Engagement for improvement - full abstract

Extended access to general practice: engaging practices and patients

Rebecca Elvey(1), Simon Bailey(2), Kath Checkland(1), James Higgerson(1), Damian Hodgson(1), Susan Howard(3), Pauline Nelson(1), Stephen Parkin(4), Natalie Ross(1), William Whittaker(1)
(1)The University of Manchester, (2)University of Kent, (3)Health Innovation Manchester, (4)King’s College London

Background: Extended access to primary care has been a national health policy priority in England since 2013 and since 2018 general practice is required to provide access to appointments during weekday evenings and at weekends. Across the country, various extended access programmes have been developed and implemented. Between 2014 and 2019, the NIHR CLAHRC GM team undertook evaluations of schemes providing extended access to primary care in nine CCG areas across Greater Manchester. All schemes involved appointments being provided via ‘hub’ systems whereby patients from several practices would access appointments at one single location (usually a local GP practice). Our aim was to understand the context in which extended access programmes developed and to ascertain the factors enabling and challenging implementation.

Methods: Three mixed methods evaluation studies were undertaken; all included process evaluations, which followed a qualitative approach. The sampling strategy was purposive and snowballing was used to find further relevant interviewees. We carried out semi-structured interviews with participants in strategic, operational, clinical, support and administrative roles in commissioning and provider organisations. Interviews were audio recorded, transcribed and subjected to thematic analysis.

Results: In total, 97 people took part in interviews. The way in which extended access was conceptualised varied, reflecting local area conditions and views of the purpose of the service. Engaging and communicating with local general practices and with patients were key challenges. Some schemes were designed to extend routine general practice, whereas others covered both routine and urgent care needs. There was also variation in how engaged local practices were with the schemes, all of which involved complex networks of organisations. Some sites built effectively upon existing relationships. At others, new relationships had to be forged; between GP site leads and staff in other local practices, between commissioners and providers and between the provider organisation and local clinicians. Sometimes the schemes had acted to foster new relationships such as collaborative working between practice managers. Local practice engagement with the extended access schemes varied; reception staff in particular welcomed the opportunity to offer appointments sooner, however, some GPs were sceptical of the value of seven day access in principle, others feared it could increase demand and therefore workload, or reported that their waiting times for appointments were manageable and there was no need for additional services.

Practices’ engagement with the scheme seems likely to have been associated with varying communication of the service to patients, which ranged from extensive campaigns including advertising on public transport, social media and/or having promotional materials in practice waiting rooms, to no direct promotion to patients at all. Access and referral routes also differed; some schemes allowed patients to self-refer through direct booking lines, but at the majority, bookings could only be made on the part of patients by their GP practices and particularly where the service was not widely publicised, this demand was also moderated by practice staff awareness, their understanding of and attitude towards the extended access service and hence the likelihood that they would refer patients on.

Implications: The findings are relevant to current and future policy ambitions for healthcare access. Implementing extended access in primary care is complex and the processes require collaboration but can also help foster relationships. Varying buy-in on behalf of practices has implications for patients in terms of equity of access. Patient awareness and experience of extended access schemes is not fully understood.

Health Experiences of Asylum seekers and Refugees (HEAR): findings and recommendations from a qualitative study 

Ashra Khanom(1), Bridie A Evans(2), Porter Alison(2), Gill Richardson(3), Lauren Couzens(3), Rebecca Fogarty(3), Helen A Snooks(2)
(1)Swansea University Medical School, (2)Swansea University, (3)Public Health Wales

Background: Asylum seekers and refugees are a particularly vulnerable group. Access to and the provision of healthcare services to address needs can be challenging. Some of these challenges relate to traumatic experiences that have led to people seeking sanctuary, language and communication and poor understanding from service providers on how to address the needs of this population. In order to provide appropriate care, we need to understand the health needs and experiences of asylum seekers and refugees and how healthcare practitioners experience providing care to this group.

Method: We conducted eight focus groups across Wales with 57 people seeking sanctuary and those employed or volunteering to support those seeking sanctuary. Interpreters were present when needed. We asked about experiences of accessing and receiving care. Respondents were recruited through third sector organisations, at multicultural events and through the peer researchers’ (asylum seekers and refugees) own networks. We also interviewed 32 health professionals and third sector support workers individually by telephone about their experiences of delivering care or supporting patients from this population. We recorded and transcribed all interviews and focus groups. We used framework analysis to analyse transcripts according to our research aims.

Results: Asylum seekers and refugees relied on specialist health professionals and support workers to navigate access to healthcare. Reported barriers included: feeling their needs were not recognised; language difficulties, including lack of interpreters; and out of pocket expenses. Respondents generally understood GPs’ role in providing and coordinating care. They acknowledged the importance of mental health and expressed regret at the poor provision of mental healthcare. Some asserted that the stress of being an asylum seeker or refugee contributed to their poor physical and mental health.

Specialist health professionals and support workers acknowledged that they potentially had resources and skills to help people seeking sanctuary, notably knowledge, time and flexibility. In comparison, mainstream health professionals reported that they lacked adequate resources to deliver healthcare effectively to these groups. Providers suggested that pressures on the healthcare system in general and the lack of appropriate tailored services to meet the needs of people seeking sanctuary combined with their isolated social conditions, contribute to poor mental and physical health outcomes.

Implications: This study provides valuable insight into asylum seekers’ and refugees’ experiences of health in Wales. It suggests that a compassionate, non-judgemental approach to providing care supports people seeking sanctuary to access healthcare with potential to reduce health inequities. These findings will be shared with NHS Wales providers and consideration given to providing: additional resources to train and support healthcare staff ; specialist service support where needed such as designated health visiting and maternity services; and swift access to mental health support for those who have suffered trauma. Interpretation (oral) and translation (written) services should be accessible to both service providers and healthcare recipients. Statutory services should continue to work closely with the voluntary sector to enhance the ability of people seeking sanctuary to navigate NHS services and improve their health literacy.

Development of an intervention to support dental practitioner communication about behaviour change to improve oral health in children (The Polar Bear Study).

Joanna Goldthorpe, Sarah Peters, Iain Pretty, Sarah Cotterill, Jo Hart
University of Manchester

Background: Routine dental appointments provide opportunities and teachable moments to deliver ongoing health behaviour change interventions however training in behaviour change techniques at both undergraduate and CDP level is not widely undertaken by the dental workforce. As a result, dental practitioners feel ill-equipped and lack confidence in starting conversations around health behaviour change with patients. In the UK, the most common reason for children to go to hospital is to have decayed teeth removed under general anaesthetic. This is risky for children and expensive for the NHS. Child tooth decay is painful, upsetting, and disrupts eating and sleep, however it is a preventable disease. Our research has shown that parents and carers want dentists’ help with making changes around their children’s health behaviours such as regular tooth-brushing with fluoride toothpaste and eating less sugar; however dental practitioners worry about offending patients and are unsure how to help families make changes. We have already developed an online training course for dental practitioners that utilises behaviour change theory to train dental practitioners in an evidence-based approach to starting relevant behaviour change conversations with adult patients. The aim of our study is to adapt the existing training using patient and practitioner expert groups so that it is relevant for conversations with parents about reducing child tooth decay, explore acceptability of the intervention to patients and practitioners and gather data to inform a future RCT to explore effectiveness.

Methods: A mixed methods pilot study will gather data to inform the feasibility of conducting a future RCT of this intervention. During phase 1 we will refine the training intervention and during phase 2 we will carry out a cluster RCT with a nested qualitative study to gather feasibility data relating to carrying out a future trial (acceptability to patients and clinicians, attrition, randomisation procedures and implementation). We will also look at a number of clinical and behavioural patient outcomes for children and parents (attendance at appointments, child oral health and treatment in primary and secondary care).

Results: Results from a survey of dentists and patients and focus groups involving parents and dental practitioners will be presented. This data has been synthesised along with theory from health psychology to inform the development and content of a web-based training programme and patient facing materials. 

Implications: I will describe the work carried out so far and discuss the vast opportunities, implications and potential outcomes of developing a dental workforce able to deliver brief and effective behaviour change interventions to improve oral health.


Engaging Families in Health Research and Understanding their Research Priorities

Samira Datoo, Rose-Marie Satherley, Elizabeth Cecil
King's College London

Background: Rigorous evaluation is key to improving and assessing the impact of health services (1), and involvement of patients is key to developing effective services and evaluations. The Children and Young People’s Health Partnership (CYPHP) is a clinical-academic partnership, delivering and assessing an innovative model of integrated care for children and young people (CYP). The model is being rolled out in phases, allowing rigorous evaluation using a cluster randomised controlled trial. The evaluation has engaged 46% of CYP who are involved in the CYPHP service. Alongside the trial, public patient involvement (PPI) is embedded, to ensure the service and evaluation methodology is suited to local needs. Here, we describe findings from a school event that explored methods of engaging the local population in health research and public attitudes towards health research priorities.

Methods: The CYPHP Evaluation Team attended a Primary School’s Winter Fair in South London. Caregivers and CYP were invited to rate what were most important to them in a new health service, as an indication of research priorities. A visual voting game required participants to vote on the World Health Organisations six pillars of healthcare quality (2), that were adapted into child-friendly phrases for the purpose of this project. Participants were asked to rate their top 3 choices from: everyone who needs care gets it, safe, child and family friendly, supported by science, timely and cost effective.

Caregivers were also invited to provide additional feedback by answering one of three questions:

  1. Why is it important to evaluate healthcare services?

  2. How could we reach people to engage in a new health service?

  3. How could we motivate people who are engaging with the CYPHP service (completed the child Health Check) to participate in the CYPHP evaluation study?

Results: Caregivers and CYP expressed a preference for equitable care (n=80) which was adaptable to ‘everyone who needs care gets it’ for this event. Caregivers reflected on the importance of conducting health research as it “keeps data current and reflective of the people who need it…” and “…makes sure people are receiving the best care possible”. When asked how to engage with the local population, families recommended the use of schools and social media.

Implications: The event was a novel way of engaging and educating Caregivers and CYP about the importance of health research and its relevance to quality of care. Answers provided from the three feedback questions highlighted the public’s interest in service evaluation. The visual voting game especially offered an interactive way of measuring qualities of care. The data collected will be valuable in shaping the design of project resources and, in targeting the recruitment and engagement of families across the local population.


  1. The Health Foundation. Evaluation: what to consider. Commonly asked questions about how to approach evaluation of quality improvement in health care. 2015 https://www.health.org.uk/sites/default/files/EvaluationWhatToConsider.pdf 

  2. World Health Organisation. Maternal, newborn, child and adolescent health. What is Quality of Care and why is it important? https://www.who.int/maternal_child_adolescent/topics/quality-of-care/definition/en/ 

Hope versus reality: A comparative case study of stakeholder engagement in the development of products from healthcare research 

Charlotte A Sharp(1), Caroline Sanders(2), Ruth Boaden(3), Will Dixon(4)
(1)Centre for Epidemiology Versus Arthritis, The University of Manchester, (2)Centre for Primary Care and Health Services Research, (3)Alliance Manchester Business School, (4)Centre for Epidemiology Versus Arthritis

Background: The ‘impact agenda’ is rising in response to changes to institutional funding arrangements and the introduction of impact cases as part of core university funding. The number of ‘non-academic’ products such as toolkits, dashboards and guidance, which aim to help mobilise knowledge from healthcare research has risen in line with the impact agenda. The knowledge mobilisation literature proposes that research and any associated outputs are likely to have greater impact if they are developed in collaboration with stakeholders. This study explored the intentions of academics and observed how stakeholders are involved in the development of products from healthcare research.

Methods: An exploratory study (20 semi-structured interviews and a focus group (n=11)) included perspectives of academics, funders and practitioners regarding toolkits as an example of products from healthcare research. Exploratory study findings informed the design of a prospective, longitudinal study of four cases of applied healthcare research projects intending to develop products. The development and subsequent application of each product was studied for a mean of 10.5 months (range 7-18months). Data generated from semi-structured interviews (38), observations (83 hours) and project documents (289) were assimilated into narrative summaries and analysed thematically, using constant comparative techniques.

Results: Exploratory study participants highlighted the importance of engaging stakeholders when developing products, and tailoring them to users’ needs. Stakeholder engagement was held in high regard by the majority of participants, and was cited as important in research funding applications and project protocols. However, in practice, only one of four cases developed a cohesive strategy for developing their product with stakeholders (using a co-design approach). This case lived up to the team’s expectations of stakeholder engagement.

Plans to achieve stakeholder engagement were harder to identify for the remaining three cases. These cases then failed to meet their own expectations of engagement, having fewer, more superficial interactions. Explanations for a lack of engagement included: difficulties identifying and gaining access to suitable individuals; time; trust; clarity of purpose (or lack thereof); and the challenge of ceding control over product development. Funding was not reported as a barrier. Assimilating and incorporating stakeholder perspectives was regarded as skilled work. Some instances were observed where teams’ reporting of stakeholder engagement did not appear to be as transparent as the reporting of other aspects of their work. Stakeholders who perceived that their input was treated tokenistically reduced engagement with the affiliated project(s).

The project with the strongest co-design element developed tools for use at local NHS study sites rather than a generic overarching toolkit. The product with the least engagement with stakeholders during its development resulted in the most widely-used output from all four cases. The implicit understanding of practice held by the projects’ clinical academic leader seemed to compensate for this lack of engagement.

Implications: This study identifies that whilst academics view stakeholder engagement as important, their intentions do not appear to be met in practice, and they may overstate the degree of stakeholder engagement.  It highlights that expectations for stakeholder engagement may be high due to the symbolic value attached to such engagement and because of an expectation amongst the academic community that engagement is a necessity, particularly to gain grant funding. This study adds weight to existing accounts of the challenges of stakeholder engagement. It adds to these accounts by highlighting that the ‘success’ of a product may rest more upon the presence of an implicit understanding of practice (which may be held by those within the developing team), than, necessarily, the engagement of external stakeholders. These findings raise awareness of the need for academics and funders to consider carefully their motivations and plans for stakeholder engagement.

Introducing physician associates to hospital patients: development and feasibility of an intervention to inform patients about the new role

Francesca Taylor(1), Jonathan Ogidi(2), Rakhee Chauhan(2), Zeena Lavda(2), Sally Brearley(3), Vari Drennan(3)
(1)St George's University of London and Kingston University, (2)St George’s University Hospitals NHS Foundation Trust, (3)Kingston University and St George's University of London

Background: Existing evidence shows poor recognition and comprehension of the physician associate (PA) role among acute inpatients. They are often confused by the title; its meaning is not immediately obvious and needs explanation. Furthermore, many patients mistakenly perceive PAs to be doctors and can express concerns when made aware of this misconception (Taylor et al, 2019; Drennan et al, 2019). Solutions are less clear, there being an overall deficit in the evidence base of how best to address the issue of clinician identification, and of inpatients’ preferences as regards what they want to know, how, and when, about PAs. No known studies have developed an intervention, with patients and clinicians, to introduce a new practitioner role to hospital patients. Therefore, the aims of this study were to: 1) Elicit inpatients’ preferences about how they want to be informed about the new PA role, 2) Evaluate an intervention, co-designed on the basis of these preferences, in terms of its feasibility and acceptability for introducing PAs.

Method: A two-stage qualitative interview study among patients and representatives of patients seen by or receiving care from one of the volunteer PAs participating in the study. The volunteer PAs were interviewed at stage two. The study was underpinned by an experience-based co-design approach (Bate and Robert, 2006). Semi-structured interviews were undertaken face-to-face in one NHS acute hospital trust in 2019. Data were coded and analysed using framework analysis (Gale et al, 2013).

Stage one elicited expectations and preferences of participants on being informed about the PA role. They were shown six different intervention ideas in written/visual form e.g. leaflet, job title on lanyard. Data collected was used to guide development of an intervention. At stage two, the intervention was tried out and evaluated in terms of its feasibility and acceptability for informing patients about the PA role.

A co-design group including - patient and public representatives from the Patient Research Expert Group in the Centre for Public Engagement, Kingston University and St George’s, University of London; PAs from St George’s University Hospitals NHS Foundation Trust; and study researchers from Kingston University and St George’s, University of London - collaboratively developed the intervention ideas shown to study participants at stage one and the intervention trialled at stage two.

Results: Thirteen patients and patient representatives participated in interviews at stage one and twenty at stage two. Three volunteer PAs were interviewed at stage two. The leaflet was the most popular intervention idea shown to participants at stage one, alongside a personal introduction by the PA. Based on these preferences the intervention developed was a two-sided, hand-size information card. PA participants personally introduced the intervention to patients, with flexibility as regards wording.

Most patient participants reported appreciating the intervention and that they felt more informed, cared for, and supported. The intervention was thought to clearly communicate the PA role within the medical team and what PAs are medically trained to do, and cannot do. More explicit communication of permission to engage with PAs through asking questions was wanted by some patient and PA participants. While there was some hesitancy among PAs about introducing the intervention unprompted during encounters, patients accepted this approach. PAs adapted how they introduced the intervention to suit to their personal style and work context.

Implications: The intervention can feasibly be used to introduce PAs to hospital patients. Consideration should be given to facilitating patients to seek additional information if wanted. There is potential for future research with larger samples and in more acute inpatient settings, to evaluate impact on awareness and understanding of the role.