Current debates about the involvement of health service users in service delivery, research and education focus on the purpose of their involvement, the methods of their involvement, barriers to their involvement and the impact of their involvement. There is little reported about the experience of service user involvement from the service user perspective although some reports are beginning to emerge. This research study explored the experiences of a group of health service users (patient representatives) who brought their experience of being a patient to contribute to an educational initiative about quality improvement and back pain. That study – the Learning to Improve the Management of Back Pain in the Community (LIMBIC) project, utilised a mixed methods approach to evaluate the impact of the educational initiative on clinical practice and patient outcomes for the management of back pain. Eleven patient representatives, uniquely placed as co-learners, participated with general practice teams learning about quality improvement principles and methods and implementing quality improvements in practice. To build on this learning initiative, the current study used semi-structured interviews to explore the patient representative experience and integrated the findings with existing LIMBIC data. The study illuminated aspects of the service user experience which led to the proposal for a model for co-learning with service users to bring about change. It contributes to the wider knowledge of service user involvement by identifying features of their experience that worked well for them and features that could be improved. The co-learner role is a new direction for service user involvement and represents a new movement in the field of inquiry about opportunities for service user involvement in the future. A debate has been opened about managing expectations of service users and about their potential for leadership and influencing change.

The fundamental questions behind this thesis are: Can we save money in the surgical treatment of osteoarthritis in the knee? And if so, what areas should we be looking at and how can we do it? Osteoarthritis represents a considerable cost to the UK economy. A review of the economic costs of osteoarthritis was performed as part of this thesis. While estimates of economic costs can be made, one conclusion from the studies does seem clear: that these costs are very significant and are continuing to rise. Based on data from the UK National Joint Registry (NJR), there has been a substantial increase in the number, and hence the costs of knee replacements to the NHS over the last 10 years. At the time this thesis started in 2011, the NHS had also begun a previously unprecedented slowdown. This resulted in a significant funding gap. The estimated shortfall in funding, in order for the NHS to cope with events such as increasing numbers of aging population or the cost of increases in new medical technology, has been calculated as £20 billion by 2014, with an additional, further funding shortfall of an estimated £30 billion by 2020. As a result, an intensive programme targeting productivity improvement was instituted with a view to solving this deficit through improvements in efficiency. It is well known amongst accounting circles that what cannot be accurately measured, cannot be controlled. One of the aims of this thesis was to improve on the existing costing methodology utilised for knee replacement surgery. In order to better control costs, and understand where the cost drivers in such surgery lay, the patient pathway for total knee replacement was prospectively mapped utilising a Time driven Activity based costing model. Timings were prospectively collected as the patient was followed through the TKR pathway. All costs for the patient pathway from admission through to discharge, as well as pre-operative assessment clinic and joint school, were analysed. The major cost drivers involved in the Total Knee Replacement pathway were identified as a result of this study. This data was then subsequently utilised at our institution to implement further cost reduction strategies in knee replacement surgery. Litigation in healthcare has also dramatically increased over the last 10 years. The outstanding liability of clinical negligence claims, according to data from the National Health Service Litigation Authority (NHSLA), exceeded £1.3 billion by 2011. The NHSLA also reported a year-on-year increase in such claims. A review of NHSLA database was performed as part of this thesis. All cases involving adverse events occurring as a result from surgery to the knee were examined, to determine the costs of these adverse events, to analyse trends and predict future costs. A significant number of events involving technical errors were identified as part of this review. In addition to the cost implications, this represents potentially preventable events, and may represent an issue with training and/or patient safety. A study analysing the clinical relevance and costs of repeating x-rays for knee osteoarthritis was also undertaken. Only a small proportion of patients referred for knee radiographs have weight-bearing films, with a significant number of hospitals in London do not routinely perform weight-bearing radiographs to investigate suspected knee osteoarthritis. The potential delay in diagnosis, referral or treatment of these patients, in addition cost burden to the NHS was examined. The principles of Time Driven Activity based costing was successfully applied to a small cohort of Total Knee Replacement patients in our study. There remains the potential for larger studies with more heterogeneous patient groups to better inform policy makers attempting to benchmark treatment costs more accurately.

No description available.

Chronic widespread pain (CWP) is common and associated with poor health. In general practice no morbidity code for CWP exists. By identifying patients in medical records consulting regularly over five years with multiple individual regional (axial, upper limb, lower limb) problems, a previous study identified patients in one practice with features consistent with CWP. This suggests patients regularly consult for regional pains without being recognised, or managed, as having a generalised condition. The original criteria for identifying these recurrent regional consulters (RRCs) had limitations including a restricted set of musculoskeletal morbidity codes. This thesis aimed to develop the existing RRC definition, determine characteristics of RRCs, and assess the extent of unrecognised CWP in primary care. The study was set in: i) a general practice database; ii) a cohort with linked self-reported health and medical records. RRCs were identified using different code lists, over altered timeframes, and with a varied number of recorded body regions. Three-quarters of RRCs were not recorded with a generalised pain code related to CWP (e.g. fibromyalgia) and are therefore potentially unrecognised as having a generalised pain condition. Recorded prevalence of recognised CWP was lower than community CWP prevalence, suggesting CWP is under-recognised in primary care. The new approach to identifying RRCs, using all regional musculoskeletal Read codes and identifying patients prospectively between three and five years from an index musculoskeletal consultation, identified more patients earlier, and returned patients with features consistent with self-reporting of CWP (e.g. increased somatic symptoms, frequent consultation, worse general health). However, RRC prevalence overestimated CWP prevalence and not all RRCs self-reported CWP, suggesting the RRC criteria identified a heterogeneous group of frequent consulters sharing features with CWP, including those less severely affected who do not necessarily fit established CWP criteria. They nonetheless lie on the spectrum of polysymptomatic distress characteristic of CWP.

Background and aims: Head injury (HI) is a cause of cognitive impairment within the homeless population (Hwang et al, 2008). One study reported that over a 30-year period, the prevalence of hospitalised HI was 5.4 times higher in the homeless than in the general population (McMillan et al, 2015). This study explores the perceptions of homeless adults who have sustained a HI and their views regarding the relevance of HI to their homeless status. Methods: Participants were seven homeless adults with a moderate or severe HI. They were asked to talk about their journey to homelessness and in particular, to reflect on any perceived links between HI and their homeless status. The data were analysed using Interpretative Phenomenological Analysis (IPA). Results and conclusions: Emerging themes included: impairment following HI; substance misuse, feeling let down by services and difficult relationships with family. Evidence for the role of HI in precipitating and maintaining homelessness was found. Despite this, co-morbid difficulties complicate the picture. Four out of seven participants viewed substance misuse as their primary difficulty. This illustrates the need for in-depth assessment within this population in order to ensure that difficulties are fully understood and that the correct supports/ interventions are offered.

Chronic back pain is an under researched area; the complexities of unseen pain in particular, present challenges to the sociological assumptions made about the concept of ‘sickness’. The lack of ‘visible’ signs and symptoms means that some people are left without a diagnosis. If left undiagnosed, their experience of chronic back pain becomes delegitimized and could result in the erosion of self-esteem, self-identity and personhood. Undiagnosed chronic back pain can undermine a person’s moral self through disrupting the person’s biography and self –esteem. Ultimately, people with chronic back pain need person centred approaches to care that support the restoration of the self. The aims of this study were to generate a theory of person-centred care predicated on the experiences of people who have chronic back pain. The research design was influenced by a constructivist paradigm, which underpinned a Grounded Theory methodological approach. A purposive sampling strategy identified 17 people with chronic back pain and 4 multi-professional teams who were involved in their care. Semi-structured interviews with people who have chronic back pain, and the multi-professional teams captured the experience of person-centred care and explicated meaning about its key concepts. Data were analysed using a constant comparative approach through which theoretical sensitivity developed and eleven categories emerged. The ‘conditional partnership’ became a core category, which formed a substantive theory to explain the experience of person-centred care. The key findings highlight the significance of legitimation on the chronic back pain experience and exposes the impact that ‘delegitimation’ has on the individual’s ability to mobilise resources and manage their pain effectively. This thesis presents the conditional partnership as a theory which explains the relationship needed to support person centred care. The theory suggests that person centred care for people with chronic back pain is underpinned by a conditional partnership which is made up of three conditions; being believed, believing in and non-maleficence which represent the expected conditions of health care and by health care.

Evidence of inadvertent patient harm due to healthcare staff errors - both within the NHS and in other healthcare providers worldwide - prompted regulator-led changes to eliminate such distressing incidents to patients and medical staff alike. Surgical disciplines, including orthopaedic surgery, became a focus of attention given the scale of the problem within operating theatres. Orthopaedic theatres are an example of a complex working environment that has been likened to an airplane cockpit whereby the delivery of unsafe and low quality service can lead to highly significant consequences. Around 32.6% of all surgical patient safety incidents reported by the NPSA are related to orthopaedics. Evidence suggests that harm incidents are influenced by the surgical team’s non-­‐technical skills, and can occur through an unpredicted combination of small, seemingly innocuous everyday events. It is also suggested that non-technical factors including the non-technical skills of the operating team can influence the technical tasks during surgery. In elective orthopaedic surgery, one important technical task during TKA surgery is achieving a neutral limb alignment making it a suitable surrogate for technical success and quality indicator for intra-operative performance. The impact of malalignment on patient outcomes is not fully understood. A systematic review of the literature demonstrated that although malalignment appears to associate with poor procedure outcomes however, the evidence in the literature to support this conclusion is subject to several limitations. There is also variability in the assessment methods qualities and a checklist to assess the radiological assessment methods is presented. Malalignment on the coronal plane is regarded as the most significant in determining long term implant survival. A novel X-­‐ray method using custom made jig and trigonometry principles designed during this thesis has demonstrated higher agreement with CT scan than the commonly used conventional short leg X-­‐rays in assessing coronal malalignment; (95% Limits of agreement = -­‐3.616867 to 3.616867 for novel technique versus -­‐6.333201 to 5.754254 for conventional short leg X-­‐rays). In order to explore the relationship between non-­‐technical factors and technical success, successive TKAs were observed to collect data on surgical team’s non-­‐ technical performance and the number of unwanted events. 3D malalignment was assessed using a low dose CT. Parson’s correlation and regression analysis showed that better overall limb alignment following TKA correlates significantly with better intra-­‐operative non-­‐technical skills measured using the Oxford NOTECHS II score (r=-­‐ 0.407, p=0.01), and not with eventless procedures (measured by the glitch count). The surgical teams’ non-­‐technical skills play a significant role in the team’s ability to carry out technical tasks. If we are to provide optimal patient care we need to invest in improving non-­‐technical skills in the theatre.

This thesis explores the NHS Service provision of prosthetic limbs from a patient centred perspective. Amputation is the removal of a limb either for medical reasons or through trauma. The amputated limb can be replaced with a manufactured device to help the patient regain movement and as much function as possible. This device is known as a prosthesis and is given to the patient by the NHS at a Disablement Services Centre (DSC). There has been increasing negative media coverage of the NHS and the service it provides with specific reference to the Postcode lottery which has allegedly become apparent. This research aims to ascertain whether the service being provided at DSCs across the UK is satisfactory to patients and how this service can be improved. The literature surrounding amputation rehabilitation and care pathways is reviewed (Chapter 2). Research philosophies and approaches are discussed (Chapter 3). A countrywide study of NHS Disablement Services Centres was conducted to ascertain how the centres functioned and the differences in service between centres (Chapter 4). The data collected from this study were used to create a questionnaire for amputees to ascertain their opinions on the service they received at their centre (Chapter 5). The data revealed that patients had many problems with the service they received, very few of which could readily be acted upon due to budget restrictions. An investigation into patient s opinions on information provision was conducted as information provision was a problem highlighted by patients that could be influenced by further research (Chapter 6). Data gathered from all three studies were used to produce a proposed clinical pathway for Disablement Services Centres to follow with a new patient (Chapter 7). The proposed pathway was critically evaluated by prosthetists at a clinical conference and improvements to the proposed pathway were made using their suggestions (Chapter 7). The benefits, drawbacks and threats to the use of the proposed pathway were discussed both from the patient and clinical perspective (Chapter 8). The work was completed by overall conclusions and a discussion of further work (Chapter 9).