Introduction
Trusts need to develop a comprehensive generic approach to PPI, introducing the approach in every directorate. This is a necessary condition for engaging with users and carers.

However, having developed the strategic approach, concrete interventions are needed that  can be employed at a number of different levels.  These interventions need to have the following characteristics:

• they involve patients who have not been involved before
• the process is enjoyable for the patients and clinicians
• the outcomes are useful to clinicians and managers
• the process is applicable to a number of specialisms
• the process can be integrated into clinical governance (CG)
• the process is cheap 

Patients as Teachers is likely to meet these needs.

Patients as Teachers
This is a technique for patient involvement that has been used in both hospital and primary care settings.

The evidence seems to be* that it has a significant effect on clinician behaviour at 6 months. In addition:

• patients enjoy it
• it has been used in a number of specialisms including working with children with asthma and in the field of mental health
• it generates user-defined outcomes that can be monitored against as part of CG
• the main cost is facilitation

The aims of the process are:

• to identify what good practice looks like from the users’ points of view
• for users to teach that to clinicians in a supportive environment
• for lay-defined guidelines to be produced
• for mutually agreed outcomes to be monitored against

The Methodology
PAT is a 2 stage process. It is most useful for chronic diseases where users have had a longish contact with services. It can be useful in either primary or secondary care or across the interface.

Hold focus groups of clinically relevant patients
For each speciality, the focus groups will be different. The aim is to identify key sub-groups. For instance, in IHD, it might be an Asian group, women, men, the elderly. In diabetes, it might be teenagers, women, an Asian group, the elderly. In urology, it might be an African-Caribbean group, Caucasian men, women, a group with Ca prostate.

The members of each group can be identified from routine OPD lists, or from GP lists. They do not need any training. They need appropriate payment, which may need to be in kind, such as a voucher.

They are brought together with a facilitator who must have experience of qualitative research. It is most helpful if the same facilitator runs every group, but this is not essential. Each group is asked the same basic question:

This ensures that the responses will focus more on what works well, rather than just focusing on complaints. In addition, it is sensible to identify a number of subsets of this question, depending on what is relevant to the Trust. For instance, you might be interested in:

• access
• communication
• information transmission
• quality of care etc

If a theme arises which has not been predicted, it is essential that this is followed up in the group: these may be the mpost important issues to pursue. Participants are encouraged to talk about their own experiences.

The good practice recommendations are identified from a transcript of the group, or can be minuted during the group. These recommendations form the agenda for the next stage of the process.

Finally, delegates are identified who are interested in appearing in the educational event.

The educational meeting.
Here, the delegates will teach clinicians (consultants, registrars, nurses, AHPs, perhaps GPs) good practice from the patients’ points of view. The meeting needs to be advertised as one that will lead to change.

The structure of the meeting is up to you. It can be a basic lecture, or a more interactive approach, such as theatre or role play. The agenda of the meeting has been defined by the patients in advance. In this meeting, they are instructed NOT to describe their personal experiences, but to represent the views of their group. The facilitator needs to be quite firm in this meeting: the commonest problem is that the professionals want to dominate the discussion.

The key change issues need to be identified through the meeting. They will be written up and sent to the participants as a reminder of what the meeting agreed.

Evaluation:
At six months, it would be helpful to assess from the professional participants whether they feel that their practice has changed in line with the lay recommendations

The lay guidelines
These can be written up and distributed. They can become an integral part of the CG process in the hospital and departments can be monitored against them.

They can be linked to NICE guidelines.

Conclusion
At the end of this process, the Trust should have useful information that will assist in progressing CG, PPI and possibly service redesign,, depending on what questions have been asked.

PAT should also be seen as an intervention that will be useful in number of contexts:

• for an emerging patient forum
• as part of advanced CG
• education and training
• improving quality                 

It should be noted that it is likely to generate ideas for change: the Trust will need to ensure that there are procedures in place to respond.

*Fisher B, Gilbert D. Clinical Effectiveness – a new paradigm. In: “New Beginnings”, King’s Fund London 2000