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UOA 12 - Allied Health Professions and Studies

University of Nottingham

RA5a: Research environment and esteem

This research group is based in University’s School of Community Health Sciences within the Faculty of Medicine www.nottingham.ac. uk/chs. At the core of the group is the Division of Rehabilitation and Ageing, which is unique in comprising staff from rehabilitation medicine, geriatric medicine and learning disabilities. A particular strength is that it includes 5 research-active occupational therapists, one of the largest groupings in the UK. 

The research group’s focus is upon rehabilitation. Research coherence is achieved by the study of the complex interactions between disease and health and processes to improve health. These complex interactions typify the patient groups that we deal with: people with learning disabilities, adults with neurological or chronic disease, frail older people and those recovering from stroke. 

As would be expected for this complex topic, the group collaborates widely with other University colleagues in Stroke Medicine, the Institute of Work Health and Organisations (I-WHO), the Institute of Mental Health and the Division of Primary Care. The group enjoys research partnerships with clinical colleagues in rehabilitation medicine, geriatric medicine and learning disabilities, neurology and psychiatry, with Derby Assistive Technology Evaluation Centre and with social services in both Nottingham and Derby. 

The group aims to undertake research that: 

        advances knowledge and theory such as understanding and measuring autonomy, the value of outdoor mobility, or the role of bullying in people with learning disabilities 

        enhances practice and influence policy in rehabilitation through its particular strength in

o        evaluating interventions in practice using complex RCTs. Our publications list 13 such RCTs, some with concurrent qualitative and economic elements, as befits trials of complex interventions. Many are conducted in community settings, a focus that is timely given the direction of travel of health care delivery in developed countries.

o        performing systematic reviews. These provide the evidence base for documents such as the National Clinical Guidelines for Stroke and thereby affect both policy and practice.

This is the first time this group will be returned in the RAE, yet it has published more than 200 peer reviewed papers in this cycle. Most of these appear in specialist journals. Of those returned, 2 were in the Lancet, 6 in the BMJ and 7 in Stroke. In this cycle it has been responsible for over £1.4 million in research spending from a variety of competitive sources including research council, European Funding and NIHR: currently staff within the group hold awards totalling over £1,100,000. 

 The group is keen to develop research capacity in this historically underfunded area. Twelve students successfully completed PhDs during this cycle. Three young researchers gained prestigious, competitive awards: Logan, an occupational therapist has won a Department of Health National Primary Care Post Doctoral Award worth £240,565; Conroy was awarded the Dhole Fellowship of £170,000, jointly funded by Research into Ageing/Help the Aged and the British Geriatrics Society; Thomas, who recently moved to another School, was awarded a Stroke Association Fellowship to support her postdoctoral research in this group, and has progressed to a level where, as PI, she submitted two successful applications to support her research, one of £180,000 from the Stroke Association. 

 

Research structure

Our work can be described as covering five cross-cutting themes (stroke rehabilitation, health of older people, long term neurological conditions, learning disabilities and assistive technology) and different constellations of staff and collaborators assemble for each project. 

 

Stroke rehabilitation

Nottingham is world-renowned for its work in stroke and stroke rehabilitation and its reputation is due in part to it having one of the largest groups of research-active post-doctoral occupational therapists (Drummond, Logan, Pinnington and Walker returned in this submission). Radford, who has been responsible for the submission of several successful applications for funding has recently left for a post as Associate Professor at another University. In recognition of her continuing contribution to our research performance the University appointed her as a Special Lecturer. The group’s work in stroke rehabilitation builds on collaborations with other stroke researchers in the University notably Professor Lincoln and Dr Thomas from I-WHO, Professor Bath from Stroke Medicine and Dr Sunderland from Psychology. Collaboration with other University colleagues also enables translational work such as the pilot RCT evaluation of bone marrow stem cells in patients with sub-acute ischaemic stroke published in Stroke 2006 which led to an MRC grant for over £500,000 to conduct a Phase 2 study and the development of virtual reality applications in stroke rehabilitation referred to below. 

 

Four of the 13 RCTs in this return are in stroke, including methodological innovations such as the first multi-centre stroke rehabilitation study ever conducted (TOTAL).  The impact of the group's work in this area is illustrated by the fact that a number of its research papers and systematic reviews have been cited and incorporated into the National Clinical Guidelines for Stroke: the RCT of community-based occupational therapy for stroke patients led to level A evidence.  This study also led to the individual patient data meta-analysis of community occupational therapy trials and we were the first rehabilitation group to conduct an analysis of this kind. Other studies have developed outcome measures that have widened the inclusion criteria for participants, for example so that those with communication disorders are included in an evaluation of an intervention for depression post-stroke.

Another indicator of the value of the research output of this group is that its members have achieved positions of distinction in stroke rehabilitation research and practice. Walker is Associate Director and Rehabilitation lead of the UK Stroke Research Network and Chair of the Rehabilitation Clinical Study Group, a national post that has a remit to develop stroke rehabilitation research in the UK. Drummond is Associate Director and Rehabilitation lead of the Trent Region Stroke Research Network. Logan isa member of the Department of Health Stroke Strategy Committee.

 

Health of older people

The main focus of this theme is frail older people and the management of their disability. One area of specific attention is patients who fall and fractures: geriatric conditions that are typical of the problems of frail older people. Highlights of our work in this area are

        a multi centre RCT investigating the complex intervention of referral to a day hospital for high risk older people (in progress)

        a RCT that showed the benefit of the removal of cataracts upon rates of falling

        a RCT showing the benefits of calcium, vitamin D and magnesium supplementation regimens in elderly women after hip fracture and in post menopausal women at risk of osteoporosis

        the largest study ever published on the prevalence of co-morbidities and associated mortality in acute hip fracture patients

The latter three are widely cited in policies and guidelines for falls and hip fracture management.

Another area of expertise is in community rehabilitation services for older people, including two RCTs of intermediate care services. This is significant since there is otherwise very little research in this internationally expanding clinical topic: Fleming et al (2004) reports the only RCT of care home intermediate care yet published. A particular strength of these studies is the methodological novelty of the use of concurrent qualitative and economic studies which enables the relationships between rehabilitation service structure and process and clinical outcomes. 

Our research has focused on those groups that tend to be neglected: two cohort studies have implications for the care of older people nursed away from home. One of older people admitted to nursing and residential homes found a difference in health status since preadmission assessment and recommended that the needs of residents in long-term care are adequately monitored and managed, in particular those in residential care with higher dependency needs. The second identified factors associated with life expectancy and mortality in a cohort of social services placements in nursing and residential homes.

We have a developing body of work considering the making of difficult decisions about end of life care. A BMJ article defined an ethical approach to resuscitation decisions for people in long term care settings and questioned current national guidelines. The paper received widespread media coverage, both nationally and internationally and reopened an important debate. It has already been cited in national guidelines.  Other publications dealt with the attitudes of carers and old age psychiatrists towards the treatment of potentially fatal events in end-stage dementia and a multi-centre prospective study on the use of sections 2 and 3 of the Mental Health Act (1983) with older people. 

 

Long term neurological conditions

This theme focuses on the long term care of people suffering from a range of chronic conditions including chronic fatigue but includes strands that have implications for our work in other themes. For example, Radford explored the predictive validity of the stroke drivers screening assessment (SDSA) and other cognitive tests for people with traumatic brain injury, people with Parkinson’s Disease and people with dementia. This is the largest single study of drivers with dementia in the world.  This work continues with further validating and reducing the length of the assessment battery to facilitate clinical application. In view of the growing number of disabled and older drivers and inevitable increase in drivers with dementia, our work has made a significant advance in predicting fitness to drive.

The results of a complex RCT evaluating an educational intervention for people with long term neurological conditions challenged assumptions about the universal benefits of education for disabled people. It was cited in the NICE Guidelines on the management of MS in primary care. 

Our work on the measurement of autonomy in disabled people produced a validation of an English-language version of the first outcome measure concerned with autonomy, a core value for person-centred rehabilitation. By combining data from this study with some Dutch data, evidence was produced on cross-cultural validity. 

An expert panel study of 119 acute admissions for people with long term neurological conditions concluded that almost a third were inappropriate and two-thirds had an inappropriate length of stay. Later stages in this project will provide much needed information for service planning as there is a need both to save and control costs and to ensure that patients are treated in an environment that meets their health and care needs.

 

Learning Disabilities

The focus of this theme is on issues that directly impact on services with benefits for not only service users but also policy makers, clinicians, therapists and formal and informal carers.  Although there are only two academic members, this theme has enhanced its impact through strong collaborations with other academics and colleagues delivering both health and social services to people with learning disabilities. This has resulted in

        A successful collaboration with colleagues from the School of Sociology and Nottingham Mencap which resulted in a grant of almost £200,000 in 2003 from the Community Fund to investigate transitions to adult services 

        awards from the EPSRC and European Social Fund totalling £250,000 jointly with Nottingham Trent University.  

        A primary care based RCT in collaboration with Primary Care resulting in a DH funded study into the impact of a positive family history on health behaviour. 

        a study with colleagues from the Institute of Mental Health (IMH) funded by the Social Exclusion Unit looking at the prevalence of multiple needs, and the evidence of effective interventions with adults with chaotic lives and multiple needs.  

The work in this theme endeavours to take innovative directions and develop theory in areas where practice has become “stuck”. Recent examples which have had a significant impact on clinical practice through invitations to write articles and run workshops across the country to disseminate to wider audiences are: 

        the exploration of attachment in people with learning disabilities with a much-cited paper with Sheard from Psychiatry describing the link betweenchallenging behaviour and insecure attachment.

        an exploration of the meaning of trauma in adults with learning disabilities such as bereavement and bullying: anti-bullying initiatives are now a national policy requirement. An article on bereavement in Philosophy, Psychiatry & Psychology was the first article on learning disabilities published in this journal with 3 invited commentaries. Responses have been received from academics from across the world commenting that it made them see the field differently. It informed local clinical guidelines on managing bereavement and staff training. 

Role of assistive technology in rehabilitation

The group has an established reputation in innovative design and evaluation of technology to support rehabilitation based on strong partnerships with:

        Derby Assistive Technology Evaluation Centre (DATEC), the only remaining DH funded centre (£350,000 annually) with responsibility for the development of an evidence-base to guide clinical practice and national policies for the purchasing and prescription of medical devices and other specialist assistive technologies.  We provide research expertise that permits the collection of strong evidence on for example, design features of portable wheelchair ramps and their implications for curb and vehicle access. We also disseminate not only through peer related journals but through reports available to potential users as the findings are useful to users, clinicians and manufacturers when selecting or developing technology and designing training programmes to optimise the efficiency and effectiveness of use.  

        School of Computing and Mathematics at Nottingham Trent University has resulted in charitable, research council and European Community funded work on the application of virtual environments for people with learning disabilities. An ESRC award allowed the development of a methodology which underpinned a later EPSRC funded study. It was the first of our virtual reality research projects to be published in a practitioner journal rather than in the human computer interaction journals where such work normally appears. A publication from the EPSRC study is the first published study that systematically collected data on use of virtual reality control devices by people with severe learning disabilities and provides baseline information against which new prototypes were evaluated in a the second part of the EPSRC funded study. The expertise acquired through working with these clients has facilitated our development of a programme systematically evaluating the therapeutic use of virtual reality for stroke patients referred to above and a postgraduate student is now evaluating the effectiveness of VR in upper limb rehabilitation after stroke. 

Structures that support research

University infrastructure and investment

Nottingham is a research-led University and has invested heavily in high quality infrastructure to support researchers, including excellent IT facilities and access to information (libraries, bibliographic databases and online journals); strong support in applying for and managing, research grants and externally funded studentships/fellowships; excellent training courses for researchers and high-quality accommodation.

Between 2002-3 and 2006-7 the University invested £6 million in biomedical research resulting in the creation of a research-focused Centre for Population Sciences to which all members of the group belong, which is part of a new Institute for Clinical Research.  In addition, funding has pump-primed a new Clinical Trials Support Unit which provides invaluable support in the design and execution of our RCTs. Some members of this group also belong to the Centre for Social Research into Health & Health Care (CSRHHC) which runs research seminars and IMH, which has several activities to promote research collaborations, support grant applications and the development of new researchers. 

The Division of Rehabilitation and Ageing

Decisions regarding research strategy changes or requirements for significant funding for research-related activity are taken at monthly Divisional Academic Staff Meetings. The use of discretionary funds that have resulted from the Division’s success in attracting external funding is decided at these meetings and has been spent on contributions towards PhD studentships, bridging funding for researchers, support for researchers presenting at conferences and IT equipment. Decisions on more substantial investment are taken by the SCHS Management Group and approved by the University Management Group. At a divisional level a supportive, stimulating, and rewarding research environment has been created in order to retain our most successful senior academics. Contract researchers and junior academics are retained through externally-funded fellowships and new grants. Mentorship and regular appraisal of staff has enabled career development and identification and addressing of potential gaps in funding and training needs especially for new members and those new to research. 

The Rehabilitation Research and Education Group (UNRREG)

This network was established in order to create an environment which allows rehabilitation research to flourish and which supports our collaborations with colleagues outside the Division.  Its primary activities will be to ensure members are aware of forthcoming calls for proposals, share expertise in research methods and applying for funds, provide a forum in which members can practice presentations and to create a research community for research students and young researchers. These will be achieved through three annual half day meetings, a web page and an on line discussion group.

In addition to support available at Faculty and School level, research activity is already promoted and research capacity enhanced through regular meetings of 

        Monthly protocol planning meetings together with colleagues from other divisions and schools (Stroke Medicine, Psychology, Nursing) where members of the group can present research funding proposals for feedback or present results from completed projects. 

        Weekly research seminars in Derby with health and social service colleagues for the presentation of protocols, research findings and practice of public presentations 

        The Research Occupational Therapy Alliance as well as divisional and other university staff includes research active OTs from the community, health and Social Services. Its purpose is to promote research in Rehabilitation and Occupational Therapy.

        Learning Disabilities research monthly meetings: journal club, outside speakers, member led research topics. Membership includes university staff as well as research active health and social service staff and trainees. 

        Postgraduate research student meetings organised and led by students.

Building capacity

During this RAE period we have successfully attracted and retained high-quality researchers and developed their careers. Four research staff and four members of teaching staff from other schools gained a PhD while working in the group. Logan, Conroy and Thomas’s research fellowships are mentioned above. The group has also attracted increasing numbers of PhD students, including overseas students and some through our MSc program, and 12 completed during this period. Clegg also supervises the research projects of D Clin Psych students.  Postgraduate students are provided with extensive learning opportunities and support within the Division (one-one with supervisors, research skills training programme, research away-day and access to the research support activities described above), the SCHS (an annual post-graduate research students conference), the faculty (Faculty Training Programme) and the Graduate School (research training programme, resource materials, opportunities for cross disciplinary research, support in obtaining funding and social events). Supervisors are provided with training in supervision via the Training and Staff Development Programme and the Graduate Schools and through pairing with a more experienced supervisor.

In 2003, together with colleagues from education, nursing, pharmacy and sociology, the School of Community Health Sciences successfully launched a £330,000 University-funded Interdisciplinary Doctoral Centre (CSRHHC). This provided funding for 12 PhD studentships and two of these are supervised by members of our group (JC, PJS).  

The Division has hosted a clinical academic lecturer post previously held by Harwood and Sahota now Conroy: all three being returned in this RAE. Contracts are provided for 3 years, giving excellent opportunities for research career development. Present incumbent SC has supervised medical student projects, gained research funding, and is supervising the PhD of a junior doctor in receipt of a RCP/Dunhill Fellowship. 

The nature and quality of the research infrastructure, including significant equipment, research facilities, and facilities for research students; 

Research training is provided through the Graduate School and Faculty and there are also SEDU courses and Master's degree modules for career research staff. Support for career research staff and research students at Faculty level will be enhanced through the appointment of a Faculty Postgraduate Manager Funded using Roberts money linked to the University Graduate School with a social space and wireless free internet access.  At School level students are supported through School doctoral studentships, induction events and the annual School postgraduate conference. This is multi-disciplinary as it is open to 6 MSc courses and MPhil/PhD students. Each PG student has dedicated workstation. All members of the group also belong to the Institute of Clinical Research and several belong to CSRHHC. Both organisations run regular research seminars. Meeting spaces are available at three of the sites where the group is based and at the main site there is also a Library and resource room for meetings, display of research documents and any hard copies of journals taken by members of the group. 

Policy and practice in relation to research governance

        Protocol planning meetings provide a system of informal peer review of proposed research and monitoring of ongoing research.

        All clinical trials are run through the School’s clinical trials unit and all research is fully compliant with NHS Research Governance in which all those who carry out NHS based research have been trained. Clegg is a member of Community Learning Disability Directorate's Clinical Governance Improvement Group and of North Notts Research Ethics Commitee

        All financial support for research is through the University thus maintaining probity. 

Relationships with research users, practitioners and policymakers are maintained through:

        A monthly Stroke research consumer group run by Walker

        Standen is a member of a learning disabilities research user group which meets monthly and  Clegg is president of Nottingham Mencap

        Gladman is a Trustee of the BGS as chair of the Academic and Research Committee which includes liaison with Age Concern, Help the Aged, the NHS Confederation and the Healthcare Commission.

        Logan runs a Falls Research Group funded by grant from Trent RDSU for dissemination of research findings, collaboration, developing  new projects and capacity building. Members include Primary Care staff, Local Authority, Housing Department, charities and care homes. 

        The Community Rehabilitation and the East Midlands Ambulance Service Research Group meet includes community geriatricians, therapists, nurses, paramedics, ambulance crews, control room staff. Chaired by Logan, their aim is to complete research projects, present papers, write grant applications, promote research capacity. 

Research strategy

Research strategy for the Division is discussed at twice yearly research awaydays but the formation of UNRREG will also be a forum for strategy making for the wider group. The strategies cover research themes, important research questions, capacity building, training needs, future funding, collaborations, dissemination and implementation of research findings. Our main research objectives are to:

        Capacity build though applications for studentships and career-development fellowships in order to retain our current researchers.

        Apply for collaborative grants through NIHR in order that research groups can continue to realise benefits from NHS R&D funding.

        Continue to develop, and maximise opportunities for collaborations across research groups within the University, nationally and internationally.

        Maintain a sufficiently flexible research strategy to take advantage of arising funding opportunities, but also to anticipate and respond to knowledge developments, changes in health policy and funding opportunities in the longer term. 

        With advent of UK Stroke Research Network aim to have more of our trials adopted. 

        Build on the VR work in learning disabilities and apply this expertise to applications with other user groups. 

        Create critical mass in research into the health of older people: two successive Lecturers in the Medicine of Older People have been appointed as Consultants at NUH and have continued to be research active. Dr Harwood has been recently awarded a Special Professorship, and Dr Sahota has received national awards for his research. Previous funding of work in this area has been almost exclusively charitable. Creating critical mass will enable this team to work towards Research Council funding and to tackle bigger questions.

Esteem indicators

In addition to indicators already mentioned

Personal awards received by:

Sahota (2006) Innovation and Leadership National Award, NHS Confederation for Leadership and Race Equality; (2005) Hospital Doctor of the Year, Health and Social Care Award, Department of Health; (2004) first prize in Celebrating Success in the NHS ‘Technological Innovations’ Department of Health. 

Ward (2004) Lawrence McHenry Prize for the History of Neurology, American Academy of Neurology,

Conroy selected as a role model to inspire the next generation of medical academic staff http://www.bma.org.uk/ap.nsf/Content/Rolemodels 

Invited contributions

Gladman (2006) Visiting Professor, Taiwan Foundation and Fellowship Training Programs in Geriatric Medicine 

Walker first Allied Health Professional to give the keynote lecture at the 2006 Annual Scientific Meeting of the Stroke Society of Australasia. She also gave the Keynote Lecture on Evidence for Stroke Rehabilitation at the European Stroke Rehabilitation Conference, Gothenburg 2006. 

Membership of advisory panels or expert committees 

Drummond: Assessment panel of the DoH Research Capacity Building Fund for Nursing and Allied Health Professions 

Gladman Specialist Advisory Committee in Geriatric Medicine to JCHMT; Stroke Association Expert Advisory Panel

Jones Public Policy Committee of Royal College of Psychiatrists; Parliamentary Liaison Sub-Committee and Confidentiality Advisory Group of PPC; advisor to NHS Ombudsman.

Walker member of Royal College of Physicians Inter-collegiate working party for stroke and writing panel, European Stroke Initiative (this group will produce the European Stroke Rehabilitation Guidelines); Chair UK Stroke Forum: coalition of 22 organisations. 

Ward 2004 External Reference Group, DoH Integrated Community Equipment Services; 2003 Guidelines Development Group, NICE Multiple Sclerosis in Primary Care; 2004 National Collaborative, Chronic Fatigue Syndrome/ME 

Positions in Learned Societies

Gladman Co-Chair, Primary and Continuing Care Special Interest Group; Vice Chair, Academic and Research Committee, British Geriatrics Society.

Ward current President, British Society for Rehabilitation Medicine.

Walker, Gladman past presidents of the Society for Rehabilitation Research.