Using co-production to improve patient carer and staff experiences in health care organizations: a multi-centre, mixed methods evaluation in inpatient stroke units (CREATE)


Objectives and brief methodology

Stroke is the largest cause of adult disability in the United Kingdom (UK), and accounts for 5% of total NHS costs. Early rehabilitation relevant to patients needs can improve independence and the intensity of activity impacts on the degree of recovery, yet national targets to increase therapy intensity and frequency are not being met. In acute stroke units staff, patients and carers can be more involved in increasing supervised and independent therapeutic activity, which has the potential to expedite discharge and decrease dependency on health and social care services in the longer term. National stroke audits have highlighted non-adherence to therapy intensity and frequency recommendations, but cannot help identify solutions.

Our research questions focus on the feasibility and impact of patients, carers and clinicians co-producing and implementing interventions to increase supervised and independent therapeutic patient activity in acute stroke units.


The research will be undertaken in three phases.

In phase 1: We will complete a rapid evidence synthesis to update the evidence on the efficacy and effectiveness of co-production approaches in acute healthcare settings.

In phase 2: We will collect baseline data on patient reported outcomes of experiences, wellbeing and satisfaction (PROM/PREM) and utilize Stroke Sentinel National Audit Programme (SSNAP) data to summarise unit performance against national standards. We will record level of stroke severity of patients receiving care in pre and post intervention periods. Non participant observations will be undertaken to examine social, professional and organisational practices and behavioural mapping methods will be used to record type and number of therapeutic activities in each stroke unit in the pre and post intervention periods

We will use Experience Based Co-Design (EBCD) as our co-production approach to design interventions and evaluate the impact in 2 stroke units. We will conduct interviews with staff, patients and carers, and produce a trigger film of patient narratives. These data will inform the co-production of interventions by patients, carers and staff to increase supervised and independent therapeutic activity. Post intervention, a review of phase 2 implementation data including observational, behavioural mapping and interview data will inform the decision to proceed to phase 3.

In phase 3: We will implement and evaluate the co-produced interventions developed in phase 2 in a further 2 stroke units. The same pre and post-test intervention measures will be used to evaluate the impact of implementation.

Process evaluation

To understand factors influencing development, implementation and embedding of interventions, a process evaluation informed by the Normalisation Process Theory (NPT) approach will be utilised.

Anticipated benefits of the study include establishing whether EBCD can be effectively employed in acute healthcare and identifying interventions to increase therapeutic inpatient activity which can be deployed in all stroke units nationally and potentially in other settings including elderly care and trauma and orthopaedic wards.

Funding agency

National Institute for Health, Health Services and Delivery Research Programme. Research Grant number: HS&DR – 13/114/95


Further information

Lead for the Yorkshire sites

Professor Anne Forster, Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Sciences, University of Leeds.


Professor Fiona Jones (Kingston and St George’s University of London (Chief Investigator) Professor Ruth Harris (Kings College London), Professor Christopher McKevitt (King’s College London), Dr Geoffrey Cloud (St Georges Hospital Acute Healthcare Trust), Professor Alastair Macdonald (Glasgow School of Art)

Funding: £683,505.00

This summary represents independent research funded by the National Institute for Health Research (NIHR) under its Health Services and Delivery Programme (Grant Reference Number HS&DR-13/114/95). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

For more information please see:

Or contact: Professor Anne Forster on 01274 383406 or by email: