Does patient and public involvement have an impact on general practice? A participatory action research study

The problem

Patient and public involvement (PPI) in service delivery is enshrined in the NHS constitution and gaining momentum. Following the 2012 NHS reforms, formal PPI roles exist in clinical commissioning groups (CCG) and Healthwatch, and from April 2015 general practices will be contracted to have patient participation groups (PPGs). However, there is little evidence about what these groups do, why, and their potential impact on quality of primary care.This study aims to understand if and how current PPI affects primary care service delivery.

The approach

A participatory action research approach was adopted. Patients and professionals with experience of PPI activities in Leeds and Manchester took part in two meetings as co-researchers. They identified six PPI groups which were observed on two occasions. Semi-structured interviews were conducted with patients, practice managers, and general practitioners, from these groups. Interviews were recorded and transcribed verbatim. Notes of observed meetings, meeting documents, and interview transcripts were analysed using a framework approach, developed with the co-researchers.

Findings

Ten co-researchers from Manchester (one engagement lead) and 15 from Leeds (one engagement lead and one practice manager) produced maps of PPI activities in their localities. From these maps, six established PPI groups were chosen: four PPGs and two CCG PPI groups. 18 interviews were conducted with group members (four GPs, four practice managers, and ten group members). The majority of people involved were white, middle class, and aged 40-70.PPI activity varied widely between, and within, Leeds and Manchester. There was confusion about the purpose, with six different, and sometimes conflicting, roles identified. General practice staff valued group members when their activities reduced workload, for example helping with flu clinics. However, they were uncomfortable with group members getting involved in organisational or business aspects of general practice, describing these as beyond their remit. Group members were motivated, committed, and keen to influence the quality of primary care, particularly general practice. However, they were unsure of the scope of their role and representativeness was viewed as a limitation, with practice staff using this to devalue the PPI input. PPG members described difficulty in raising concerns, citing worries about the impact on their clinical patient-doctor relationship. CCG PPI groups were more critical about general practice, but were frustrated that their influence was limited to non-general practice primary care.

Consequences

Health policy suggests PPI could improve services resulting in more patient centred care. However, there is little evidence of healthy partnership working in general practice. Barriers include lack of clarity of purpose, issues of representation, transparency about the organisation of general practice, and power dynamics between patients and general practices. These barriers need to be addressed to avoid tokenistic PPI resulting in patient disillusionment with general practice.

Credits

• Jess Drinkwater
• Maureen Twiddy
• Vicky Ward
• Robbie Foy