How can qualitative research be utilised in the NHS when re-designing and commissioning services?

Patient experience is acknowledged as a key quality metric of healthcare quality and can be used to identify problems with healthcare delivery, to drive quality improvements and to inform commissioning of services that promote patient choice.^1,2 Under the National Health Service (NHS) Constitution, there is a commitment to empowering patients and communities to play a greater role in shaping health services with a strong emphasis on patient and public involvement (PPI). ³ However, it has been difficult to identify the impact that PPI has made on the design, evaluation and reconfiguration of healthcare services.^4,5

Many tools and methodologies are utilised to try and capture the patient voice, but traditionally there is a reliance on patient satisfaction questionnaires, NHS inpatient surveys, collation of patient reported clinical outcome measures and data from complaints, incidents or patient liaison services contacts. Patients’ experience as recipients of healthcare services can provide valuable insight into the experience of care, and the measurement of their experience can help to provide a wider viewpoint than that derived from more discrete measures of patient safety and clinical effectiveness. ⁶ There is strong evidence that patient participation is linked to better treatment results, higher patient satisfaction and services that are more responsive to patients’ needs.^7,8 Despite this, there is evidence that existing healthcare quality frameworks are failing to capture the importance of diverse experiences of healthcare delivery and that service providers and policy makers need to seriously attempt to capture the range of experiences that matter to any given target population when designing and commissioning services that are responsive to patients’ needs. ⁹ The use of qualitative research using methodologies such as focus groups and individual interviews can explore issues with patients to a much greater depth and allow the true voice of patients to emerge, unconstrained by the restrictions of questionnaires and surveys and the relatively poor discriminative power of existing patient experience survey tools. ¹⁰ The contribution of qualitative research studies to inform the redesign and patient-focussed commissioning of services is considered, illustrated with particular reference to elective orthopaedic surgical services.

Several studies have focussed on the lack of consensus about who will gain most benefit from joint replacement, with considerable variation in surgical rates. This has been addressed by an increased focus on referral thresholds that are more closely based upon discussions and shared decision-making between clinicians and patients. ¹¹ There is recognition that decisions about joint replacement are highly personal, but may be strongly influenced by the doctor–patient consultation.^12,13 Toye et al. ¹⁴ explored patients’ personal meanings of knee osteoarthritis and total knee replacement (TKR) and found that personal meanings were important because decisions regarding the need for TKR were not explained by symptoms alone, but rather, they were mediated by factors such as gender differences where women may be less likely to discuss treatment options with their doctor, and to have heard negative examples of TKR from friends or family. The use of decision-making aids have been shown to empower patients and effect surgery rates, ¹⁵ yet while the shared decision-making model is advocated in best practice guidance as the ideal model, the experience of patients is that this genuine shared decision-making is hard to achieve in practice, ¹⁶ and it is suggested that patients need advocates to help them fully benefit from decision aid tools. Furthermore, qualitative research has helped clinicians to understand the need to consider the route to orthopaedic surgery that a patient has taken be it those who waited until they could wait no longer with advanced symptoms or those who sought intervention early before they became too bad. Sansom et al. ¹⁷ counsel that clinicians must understand the perception of need from the patients’ perspective if they are to support patients through the shared decision-making model.

In recent years, health policy has focussed on managing the demand and affordability of lower limb joint replacement. Several qualitative research studies have identified a mismatch between the policy of waiting times dictated by Government policy where once referred patients must receive surgery within 18 weeks and joint replacement becomes an acute event and the long-term nature of lower limb osteoarthritis.^17–19 The helpful insight offered by studies such as that by Webster et al. ¹⁸ show that from a patients’ perspective joint replacement surgery is an acute intervention on a background of an ongoing and multiple joint long-term condition. Thus, patients perceive their condition as chronic and struggle to cope with simultaneous treatment provided in a model that is localised to one episode focussed on a single joint. An understanding that for patients, joint replacement is an acute intervention in the context of a chronic disease enables health-care providers to review service delivery models beyond the simple see, operate and review post surgically no more than twice before discharge that forms the current model for commissioning and reimbursement under the Best Practice Tariff guidance. ²⁰

Similarly, qualitative research can be invaluable in assessing the acceptability of new models of service delivery, particularly Enhanced Recovery Programmes and decreased lengths of stay. Reilly et al. sought to establish the efficacy of an accelerated recovery protocol after knee arthroplasty. They found this could be achieved with significant reductions in hospital bed days and cost savings of 27%. ²¹ However, a simultaneous qualitative study revealed clear differences in the acceptance of this protocol by different types of patients, with a third of women expressing the opinion that decreased length of stay was easier for men as they were traditionally used to being cared for, but similar levels of support may not be available for them. ²² Awareness of the differing perceptions of male and female patients helped to shape the nature of the information given to patients at the pre-admission clinic visit and to tailor the preparation of female patients for early discharge to address their concerns about support at home.

To fully embrace the concept of PPI and to embed it in service delivery, health service design and informing commissioners to purchase healthcare that truly meets patient need and expectations, qualitative research has an increasingly important role to play. Through well-conducted qualitative research exploring patients’ experiences, their knowledge and experiences of conditions can be utilised for the benefit of others and the impact of the patient voice truly heard when designing and commissioning healthcare services.