Patient safety in marginalised groups: a narrative scoping review.

BACKGROUND: Marginalised groups ('populations outside of mainstream society') experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising. METHODS: Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day. RESULTS: The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors. CONCLUSIONS: This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks. TRIAL REGISTRATION: Not applicable for a scoping review.

Implementing a digital patient feedback system: an analysis using normalisation process theory.

BACKGROUND: Patient feedback in the English NHS is now widespread and digital methods are increasingly used. Adoption of digital methods depends on socio-technical and contextual factors, alongside human agency and lived experience. Moreover, the introduction of these methods may be perceived as disruptive of organisational and clinical routines. The focus of this paper is on the implementation of a particular digital feedback intervention that was co-designed with health professionals and patients (the DEPEND study). METHODS: The digital feedback intervention was conceptualised as a complex intervention and thus the study focused on the contexts within which it operated, and how the different participants made sense of the intervention and engaged with it (or not). Four health care sites were studied: an acute setting, a mental health setting, and two general practices. Qualitative data was collected through interviews and focus groups with professionals, patients and carers. In total 51 staff, 24 patients and 8 carers were included. Forty-two observations of the use of the digital feedback system were carried out in the four settings. Data analysis was based on modified grounded theory and Normalisation Process Theory (NPT) formed the conceptual framework. RESULTS: Digital feedback made sense to health care staff as it was seen as attractive, fast to complete and easier to analyse. Patients had a range of views depending on their familiarity with the digital world. Patients mentioned barriers such as kiosk not being visible, privacy, lack of digital know-how, technical hitches with the touchscreen. Collective action in maintaining participation again differed between sites because of workload pressure, perceptions of roles and responsibilities; and in the mental health site major organisational change was taking place. For mental health service users, their relationship with staff and their own health status determined their digital use. CONCLUSION: The potential of digital feedback was recognised but implementation should take local contexts, different patient groups and organisational leadership into account. Patient involvement in change and adaptation of the intervention was important in enhancing the embedding of digital methods in routine feedback. NPT allowed for a in-depth understanding of actions and interactions of both staff and patients.

The ethnographer as health service leader: An insider's view of organisational change.

PURPOSE: The conceptual presentation of a detailed case study of structural reorganisation in the English NHS illustrates what factors lead to productive or unproductive organisational change. FINDINGS: This autoethnography of a NHS Trust chair provides an account of two reorganisations over an 8-year period. The paper is based on diaries that allow for the presentation of examples that highlight different processes and outcomes. The various actors in the two reorganisations gave complex and multilayered meanings to structural changes and their impact. Two theoretical frameworks helped to analyse the dynamics of productive and unproductive changes. CONCLUSION: It is argued that structural change rarely delivers and that working through people and paying due attention to their motivations and moral imperatives will more likely produce benefits to organisations, staff, and patients.

Cost-effectiveness of a model consultation to support self-management in patients with osteoarthritis.

Objectives: The aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care. Methods: An incremental cost-utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves. Results: Differences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by -0.28 (95% CI: -0.55, -0.06). The cost-utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £-13.11 (95% CI: -81.09 to 54.85) and an incremental quality adjusted life year (QALY) of -0.003 (95% CI: -0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm. Conclusion: Implementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective.

Risk and self-managing chronic joint pain: looking beyond individual lifestyles and behaviour.

Self-managing chronic musculoskeletal pain is predominantly framed within a discourse of modifying behaviour, or lifestyle risk factors such as diet, weight loss and exercise by policymakers, researcher and clinicians. Little research has been conducted which explores how 'risk' is understood or encountered by those with joint pain and how it may relate to self-management. Drawing from serial interviews and a diary study with 22 participants, the findings demonstrate that people with chronic pain engage in a process of assessing and adapting to hazardous or pain conferring situations in relation to daily activities. 'Risks' are embedded within a dialectic between corporeal experience and the design features of everyday social environments. Self-management, in this context, is not necessarily solely related to following clinical advice, rather it includes dealing with 'risks' of pain, hazards relating to bodily limitations and the environment, and ensuring the ability to continue with valued activities. Findings contribute to sociological understandings of self-management and risk while demonstrating the limits of viewing self-management as an individualised endeavour of changing behaviour.

Introducing Evidence Through Research "Push": Using Theory and Qualitative Methods.

A multitude of factors can influence the uptake and implementation of complex interventions in health care. A plethora of theories and frameworks recognize the need to establish relationships, understand organizational dynamics, address context and contingency, and engage key decision makers. Less attention is paid to how theories that emphasize relational contexts can actually be deployed to guide the implementation of an intervention. The purpose of the article is to demonstrate the potential role of qualitative research aligned with theory to inform complex interventions. We detail a study underpinned by theory and qualitative research that (a) ensured key actors made sense of the complex intervention at the earliest stage of adoption and (b) aided initial engagement with the intervention. We conclude that using theoretical approaches aligned with qualitative research can provide insights into the context and dynamics of health care settings that in turn can be used to aid intervention implementation.

Acceptability of a 'guidebook' for the management of Osteoarthritis: a qualitative study of patient and clinician's perspectives.

BACKGROUND: Written information can be of benefit to both practitioners and patients and the provision of quality information is emphasised as a core intervention by United Kingdom National Institute of Clinical Excellence (NICE) OA guidelines. Researchers, patients and HCPs developed an 'OA guidebook' to provide; a) a balanced source of information for patients; b) a resource to aid practitioners when discussing self-management. This study aimed to evaluate the acceptability and usefulness of the OA guidebook as part of complex intervention to deliver NICE OA guidelines in General Practice. METHODS: The intervention comprises a series of consultations with GPs and practice nurses in which supported self-management is offered to patients. Eight practices in the West Midlands and North West of England were recruited to take part: four control practices and four intervention practices. Semi-structured interviews were undertaken with patients (n = 29), GPs (n = 9) and practice nurses (n = 4) from the intervention practices to explore experiences of the intervention and use of the guidebook. Data were analysed using thematic analysis and constant comparison of data within and across interviews. RESULTS: GPs thought the guidebook helped provide patients with information about OA aetiology, prognosis and self-management. Thus, it backed up key messages they provided patients during consultations. GPs also found the guidebook helped them 'close off' consultations. Nurses also thought the guidebook helped them describe OA disease processes in consultations. Patients valued the explanations of disease onset, process and prognosis. The use of 'real' people and 'real life' situations contained within the guidebook made self-management strategies seem more tangible. A sense of inclusion and comfort was obtained from knowing other people encountered similar problems and feelings. CONCLUSION: An OA specific written information guidebook was deemed acceptable and useful to practitioners and patients alike as part of the MOSAICS study. Findings reinforce the utility of this model of patient information as a resource to support patients living with chronic illnesses. An OA guidebook featuring a mixture of lay and professional information developed by professionals and lay people is useful and could effectively be used more widely in usual care.

Perceptions of health professionals towards the management of back pain in the context of work: a qualitative study.

BACKGROUND: Musculoskeletal complaints have a significant impact on work in terms of reduced productivity, sickness absence and long term incapacity for work. This study sought to explore GPs' and physiotherapists' perceptions of sickness certification in patients with musculoskeletal problems. METHODS: Eleven (11) GPs were sampled from an existing general practice survey, and six (6) physiotherapists were selected randomly using 'snowball' sampling techniques, through established contacts in local physiotherapy departments. Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes. The interviews were audio recorded and transcribed verbatim, following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology, where themes were identified and contrasted between and within both groups of respondents. RESULTS: Three themes were identified from the analysis: 1) Approaches to evaluating patients' work problems 2) Perceived ability to manage 'work and pain', and 3) Policies and penalties in the work-place. First, physiotherapists routinely asked patients about their job and work difficulties using a structured (protocol-driven) approach, whilst GPs rarely used such structured measures and were less likely to enquire about patients' work situation. Second, return to work assessments revealed a tension between GPs' gatekeeper and patient advocacy roles, often resolved in favour of patients' concerns and needs. Some physiotherapists perceived that GPs' decisions could be influenced by patients' demand for a sick certificate and their close relationship with patients made them vulnerable to manipulation. Third, the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption, and over which GPs and physiotherapists could exercise only limited control. CONCLUSION: We conclude that healthcare professionals need to take account of patients' work difficulties, their own perceived ability to offer effective guidance, and consider the 'receptivity' of employment contexts to patients' work problems, in order to ensure a smooth transition back to work.

Behaviour change and social blinkers? The role of sociology in trials of self-management behaviour in chronic conditions.

Individual-focused self-management interventions are one response to both an ageing society and the purported increase in chronic conditions. They tend to draw on psychological theories in self-management interventions, but over-reliance on these theories can reinforce a narrow focus on specified attitudinal and behavioural processes, omitting aspects of living with a chronic condition. While advances have been made in health behaviour change theory and practice, scant attention has been paid to the social, with the question of social context remaining under-theorised and under-explored empirically. This is particularly noticeable in trials of behaviour change interventions for self-management. The common sociological critique is that these ignore context and thus no explanation can be given as to why, for whom and under what circumstances a treatment works. Conversely, sociologists are criticised for offering no positive suggestions as to how context can be taken into account and for over-emphasising context with the risk of inhibiting innovation. This article provides an overview of these issues and provides examples of how context can be incorporated into the rigid method of trials of self-management for chronic conditions. We discuss modifications to both trial interventions and design that make constructive use of the concept of context.

Understanding Help Seeking for Chronic Joint Pain: Implications for Providing Supported Self-Management.

Osteoarthritis-related joint pain is prevalent and potentially disabling. United Kingdom clinical guidelines suggest that patients should be supported to self-manage in primary care settings. However, the processes and mechanisms that influence patient consultation decisions for joint pain are not comprehensively understood. We recruited participants (N = 22) from an existing longitudinal survey to take part in in-depth interviews and a diary study. We found that consultation decisions and illness actions were ongoing social processes. The need for and benefits of consulting were weighed against the value of consuming the time of a professional who was considered an expert. We suggest that how general practitioners manage consultations influences patient actions and is part of a broader process of defining the utility and moral worth of consulting. Recognizing these factors will improve self-management support and consultation outcomes.

Implementing change in physiotherapy: professions, contexts and interventions.

PURPOSE: The purpose of this paper is to report findings from qualitative interviews with physiotherapists to demonstrate why even minor changes to clinical work resulting from the introduction of new interventions, are often difficult to implement. The paper seeks to illustrate how some of the obstacles to implementing change were managed by physiotherapists. DESIGN/METHODOLOGY/APPROACH: A total of 32 qualitative interviews with participating physiotherapists were conducted, 12 interviews prior to the introduction of the new system, and 20 afterwards. The interviews were coded and analysed thematically. FINDINGS: The findings reveal a number of perceived limitations of current management of low back pain and identify key themes around convergence with the new approach, such as willingness by physiotherapists to adopt the new approach, the perception of benefits to adopting the new approach, as well as some difficulty in adjusting to it. The authors refer to the positive and negative elements as "soft" and "hard" disruption. The adoption of the new approach is explored with reference to the "situated" dimensions of physiotherapy practice and normalisation process theory. RESEARCH LIMITATIONS/IMPLICATIONS: The study raises the need to conduct future observational research to support the interview findings. ORIGINALITY/VALUE: The study describes the "situated" components of physiotherapy work, which have received limited research attention. The value of the study lies less in its ability to explain specifically why physiotherapists adopted or rejected the new system, but in describing the conditions and consequences of change that might be translated to other professions, contexts and interventions.

Biopsychosocial care and the physiotherapy encounter: physiotherapists' accounts of back pain consultations.

BACKGROUND: The physiotherapy profession has undergone a paradigmatic shift in recent years, where a 'biopsychosocial' model of care has acquired popularity in response to mounting research evidence indicating better patient outcomes when used alongside traditional physiotherapy. However, research has not examined how this new dimension to traditional physical therapy is implemented within the therapeutic consultation. METHODS: The study aimed to investigate physiotherapists' reported approaches to back pain care in the context of increasing pressure to address patients' psychosocial concerns. A secondary analysis of semi-structured qualitative interviews with 12 UK physiotherapists was conducted. Respondents were sampled from a national survey, to include a broad mix of physiotherapists. Data were analysed thematically, adopting the constant comparative methodology. RESULTS: The combination of traditional physical therapy with a broader biopsychosocial approach presented significant challenges. Physiotherapists responded by attempting to navigate patients' biopsychosocial problems through use of various strategies, such as setting boundaries around their clinical role and addressing lay health beliefs of patients through the provision of reassurance and lifestyle advice. CONCLUSIONS: As psychosocial issues, alongside biomechanical factors, command a prominent place within the back pain consultation, physiotherapists may benefit from further specific training and mentoring support in identifying specific strategies for combining the best of traditional physiotherapy approaches with greater focus on patients' beliefs, fears and social context.

A study to explore the usefulness of a mobile health application to support people with mild cognitive and/or communication impairment due to dementia and their carers.

Background: Mobile apps for health (mHealth) have the potential to support people living with dementia. However, dementia is a complex and progressive condition that imposes specific constraints on the introduction/use of mhealth. Few studies have explored mHealth adoption and use within the complexity of everyday domestic settings. This study used an existing App co-designed with people living with mild cognitive and communication impairment (PWMCCI) due to learning disabilities and examined the usefulness for PWMICCI due to dementia and their carers. Methods: A qualitative study of people with dementia and their carers. Data were collected in a phased approach to identify the potential need for, as well as the usability and utility of the app. Analysis employed the Domestication of Technology Model (DTM) to explore, in a novel way mHealth, in this user group(s). Results: Most participants did not adopt the mHealth during the study period but some (n = 2) did routinely as it fulfilled a unique, unmet need. The use of DTM highlighted the complexities of dementia, pressure on carers and duplication of effort created barriers to app adoption and use in the long term. Conclusions: The ability of mHealth to support PWMCCI due to dementia and/or their carers may have potential. Users were motivated to try the technology but for any potential to be fully realised, the interplay between complexity of the condition including its progressive nature, demand on carers and nature of the technology needs to be more fully understood. Such issues place unique constraints around the size and window of opportunities for mHealth in this user group.

Public priorities for joint pain research: results from a general population survey.

OBJECTIVE: We aimed to identify the priorities for joint pain research from a large general population survey and identify characteristics associated with these priorities. METHODS: A question about research priorities was developed in collaboration with the Arthritis Research UK Primary Care Centre's Research Users' Group. The question was embedded in a postal survey to an existing cohort of adults with self-reported joint pain, aged ≥56 years, in North Staffordshire. Respondents were asked to rank their top three priorities for research. Factor mixture modelling was used to determine subgroups of priorities. RESULTS: In all, 1756 (88%) people responded to the survey. Of these, 1356 (77%) gave three priorities for research. Keeping active was rated the top priority by 38%, followed by research around joint replacement (9%) and diet/weight loss (9%). Two clusters of people were identified: 62% preferred lifestyle/self-management topics (e.g. keeping active, weight loss) and 38% preferred medical intervention topics (e.g. joint replacement, tablets). Those who preferred the medical options tended to be older and have hip or foot pain. CONCLUSION: This study has provided population data on priorities for joint pain research expressed by a large cohort of older people who report joint pain. The most popular topics for research were linked to lifestyle and self-management opportunities. Pharmaceutical and invasive interventions, despite being common topics of research, are of less importance to these respondents than non-medical topics. Specific research questions will be generated from this study with collaboration of the patient's group.

" Keep mobile, I think that's half the battle." A qualitative study of prevention of knee pain in symptomless older adults.

BACKGROUND: The emphasis on prevention in English health policy continues to centre predominantly on major diseases such as coronary heart disease and diabetes. A number of key documents detailing self-management techniques and prevention of osteoarthritis (OA) are currently available, including the NICE guidelines and the Arthritis Foundation's National Public Health Agenda for Osteoarthritis. However, few investigations have explored preventative knowledge of knee OA amongst the population. In particular, asymptomatic members of the population may use further information in considering how to prevent knee pain. This study considers perceptions around the prevention of knee pain amongst an asymptomatic population; this target population may provide alternative insights by which to stimulate preventative behaviours. METHODS: A sample of thirteen patients with no current knee pain was selected from responders to a population survey. Each interview was tape recorded and fully transcribed. Qualitative computer software package NVivo8 was used to manage the data. Thematic analysis was conducted using the constant comparative method. RESULTS: The definition and causes of knee pain were interpreted in a multitude of ways. The importance of prevention was recognised by a sub-set, while a small proportion of participants negated the role of prevention. A range of social factors, including early adoption of actions, influenced the implementation and continuation of preventative behaviours. Individual responsibility for prevention was a key theme, although the role of society was also considered. Exercise was cited as a principal preventative strategy, although some participants viewed exercise as a destructive activity. A number of participants deemed pharmacotherapy to be harmful and at odds with normal physiology, instead preferring to adopt preventative behaviour over medication usage. CONCLUSIONS: This asymptomatic population exhibit considerable breadth and variation in knowledge of preventative strategies for knee pain. Similarities in perceptions of prevention exist when comparing to the symptomatic population. These range from emphasis on individual responsibility, through to observations on the role of exercise and pharmacotherapy in knee pain. In general individuals are agreeable to act upon recommended treatments in line with NICE guidance. This receptiveness demands a greater consideration of preventative strategies in consultations, as well as wider availability and promotion of preventative strategies in order to improve the musculoskeletal health of the general population.

Resistance or appropriation?: Uptake of exercise after a nurse-led intervention to promote self-management for osteoarthritis.

The philosophical underpinning of trials of complex interventions is critiqued for not taking into account causal mechanisms that influence potential outcomes. In this article, we draw from in-depth interviews (with practice nurses and patients) and observations of practice meetings and consultations to investigate the outcomes of a complex intervention to promote self-management (in particular exercise) for osteoarthritis in primary care settings. We argue that nurses interpreted the intervention as underpinned by the need to educate rather than work with patients, and, drawing from Habermasian theory, we argue that expert medicalised knowledge (system) clashed with lay 'lifeworld' prerogatives in an uneven communicative arena (the consultation). In turn, the advice and instructions given to patients were not always commensurate with their 'lifeworld'. Consequently, patients struggled to embed exercise routines into their daily lives for reasons of unsuitable locality, sense-making that 'home' was an inappropriate place to exercise and using embodied knowledge to test the efficacy of exercise on pain. We conclude by arguing that using Habermasian theory helped to understand reasons why the trial failed to increase exercise levels. Our findings suggest that communication styles influence the outcomes of self-management interventions, reinforce the utility of theoretically informed qualitative research embedded within trials to improve conduct and outcomes and indicate incorporating perspectives from human geography can enhance Habermas-informed research and theorising.

Challenges and adaptations to public involvement with marginalised groups during the COVID-19 pandemic: commentary with illustrative case studies in the context of patient safety research.

Patient and public involvement (PPI) is integral to research on patient safety in the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GMPSTRC), and is central to our patient safety research within our theme focusing on people in marginalised groups. Due to the impact of COVID-19, researchers had to adapt how they do PPI. For marginalised groups, remote working and digital adaptations (the key adaptations made in accessing and utilising health services in the United Kingdom during COVID-19) can potentially lead to further marginalisation of people already marginalised and provide new barriers to others. This editorial showcases three case examples of PPI with marginalised groups during COVID-19, these are with: (1) adults with vision impairments, (2) adults and carers with lived experience of self-harm and/ or suicide and (3) adults with lived experience of homelessness. In these case examples, we focus on challenges relating to key aspects of PPI during the pandemic. First, setting up a PPI advisory group and secondly maintaining relationships and effective PPI with a pre-existing advisory group. We contrast these examples using more traditional ways of 'doing PPI' i.e. involving public contributors in various stages of the research cycle, with a more fully 'co-produced' approach to research when developing a new patient safety intervention. Important considerations for PPI with marginalised groups during COVID-19 include: how to avoid exacerbating the digital divide when using video conferencing for PPI, the need for enhanced awareness around flexibility and resources, and the value of working closely with specialist charities to enable adaptations that are sensitive to the changed circumstances and needs of PPI contributors.

The National Institute of Health Research (NIHR) Greater Manchester Patient Safety Translational research Centre (GMPSTRC) carries out research to improve patient safety. We work in partnership with patients and members of the public to plan, manage, design, and carry out the research. This is labelled as patient and public involvement. A key area of GMPSTRC research focuses on people who may be marginalised from healthcare and potentially suffer increased patient safety risks relative to the general population. COVID-19 impacted on research in multiple ways, notably how researchers work with members of the public. Remote working via the use of internet enabled technology has now become more commonplace, although this raises concerns about digital exclusion and how to address barriers when face-to-face PPI is not possible. This article showcases three examples of how researchers and public contributors with lived experience have adapted to working together during the COVID-19 pandemic. These case examples are: (1) setting up a public involvement group for developing an intervention to reduce medication errors for adults with vision impairments; (2) working with a pre-existing group of public contributors who are adults and carers with lived experience of self-harm and/or suicide; and (3) working with a charity called Groundswell who train and support researchers with lived experience of homelessness. Challenges during COVID-19 have been making video conferencing meetings accessible to members who have a range of different needs, and addressing the digital divide by allowing members flexibility in how they contribute to research. The article provides examples of how these challenges were addressed.

Perceptions of general practitioners towards the use of a new system for treating back pain: a qualitative interview study.

BACKGROUND: Changing clinicians' behaviour is recognised as a major challenge. It is clear that behaviour change not only depends on demonstrating the proven effectiveness of clinical interventions; contextual and occupational factors, such as 'change readiness', may be central to their implementation. This paper highlights the context of behaviour change in relation to a healthcare innovation introduced within primary care, highlighting the importance of organisational and interpersonal factors that may help explain the dynamics of implementation. METHODS: Qualitative interviews were conducted with general practitioners (GPs) before (n = 32) and after (n = 9) the introduction of a subgrouping for targeted treatment system. GPs were offered an electronic six-item subgrouping tool, to identify patients according to their risk of poor outcome ('high', 'low') in order to help inform their decision making about treatment approaches. Recruitment was based on a 'maximum diversification sample', to obtain a wide representation of views across all five practices. A coding scheme was developed based on the emergent findings, and the data were analysed using 'constant comparison', drawing upon insights and developing connections between themes. We adopted the normalisation process theory (NPT) to explain the uptake of the new system and to examine the relevance of coherence for the implementation of innovations in organisations. RESULTS: GPs perceived back pain as a low clinical priority, and highlighted the importance of 'practical' and 'relational' coherence in decisions to adopt and engage with the new subgrouping for targeted treatment system. Health professionals often engage in 'sense making' about new innovations to 'road test' their applicability or relevance to daily clinical routines. Low back pain was generally perceived as an 'uninteresting' and clinically unchallenging health problem by GPs, which may partly explain their lack of engagement with the new subgrouping for targeted treatment system. The adoption of this new way of working by GPs was determined by the meaning that they ascribed to it in the context of their daily clinical routines. CONCLUSIONS: We conclude that the key obstacle to implementation of the new subgrouping for targeted treatment system for low back pain in primary care was an initial failure to achieve 'coherence' of the desired practice change with GPs. Despite this, GPs used the tool to different degrees, though this signified a general commitment to participating in the study rather than a deeper attitude change towards the new system.

Exploring engagement with digital screens for collecting patient feedback in clinical waiting rooms: The role of touch and place.

Health service settings are increasingly installing digital devices to enable people to engage digitally with multiple processes, including automated 'check-in', as well as collecting feedback on experiences of care. In addition, policy is increasingly driving digital agendas to promote patient engagement with online services, management of health records and routine monitoring. While this tendency towards widespread digital diffusion has been viewed as a means of enabling greater empowerment of patients and improved responsiveness of services to 'patient voice', social scientists have provided critical insights on the use of digital technologies in practice. However, there remains limited understanding of the mechanisms and contexts for digital engagement. In particular, there is a need for further research on the sensory and spatial aspects of engagement that are integral to everyday use (or non-use) of technology in practice. This article reports new insights from detailed qualitative case studies utilising in-depth interviews with patients, carers and staff, in addition to ethnographic observations of different digital modalities and their usage in specific health care contexts. A sociomaterial approach and concepts of affective atmosphere and technogeography are drawn upon to analyse the role of touch and place in the collection of digital feedback in multiple waiting room settings for people with physical and mental health long-term conditions. The findings highlight how barriers to engagement varied by context such as particular concerns about privacy for those with mental health problems and physical and sensory barriers for those with physical impairments. The findings demonstrate how digital inequalities can play out in practice and have implications for the design and development of digital innovations and tackling inequalities that may be associated with implementation of new digital technologies in healthcare.

Co-designing new tools for collecting, analysing and presenting patient experience data in NHS services: working in partnership with patients and carers.

BACKGROUND: The way we collect and use patient experience data is vital to optimise the quality and safety of health services. Yet, some patients and carers do not give feedback because of the limited ways data is collected, analysed and presented. In this study, we worked together with researchers, staff, patient and carer participants, and patient and public involvement and engagement (PPIE) contributors, to co-design new tools for the collection and use of patient experience data in multiple health settings. This paper outlines how the range of PPIE and research activities enabled the co-design of new tools to collect patient experience data. METHODS: Eight public contributors represented a range of relevant patient and carer experiences in specialist services with varied levels of PPIE experience, and eleven members of Patient and Participation Groups (PPGs) from two general practices formed our PPIE group at the start of the study. Slide sets were used to trigger co-design discussions with staff, patient and carer research participants, and PPIE contributors. Feedback from PPIE contributors alongside verbatim quotes from staff, patient and carer research participants is presented in relation to the themes from the research data. RESULTS: PPIE insights from four themes: capturing experience data; adopting digital or non-digital tools; ensuring privacy and confidentiality; and co-design of a suite of new tools with guidance, informed joint decisions on the shaping of the tools and how these were implemented. Our PPIE contributors took different roles during co-design and testing of the new tools, which supported co-production of the study. CONCLUSIONS: Our experiences of developing multiple components of PPIE work for this complex study demonstrates the importance of tailoring PPIE to suit different settings, and to maximise individual strengths and capacity. Our study shows the value of bringing diverse experiences together, putting patients and carers at the heart of improving NHS services, and a shared approach to managing involvement in co-design, with the effects shown through the research process, outcomes and the partnership. We reflect on how we worked together to create a supportive environment when unforeseen challenges emerged (such as, sudden bereavement).

The way we collect and use patient experience data is important because of concern that patients and carers may be excluded by the limited ways it is currently done in NHS services. In this study, we worked in partnership with researchers, staff, patient and carer participants, and patient and public involvement and engagement contributors, to co-design new tools for the collection, analysis and presentation of patient experience data. We focused on services for people with musculoskeletal conditions and services for people with severe mental health conditions. Our PPIE group, formed at the start of the study, represented a range of relevant and diverse health experiences from patients and carers of specialist services, and primary care. The aim of this paper is to share our experiences from working in partnership with our PPIE contributors on the co-design work of the study. Illustrations of how the PPIE activities added crucial insights in the shaping of the tools are given alongside the research data from patients, carers and staff participants. We experienced some challenges during the project. We discuss how we managed to work together to create a supportive environment when unforeseen challenges emerged (such as, sudden bereavement). Our experiences of developing multiple components of PPIE work for this study demonstrates the importance of tailoring PPIE to suit different settings, and to complement people's strengths and capacity. It also shows the value of bringing diverse experiences together enabling a shared approach to co-design. Researchers and PPIE contributors wrote this paper jointly.