Background and aim The NHS collects a large number of data on patient experience, but there are concerns that it does not use this information to improve care. This study explored whether or not and how front-line staff use patient experience data for service improvement. Methods Phase 1 – secondary analysis of existing national survey data, and a new survey of NHS trust patient experience leads. Phase 2 – case studies in six medical wards using ethnographic observations and interviews. A baseline and a follow-up patient experience survey were conducted on each ward, supplemented by in-depth interviews. Following an initial learning community to discuss approaches to learning from and improving patient experience, teams developed and implemented their own interventions. Emerging findings from the ethnographic research were shared formatively. Phase 3 – dissemination, including an online guide for NHS staff. Key findings Phase 1 – an analysis of staff and inpatient survey results for all 153 acute trusts in England was undertaken, and 57 completed surveys were obtained from patient experience leads. The most commonly cited barrier to using patient experience data was a lack of staff time to examine the data (75%), followed by cost (35%), lack of staff interest/support (21%) and too many data (21%). Trusts were grouped in a matrix of high, medium and low performance across several indices to inform case study selection. Phase 2 – in every site, staff undertook quality improvement projects using a range of data sources. The number and scale of these varied, as did the extent to which they drew directly on patient experience data, and the extent of involvement of patients. Before-and-after surveys of patient experience showed little statistically significant change. Making sense of patient experience ‘data’ Staff were engaged in a process of sense-making from a range of formal and informal sources of intelligence. Survey data remain the most commonly recognised and used form of data. ‘Soft’ intelligence, such as patient stories, informal comments and daily ward experiences of staff, patients and family, also fed into staff’s improvement plans, but they and the wider organisation may not recognise these as ‘data’. Staff may lack confidence in using them for improvement. Staff could not always point to a specific source of patient experience ‘data’ that led to a particular project, and sometimes reported acting on what they felt they already knew needed changing. Staff experience as a route to improving patient experience Some sites focused on staff motivation and experience on the assumption that this would improve patient experience through indirect cultural and attitudinal change, and by making staff feel empowered and supported. Staff participants identified several potential interlinked mechanisms: (1) motivated staff provide better care, (2) staff who feel taken seriously are more likely to be motivated, (3) involvement in quality improvement is itself motivating and (4) improving patient experience can directly improve staff experience. ‘Team-based capital’ in NHS settings We propose ‘team-based capital’ in NHS settings as a key mechanism between the contexts in our case studies and observed outcomes. ‘Capital’ is the extent to which staff command varied practical, organisational and social resources that enable them to set agendas, drive process and implement change. These include not just material or economic resources, but also status, time, space, relational networks and influence. Teams involving a range of clinical and non-clinical staff from multiple disciplines and levels of seniority could assemble a greater range of capital; progress was generally greater when the team included individuals from the patient experience office. Phase 3 – an online guide for NHS staff was produced in collaboration with The Point of Care Foundation. Limitations This was an ethnographic study of how and why NHS front-line staff do or do not use patient experience data for quality improvement. It was not designed to demonstrate whether particular types of patient experience data or quality improvement approaches are more effective than others. Future research Developing and testing interventions focused specifically on staff but with patient experience as the outcome, with a health economics component. Studies focusing on the effect of team composition and diversity on the impact and scope of patient-centred quality improvement. Research into using unstructured feedback and soft intelligence. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Background The COVID-19 pandemic has led to changes in health service utilization patterns and a rapid rise in care being delivered remotely. However, there has been little published research examining patients’ experiences of accessing remote consultations since COVID-19. Such research is important as remote methods for delivering some care may be maintained in the future. Objective The aim of this study was to use content from Twitter to understand discourse around health and care delivery in the United Kingdom as a result of COVID-19, focusing on Twitter users’ views on and attitudes toward care being delivered remotely. Methods Tweets posted from the United Kingdom between January 2018 and October 2020 were extracted using the Twitter application programming interface. A total of 1408 tweets across three search terms were extracted into Excel; 161 tweets were removed following deduplication and 610 were identified as irrelevant to the research question. The remaining relevant tweets (N=637) were coded into categories using NVivo software, and assigned a positive, neutral, or negative sentiment. To examine views of remote care over time, the coded data were imported back into Excel so that each tweet was associated with both a theme and sentiment. Results The volume of tweets on remote care delivery increased markedly following the COVID-19 outbreak. Five main themes were identified in the tweets: access to remote care (n=267), quality of remote care (n=130), anticipation of remote care (n=39), online booking and asynchronous communication (n=85), and publicizing changes to services or care delivery (n=160). Mixed public attitudes and experiences to the changes in service delivery were found. The proportion of positive tweets regarding access to, and quality of, remote care was higher in the immediate period following the COVID-19 outbreak (March-May 2020) when compared to the time before COVID-19 onset and the time when restrictions from the first lockdown eased (June-October 2020). Conclusions Using Twitter data to address our research questions proved beneficial for providing rapid access to Twitter users’ attitudes to remote care delivery at a time when it would have been difficult to conduct primary research due to COVID-19. This approach allowed us to examine the discourse on remote care over a relatively long period and to explore shifting attitudes of Twitter users at a time of rapid changes in care delivery. The mixed attitudes toward remote care highlight the importance for patients to have a choice over the type of consultation that best suits their needs, and to ensure that the increased use of technology for delivering care does not become a barrier for some. The finding that overall sentiment about remote care was more positive in the early stages of the pandemic but has since declined emphasizes the need for a continued examination of people’s preference, particularly if remote appointments are likely to remain central to health care delivery.

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NHS England, the Institute for Healthcare Improvement, Picker and NHS Improvement started the work described in this article to strengthen how patients, carers and staff working together in co-design and co-production can make a real difference in improving experience of care. Always Events®, which is an improvement methodology for the co-design and consistent implementation of those aspects of patient experience that matter most to patients in a health care setting, was chosen. The approach has been to first test the methodology with three organizations then to spread to a substantial proportion of acute health care providers, with concurrent scale-up within organizations that were early adopters in single settings, and then spread to other providers including care homes, primary care and integrated care systems. For organizations to be successful in embedding and sustaining Always Events, and to have a significant impact on improving experience, we learnt that health organizations should: a) co-produce with patients/service users from the very start and throughout every phase, b) integrate quality improvement, patient experience and person-centered care, c) identify an Executive Leader champion who can support the team to gain momentum from the beginning, d) keep an open mind and not be tempted to predetermine what changes need to be made; patients/service users & staff know the challenges and have the best, simplest and most affordable ideas for improvement and finally, e) involving point of care staff from the beginning and co-designing the Always Event with them will support engagement and reduce resistance to change.

BACKGROUND The Covid-19 pandemic has led to changes in health service utilization patterns and a rapid rise in care being delivered remotely. There has been little published research examining patients’ experiences of accessing remote consultations since Covid-19. Such research is important as remote methods for delivering some care may be maintained in the future. OBJECTIVE To use content from Twitter to understand public discourse around health and care delivery in the UK as a result of Covid-19, in particular views on and attitudes to care being delivered remotely. METHODS Tweets posted from the UK between January 2018 and October 2020 were extracted using the Twitter API. 1,408 tweets across three search terms were extracted into Excel. 161 tweets were removed following de-duplication, and 610 were identified as irrelevant to the research question. Relevant tweets (n=637) were coded into categories using NVivo software, and assigned a positive, neutral, or negative sentiment. To examine views of remote care over time, the coded data was imported back into Excel so that each tweet was associated with both a theme(s) and sentiment. RESULTS The volume of tweets on remote care delivery increased markedly following the Covid-19 outbreak. Five main themes were identified in the tweets: access to remote care (n=267), quality of remote care (n=130), anticipation of remote care (n=39), online booking and asynchronous communication (n=85) and publicising changes to services or care delivery (n=160). Mixed public attitudes and experiences to the changes in service delivery were found. The proportion of positive tweets regarding access to, and quality of, remote care was higher in the immediate period following the Covid-19 outbreak (March-May 2020) when compared to the time before the Covid-19 onset, and the time when restrictions from the first lockdown eased (June-October 2020). CONCLUSIONS Using Twitter data to address our research questions proved beneficial for providing rapid access to a breadth of attitudes to remote care delivery at a time when it would have been difficult to conduct primary research due to Covid-19. It allowed us to examine public discourse on remote care over a relatively long period and explore shifting public attitudes at a time of rapid changes in care delivery. The mixed attitudes towards remote care highlights the importance that patients have a choice over the type of consultation that best suits their needs, and that the increased use of technology for delivering care does not become a barrier for some. The finding that overall sentiment about remote care was more positive in the early stages of the pandemic but since declined emphasises the need for a continued examination of people’s preference, particularly if remote appointments are likely to remain central to healthcare delivery.