Medicine, Nursing and Allied Health Professions


In progress PhD/MD

Charlotte Bramwell (PhD)
Models of care for patients with multimorbidity. University of Exeter

Antoinette Davey (PhD)
Intra-individual cyclical variation of patient reported outcome measures in patients with chronic health conditions. University of Exeter.

Abdullah Mubarky (PhD)
Assessing primary health care reform in Saudi Arabia. University of Exeter


Completed PhD/MD

Mr Jon Evans (MD) Completed November 2018

Evidence-based patient-centred management of patients with Lateral Elbow Tendinopathy: PROMs (reviews and validation study) and platelet injection (cadaveric experiments, consensus on methods, pilot RCT)

Models of care for patients with multimorbidity

Funding: University of Exeter

Researcher Group: Bramwell C, Anderson R, Dickins C, Lloyd H and Valderas JM

PhD Overview

The overall aim of the research is to increase understanding into how care can be improved for patients with multimorbidity within primary care and community settings, and to understand the mechanisms by which current UK healthcare initiatives, specifically designed for patients with multimorbidity, aim to achieve this. I will be using a realist methodological approach throughout my research.


Multimorbidity is a term that is applied to the coexistence of multiple chronic medical conditions within the same patient [1] and as a concept does not privilege one condition over another [2].  The management of patients with multimorbidity is an increasingly common problem faced by health systems worldwide and is present in the majority of GP consultations in the UK. The prevalence of multimorbidity is substantial and has been consistently shown to rise substantially with age and affects the majority of the over 65 year old population, but in terms of absolute numbers, the number of people affected is higher in those under 65yrs [3,4], meaning this is not just an issue for the older patient population. Patients from deprived areas are prone to earlier onset of multiple heath conditions by a significant 10-15 years compared to those living in more affluent areas. Chronic illness care has traditionally been disease orientated, but this is not necessarily an effective model for patients suffering with multimorbidity [3], who tend to experience high levels of treatment burden [5], for example issues with polypharmacy, duplication of tests, conflicting advice, multiple healthcare appointments and worse general health outcomes including reduced quality of life [6] and increased mortality [7]. This patient group often receive suboptimal care [8] with poor levels of continuity [3]. Multimorbidity often requires more complex clinical management [1,4,8], leading to increased healthcare use and the high level of cost.

Focused research on models of care for patients with multimorbidity has relevance due to the inevitable burden on healthcare systems and finances. There is a need to improve healthcare and quality of life for this rapidly increasing patient population [6]. Effective models of care require development in order to increase co-ordination and improve aspects of care relevant to people with multimorbidity [9]. The frequency of healthcare use, combined with the greater array of services utilised, make co-ordination of care much more challenging, yet increasingly vital for individuals with multimorbidity [8].

Research Questions

  • What is the existing care structure for patients with multimorbidity in the UK, and what are the perceived problems?
  • What care models are being used?
  • What initiatives are being implemented by primary care for multimorbidity patients within the UK, how are they being designed and are they working?

Outline of PhD Projects

Project 1. UK Multimorbidity Initiative Mapping


To map current or recent initiatives focused on patients with multimorbidity in the UK.

Project 2. Secondary analysis of qualitative interviews of multimorbidity patients


To perform a secondary analysis of qualitative interviews from patients with multimorbidity to explore the following questions:

  • “What” is important to multimorbidity patients in terms of the healthcare (both short and long term) that they receive?
  • What are the contextual factors that enable or inhibit the achievement of the above outcomes?

Project 3.  Realist synthesis

Aim and objectives:

The primary aim of this synthesis is to establish perceived shortcomings of usual care for multimorbidity patients and explain how and why primary healthcare-led models of care are designed specifically for this patient group. To identify relevant underlying programme theories and context-relevant mechanisms by which initiatives (e.g. services and pathways) provide optimal care for the multimorbid population. The objectives are:

  • To establish why conventional disease-specific models of health service provision are perceived to provide suboptimal care for patients with multimorbidity.
  • To identify themes and issues pertinent to patients with multimorbidity within the literature.
  • To conduct a realist synthesis of the literature, developing and refining programme theories, mechanisms and key contexts. Identifying the determinants by establishing the mechanisms and circumstances that generate different outcomes within multimorbidity-focused models of care and ascertaining the underlying reasons of how and why these occur.

Project 4.  Case Study


To carry out a case study of a multimorbidity-focused healthcare initiative using a Realist methodological approach (due to commence May 2020).


  1. Valderas, JM et al. Defining comorbidity: Implications for understanding health and health services. Ann Fam Med. 2009 Jul-Aug; 7(4):357-63.
  2. Valderas JM et al. Research on patients with multiple health conditions: different constructs, different views, one voice. J Comorb. 2011; 1: 1-3.
  3. Salisbury C et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011; 61(582):e12-e21.
  4. Barnett K et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; Jul 7; 380(9836):37-43.
  5. Rosbach M, Andersen JS. Patient experienced burden of treatment in patients with multimorbidity – A systematic review of qualitative data. PLoS ONE 12(6): e0179916.
  6. Mujica-Mota, RE et al. Common patterns of morbidity and multi-morbidity and their impact on health-related quality of life: evidence from a national survey Qual Life Res. 2015; 24(4): 909–918.
  7. Nunes, BP et al. Multimorbidity and mortality in older adults: A systematic review and meta-analysis. Arch Gerontol Geriatr. 2016 Nov-Dec; 67:130-8.
  8. Vogeli, C et al.  Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007 Dec; 22(Suppl 3): 391–395.
  9. A. Marengoni. Multimorbidity: epidemiology and models of care. BioMed Research International 2016 (2016), Article ID 7029027.

Intra-individual cyclical variation of patient reported outcome measures in patients with chronic health conditions

Funding: University of Exeter

HSPRG Researchers: Davey A and Valderas JM

Description: The aim of the PhD project is to find out the association between chronobiology and patient reported outcome measurements in patients with chronic health conditions. Although there has been significant progress made in the clinical application of PROMs within healthcare settings, their routine use in all aspects of healthcare has been slow. Most of the previous efforts have concentrated on establishing the use of PROMs at the group level, but there is still little evidence from investigations of the factors that may impact on patients' reported experience of their condition at the individual level, in particular in terms of intra-individual variation. The effects of rhythmical phenomena (chronobiology) are important factors to consider for individual applications of PROMs. Chronobiology is the biology of time and internal biological rhythms (such as circadian rhythms) in living organisms and their adaptation to solar- and lunar- related rhythms.

Biological rhythms and seasonal variation have been shown to impact on patients suffering from a variety of conditions. Focus within the field of chronobiology has tended to focus on circadian rhythms as research has shown that these can influence the response of patients to diagnostic tests and interventions depending on their timing with reference to body rhythms (Smolensky et al 1999). Research into cardiovascular disease, for example, and the circadian rhythm of blood pressure during the day has shown that a morning surge of blood pressure is linked to increased cardiovascular complications (Elliott 2001; Gosse and Schmacher 2006).

Chronobiology is crucial to individual applications of PROMs both because of rhythmical fluctuations in the health related phenomena that PROMs aim to capture, but also because of fluctuations of the mental complex components of mental functioning that underlie the integration of perceptions related to those very phenomena, such as cognition or mood. Humans awake in a good mood that deteriorates as the day progresses, and seasonal change in baseline positive affect varies with change in day length (Golder SA, Macy MW. 2011). Moreover different chrono-types have been identified, suggesting that the previous estimates may present average effects that may vary between defined groups (morning- [MT], neither- [NT] and evening-type [ET]). About 40% of the adult population is classified in one of the two extreme groups, while 60% are NT (Adan A et al. 2012). Circadian rhythms are potentially of great importance, but there are other relevant rhythms with longer amplitudes, such as those related to menstruation, weather-related seasonal variations (such as light, temperature, humidity, air pressure) and also culturally determined social patterns (such as weekly patterns of work and leisure, holidays and more complex human behaviours associated for instance with annual variations in food intake, such as those associated with religious fasting).

Given the large scope chronobiology can cover for the purpose of this PhD project we will focus on the following aspects of chronobiology: circadian rhythm, weather related seasonal variation and culturally determined social patterns.


Elliott WJ. Cyclic and circadian variations in vardiovascular events. Am J Hypertens 2001; 14:2915-55. 

Golder SA, Macy MW. Diurnal and seasonal mood vary with work, sleep and daylength across diverse cultures. Science 2011;333(6051):1878-81.

Gosse P, Schumacher H. Early morning blood pressure surge. Journal of Clinical Hypertension 2006; 8(8).

Smolensky MH, Reinberg AE, Martin RJ, Haus E. Clinical chronobiology and chronotherapeutics with applications to asthma. Chronobiology International 1999;16(5):539-35.


Assessing the impact of primary care reform in Saudi Arabia on patient experience

Funding: University of Exeter

HSPRG Researchers: Abdullah Mubarky and JM Valderas 


Primary care (PC) is the backbone of most health systems around the world. In Saudi Arabia, the health system is reforming as part of country’s Vision 2030 and health transformation strategy 2020. One of the main objectives of this reform is to build a new, strong PC system to attract patients and enhance preventive care. PC will play a significant role within this transformation strategy, which calls for PC improvement in terms of facilities, services, and technology. To understand the impact of this reform on PC, this PhD project aims to evaluate PC reform in Saudi Arabia, focusing on patient experiences. The main question of this study is this: How does the new PC model impact patients’ experiences as compared with the old one?
Three objectives are considered to achieve the main aim of this study: (1) to map the approaches to the evaluation of patients’ experiences, identify the main domains, and distinguish the factors affecting patients’ experiences of PC; (2) to gather an in-depth understanding of the key issues of PC reform from the patients’ perceptions; and (3) to compare patients’ experiences of the new and old PC systems. To achieve the objectives, interrelated work elements using different methodological approaches with a sequential design are adopted. The first element is a scoping review to map the approaches to the evaluation of patients’ experiences, identify the main domains of patients’ experiences, and distinguish the factors affecting patients’ experiences of PC. The first element also informs the design of subsequent elements of the work: a guide for focus groups and survey content and candidate measures. The second element is a series of focus groups with PC patients to gather an in-depth understanding of the key issues of PC reform from their perspective. The third element is a patient survey to compare patients’ experiences of the old and new PC models. The sampling for the focus groups and the survey will consider that the patients have experienced both models of PC. To ensure this criterion implementation, the data will be collected from new PC centres, which were reformed recently from less than two years. Moreover, the participants to be selected will be patients who have been registered in these centres for four years or more with at least two visits per year.


In Saudi Arabia, there is currently an ongoing transformation in healthcare services (4). This transformation is part of the National Transformation Program under the Vision 2030 umbrella (4). A fundamental aim of this transformation is strengthening PCs as a cornerstone for better accessibility and affordability (4). Despite a substantial improvement in health services in Saudi Arabia before this transformation began, PC still faced several challenges, such as the increased demand due to the rapid population growth, high costs, and increased morbidity with chronic diseases and lifestyle health-related issues such as obesity, diabetes, hypertension, stroke, and cardiac diseases (5). According to the Saudi Minister of Health, PC will play a significant role within this transformation strategy, which calls for PC improvement in terms of facilities, services, and technology (6). The old PC system in Saudi Arabia has several problems, such as lack of a good information system, shortage in resources, stressful work conditions with overload pressure on the physician, and poor technology (7). Reforming PC aims to improve and overcome such challenges, including population growth, health cost inflation and disease pattern diversion (4). As a result of this ongoing transformation, it is crucial to consider patients’ experiences in evaluating this reform to ensure the alignment of government efforts with patients’ needs.

Proposed work
1. Scoping review

The scoping review protocol has been drafted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review extension (PRISMA-ScR) checklist item guidelines and registered in the Open Science Framework (OSF) registry 10.17605/OSF.IO/7S3K9. A methodological framework has been used to guide the team during the formulation of the review questions that tackled the determinants of patients’ experiences, the different approaches of measuring patients’ experiences, as well as identifying the factors that affect patients’ experiences in PC settings (8).

The scoping review has now been completed, and the results are available. The review has explored different approaches to measure patients’ experiences in PC, such as surveys, focus groups, interviews and organisational databases (9-13). Surveys are the most common instruments used to measure patients’ experiences with PCs. Also, the scoping review identified the main domains of patients’ experiences in PC, which include accessibility, continuity, coordination, comprehensiveness, and patient-centeredness (14-17). Furthermore, the factors affecting patients’ experiences have been distinguished in this review

2. Focus groups

To gather an in-depth understanding of the key issues of PC reform from the patients’ perceptions, focus groups will be conducted with the patients in PC centres. A protocol and structured topic guide will be developed, informed by the scoping review results (18). The scoping review identified the main domains of patients’ experiences of PC, which include accessibility, continuity, coordination, patient-centeredness, comprehensiveness, and safety. These domains will be the subjects for the focus group discussions (10).
Data collection will begin once ethical approval from the University of Exeter and administrative access letter from the Saudi Ministry of Health are received. Face-to-face focus groups are planned, but an online focus group through Zoom will be adopted as an alternative should the constraints of the pandemic render this unfeasible.

A small session after each focus group will take place to summarise the reflective notes and the key points (19). All focus groups will be conducted, recorded, transcribed, and analysed in the Arabic language. The results of the focus group analysis will be translated into English to fit with the study language. The recording is important to precisely capture the nuances of the discussion. They will be compared with written notes to fill in the gaps with inaudible content and non-verbal responses, such as frustrated tones and anger expressions (20). Mixed content analysis and data coding will be implemented in data analysis using the three-element coding framework (21). NVivo 12 software will be used for the data analysis process, and the results will be reported in a narrative format.

3. Patient survey

While the focus group interviews will gather the patients’ views and experiences about PC reform in Saudi Arabia, the last stage of this project will quantitatively measure patients’ experiences with Saudi Arabia’s new PC model as compared with the old model. Surveys are a widespread method of assessing the knowledge and attitudes of patients about a particular issue or phenomenon (22). Questionnaires about patients’ experiences elicit subjective evaluations of the care services that complement more objective measurements (23).
Cluster sampling will be implemented by dividing Saudi Arabia into five regions: central, north, south, east, and west. The specific sample size will be dependent on the identification of a key variable of interest measured with the survey that we select. Preliminary estimates suggest that the sample size will be around 1,250 participants (250 for each region) (24). Anonymity and confidentiality will be granted through coding the data and saving all data on a protected computer with a password.

We will apply for ethical approval from the University of Exeter and request a permission letter from the Saudi Ministry of Health to access the participants’ and PC patients’ lists. Eligibility criteria will be like those for the focus group. A survey link with the information and electronic consent form will be sent through text messages to identified eligible patients from the PC centres lists.


1. Starfield B. Primary care: concept, evaluation, and policy/Barbara Starfield. New York: Oxford University Press; 1992.
2. Dawson, Bond CJ, Bennett NG, Bolam RA, Bonney V, Dain HG, et al. The Dawson Report on The Future of Medical and Allied Services. London: The King's Fund; 1920.
3. World Health Organization and the United Nations Children’s Fund (UNICEF). A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: UNICEF and WHO; 2018 (WHO/HIS/SDS/2018.X).
4. Roodenburg E, Pall N. The paradox of primary care: How Saudi Arabia can leapfrog world class primary care systems. KPMG International. Switzerland; 2019.
5. Al Asmri M, Almalki MJ, Fitzgerald G, Clark M. The public healthcare system and primary care services in Saudi Arabia: a system in transition. EMHJ. 2020;26(4):468–476.
6. Edwards N, King T, Judith Smith F, Trust Rebecca Rosen N, Trust N. The primary care paradox. 2014.
7. Al-Ahmadi H, Roland M. Quality of primary health care in Saudi Arabia: a comprehensive review. Int J Qual Heal Care. 2005;17(4):331–346.
8. Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol Theory Pract. 2005 Feb;8(1):19–32.
9. Forbes LJL, Forbes H, Sutton M, Checkland K, Peckham S. Changes in patient experience associated with growth and collaboration in general practice: Observational study using data from the uk gp patient survey. Br J Gen Pract. 2020 Dec 1;70(701):E906–915.
10. Browne K, Roseman D, Shaller D, Edgman-Levitan S. Measuring patient experience as a strategy for improving primary care. Health Affairs; 2010. 29: 921–925.
11. Papp R, Borbas I, Dobos E, Bredehorst M, Jaruseviciene L, Vehko T, et al. Perceptions of quality in primary health care: Perspectives of patients and professionals based on focus group discussions. BMC Fam Pract. 2014;15(1):84–88.
12. Holmboe O, Iversen HH, Danielsen K, Bjertnaes O. The Norwegian patient experiences with GP questionnaire (PEQ-GP): Reliability and construct validity following a national survey. BMJ Open. 2017;7(9):1–9.
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15. Aoki T, Miyashita J, Yamamoto Y, Ikenoue T, Kise M, Fujinuma Y, et al. Patient experience of primary care and advance care planning: A multicentre cross-sectional study in Japan. Fam Pract. 2017;34(2):206–212.
16. Chung VCH, Yip BHK, Griffiths SM, Yu ELM, Liu S, Ho RST, et al. Patients’ experience of Chinese Medicine Primary Care Services: Implications on Improving Coordination and Continuity of Care. Sci Rep. 2015;5(March):1–9.
17. Dullie L, Meland E, Hetlevik Ø, Mildestvedt T, Kasenda S, Kantema C, et al. Performance of primary care in different healthcare facilities: A cross-sectional study of patients’ experiences in Southern Malawi. BMJ Open. 2019;9(7):1–10.
18. Wilkinson S. Focus Groups in Health Research. J Health Psychol. 1998;3(3):329–348.
19. Green J, Thorogood N. Qualitative Methods for Health Research. Third edit. Seaman J, editor. London: SAGE Publications London; 2014.
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21. O.Nyumba T, Wilson K, Derrick CJ, Mukherjee N. The use of focus group discussion methodology: Insights from two decades of application in conservation. Geneletti D, editor. Methods Ecol Evol. 2018 Jan 11;9(1):20–32.
22. Jones TL, Baxter M, Khanduja V. A quick guide to survey research. Rev Ann R Coll Surg Engl. 2013;95:5–7.
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Evidence-based patient-centred management of patients with Lateral Elbow Tendinopathy: PROMs (reviews and validation study) and platelet injection (cadaveric experiments, consensus on methods, pilot RCT)

Completed MD September 2019

Medline search strategy for elbow outcome measures


Jonathan Evans - Orthopaedic Registrar and Postgraudate Researcher

Jose M Valderas - GP and Professor of Health Services and Policy

Chris Smith - Orthopaedic Consultant

Vicki Goodwin - Physiotherapist and Senior Research Fellow

Rod Taylor - Professor of Health Services Research

Follow us on Twitter -  @TennisElbowUK or @jon_evans_uk

Join our Facebook group - TennisElbowUK

Our projects

1)     Systematic evaluation of elbow related outcome measures using the EMPRO (Evaluating the Measurement of Patient-Reported Outcomes) tool

For search strategy please see 

Status - Completed

2)     Patient-Led Treatment in Lateral Epicondylar Tendinopathy – A feasibility trial assessing outcome measurement validity

Supported by a British Elbow and Shoulder Society (BESS) pump-priming grant

Status - Awaiting ethical approval

3)     Platelet Rich Plasma vs Open Surgery in the Treatment of Chronic Lateral Epicondylar Tendinopathy (Tennis Elbow) - A Pilot Randomized Control Trial

Supported by a Royal Devon and Exeter Hospital Small Grant

Status - Recruiting

4) Cadaveric evaluation of the spread of injectate after ultrasound-guided lateral elbow injection

Supported by a British Elbow and Shoulder Society (BESS) pump-priming grant

Status - Data collection

5) Platelet-Rich-Plasma Injection Technique in Lateral Epicondylar Tendinopathy -Exploring Consensus with the Delphi Method

Status - Data collection


As part of a collaboration between the Health Services and Policy Research Group and the Royal Devon and Exeter Hospital we are conducting research into Tennis Elbow management. 

Our studies are aiming to improve how patients with tennis elbow (lateral epicondylar tendinopathy) are treated. Tennis elbow is a common problem that gives you a pain on the outside of the elbow. At its worst the pain can be disabling. At the moment the advice and treatment you get if you see a doctor with this problem can vary.

We believe that it is better for both the individual patient, and the NHS as a whole, if people with tennis elbow are given the most appropriate and evidence-based advice and treatment as soon as possible, delivered at the right level of care. 

What are the research aims?

Our ultimate aim is to produce a treatment pathway that is centred around the patient's experience of how bad their symptoms are.

How many people suffer from Tennis Elbow? How long do the symptoms last?

Tennis elbow is common; three in 100 people will get tennis elbow at some time. However, it is more common in people who are middle-aged and physically active. Though the name suggests it is related to sport, it is most common in people with manual jobs such as builders and plumbers. Tennis elbow usually lasts for between 6 and 12 months. Importantly one out of five people have symptoms for longer than this and almost one in ten people will suffer with tennis elbow more than once. 

How will this aim be realised?

We will produce an evidence-based tool, developed from a current elbow assessment measure that asks each patient specific questions about how tennis elbow affects them. By applying a score to the answers to these questions we will be able to provide advice on treatment that is individually tailored. We hope that this will reduce treatment variation and improve care. 

We believe that only by placing the patient at the centre of the treatment process can we deliver the best care the NHS has to offer.

Delivering care in this way puts the patient in control and gives them a voice. It also recognises how bad their condition is to them and measures the impact it has on their lives. By making sure the patient gets early treatment, including advice on self-management, we hope to improve their independence, to return to work or get back to a favourite hobby, as quickly as possible.

This method of delivering care is a hot topic. It is being tried by our research group for diseases in the elderly and is being used by others for hip and knee arthritis and back pain. However this method remains quite new and has not been used for tendon pain and specifically tennis elbow, even though it is a very common problem. What we need is good quality evidence that assesses how appropriate and acceptable this is to both patients and healthcare providers.

By improving our evidence-based approach and decreasing treatment variation we hope to provide long-term benefit to a whole population of tennis elbow sufferers. For each individual we believe that by engaging and advising patients early, giving specific treatments and providing an internet based platform to monitor their symptoms, we will speed their recovery and improve their healthcare experience.

Updated 8 February 2017