REF2021: Health case studies

Multiple sclerosis (MS) is a condition that affects the brain and spinal cord, impacting a person’s vision, mobility, sensation or balance. There are around 2.8m people living with MS around the world – around 1 in every 3,000 – and the number is growing. And it’s the greatest cause of disability in young people.

So, developing better treatments and improving care for those with MS is of paramount importance – and a major focus for health services and for drug companies. And that’s where the University has played a major role, at the forefront of groundbreaking work to measure the impact of the disease from the patient’s perspective.

Led by Professor Jeremy Hobart, a Consultant Neurologist, the University has developed Patient Reported Outcome Measures that are being used in clinical trials around the world to better record the impact of drugs. And through the MS Brain Health Initiative, it has developed a positioning statement, international guidelines for MS care and an audit tool that is being piloted in 14 different countries. Together, these two world-leading areas of excellence are improving treatments and care quality – and thus, improving life for people with MS.

Hepatitis C is a global health crisis impacting the lives of an estimated 180 million people. A major contributor to liver disease, in the UK alone, around 180,000 people are infected by hepatitis C at any one time.

This is where the work of Professor Matthew Cramp has made such a huge impact. Over the course of two decades, Matthew has established the Hepatology Research Group at PUPSMD and built from scratch the South West Liver Unit at Derriford Hospital, from where he both treats patients and conducts many clinical trials.

Whether defining the immunology of what can protect people from infection, developing and designing clinical trials for new drugs, or actually translating them to a clinical context and treating a large number of patients, Matthew’s work has covered all stages of the bench to bedside spectrum. The result has been a more-than-doubling of the number of people being treated for hepatitis C with antiviral therapies and a 20% reduction in the number of people facing terminal liver disease and requiring transplants.

There are more than 100 variants of the disease commonly classified as non-Hodgkin lymphoma (NHL), a form of cancer that derives from the immune system. One of the most aggressive is the incurable Mantle Cell Lymphoma (MCL), which accounts for around 6% of all NHL cases and can reduce a person’s life expectancy to around 3—4 years from diagnosis.

Simon Rule, a Professor in Haematology and Consultant Haematologist at Plymouth Hospitals NHS Trust, is one of the world’s leading experts in MCL and has coordinated scores of ground-breaking clinical trials over the last 15 years, in conjunction with the pharmaceutical industry. He has also established Europe’s only MCL clinic, drawing patients from around the world.

Simon’s work has pioneered adapted treatments with novel therapies that have doubled the mean life expectancy of patients with MCL – including simply observing those asymptomatic patients who are found to have a rare indolent strain. His work was fundamental to the international licensing of Ibrutinib in 90 countries worldwide, and the incorporation of the drug into all of the major guidelines for the treatment of the disease. To date, more than 200,000 patients worldwide have been treated with Ibrutinib, generating sales in excess of $4.5 billion.

Cataract surgery is the most common form of surgical procedure in the world – and in the UK alone, around 400,000 operations are performed each year. It involves the removal of the natural lens – that has become ‘crystalised’ and opaque – with an artificial one made from plastic to improve or restore the patient’s sight.

These intra-ocular lenses have been the subject of extensive, world-leading research by Plymouth experts in optometry, in three specific fields. Among them is the impact made by toric lenses, which are used to correct astigmatism – where the cornea or lens isn't a perfectly curved shape, and the result is blurred vision. Working with patients at Derriford Hospital, the results produced by the team have been hugely positive, with two-thirds of users no longer requiring the use of glasses when driving.

Within this four-star case study, led by Professor Phillip Buckhurst, is also work on multi-focal and micro-incisional intra-ocular lenses – the former enabling people to see things both in the distance and up close; the latter relating to lenses that can be inserted through tiny incisions in the eye. They’ve also been involved in large clinical trials in North America and Europe, through which two specific toric lenses have gained regulatory approval – leading to 130,000 of them being implanted. It all amounts to research that is helping to restore sight to thousands of people.

Computed tomography (CT) scanners have been used in medicine and healthcare for around half a century – but their versatility in mapping the interior structures of the body are limited when it comes to moving objects. This has historically been the case with a major organ such as the heart, which therefore necessitates more invasive and therefore risky methods of analysis. But that has changed now, thanks to the work of Professor Carl Roobottom, an Honorary Consultant at the University and a Radiographer at Derriford Hospital.

For around 15 years, Carl has used new and improving computing techniques to upgrade the capabilities of CT technology, enabling it to peer into a beating heart. Beginning with relatively healthy coronary arteries, Carl was able to refine his methods for those arteries with calcium deposits in them, or those that had previously had surgery or stents implanted. Having proven the technique, he then began to disseminate it, firstly through research papers but then more profoundly via educational courses and materials, and then a national training and accreditation process.

The work has also made a significant impact in dealing with the very sudden and very serious cases where an apparently healthy person manifests as having coronary artery disease. Thanks to this new form of CT coronary angiography, doctors can identify the disease within the wall of the vessel, rather than just the narrowing it causes, ensuring it can be picked up early and treated.

The formulae used by government to distribute resources to public services – to the NHS, social care, education and the police – is fundamental to determining ‘who gets what?’ in the country. But formula funding can be extremely difficult to understand. Based upon econometric modelling, historic variations in spending are analysed to identify variables in service need – and this can lead to areas becoming trapped in vicious or virtuous circles if their needs are under-or overestimated.

This is the arena that has defined the hugely influential work of Sheena Asthana, Director of the Plymouth Institute of Health and Care Research, and a Professor of Health Policy specialising in the formula funding of public services. Working with partner Dr Alex Gibson, Sheena – also a member of NHS England’s Advisory Committee on Resource Allocation – has published papers, books and provided evidence to committees on how, for example, deprivation should be less of an indication of health need than demographics such as ageing. This has helped shape a move to a more community-based service allocation in health.

Their work in education and children services is no less profound. They’ve shown that London receives a disproportionately large amount of funding, particularly as it is the best performing area, while work on children’s services has resulted in the creation of innovative predictive models regarding the children’s needs for different levels of support. By applying these models to all 11.8 million children in the country, they were able to produce detailed local estimates of the proportion and number of children requiring different levels of support.

The welcome increase in life expectancy has created new challenges for health care. One of those challenges is that greater numbers of older people are now living with multiple long-term conditions. This has amplified the demand on healthcare services at a time when UK healthcare costs are rising faster than GDP. Traditional, single-disease-focused approaches to clinical care are not necessarily accommodating to the person-centred care that older people with multiple long-term conditions need and benefit from most. Person-centred approaches to care have also been shown to reduce costs, for example through reduced bed days and reduced readmission rates) and improve outcomes for patients (e.g. increasing wellbeing, self-efficacy, and reductions in pain and fatigue). Dr Helen Lloyd’s work has been instrumental in developing models and approaches to integrating person-centred and coordinated care (P3C, from ‘PCCC’) for people with multiple long-term conditions.

Surgical patients often worry that they will wake up during their operation. In fact, accidental awareness during general anaesthesia, or AAGA, is poorly understood because it is very rare. Jackie Andrade led the psychological component of the world’s largest study on AAGA, set up by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland to understand the causes and consequences of AAGA and develop strategies for its prevention and management. The project showed that AAGA can cause lasting psychological harm, and that this harm can be reduced and even prevented through good communication and psychological management. The project also discovered a very strong association between using drugs to paralyse patients for surgery and reports of AAGA.

Alarm fatigue’ is recognized throughout clinical care as a safety issue relevant to both staff and patients, as well as an important issue for the multi-billion dollar medical device industry. It is generally thought of as a sensory overload, which clinicians experience due to an excessive number of alarms. This leads to a desensitization, resulting in missed alarms that can cause patient decline or even death. A substantial part of the problem is that the audible alarms currently used are poorly specified from both a psychoacoustic and cognitive psychological perspective. Working closely with key policymakers and committees, Professor Judy Edworthy has led a project which has resulted in the update of the alarms specified in a global medical device safety standard (IEC 60601-1-8), to be published in July 2020. The demonstration of the superiority of these new alarms has been demonstrated through a series of peer-reviewed papers that show the development and testing of the sounds, both in the lab and in simulation. The updated standard will also contain evidence-based guidance for developing and testing auditory alarms and new alarm categories, written by Professor Edworthy.

The updated alarm signals are publicly available for immediate implementation by manufacturers. The sounds themselves will have an impact on the soundscape of all areas where clinical alarms are used, and will make that environment less stressful and more conducive to clinical care. In addition, clinicians find the new alarms more memorable, more localizable, and less fatiguing, than the old alarms. Transition from the old to the new alarms will benefit clinical care and safety in all healthcare areas where alarms are used.