretary for Health & Wellbeing [3], during parliamentary debate that led the Scottish Government to conclude in July 2013 that “the establishment of a cancer drugs fund in Scotland would not be the answer”. Cancer Drugs Funds in Scotland and Wales would have cost about £32m annually, at an opportunity cost (i.e. the health benefits forgone) of around 1,000 Quality-Adjusted Life-Years (QALYs).

Dyfrig Hughes – Professor of Pharmacoeconomics and co-director of the Centre for Health Economics and Medicines Evaluation at Bangor University.

Impact of Primary Care Oncology Research at Bangor University:

The role of primary care in the diagnosis of symptomatic cancer

Achieving diagnoses at a more treatable stage should subsequently improve survival. We have developed a tool to measure diagnostic intervals,1 and tested in an implementation trial.2 The tool is being used in clinical trials and service evaluations, and informed the Aarhus consensus statement on the design and reporting of early cancer diagnosis studies.3

We have measured diagnostic intervals4 and the number of pre-diagnostic consultations5 in different cancers to identify ‘harder to diagnose’ cancers. The outcomes of delay have been characterised by a major systematic review of the association of time to diagnosis in cancer with clinical outcomes (now being updated).6

The predictive value of symptoms for bladder, kidney, pancreas, and upper gastrointestinal cancers have been determined,7–10 and are used in at 1104 general practices in England, with impacts on improved cancer diagnosis, for example by lowering GPs’ threshold for investigating and referring patients with suspected cancers.11 The risk of an underlying, undiagnosed cancer has been determined for patients with herpes zoster.12

The contribution of primary care to cancer follow-up and the management of survivorship

Two million people are now living with or beyond cancer in the UK. Our systematic review revealed little work in this emerging chronic disease area in primary care.13 Feasibility, piloting and development work followed with prostate and lung cancer survivors as exemplar groups.14 Qualitative studies and needs measurement studies showed specific unmet needs such as asking about impotence and erectile function.15–17 This has led to further trials, one which field tests a psycho-social nurse intervention, and the other which re-designs the system for follow up care of prostate cancer patients in Betsi Cadwaladr University Health Board. A particular focus is the exposure of men’s unmet needs, and system errors, and to embed new nursing roles to deliver the interventions. This will affect 5000 patients with prostate cancer across the region. There have been further similar interactions with England’s National Cancer Survivorship Initiative (NCSI) pilot sites.

Our work on personalised risk-stratification to allow targeted cancer related interventions.18 This informed the NCSI work on personalised risk-stratification in 2012, leading directly to measures to improve risk management. The NCSI’s models for ‘key workers’ in cancer survivorship are partly designed according to findings our prostate studies.

Communication of new cancer related science in primary care to empower patients

This uses cervical cancer screening and HPV related cancers as exemplars. We have conducted three trials. Following early intervention development research that used simple, honest, pictorial risk information, delivered by health professionals to women with abnormal smears in colposcopy consultations, a Randomised Control Trial (RCT) demonstrated a marked beneficial effect on anxiety. A further RCT using this individual risk communication / pictorial information (now called scripted consultations) showed persistent anxiety while under surveillance for pre-cancer is harder to alleviate. The final RCT used an individualised risk communication package, and showed that women’s perception of risk contributes to determining screening intervals, and simple risk information delivered in primary care reduced women’s stated preference for overly frequent tests by allaying anxiety and increasing knowledge.20 The findings from these trials were taken up by the Cervical Screening Programme in the UK, and have informed the way that cervical screening information is now presented to women to achieve informed uptake and limit anxiety.

A multi-methods approach was used to build on this research programme to address the introduction of the new HPV technologies. A combination of two systematic reviews and qualitative studies revealed salient patient issues (refs),21–23 and surveys were combined to produce the core messages for HPV to use in clinical situations. The HPV core messages project has already been disseminated widely throughout the cervical screening programme, impacting on patients’ wellbeing since 2011.

Richard Neal – Professor of Primary Care Medicine and Director of the North Wales Centre for Primary Care Research