As we launch the new 4Pi Involvement Standards hub (link will open in a new tab), we hear about an organisation's approach to embedding 4Pi and consider their reflections on the future of the Involvement Standards.

Authors: Meerat Kaur, Sandra Jayacodi, Rachel Matthews

October 2020

A number of organisations across the United Kingdom position patients and the public as central to healthcare improvements. These organisations see these individuals as crucial parts of a collaborative approach - necessary because it brings multiple skills, knowledges, and experiences that can uncover the realities of care to inform and prioritise improvement.

But just because this way of working is mandated and encouraged by these organisations, it does not mean people work together any better in practice. Even in these supportive organisations, the question remains about how we facilitate collaboration between people from ultimately different worlds, with different experiences and knowledges, to work together to improve healthcare.

We aimed to address this in the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (henceforth CLAHRC NWL). This organisation aimed to bridge the gap between research and practice by supporting healthcare improvements in the NHS. Facilitating meaningful partnerships between patients, the public, healthcare professionals, and researchers was a fundamental part of our approach.

It was often healthcare professionals and researchers who needed guidance and support to learn how to work with the public. Staley and Baron (2019) state this is because this way of working is a learning experience. They say it can be difficult to plan how to work together when “researchers [and healthcare professionals] ‘don’t know what they don’t know’”1.

We tried and tested much existing guidance describing how the public can be involved in improvement. The National Involvement Standards: 4Pi seemed to resonate with the healthcare professionals and researchers with whom we shared it. We hypothesise this is because it is created with service users, and is therefore accessible but also provides enough structure to guide how people can work together.

Two factors were important to enable us to use 4Pi across healthcare improvement initiatives that took place across different healthcare settings. Firstly, we translated the method into the improvement context. The aim was to make it familiar to the people who were already working in this setting (including public partners). We therefore adapted the 4Pi into a series of flow charts which aimed to mirror process maps, a specific method that is used in healthcare improvement. (See Figure 1).

Secondly, we focused and built up facilitation expertise. We would use the flow charts and train up healthcare improvement managers and public partners with whom we worked. These individuals could then guide others to use 4Pi, and facilitate the process for public partners, healthcare professionals and researchers who were new to the method.

Figure 1:

So how did we use this with our healthcare improvement teams? Green et al. (2016) have written about their experience of using 4Pi in one of the CLAHRC funded initiatives that aimed to improve the physical health assessment of people admitted to an acute mental health setting2. They found it was a useful framework and was particularly enhanced when aligned with the healthcare improvement methods that they were using. 

Two challenges remain with 4Pi. Firstly, we need more organisations (especially those who are trying to engage mental health service users and carers) to sign up to and embed the 4Pi Involvement Standards as well as sharing them within the sector.

Secondly, in our experience, it remains unclear the extent to which 4Pi is helping advance the attempts to assess the impact of involvement. We, as a community, still appear to struggle to assess the impact of how we work together. And it would be interesting to understand the extent to which and how 4Pi helps people assess that. Sandra’s (co-author) more recent experiences question whether anyone is capturing this, and few in her experience review what they have done, and assess how the involvement worked. Crucially, healthcare professionals or researchers feeding back to public partners and all partners being able to plan improvements to how they have worked and what they have achieved is absent.

How then do we strengthen the potential of 4Pi? Because our fear is without doing that, we risk people creating ever more tools rather than focusing on improving what matters – how we work together to realise improvements to healthcare.


  1. Staley K, Barron D. Learning as an outcome of involvement in research : what are the implications for practice , reporting and evaluation ? Res Involv Engagem. 2019;5(14):1-9.
  2. Green SA, Carnegie W, Barber S, Matthew D, Matthews R. Co-designing interventions within quality improvement initiatives : Notes from the field. J Heal Des. 2018;3(1):49-56.