Group art therapy as an adjunctive treatment for people with schizophrenia: a randomised controlled trial (MATISSE)

Group art therapy

Those randomised to group art therapy were offered weekly sessions of 90 minutes’ duration for an average period of 12 months (and never < 9 months). We planned that no group would have more than eight members, although more than eight people were sometimes referred when those allocated did not engage (see Table 2). All groups were led by art therapists who had previous experience of working with people with psychosis and were registered with the Health Professions Council. Groups were co-facilitated by another member of staff or a volunteer.

Group art therapy was conducted in keeping with recommendations of the British Association of Art Therapists. 20 The key ingredients of group art therapy are considered to be the process of art-making and the tripartite relationship, which involves therapist, participant and image. 9 The groups aimed to give people the potential to explore and utilise the experience of other relationships between group members. 10 A range of art materials were available in each group and participants were encouraged to use them to express themselves freely and spontaneously. Relationships within the group were considered in relation to both conscious and unconscious processes. Art therapists generally adopted a supportive approach, offering empathy and encouragement. They rarely provided symbolic interpretations of interpersonal process or images to participants. However, they did frequently discuss these processes in supervision. Within this framework, therapists used a range of interventions thought appropriate to each participant. This approach is in keeping with recommendations for the pragmatic evaluation of complex interventions21 in which individual therapists are encouraged to apply treatment principles flexibly to fit with the needs of participants. 22

Activity groups

Activity groups were designed to control for the non-specific effects of group art therapy, identified as structured time with an empathic professional and opportunities for interaction with peers in a group setting. They were also designed to reflect the kind of activity-based groups currently provided by mental health and social care services for people with psychosis in the UK. Allocated participants were offered a place in a weekly activity group of up to 90 minutes’ duration for an average of 12 months (and a minimum of 9 months). No group had more than eight members, although more than eight people could be referred to a group to support membership up to this level. All lead facilitators had previous experience of working with people with psychosis in groups and all groups were co-facilitated by another member of staff or volunteer.

Group facilitators offered various activities to members and encouraged participants to collectively select activities for the group. Activities included themed discussion, board games, watching and discussing DVDs, visits to local cafés and occasional visits to places of interest. The use of art and craft materials was prohibited. Group facilitators were asked to refrain from exploring the thoughts and feelings of study participants or offering psychotherapeutic interventions. Where necessary, if, for example, participants became distressed or wanted to discuss their mental health, facilitators used diversion and/or encouraged participants to take up any specific concerns with professionals already involved in their care.

Prior to entry into groups, art therapists and activity group facilitators met participants individually or in small groups to provide information about the group and promote engagement. Telephone and postal contact with participants and those involved in their care was used to promote engagement and retention in groups.

Standard care

Standard care involved follow-up by secondary-care mental health services, care co-ordination, pharmacotherapy and the option of referral to other services. No restrictions were imposed on referral to other services apart from arts therapies, which participants agreed not to use until the final follow-up assessment had been completed.

Completed by the researcher

1. Global functioning (co-primary outcome) was assessed using the GAF Scale, a 100-point single-item, observer-rated scale that rates functioning on a continuum from health to illness (where ‘0’ indicates the lowest and ‘100 indicates the highest attainable level of function). It is a reliable and valid measure of global functioning that has been widely used in previous studies of people with schizophrenia and is sensitive to change. 23

2. Mental health (co-primary outcome) was assessed using the Positive and Negative Syndrome (PANSS) Scale. 24 This is a 30-item rating scale that is accompanied by a structured interview. It takes approximately 30 minutes to complete, has been widely used to examine changes in symptoms in people with schizophrenia and related psychoses, and includes validated subscales that can be used to examine changes in positive, negative and general symptoms of schizophrenia. Scores on the PANSS Scale range from 30 to 210, with higher scores indicating poorer mental health.

3. Medication All medication being prescribed to participants was recorded and concordance assessed using the Morisky Scale, a four-item questionnaire that provides a valid estimate of use of psychotropic medication. 25 A higher score on this scale indicates lower levels of compliance.

4. Health-related quality of life was assessed using the European Quality of Life-5 Dimensions (EQ-5D). 26 This is a generic preferenced-based measure for describing and valuing health-related quality of life (HRQoL) assessed in five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) and higher scores indicate a better quality of life.

5. Resource use Information about use of services was collected in interview at BSL and at 12- and 24-month follow-up interviews using the Adult Service Use Schedule (AD-SUS), an instrument designed on the basis of previous studies in adult mental health populations. 27,28 At BSL, information covered the previous 12 months. At each of the follow-up interviews, service use since the previous interview was recorded; in this way, the entire period from BSL to final follow-up was covered. The AD-SUS asks participants for the number and duration of contacts with various services and professionals over the previous 12 months or since the last interview. The 12-month period between interviews meant that there may have been questions over the accuracy of participant recall. In order to increase accuracy and completeness of the data collected, inpatient psychiatric admissions, known to be a key cost driver in this population,29 were collected from clinical records. Data on attendance at the art and activity groups were collected from therapist records to avoid unmasking of the research assessors.

Completed by the participant

1. Social function was assessed using the Social Function Questionnaire (SFQ),30 a widely used self-completed measure of social function with established reliability and validity. Scores on the SFQ range from 0 to 24, with ‘24’ indicating poorer social functioning.

2. Well-being was assessed using the General Well-Being Scale. This 18-item, self-report instrument was originally developed for the US Health and Nutrition Survey, but has subsequently been used in studies of people with schizophrenia and has good psychometric properties. 31 Scores on the General Well-Being Scale range from 0 to 110, with lower scores indicating lower levels of well-being.

3. Satisfaction with mental health services was assessed using the Client Satisfaction Questionnaire (CSQ), an eight-item measure that has been widely used in previous studies and is sensitive to change. 32 Scores on the CSQ range from 0 to 32, with higher scores indicating higher levels of satisfaction with care.

Completed by the participants’ key worker

1. Engagement with mental health services was assessed using the four-item Service Engagement Scale (SES). 33 Scores on the SES range from 0 to 16, with higher scores indicating greater levels of engagement and acceptance of treatment.

2. Data on occupational and housing status were gathered, indicating whether the participant lived in independent or supported accommodation (and the degree of support provided), together with a short description of any paid work, voluntary work or educational/training activities undertaken by the participant during the previous 6 months.

3. Any incidents of suicidal behaviour, violence or aggression in the previous year were recorded using a pro forma based on the one used by Johnson et al. 34

4. Global functioning was measured using the GAF Scale,23 rated from the perspective of the lead mental health professional involved in providing mental health services to the patient.

5. Following the collection of all of the 24-month follow-up data, participants’ electronic and written records were examined to obtain details of any period of inpatient treatment received during the previous 2 years.

Preparatory phase

During the preparatory phase of the project, researchers were inducted. This involved ensuring they were familiar with study procedures and trained in the use of study outcome measures. Training in the use of the primary outcome measures (GAF and PANSS Scales) was carried out by HK and TB.

Following initial meetings of the Trial Steering Group and Patient Reference Group, we made minor changes to the study protocol, as detailed at the beginning of this chapter.

Recruitment

In each centre, researchers publicised the study through meetings with staff at local inpatient units, community teams, day centres, and rehabilitation and residential units. Researchers visited these teams on a regular basis to promote referral of potential participants. Researchers were assisted in this by clinical studies officers of the UK Mental Health Research Network. Clinical staff were given a copy of an information sheet, which summarised the study protocol and provided details of eligibility criteria. Researchers met those who gave verbal consent to be contacted about the study, assessed eligibility, provided written and verbal information, obtained written consent and collected BSL data.

Randomisation

Participants were randomised via an independent remote telephone randomisation service provided by the Aberdeen Clinical Trials Unit, University of Aberdeen, Foresterhill, Aberdeen. We used permuted stacked blocks, stratified by site. The block size was randomly assigned between 3 and 6. Each element within the block was randomly assigned to one of the three treatments in proportion to the size of the block. Equal numbers were assigned to each of the three arms of the trial.

Participants, their key worker and their general practitioner (GP) were notified of allocation status by an independent administrator. The administrator simultaneously informed the relevant art therapist or activity group facilitator of the allocation status of each participant, so that arrangements could be made for them to receive their allocated intervention. Researchers involved in collecting follow-up data remained masked.

Masking of raters

Rater masking was maintained by providing specific instructions to participants and their clinical teams not to disclose allocation status to researchers carrying out the follow-up interviews. In addition, data were held securely and password protected, had all personal identifiers removed, and randomisation details were held separately and were not accessible to the researchers. Data on participants’ uptake of the trial interventions were monitored through pro formas completed by group facilitators after each group, as described above. Thus, researchers did not have to record this information from case files, as this would have led to unmasking.

Participant honoraria

Participants completing follow-up interviews were offered a £15 honorarium in recognition of their time in completing research interviews and any inconvenience related to their involvement in the study.

Calculation of quality-adjusted life-years

Quality-adjusted life-years (QALYs) were calculated on the basis of the EQ-5D health state classification instrument, which has five domains: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. For each domain the respondent chooses one of three levels of functioning – good to poor. The three levels for each of the five domains are used to define 243 health states. 48 The health states are then given a utility score using responses from a representative sample of adults in the UK. 49 The QALYs in the second year were discounted at a rate of 3.5%, as recommended by NICE. 50 The QALYs were calculated as the area under the curve as defined by the utility values at BSL and at 12 and 24 months’ follow-up, and it was assumed that changes in utility score over time followed a linear path. 51 The QALYs were adjusted for BSL covariates.

Cost-effectiveness analysis

Differences in the use of services between randomised groups at 12 and 24 months’ follow-up are reported descriptively and are not compared statistically to avoid problems associated with multiple testing, and because the focus of the economic evaluation was on cost and cost-effectiveness. Costs and cost-effectiveness were compared in two sets of analyses: (1) art therapy versus standard care and (2) art therapy versus activity groups.

Primary analysis used available case analysis, including those for whom full data at 12 and 24 months were available; there was no imputation of missing service-use observations. Data on the use of hospital services were available for a larger sample and the impact on results of using these costs alone were explored in sensitivity analysis. Initially, standard statistical tests for differences in costs were used. Alt hough costs were not normally distributed, analyses compared the mean costs between groups using the standard Student’s t-test. Ordinary least squares regression was used for the adjusted analyses and the validity of results was confirmed using bootstrapping. 52 This approach, rather than logarithmic transformation or the use of non-parametric tests, is used in the analysis of cost data because of the need to make inferences about the arithmetic mean. 53 The primary analysis was of total costs over 24 months. Multiple regression was used to adjust for the following prespecified BSL characteristics: site, age, sex and total costs at BSL. The BSL covariates were chosen when the statistical plan was written; they were the factors that the clinical members of the research team considered to be the most important.

Cost-effectiveness and cost–utility of the art therapy intervention were explored through the calculation of incremental cost-effectiveness ratios (ICERs) – the difference in mean costs divided by the difference in mean effects. 54 For the cost-effectiveness analysis, repeat re-sampling (bootstrapping) from the costs and GAF outcome measure were used to generate a distribution of mean costs and effects for each of the two sets of analyses. 55 These distributions were used to calculate the probability that each of the treatments is the optimal choice, subject to a range of possible maximum values (the ceiling ratio, λ) that a decision-maker might be willing to pay for a unit improvement in outcome. To explore the uncertainty that exists around the estimates of mean costs and effects as a result of sampling variation and uncertainty regarding the maximum cost-effectiveness ratio that a decision-maker would consider acceptable, cost-effectiveness acceptability curves (CEACs) are presented by plotting these probabilities for a range of possible values of the ceiling ratio. 56 The same analysis was carried out for the cost–utility analysis using QALYs.

A number of sensitivity analyses were carried out to test the robustness of the assumptions made:

1. The discount rate was varied from 0% to 6%.

2. Hospital costs only were included to increase the sample size to include those with missing AD-SUS data.

3. The cost of art therapy assistants and co-facilitators was changed to zero to test the impact of volunteer time being valued at zero.

Art therapy versus standard care

Those randomised to art therapy had lower costs and better outcomes than those randomised to standard care: the ICERS were –£1011 per unit change in GAF score and –£28,105 per QALY, which suggest that the art therapy could save money and improve outcomes. However, the ICERs are based on raw, unadjusted mean scores and do not account for uncertainty around costs and outcomes. The adjusted bootstrapped replications for the cost and effectiveness pairs and the CEAC, using GAF scores as the outcome measure, are presented in Figures 7 and 8, respectively. Figure 8 shows that art therapy has at least a 50% probability of being cost-effective compared with standard care, and the probability that it is cost-effective increases if decision-makers are willing to pay increasing amounts for unit improvements in GAF. However, the probability that referral to art therapy is cost-effective never rises above 67% for willingness-to-pay values up to £10,000. For the cost–utility analysis (Figures 9 and 10), the CEAC stays very close to 50%, suggesting that the probability that referral to art therapy is cost-effective compared with standard care is no greater than 50% for any value that a decision-maker may be willing to pay for improvements in outcome.

FIGURE 7.

Scatterplot showing the bootstrapped mean differences in costs and effects of art therapy and standard care using the GAF score.

FIGURE 8.

Cost-effectiveness acceptability curve showing probability that art therapy is cost-effective compared with standard care for different values of willingness to pay for improvements in GSF.

FIGURE 9.

Scatterplot showing the bootstrapped mean differences in costs and effects of art therapy and standard care using QALYs.

FIGURE 10.

Cost-effectiveness acceptability curve showing probability that art therapy is cost-effective compared with standard care for different values a decision-maker may be willing to pay per QALY.

Art therapy versus activity groups

Those randomised to art therapy had lower costs and better outcomes compared with those randomised to activity groups. The ICER was –£15,944 per unit change in GAF score and –£303,793 per unit change in QALY. Scatterplots for both GAF score (Figure 11) and QALYs (Figure 12) are centred around zero, generating CEACs (Figures 13 and 14, respectively) that stay very close to 50%, so the probability that art therapy is cost-effective compared with activity groups is not > 50% for any value that a decision-maker may be willing to pay for improvements in outcome.

FIGURE 11.

Scatterplot showing the bootstrapped mean differences in costs and effects of art therapy and activity groups using GAF score.

FIGURE 12.

Scatterplot showing the bootstrapped mean differences in costs and effects of art therapy and activity groups using QALYs.

FIGURE 13.

Cost-effectiveness acceptability curve showing probability that art therapy is cost-effective compared with activity groups for different values of willingness to pay for improvements in GAF.

FIGURE 14.

Cost-effectiveness acceptability curve showing probability that art therapy is cost-effective compared with activity groups (ACTs) for different values of willingness to pay per QALY.

Project title

(04/39/04) Group art therapy for people with schizophrenia.

Study acronym

MATISSE Multicentre study of Art Therapy In Schizophrenia: Systematic Evaluation.

Planned investigation

Project timetable and milestones

Expertise

Consumers

It is clear from our preliminary contact with user groups that consumers welcome the proposed study. Lack of availability of psychosocial treatments is a concern often voiced by service users, and we intend to draw on the expertise of service users throughout the course of the project. Rogan Woolf (User Involvement Coordinator for the North London Hub of MHRN) will assist in coordinating user involvement in the project, and will work in close collaboration with Scott Stevens who is a service user who chairs SURF (Service User Research Forum). Rogan Woolf and Scott Stevens will both be appointed to the Trial Steering Group which will monitor study progress and overseeing all other aspects of the study. Mr Stevens will also chair a User Reference Group comprising patients and carer’s of people who have schizophrenia. The User Reference Group will meet on four occasions during the course of the study and play an important role in:

• assisting in the design of participant information sheets and consent forms

• advising us on the methods we will use for providing feedback on the study to study participants

• contribute to the process of communicating study findings. In addition to assisting us with the production of the final project report, members of the User Reference Group will be asked too help us prepare a summary of study findings suitable for publication is a service user journal.

Service users have already contributed to the design of the study; with feedback from qualitative interviews with service users resulting in our amending our secondary outcome measures by including a measure of well-being (please see previous correspondence).

Justification of support required

The majority of costs are those associated with employing research workers, and input from a part-time study coordinator, statistician and health economist. Additional costs of been kept to a minimum in order to deliver value for money.

Staff The project requires a part-time project coordinator who has previous experience coordinating multi-centre studies. The coordinator will play an important role in organising meetings, supporting research workers, facilitating user involvement on the project, and assisting with other administrative duties. Four full time researchers, one at each study site, will be responsible for recruiting study participants and collecting baseline and follow-up data. We have also costed for the help of a statistician and health economist (15% in year one, 10% in year 2 and 25% in year three), and for consultancies for DW, HOM and KK.

Travel Travel costs have to meet the needs of this multi-centre study with off-peak standard fare intercity travel for collaborators to attend meetings in London. Costs of travel by local public transport for follow-up interviews are also included.

Materials and consumables Stationery and photocopying costs associated with data collection have been added. Honoraria will be offered to all study participants at the end of data collection (£15 per participant) and for unwaged service users who are members of the Trial Steering Group (£50 per meeting),

Exceptional items This will cover costs for advertising posts and paying for independent randomisation by the Clinical Trials Unit at the Institute of Psychiatry.

Equipment These cover the costs of four computers with printers and four digital cameras. For health and safety reasons we will provide a mobile telephone for each of the researchers collecting field data.

References

Prioritisation Group

1. Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

2. Professor Imti Choonara, Professor in Child Health, Academic Division of Child Health, University of Nottingham

   Chair – Pharmaceuticals Panel

3. Dr Bob Coates, Consultant Advisor – Disease Prevention Panel

4. Dr Andrew Cook, Consultant Advisor – Intervention Procedures Panel

5. Dr Peter Davidson, Director of NETSCC, Health Technology Assessment

6. Dr Nick Hicks, Consultant Adviser – Diagnostic Technologies and Screening Panel, Consultant Advisor–Psychological and Community Therapies Panel

7. Ms Susan Hird, Consultant Advisor, External Devices and Physical Therapies Panel

8. Professor Sallie Lamb, Director, Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick

   Chair – HTA Clinical Evaluation and Trials Board

9. Professor Jonathan Michaels, Professor of Vascular Surgery, Sheffield Vascular Institute, University of Sheffield

   Chair – Interventional Procedures Panel

10. Professor Ruairidh Milne, Director – External Relations

11. Dr John Pounsford, Consultant Physician, Directorate of Medical Services, North Bristol NHS Trust

    Chair – External Devices and Physical Therapies Panel

12. Dr Vaughan Thomas, Consultant Advisor – Pharmaceuticals Panel, Clinical

    Lead – Clinical Evaluation Trials Prioritisation Group

13. Professor Margaret Thorogood, Professor of Epidemiology, Health Sciences Research Institute, University of Warwick

    Chair – Disease Prevention Panel

14. Professor Lindsay Turnbull, Professor of Radiology, Centre for the MR Investigations, University of Hull

    Chair – Diagnostic Technologies and Screening Panel

15. Professor Scott Weich, Professor of Psychiatry, Health Sciences Research Institute, University of Warwick

    Chair – Psychological and Community Therapies Panel

16. Professor Hywel Williams, Director of Nottingham Clinical Trials Unit, Centre of Evidence-Based Dermatology, University of Nottingham

    Chair – HTA Commissioning Board

    Deputy HTA Programme Director

HTA Commissioning Board

1. Professor of Dermato-Epidemiology, Centre of Evidence-Based Dermatology, University of Nottingham

2. Department of Public Health and Epidemiology, University of Birmingham

3. Professor of Clinical Pharmacology, Director, NIHR HTA programme, University of Liverpool

1. Professor Ann Ashburn, Professor of Rehabilitation and Head of Research, Southampton General Hospital

2. Professor Judith Bliss, Director of ICR-Clinical Trials and Statistics Unit, The Institute of Cancer Research

3. Professor Peter Brocklehurst, Professor of Women’s Health, Institute for Women’s Health, University College London

4. Professor David Fitzmaurice, Professor of Primary Care Research, Department of Primary Care Clinical Sciences, University of Birmingham

5. Professor John W Gregory, Professor in Paediatric Endocrinology, Department of Child Health, Wales School of Medicine, Cardiff University

6. Professor Steve Halligan, Professor of Gastrointestinal Radiology, University College Hospital, London

7. Professor Angela Harden, Professor of Community and Family Health, Institute for Health and Human Development, University of East London

8. Dr Martin J Landray, Reader in Epidemiology, Honorary Consultant Physician, Clinical Trial Service Unit, University of Oxford

9. Dr Joanne Lord, Reader, Health Economics Research Group, Brunel University

10. Professor Stephen Morris, Professor of Health Economics, University College London, Research Department of Epidemiology and Public Health, University College London

11. Professor Dion Morton, Professor of Surgery, Academic Department of Surgery, University of Birmingham

12. Professor Gail Mountain, Professor of Health Services Research, Rehabilitation and Assistive Technologies Group, University of Sheffield

13. Professor Irwin Nazareth, Professor of Primary Care and Head of Department, Department of Primary Care and Population Sciences, University College London

14. Professor E Andrea Nelson, Professor of Wound Healing and Director of Research, School of Healthcare, University of Leeds

15. Professor John David Norrie, Chair in Clinical Trials and Biostatistics, Robertson Centre for Biostatistics, University of Glasgow

16. Dr Rafael Perera, Lecturer in Medical Statisitics, Department of Primary Health Care, University of Oxford

17. Professor Barney Reeves, Professorial Research Fellow in Health Services Research, Department of Clinical Science, University of Bristol

18. Professor Peter Tyrer, Professor of Community Psychiatry, Centre for Mental Health, Imperial College London

19. Professor Martin Underwood, Professor of Primary Care Research, Warwick Medical School, University of Warwick

20. Professor Caroline Watkins, Professor of Stroke and Older People’s Care, Chair of UK Forum for Stroke Training, Stroke Practice Research Unit, University of Central Lancashire

21. Dr Duncan Young, Senior Clinical Lecturer and Consultant, Nuffield Department of Anaesthetics, University of Oxford

1. Dr Tom Foulks, Medical Research Council

2. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

HTA Clinical Evaluation and Trials Board

1. Director, Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick and Professor of Rehabilitation, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford

2. Professor of the Psychology of Health Care, Leeds Institute of Health Sciences, University of Leeds

3. Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

1. Professor Keith Abrams, Professor of Medical Statistics, Department of Health Sciences, University of Leicester

2. Professor Martin Bland, Professor of Health Statistics, Department of Health Sciences, University of York

3. Professor Jane Blazeby, Professor of Surgery and Consultant Upper GI Surgeon, Department of Social Medicine, University of Bristol

4. Professor Julia M Brown, Director, Clinical Trials Research Unit, University of Leeds

5. Professor Alistair Burns, Professor of Old Age Psychiatry, Psychiatry Research Group, School of Community-Based Medicine, The University of Manchester & National Clinical Director for Dementia, Department of Health

6. Dr Jennifer Burr, Director, Centre for Healthcare Randomised trials (CHART), University of Aberdeen

7. Professor Linda Davies, Professor of Health Economics, Health Sciences Research Group, University of Manchester

8. Professor Simon Gilbody, Prof of Psych Medicine and Health Services Research, Department of Health Sciences, University of York

9. Professor Steven Goodacre, Professor and Consultant in Emergency Medicine, School of Health and Related Research, University of Sheffield

10. Professor Dyfrig Hughes, Professor of Pharmacoeconomics, Centre for Economics and Policy in Health, Institute of Medical and Social Care Research, Bangor University

11. Professor Paul Jones, Professor of Respiratory Medicine, Department of Cardiac and Vascular Science, St George‘s Hospital Medical School, University of London

12. Professor Khalid Khan, Professor of Women’s Health and Clinical Epidemiology, Barts and the London School of Medicine, Queen Mary, University of London

13. Professor Richard J McManus, Professor of Primary Care Cardiovascular Research, Primary Care Clinical Sciences Building, University of Birmingham

14. Professor Helen Rodgers, Professor of Stroke Care, Institute for Ageing and Health, Newcastle University

15. Professor Ken Stein, Professor of Public Health, Peninsula Technology Assessment Group, Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth

16. Professor Jonathan Sterne, Professor of Medical Statistics and Epidemiology, Department of Social Medicine, University of Bristol

17. Mr Andy Vail, Senior Lecturer, Health Sciences Research Group, University of Manchester

18. Professor Clare Wilkinson, Professor of General Practice and Director of Research North Wales Clinical School, Department of Primary Care and Public Health, Cardiff University

19. Dr Ian B Wilkinson, Senior Lecturer and Honorary Consultant, Clinical Pharmacology Unit, Department of Medicine, University of Cambridge

1. Ms Kate Law, Director of Clinical Trials, Cancer Research UK

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

Diagnostic Technologies and Screening Panel

1. Scientific Director of the Centre for Magnetic Resonance Investigations and YCR Professor of Radiology, Hull Royal Infirmary

2. Professor Judith E Adams, Consultant Radiologist, Manchester Royal Infirmary, Central Manchester & Manchester Children’s University Hospitals NHS Trust, and Professor of Diagnostic Radiology, University of Manchester

3. Mr Angus S Arunkalaivanan, Honorary Senior Lecturer, University of Birmingham and Consultant Urogynaecologist and Obstetrician, City Hospital, Birmingham

4. Dr Diana Baralle, Consultant and Senior Lecturer in Clinical Genetics, University of Southampton

5. Dr Stephanie Dancer, Consultant Microbiologist, Hairmyres Hospital, East Kilbride

6. Dr Diane Eccles, Professor of Cancer Genetics, Wessex Clinical Genetics Service, Princess Anne Hospital

7. Dr Trevor Friedman, Consultant Liason Psychiatrist, Brandon Unit, Leicester General Hospital

8. Dr Ron Gray, Consultant, National Perinatal Epidemiology Unit, Institute of Health Sciences, University of Oxford

9. Professor Paul D Griffiths, Professor of Radiology, Academic Unit of Radiology, University of Sheffield

10. Mr Martin Hooper, Public contributor

11. Professor Anthony Robert Kendrick, Associate Dean for Clinical Research and Professor of Primary Medical Care, University of Southampton

12. Dr Nicola Lennard, Senior Medical Officer, MHRA

13. Dr Anne Mackie, Director of Programmes, UK National Screening Committee, London

14. Mr David Mathew, Public contributor

15. Dr Michael Millar, Consultant Senior Lecturer in Microbiology, Department of Pathology & Microbiology, Barts and The London NHS Trust, Royal London Hospital

16. Mrs Una Rennard, Public contributor

17. Dr Stuart Smellie, Consultant in Clinical Pathology, Bishop Auckland General Hospital

18. Ms Jane Smith, Consultant Ultrasound Practitioner, Leeds Teaching Hospital NHS Trust, Leeds

19. Dr Allison Streetly, Programme Director, NHS Sickle Cell and Thalassaemia Screening Programme, King’s College School of Medicine

20. Dr Matthew Thompson, Senior Clinical Scientist and GP, Department of Primary Health Care, University of Oxford

21. Dr Alan J Williams, Consultant Physician, General and Respiratory Medicine, The Royal Bournemouth Hospital

1. Dr Tim Elliott, Team Leader, Cancer Screening, Department of Health

2. Dr Joanna Jenkinson, Board Secretary, Neurosciences and Mental Health Board (NMHB), Medical Research Council

3. Professor Julietta Patrick, Director, NHS Cancer Screening Programme, Sheffield

4. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

5. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

6. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Disease Prevention Panel

1. Professor of Epidemiology, University of Warwick Medical School, Coventry

2. Dr Robert Cook, Clinical Programmes Director, Bazian Ltd, London

3. Dr Colin Greaves, Senior Research Fellow, Peninsula Medical School (Primary Care)

4. Mr Michael Head, Public contributor

5. Professor Cathy Jackson, Professor of Primary Care Medicine, Bute Medical School, University of St Andrews

6. Dr Russell Jago, Senior Lecturer in Exercise, Nutrition and Health, Centre for Sport, Exercise and Health, University of Bristol

7. Dr Julie Mytton, Consultant in Child Public Health, NHS Bristol

8. Professor Irwin Nazareth, Professor of Primary Care and Director, Department of Primary Care and Population Sciences, University College London

9. Dr Richard Richards, Assistant Director of Public Health, Derbyshire County Primary Care Trust

10. Professor Ian Roberts, Professor of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine

11. Dr Kenneth Robertson, Consultant Paediatrician, Royal Hospital for Sick Children, Glasgow

12. Dr Catherine Swann, Associate Director, Centre for Public Health Excellence, NICE

13. Mrs Jean Thurston, Public contributor

14. Professor David Weller, Head, School of Clinical Science and Community Health, University of Edinburgh

1. Ms Christine McGuire, Research & Development, Department of Health

2. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

External Devices and Physical Therapies Panel

1. Consultant Physician North Bristol NHS Trust

2. Reader in Wound Healing and Director of Research, University of Leeds

3. Professor Bipin Bhakta, Charterhouse Professor in Rehabilitation Medicine, University of Leeds

4. Mrs Penny Calder, Public contributor

5. Dr Dawn Carnes, Senior Research Fellow, Barts and the London School of Medicine and Dentistry

6. Dr Emma Clark, Clinician Scientist Fellow & Cons. Rheumatologist, University of Bristol

7. Mrs Anthea De Barton-Watson, Public contributor

8. Professor Nadine Foster, Professor of Musculoskeletal Health in Primary Care Arthritis Research, Keele University

9. Dr Shaheen Hamdy, Clinical Senior Lecturer and Consultant Physician, University of Manchester

10. Professor Christine Norton, Professor of Clinical Nursing Innovation, Bucks New University and Imperial College Healthcare NHS Trust

11. Dr Lorraine Pinnigton, Associate Professor in Rehabilitation, University of Nottingham

12. Dr Kate Radford, Senior Lecturer (Research), University of Central Lancashire

13. Mr Jim Reece, Public contributor

14. Professor Maria Stokes, Professor of Neuromusculoskeletal Rehabilitation, University of Southampton

15. Dr Pippa Tyrrell, Senior Lecturer/Consultant, Salford Royal Foundation Hospitals’ Trust and University of Manchester

16. Dr Nefyn Williams, Clinical Senior Lecturer, Cardiff University

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

4. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Interventional Procedures Panel

1. Professor of Vascular Surgery, University of Sheffield

2. Consultant Colorectal Surgeon, Bristol Royal Infirmary

3. Mrs Isabel Boyer, Public contributor

4. Mr Sankaran Chandra Sekharan, Consultant Surgeon, Breast Surgery, Colchester Hospital University NHS Foundation Trust

5. Professor Nicholas Clarke, Consultant Orthopaedic Surgeon, Southampton University Hospitals NHS Trust

6. Ms Leonie Cooke, Public contributor

7. Mr Seumas Eckford, Consultant in Obstetrics & Gynaecology, North Devon District Hospital

8. Professor Sam Eljamel, Consultant Neurosurgeon, Ninewells Hospital and Medical School, Dundee

9. Dr Adele Fielding, Senior Lecturer and Honorary Consultant in Haematology, University College London Medical School

10. Dr Matthew Hatton, Consultant in Clinical Oncology, Sheffield Teaching Hospital Foundation Trust

11. Dr John Holden, General Practitioner, Garswood Surgery, Wigan

12. Dr Fiona Lecky, Senior Lecturer/Honorary Consultant in Emergency Medicine, University of Manchester/Salford Royal Hospitals NHS Foundation Trust

13. Dr Nadim Malik, Consultant Cardiologist/Honorary Lecturer, University of Manchester

14. Mr Hisham Mehanna, Consultant & Honorary Associate Professor, University Hospitals Coventry & Warwickshire NHS Trust

15. Dr Jane Montgomery, Consultant in Anaesthetics and Critical Care, South Devon Healthcare NHS Foundation Trust

16. Professor Jon Moss, Consultant Interventional Radiologist, North Glasgow Hospitals University NHS Trust

17. Dr Simon Padley, Consultant Radiologist, Chelsea & Westminster Hospital

18. Dr Ashish Paul, Medical Director, Bedfordshire PCT

19. Dr Sarah Purdy, Consultant Senior Lecturer, University of Bristol

20. Dr Matthew Wilson, Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust

21. Professor Yit Chiun Yang, Consultant Ophthalmologist, Royal Wolverhampton Hospitals NHS Trust

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

4. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Pharmaceuticals Panel

1. Professor in Child Health, University of Nottingham

2. Senior Lecturer in Clinical Pharmacology, University of East Anglia

3. Dr Martin Ashton-Key, Medical Advisor, National Commissioning Group, NHS London

4. Dr Peter Elton, Director of Public Health, Bury Primary Care Trust

5. Dr Ben Goldacre, Research Fellow, Division of Psychological Medicine and Psychiatry, King’s College London

6. Dr James Gray, Consultant Microbiologist, Department of Microbiology, Birmingham Children’s Hospital NHS Foundation Trust

7. Dr Jurjees Hasan, Consultant in Medical Oncology, The Christie, Manchester

8. Dr Carl Heneghan, Deputy Director Centre for Evidence-Based Medicine and Clinical Lecturer, Department of Primary Health Care, University of Oxford

9. Dr Dyfrig Hughes, Reader in Pharmacoeconomics and Deputy Director, Centre for Economics and Policy in Health, IMSCaR, Bangor University

10. Dr Maria Kouimtzi, Pharmacy and Informatics Director, Global Clinical Solutions, Wiley-Blackwell

11. Professor Femi Oyebode, Consultant Psychiatrist and Head of Department, University of Birmingham

12. Dr Andrew Prentice, Senior Lecturer and Consultant Obstetrician and Gynaecologist, The Rosie Hospital, University of Cambridge

13. Ms Amanda Roberts, Public contributor

14. Dr Gillian Shepherd, Director, Health and Clinical Excellence, Merck Serono Ltd

15. Mrs Katrina Simister, Assistant Director New Medicines, National Prescribing Centre, Liverpool

16. Professor Donald Singer, Professor of Clinical Pharmacology and Therapeutics, Clinical Sciences Research Institute, CSB, University of Warwick Medical School

17. Mr David Symes, Public contributor

18. Dr Arnold Zermansky, General Practitioner, Senior Research Fellow, Pharmacy Practice and Medicines Management Group, Leeds University

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Mr Simon Reeve, Head of Clinical and Cost-Effectiveness, Medicines, Pharmacy and Industry Group, Department of Health

3. Dr Heike Weber, Programme Manager, Medical Research Council

4. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

5. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Psychological and Community Therapies Panel

1. Professor of Psychiatry, University of Warwick, Coventry

2. Consultant & University Lecturer in Psychiatry, University of Cambridge

3. Professor Jane Barlow, Professor of Public Health in the Early Years, Health Sciences Research Institute, Warwick Medical School

4. Dr Sabyasachi Bhaumik, Consultant Psychiatrist, Leicestershire Partnership NHS Trust

5. Mrs Val Carlill, Public contributor

6. Dr Steve Cunningham, Consultant Respiratory Paediatrician, Lothian Health Board

7. Dr Anne Hesketh, Senior Clinical Lecturer in Speech and Language Therapy, University of Manchester

8. Dr Peter Langdon, Senior Clinical Lecturer, School of Medicine, Health Policy and Practice, University of East Anglia

9. Dr Yann Lefeuvre, GP Partner, Burrage Road Surgery, London

10. Dr Jeremy J Murphy, Consultant Physician and Cardiologist, County Durham and Darlington Foundation Trust

11. Dr Richard Neal, Clinical Senior Lecturer in General Practice, Cardiff University

12. Mr John Needham, Public contributor

13. Ms Mary Nettle, Mental Health User Consultant

14. Professor John Potter, Professor of Ageing and Stroke Medicine, University of East Anglia

15. Dr Greta Rait, Senior Clinical Lecturer and General Practitioner, University College London

16. Dr Paul Ramchandani, Senior Research Fellow/Cons. Child Psychiatrist, University of Oxford

17. Dr Karen Roberts, Nurse/Consultant, Dunston Hill Hospital, Tyne and Wear

18. Dr Karim Saad, Consultant in Old Age Psychiatry, Coventry and Warwickshire Partnership Trust

19. Dr Lesley Stockton, Lecturer, School of Health Sciences, University of Liverpool

20. Dr Simon Wright, GP Partner, Walkden Medical Centre, Manchester

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

4. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Expert Advisory Network

1. Professor Douglas Altman, Professor of Statistics in Medicine, Centre for Statistics in Medicine, University of Oxford

2. Professor John Bond, Professor of Social Gerontology & Health Services Research, University of Newcastle upon Tyne

3. Professor Andrew Bradbury, Professor of Vascular Surgery, Solihull Hospital, Birmingham

4. Mr Shaun Brogan, Chief Executive, Ridgeway Primary Care Group, Aylesbury

5. Mrs Stella Burnside OBE, Chief Executive, Regulation and Improvement Authority, Belfast

6. Ms Tracy Bury, Project Manager, World Confederation of Physical Therapy, London

7. Professor Iain T Cameron, Professor of Obstetrics and Gynaecology and Head of the School of Medicine, University of Southampton

8. Professor Bruce Campbell, Consultant Vascular & General Surgeon, Royal Devon & Exeter Hospital, Wonford

9. Dr Christine Clark, Medical Writer and Consultant Pharmacist, Rossendale

10. Professor Collette Clifford, Professor of Nursing and Head of Research, The Medical School, University of Birmingham

11. Professor Barry Cookson, Director, Laboratory of Hospital Infection, Public Health Laboratory Service, London

12. Dr Carl Counsell, Clinical Senior Lecturer in Neurology, University of Aberdeen

13. Professor Howard Cuckle, Professor of Reproductive Epidemiology, Department of Paediatrics, Obstetrics & Gynaecology, University of Leeds

14. Professor Carol Dezateux, Professor of Paediatric Epidemiology, Institute of Child Health, London

15. Mr John Dunning, Consultant Cardiothoracic Surgeon, Papworth Hospital NHS Trust, Cambridge

16. Mr Jonothan Earnshaw, Consultant Vascular Surgeon, Gloucestershire Royal Hospital, Gloucester

17. Professor Martin Eccles, Professor of Clinical Effectiveness, Centre for Health Services Research, University of Newcastle upon Tyne

18. Professor Pam Enderby, Dean of Faculty of Medicine, Institute of General Practice and Primary Care, University of Sheffield

19. Professor Gene Feder, Professor of Primary Care Research & Development, Centre for Health Sciences, Barts and The London School of Medicine and Dentistry

20. Mr Leonard R Fenwick, Chief Executive, Freeman Hospital, Newcastle upon Tyne

21. Mrs Gillian Fletcher, Antenatal Teacher and Tutor and President, National Childbirth Trust, Henfield

22. Professor Jayne Franklyn, Professor of Medicine, University of Birmingham

23. Mr Tam Fry, Honorary Chairman, Child Growth Foundation, London

24. Professor Fiona Gilbert, Consultant Radiologist and NCRN Member, University of Aberdeen

25. Professor Paul Gregg, Professor of Orthopaedic Surgical Science, South Tees Hospital NHS Trust

26. Bec Hanley, Co-director, TwoCan Associates, West Sussex

27. Dr Maryann L Hardy, Senior Lecturer, University of Bradford

28. Mrs Sharon Hart, Healthcare Management Consultant, Reading

29. Professor Robert E Hawkins, CRC Professor and Director of Medical Oncology, Christie CRC Research Centre, Christie Hospital NHS Trust, Manchester

30. Professor Richard Hobbs, Head of Department of Primary Care & General Practice, University of Birmingham

31. Professor Alan Horwich, Dean and Section Chairman, The Institute of Cancer Research, London

32. Professor Allen Hutchinson, Director of Public Health and Deputy Dean of ScHARR, University of Sheffield

33. Professor Peter Jones, Professor of Psychiatry, University of Cambridge, Cambridge

34. Professor Stan Kaye, Cancer Research UK Professor of Medical Oncology, Royal Marsden Hospital and Institute of Cancer Research, Surrey

35. Dr Duncan Keeley, General Practitioner (Dr Burch & Ptnrs), The Health Centre, Thame

36. Dr Donna Lamping, Research Degrees Programme Director and Reader in Psychology, Health Services Research Unit, London School of Hygiene and Tropical Medicine, London

37. Professor James Lindesay, Professor of Psychiatry for the Elderly, University of Leicester

38. Professor Julian Little, Professor of Human Genome Epidemiology, University of Ottawa

39. Professor Alistaire McGuire, Professor of Health Economics, London School of Economics

40. Professor Neill McIntosh, Edward Clark Professor of Child Life and Health, University of Edinburgh

41. Professor Rajan Madhok, Consultant in Public Health, South Manchester Primary Care Trust

42. Professor Sir Alexander Markham, Director, Molecular Medicine Unit, St James’s University Hospital, Leeds

43. Dr Peter Moore, Freelance Science Writer, Ashtead

44. Dr Andrew Mortimore, Public Health Director, Southampton City Primary Care Trust

45. Dr Sue Moss, Associate Director, Cancer Screening Evaluation Unit, Institute of Cancer Research, Sutton

46. Professor Miranda Mugford, Professor of Health Economics and Group Co-ordinator, University of East Anglia

47. Professor Jim Neilson, Head of School of Reproductive & Developmental Medicine and Professor of Obstetrics and Gynaecology, University of Liverpool

48. Mrs Julietta Patnick, Director, NHS Cancer Screening Programmes, Sheffield

49. Professor Robert Peveler, Professor of Liaison Psychiatry, Royal South Hants Hospital, Southampton

50. Professor Chris Price, Director of Clinical Research, Bayer Diagnostics Europe, Stoke Poges

51. Professor William Rosenberg, Professor of Hepatology and Consultant Physician, University of Southampton

52. Professor Peter Sandercock, Professor of Medical Neurology, Department of Clinical Neurosciences, University of Edinburgh

53. Dr Philip Shackley, Senior Lecturer in Health Economics, Sheffield Vascular Institute, University of Sheffield

54. Dr Eamonn Sheridan, Consultant in Clinical Genetics, St James’s University Hospital, Leeds

55. Dr Margaret Somerville, Director of Public Health Learning, Peninsula Medical School, University of Plymouth

56. Professor Sarah Stewart-Brown, Professor of Public Health, Division of Health in the Community, University of Warwick, Coventry

57. Dr Nick Summerton, GP Appraiser and Codirector, Research Network, Yorkshire Clinical Consultant, Primary Care and Public Health, University of Oxford

58. Professor Ala Szczepura, Professor of Health Service Research, Centre for Health Services Studies, University of Warwick, Coventry

59. Dr Ross Taylor, Senior Lecturer, University of Aberdeen

60. Dr Richard Tiner, Medical Director, Medical Department, Association of the British Pharmaceutical Industry

61. Mrs Joan Webster, Consumer Member, Southern Derbyshire Community Health Council

62. Professor Martin Whittle, Clinical Co-director, National Co-ordinating Centre for Women’s and Children’s Health, Lymington