In current Role
Head of Service/
Head of Service/
Clinical Lead Orthotist.
Orthotic Service Manager.
Clinical Lead Orthotist.
Clinical Service Lead.
Clinical Lead Orthotist.
Clinical Lead Orthotist.
Clinical Lead/Head of Regional Orthotic Services
Clinical Lead Orthotist
Senior Manager for NHS Orthotics and Wheelchair Services
Manager of Podiatry and Orthotics
Themes and subthemes
Title of Theme
The Role of Goal Setting.
Managing expectations / compromise.
Achieving Behavioural Change.
The role of education.
Acceptance and satisfaction.
The Barriers to Measuring Outcomes.
Fluctuating disease and changing goals.
Impact of multiple interventions.
Varied case load.
Overcoming the Barriers to Using Outcome Measures.
What We Need.
Role of Technology.
Theme 1: The role of goal setting
Subtheme: conflicting goals
“What's the outcome from the initial referrer because it could be totally different from what ours is.” P6
These differing goals between parties were also discussed when considering the challenges of using outcome measures:“Because what other clinicians feel an orthosis does and what we are telling them it actually does are sometimes very different … You've got the three different concerns you've got the referrers you've got the patients and then you've got ours.” P1
Participants attributed these differing goals, particularly for patients, to differing priorities. They felt the important goals for clinicians often were not the important goal for patients:“We have been using the GAS lite system which relies on you getting what the patient wants, what the orthotist wants and combining the two … the problem is when we actually started doing that, the objectives the patient wanted and what the orthotist wanted weren’t even vaguely close and the perception coming through with the referral and with the referrer didn’t match up with either of them either.” P7
Participants talked of identifying goals at the outset of treatment as an important start towards the measurement of outcomes. However, the different opinions (themselves, the referrer and the patient) on what the intended goal should be is vital in maximising the potential for a positive outcome.“ … we are all guilty about still pursuing to make them safer on their feet … make sure we are reducing the level of risk but actually at the end of the day it’s still not the patient’s goal.” P7
Subtheme: achieving agreement
“We see the patients … they’ve got their own ideas, they talk to friends, their families … it’s getting the marriage of those two things.” P6
“well the question is … can you achieve an outcome that the patient understands what’s wrong with them … why the clinician is suggesting what their suggesting and you’ve agreed on what the goal will be.” P5
Participants described the need for a process of joint decision making for goals that resulted in an agreed treatment plan.“It has to meet the patients and the healthcare professional’s expectations of what it aims to do.” P2
Subtheme: managing expectations/compromise
“Is the patient’s objective to reduce pain, prevent falls, walk better when you know it is managing those expectations.” P13
“The whole point of an orthosis is to achieve a successful clinical function, but if we have actually provided them with something and they are happy … is that really the ultimate goal, even though it may not be as functionally or as clinically appropriate?” P1
“You’re going to make something that’s not going to be fantastic but that will fit in the shoes that they wear and will be usable.” P5
“Because if you establish at the front end that actually the two [goals] won’t ever meet and we’re not going to satisfy the patients expectations why order the product and pursue any further.” P1
Theme 2: Achieving behavioural change
Subtheme: users motivation
“If you have got someone that’s determined enough to get back to sport then they will wear that massive knee brace, because it means they can go play football again.” P2
“I work a lot with neuro patients and I can see they tip or fall or have a foot drop, and I’ll say well we’ll put an intervention in and that stopped you tripping and you’re not going to fall, but to that patient them falling isn’t a big enough problem for them to change their footwear” P2
“ … that’s still the clinical measure and your expectations of what you want for that patient … reduce the Falls … but actually at the end of the day it’s still not the patient’s goal and cosmesis is the big one for that especially if it’s about clothing choices”. P1
Subtheme: the role of education
“… the most powerful tool we have is the ability … to educate our patients … help them understand what’s going on and what your aims are and therefore why you’re going to design something in the way you’re going to design it …” P5
“My patients are all very happy but some of them don’t achieve the goal they wanted to achieve, but they’re still very happy because they understood what we were trying to achieve … they felt a part of the process.” P3
“We have an early intervention rehab team … they will refer into my orthotic clinic and part of that is … they are educated … they are more likely to have successful outcomes … they know what to expect, they know what their options are.” P1
Subtheme: acceptance and satisfaction
“Something that the patient will wear and use, if it goes into a cupboard it’s a useless orthosis no matter how good it is.” P7
“Patient satisfaction from start to finish with their journey and that for me...that’s the one I go to because my patients are happy if they’ve enjoyed their journey … they’ve had a good outcome. I’m happy.” P5
“...we looked into outcomes but it’s very much a case of we still use the review or the return of the patient coming back to then think have we achieved it.” P1
Theme 3: The barriers to measuring outcomes
Subtheme: fluctuating disease and changing goals
“What can happen especially with chronic disease is those goals change.” P6
“… some of them are chronic, like RA condition … you know on that day might be ok but then after, or an hour after it might not, so it’s really tricky.” 13
“… a lot of our patients are just long-term chronic patients and their needs change for all sorts of reasons, which can be vocational as well as their disease progression, you know they can change because they decided to take up bowls which is really good for them socially, so we actually need to adapt to that.” P2
Subtheme: impact of multiple interventions
“I think those that are diabetic change things considerably really … there are so many other factors that will determine that outcome it’s very hard to, I think, pin down and hard to measure success based on other variables that you don’t have control over, compliance, diabetic control, vascular supply …” P5
“And on the back of that it’s a case of a lot of orthosis, especially for diabetic care are about maintenance and prevention and its quite hard to measure whether it’s successful other than they haven’t re-ulcerated. But they might not have re-ulcerated for many other factors.” P1
Subtheme: time constraints
“I use … the Manchester foot pain disability index; don’t use it routinely as it takes too long.” P5
“I’ve used OPUS before … this was the worst outcome measure because of the length of i.t” P9
“The only problem with both of these, they are massive to do …” P7
“They are too lengthy to feel like they are practical within a 20/30 minutes appointment slot” Participant 1
Subtheme: varied case load
“There’s a certain amount of apathy with me in the fact that I’m doing a lot of other things … and so when that patient comes through the door who fits the bill for the outcome measure … I’ve ran out of time.” P1
“Because within a day, the day starts, and you know you can have your rheumatoid one moment and something else the next, you can’t have all the questionnaires at reception for ‘what type of patient are you?” P5
“That’s what’s often the problem isn’t it. It’s a different outcome for everybody.” P2
Theme 4: Overcoming the barriers to using outcome measures
Sub theme – what we need
“We need a scale that allows us to have three questions; GAS lite gives us that straight away.” P7
“The most effective thing in the vast majority of the population is a really simple text message with three questions.” P7
“When we looked at them there was such a huge variety of different outcome measures and we couldn’t find one that gave us a clinical outcome that we could put across the board.” P10
“So that’s why it’s always good to have the service one. How were reception staff? Did you feel like you were listened to? Where you given enough time? Did you feel like all your questions were answered? Did you get something that was usable? Do you find that it helps you? Are you happy with the service?” P5
Subtheme: role of technology
“the problem is you’ve got all these outcome measures that are stuck in these cupboards and written on Post-it notes, in files, it’s all just lost.” P9
“It’s all paper again. We’re miles off technology, you could have all this stuff on an iPad, it’s very easy, you could email it to patients.” P9
“The IT systems make or break a lot of this as far as measuring because … can’t retrieve as a report … our IT system doesn’t do it.” P1
“We’re using telephone reviews … telephone reviews are being done by our orthotic assistant.” P11
“I also am exploring whether it has to be an orthotist that makes that phone call, whether someone else can make that phone call to ask some risk based questions which would then either send the patient back through triage and for review or we would say that’s a happy person and we have achieved what we wanted.” P13
“I use … the Manchester foot pain disability index … we will do a full week or a snapshot … it’s a bit labour intensive for that week but it’s only that week.” P5
“So, what we decided to do is to have 6 months on an area of a group of patients with one outcome measure for that and then to move on to another cohort of patients and probably with a different outcome measure.” P10
“I think … if you did some random sampling maybe in a quota and ran 20, 30, 40, 50 patients, whatever the sample size … you could do a modelling thing.” P13