Research Impact

We were delighted to be recognised once again for our world-leading research by the Research Excellence Framework (REF). HERU contributed to the University of Aberdeen's UoA2 (Public Health, Health Services and Primary Care Unit of Assessment) submission, with 95% of our activity being rated as internationally-excellent or world-leading. This placed us 8th out of 32 institutions in the UK, and top in Scotland. These results highlight HERU's position as a leading health economics research centre, with a reputation for delivering applied and methodological work that is nationally and internationally significant.

In February 2018, the Queen's Anniversary Prize for Higher and Further Education was awarded to the University of Aberdeen at a ceremony in Buckingham Palace. The awards were presented by the Prince of Wales and the Duchess of Cornwall in recognition of world-leading research into health economics and health services undertaken at HERU and the Health Services Research Unit (HSRU) over the last 40 years.

The Queen's Anniversary Prize is awarded once every two years to recognise world-class excellence and achievement. It is the most prestigious form of national recognition open to a UK academic institution. The focus of the award is on innovation and practical benefit to people and society. HERU and HSRU were recognised for 'Health service research leading to improvements in academic and clinical practice and delivery of health care.'

Professor Mandy Ryan, Director of HERU, said: “What a fantastic achievement for HERU and HSRU. This is the highest national award to a university and I feel both proud and privileged to be leading HERU at this time of great success. Over the years we have worked tirelessly, collaborating with HSRU, to ensure improved health and healthcare for the people of Scotland and beyond. I would like to thank everyone for their contribution to this award, including those who have moved on, and also acknowledge the visionary thinking of Professors Roy Weir and Elizabeth Russell who forty years ago recognised the potential of health economics and health services research in improving the health and well-being of the population.”

• University of Aberdeen feature on the Queen's Prize

Professor Mandy Ryan, Director of HERU, and Professor Craig Ramsay, Director of HSRU, pictured with the Queen's Award medal.

The staff Market Forces Factor is an index used within the mechanism that allocates government funding to hospitals and primary care organisations in England. Its role is to ensure that funding decisions are based on current local labour market conditions and as such reflect unavoidable costs in both the commissioning and supply of healthcare services across different geographical areas in England. The sMFF impacts on the allocation of funds for commissioning secondary care services, adjusts the national tariff (price) providers can charge for supplying services, and is used as part of the primary care allocation formula.

The ability of the sMFF to accurately reflect local labour market conditions is key to its role within the funding formulae and HERU has been associated with this area of research for over a decade. The development of the methodology was described in a REF2014 impact case study. HERU has provided the figures from which the sMFF was calculated and subsequently incorporated into the relevant funding formulas. More recently, HERU has supported the revision and updating of the index.

Obesity is a worldwide problem. Rates of obesity are increasing with major impacts on health and quality of life. Treating obesity related disease is expensive. In 2018, NHS Scotland spent between £363 and £600 million per year treating obesity related disease. Evidence is needed on the most effective and cost-effective interventions to help adults wishing to lose weight.

Researchers from HERU have worked in collaboration with researchers from the Health Services Research Unit at the University of Aberdeen to lead work developing that evidence. We have participated in major evidence synthesis projects and contributed to economic modelling of adult weight management programmes.

In 2000-2001, we contributed to the first UK economic evaluation of lifestyle weight management programmes for adults with obesity. The evaluation was part of a wider National Institute for Health Research (NIHR) review on the long-term effects of treatments for obesity. The review provided an evidence base on dietary interventions, physical activity and behavioural interventions to achieve weight loss and to prevent obesity related disease. Subsequent NIHR funded reviews on the management of obesity in men and on obesity interventions for people with severe obesity were undertaken.

The ROMEO project reviewed the quantitative, qualitative and economic evidence base for the management of obesity in men. The review found that overall weight reduction for men was best achieved and maintained through a combination of tailored advice and behaviour change techniques. Programmes that emphasised physical activity and healthy eating were preferred, and men-only group activity, delivered outside traditional healthcare settings, for example in football grounds, was effective. The services that were most clinically effective were also most cost-effective.

The REBALANCE project looked at weight management programmes for people with severe obesity. Severe obesity is defined as a body mass index (BMII) of 35kg/m2 or over. Economic modelling conducted as part of the project found that bariatric surgery was the most expensive option. However, it also had the best weight loss outcomes and provided the best value for money overall. This is because surgery patients lost the most weight, kept that weight off, and had fewer obesity related diseases. For patients who did not want surgery low intensity weight management programmes were also effective and provided value for money for the NHS.

Evidence from the first systematic review contributed to the development of the NICE clinical guideline on the identification, assessment and management of obesity. The body of work was also cited in obesity management guidelines in India, the United States and New Zealand and contributed to the development of a successful weight management programme for men.

There is more information on the research in the following publications.

Avenell, A., Broom, J., Brown, T.J., Poobalan, A., Aucott, L., Stearns, S.C, Smith, W.C.S., Jung, R.T., Campbell, M.K. and Grant, A.M. (2004) 'Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement', Health Technology Assessment, 8(21).

Robertson, C., Archibald, D., Avenell, A., Douglas, F., Hoddinott, P., Van Teijlingen, E., Boyers, D., Stewart, F., Boachie, C., Fioratou, E., Wilkins, D., Street, T. and Carrol, P. and Fowler, C. (2014) 'Systematic reviews of and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men', Health Technology Assessment, 18(35).

Avenell, A., Robertson, C., Skea, Z., Jacobsen, E., Boyers, D., Cooper, D., Aceves-Martins, M., Retat, L., Fraser, C., Aveyard, P., Stewart, F., MacLennan, G., Webber, L., Corbould, E., Xu, B., Jaccard, A., Boyle, B., Duncan, E., Shimonovich, M. and Bruin, M. (2018) 'Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation', Health Technology Assessment, 22(68).

Boyers, D., Retat, L., Jacobsen, E., Avenell, A., Aveyard, P., Corbould, E., Jaccard, A., Cooper, D., Robertson, C., Aceves-Martins, M., Xu, B., Skea, Z., de Bruin, M. and the REBALANCE team (2021) 'Cost-effectiveness of bariatric surgery and non-surgical weight management programmes for adults with severe obesity: a decision analysis model', International Journal of Obesity, [Epub ahead of print].

In 2006, the Scottish Government introduced free eye care tests at any high street optician, with the costs subsidised by NHS Scotland. A three-year project funded by the Scottish Government's Chief Scientist Office and involving staff from HERU aimed examine the success of the free eye care policy by establishing if more people chose to have their eyes tested and if the led to wider health care benefits across all socioeconomic groups.

The team's research reported that prior to the policy there were already socioeconomic inequalities in the demand of eye care in Scotland. The introduction of free, NHS-funded, eye examinations did not manage to narrow this gap. There was an overall increase in the uptake of eye examinations, but this was primarily evident in the upper part of the income distribution.

There are more details of the research at the case study site in the University of Aberdeen research impact pages and at the following publications.

Dickey, H., Ikenwilo, D., Norwood, P., Watson, V. and Zangelidis, A. (2012) 'Utilisation of eye-care services: the effect of Scotland's free eye examination policy', Health Policy, 108(2-3), 286-293.

Dickey, H., Ikenwilo, D., Norwood, P., Watson, V. and Zangelidis, A. (2016) 'Doctor my eyes: a natural experiment on the demand for eye care services', Social Science and Medicine, 150, 117-127.

Dickey, H., Norwood, P., Watson, V. and Zangelidis, A. (2018) More than meets the eye: has the eye care policy in Scotland had wider health benefits?, Discussion Papers in Economics, 18-1, Aberdeen: University of Aberdeen Business School.

Deciding whether a patient might benefit from intensive care is a clinical and ethical challenge for healthcare professionals. The COVID-19 pandemic intensified the challenges involved. As the pandemic progressed the National Institute for Health and Care Excellence (NICE) developed a 'COVID-19 rapid guideline on critical care in adults' to help doctors make such decisions. The guideline has since been integrated into the NICE COVID-19 rapid guideline.

The guideline made use of research we undertook to understand and support consultants in making ethical decisions about admissions to Intensive Care Units (ICUs). This research was funded by the National Institute for Health Research (NIHR) and carried out in collaboration with the University of Warwick Medical School. As part of the study, we developed a discrete choice experiment (DCE) to investigate what factors determined decisions to admit patients to ICUs. The findings of the DCE led to the development of a decision support pack. The tool was recommended for use in the NICE guideline.

Our DCE identified that for ICU doctors, patient's age had the largest impact at admission followed by the views of their family and severity of other illnesses. How sick the patient was had less impact than how the junior ICU doctor thought the patient was doing. The least important factor was if there were enough doctors and nurses on a ward where a patient would have care.

Informed by the findings of the DCE, the team developed a decision support pack that included:

• A step-by-step guide about what needs to be thought about for a clear and fair decision.
• Forms that helped give the right information to make a good referral for ICU treatment.
• Patient and family information leaflets.

We hope our research and decision support pack can help all those involved in difficult decisions about who to admit to ICU during the COVID-19 pandemic and beyond.

There is more information of the study in our HERU Blog post on the research and at the at the University of Warwick Medical School project page.

Publications:

Bassford, C., Griffiths, F., Svantesson, M., Ryan, M., Krucien, N., Dale, J., Rees, S., Rees, K., Ignatowicz, A., Parsons, H., Flowers, N., Fritz, Z., Perkins, G., Quinton, S., Symons, S., White, C., Huang, H., Turner, J., Brooke, M., McCreedy, A., Blake, C. and Slowther, A. (2019) 'Developing an intervention around referral and admissions to intensive care: a mixed-methods study', Health Services and Delivery Research, 7(39).

Bassford, C.R., Krucien, N., Ryan, M., Griffiths, F.E., Svantesson, M., Fritz, Z., Perkins, G.D., Quinton, S. and Slowther, A.-M. (2019) 'U.K. intensivists' preferences for patient admission to ICU: evidence from a choice experiment', Critical Care Medicine, 47(11), 1522-1530.

Professor Anne Ludbrook of HERU has been involved in research for over 12 years that has influenced the development and implementation of minimum unit pricing (MUP) for alcohol in Scotland. We were involved in the initial conception, the passage of legislation through the Scottish Parliament and the defence against legal challenges.

Minimum unit pricing (MUP) became law in Scotland on 1st May 2018. The legislation has led to a reduction in off-trade (i.e. off-license) alcohol purchasing, and this reduction has been concentrated in the heaviest purchasing households. This is consistent with our research which predicted that the policy would impact on harmful drinkers rather than low-income households.

This research formed an important part of the defence of the legislation as it passed through the Parliamentary process to become law, and, thereafter, to the rejection of a series of legal challenges. The Court of Session appeal ruling upholding the introduction of MUP cited the research and evidence provided by Professor Ludbrook..

Since the introduction in Scotland, minimum unit pricing legislation has also been passed in Wales, the Republic of Ireland and Guernsey, and is being explored in other countries.

More details of our research underpinning the MUP legislation:

Ludbrook, A. (2004) Effective and cost-effective measures to reduce alcohol misuse in Scotland: an update, Edinburgh: Scottish Executive.

Ludbrook, A., Petrie, D., McKenzie, L. and Farrar, S. (2012) 'Tackling alcohol misuse: purchasing patterns affected by minimum pricing for alcohol', Applied Health Economics and Health Policy, 10(1), 51-63.

Our researchers participated in a clinical and cost-effectiveness review of the use of point-of-care coagulometers to support warfarin patients to self-monitor their coagulation status. The findings led the National Institute for Health and Care Excellence (NICE) to recommend the technology for use with patients who have atrial fibrillation and heart valve disease and are on long-term vitamin K antagonist therapy.

The review examined the effectiveness of three blood monitoring systems: CoaguChek®, INRatio2® PT/INR monitor and ProTime Microagulation system®. The research was funded by the National Institute for Health Research (NIHR) and assessed randomised controlled trials that evaluated self-monitoring in people with atrial fibrillation or heart valve disease requiring long-term anticoagulation therapy. Self-monitoring was compared with monitoring by GP or hospital clinics.

It was found that self-monitoring halved the number of blood clots compared with standard care. Health and social costs were more equal, but the two devices had an 80% chance of being value for money at the usual threshold for the NHS. Self-monitoring could be offered to people who would like to self-monitor, and where they, or their carer, are able to do so.

NICE used the findings to recommend two coagulometers (CoaguChek XS and InRatio2 PT/INR) for use by people taking long-term anti-blood clotting therapy who have atrial fibrillation or heart valve disease, if they prefer and are able to effectively use this type of monitoring. The report was also reviewed by the Scottish Health Technologies Group to inform the Health Improvement Scotland Evidence Note 57.

Further information

National Institute for Health Research (2015) 'Self-monitoring of warfarin is safe and cost-effective', NIHR Signal.

Sharma, P., Scotland, G., Cruickshank, M., Tassie, E., Fraser, C., Burton, C., Croal, B., Ramsay, C. R. and Brazzelli, M. (2015) 'The clinical effectiveness and cost-effectiveness of point-of-care tests (CoaguChek system, INRatio2 PT/INR monitor and ProTime Microcoagulation system) for the self-monitoring of the coagulation status of people receiving long-term vitamin K antagonist therapy, compared with standard UK practice: systematic review and economic evaluation', Health Technology Assessment, 19(48).

Sharma, P., Scotland, G., Cruickshank, M., Tassie, E., Fraser, C., Burton, C., Croal, B., Ramsay, C. R. and Brazzelli, M. (2015) 'Is self-monitoring an effective option for people receiving long-term vitamin K antagonist therapy? A systematic review and economic evaluation', BMJ Open, 5(6), e007758.

Researchers from HERU have been involved in a body of research on chronic pain that has helped put the issue on the national agenda and contributed to treatment guidelines.

Large-scale epidemiological studies conducted at the University of Aberdeen were cited as evidence contributing to the development of the Scottish Government's Scottish Service Model for Chronic Pain. As part of a package of measures to address chronic pain the Government also funded Service Improvement Groups (SIGs) or Managed Clinical Networks to develop services for chronic pain in NHS Boards. Professor Paul McNamee of HERU acted as advisor to the NHS Grampian SIG from 2012-2014.

The body of expertise in researching chronic pain led to the development of evidence underpinning national guidance in pain management across a range of conditions. HERU researchers were involved in work assessing the clinical and cost effectiveness of cognitive behaviour therapy, compared to or alongside exercise, as a treatment for chronic pain.

The research in the MUSICIAN (Managing Unexplained Symptoms In Primary Care: Involving Traditional and Accessible New Approaches) randomised controlled trial showed that both treatments are associated with substantial, statistically significant improvements in pain. The research went on to show that long-term improvements could be achieved and that the treatments were cost-effective and could be delivered in primary care, making them more accessible.

The work informed the development of several guidelines on non-pharmacological interventions for chronic pain management. These include parts of the Scottish Service Model for Chronic Pain, the SIGN (Scottish Intercollegiate Guidelines Network) guideline on chronic pain, and NICE (National Institute for Health and Care Excellence) guidance on chronic pain.

There is further information on the research in the following publications.

McBeth, J., Prescott, G., Scotland, G., Lovell, K., Keeley, P., Hannaford, P.C., McNamee, P., Symmons, D., Woby, S., Gkazinou, C., Beasley, M. and Macfarlane G.J. (2012) 'Cognitive behaviour therapy, exercise, or both for treating chronic widespread pain', Archives of Internal Medicine, 172, 48-57.

Beasley, M., Prescott, G. J., Scotland, G., McBeth, J., Lovell, K., Keeley, P., Hannaford, P. C., Symmons, D. P. M., MacDonald, R. I. R., Woby, S. and Macfarlane, G. J. (2015) 'Patient-reported improvements in health are maintained 2 years after completing a short course of cognitive behaviour therapy, exercise or both treatments for chronic widespread pain: long-term results from the MUSICIAN randomised controlled trial', RMD Open, 1, e000026.