Participatory evaluation of a co-designed intervention to strengthen patient involvement in improving general practice.

Problem

Patient and public involvement in health care design and delivery is recognised as important internationally. Health policy cites the moral rationale for involving patients, but also claims involvement will result in more patient centred services, despite little evidence of the mechanism to achieve this. In England, this policy is enacted through contractual requirements for every general practice to involve patients in service improvement through Patient Participation Groups (PPGs). However, there are problems with making this routine and meaningful for all stakeholders. To address this policy-practice gap we co-designed an intervention to strengthen patient involvement in general practice.

Approach

A participatory action research study, working with a co-research group involving ten patients (seven core members), six general practitioners (two core members), one receptionist, and a PhD researcher, to evaluate a co-designed intervention. The intervention consists of a series of four facilitated meetings, using participatory methods to address power; a bespoke survey to address demographic legitimacy; PPG training focused on representational legitimacy; and a further facilitated meeting to develop a credible action plan. The intervention is being evaluated by the co-research group in two general practices in the North of England. The dataset includes two sets (PhD and patient co-researcher) of observational notes of intervention meetings and four to six follow up meetings (total meeting time per practice: 15 hours over 1 year); and semi-structured interviews with patients (four completed, six outstanding) and staff members (three completed, four outstanding) involved in the intervention. Data co-analysis uses both an inductive and deductive approach drawing on normalisation process theory.

Findings

This work is in progress. Interim analysis suggests that patients and staff valued working together during the intervention, and one practice rebranded as ‘the listening practice’. However, there is little evidence of longer term change in working relationships between patients and staff. Patients and staff were motivated by the opportunity to make patient centred services changes. Unlike staff, patients were also motivated by the concept of working together. Both patients and staff lacked skills to engage with each other. Where individuals possessed these skills, barriers to enacting them included hierarchal practice structures, institutional norms, and societal expectations about the role of patients. External facilitation and participatory methods helped to address some of these barriers. A lack of reflective space during implementation resulted in missed opportunities to consolidate new long term working relationships.

Consequences

The intervention resulted in actions consistent with patient priorities for service change. However, several barriers have been identified that warrant further attention to support implementation and the scope for long term change in how patients and staff work together. The policy of mandatory patient involvement is unlikely to be successful unless patient involvement work is recognised as a separate skill set and adequately resourced.