{"id":1135,"date":"2026-04-01T07:00:01","date_gmt":"2026-04-01T07:00:01","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjleader\/?p=1135"},"modified":"2026-03-27T14:32:13","modified_gmt":"2026-03-27T14:32:13","slug":"shift-the-seat-shift-the-influence-a-new-four-seat-approach-to-patient-partnership-by-dr-kate-pryde-dr-christina-rennie-and-emlyn-marshall","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjleader\/2026\/04\/01\/shift-the-seat-shift-the-influence-a-new-four-seat-approach-to-patient-partnership-by-dr-kate-pryde-dr-christina-rennie-and-emlyn-marshall\/","title":{"rendered":"Shift the Seat, Shift the Influence: A New Four Seat Approach to Patient Partnership. By Dr Kate Pryde, Dr Christina Rennie and Emlyn Marshall"},"content":{"rendered":"

Healthcare uses many metaphors, but few help us speak honestly about power. Leaders often aspire to stronger patient partnership, yet real practice varies widely. In some settings patients shape strategy; in others their influence appears only through complaints or litigation. Co-production literature shows that although it is increasingly valued, practice remains inconsistent and often unclear about power, process, and purpose.<\/span><\/p>\n

In our work at University Hospital Southampton, a large University teaching Hospital in the UK, one of our patient partners has developed a simple framework to help teams articulate where patients currently \u201csit\u201d in relation to involvement in patient safety and improvement work. The aim being it\u2019s memorable rather than diagnostic. A way to open conversations about patient involvement. The metaphor is a car with four possible seats: baby, teenager, passenger, and driver. Each represents a different relationship to the power, voice, and leadership patients have in health care improvement see figure.<\/span><\/p>\n

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Baby in the Backseat – The System Drives, Patients React<\/b>
\nMany organisations still rely heavily on complaints, incident reports, or generic feedback as their primary \u201cpatient voice\u201d. These mechanisms matter, but they reflect a reactive form of engagement. The co-production evidence shows that when patient involvement happens only retrospectively, the relationship becomes adversarial, and learning remains superficial.\u00a0<\/span><\/p>\n

This is the <\/span>baby seat<\/span><\/i>: the organisation drives, and the patient is acted upon. It\u2019s a position leaders should recognise not as a failing but as a signal, a sign that patients were not involved early enough in shaping decisions, defining outcomes, or co-creating solutions.<\/span><\/p>\n

Teenager in the Backseat – Reactive and growing autonomy<\/b>
\nMany teams genuinely want to involve patients but feel unsure how. Involvement becomes patchy, dependent on champions, time, or confidence. Studies of patient participation groups show similar variability, often shaped by deprivation, capacity, and organisational readiness. <\/span>[Gobat et al, 2025]<\/span><\/a><\/p>\n

This is the <\/span>teenager seat<\/span><\/i>: emerging autonomy but without consistent power. These patients may often feel frustrated that they aren\u2019t being heard when they have much to contribute. The literature identifies limited infrastructure, varied inclusion, and selective use of patient insight as common barriers to meaningful involvement.<\/span><\/p>\n

For leaders, the question becomes: what are the minimum conditions that allow patient involvement to flourish reliably? Often the answer is simple; build a trained pool of patient partners, clarify expectations in project templates, and make early engagement routine.<\/span><\/p>\n

Passenger Seat – Strong Partnership & Co-driving<\/b>
\nIn the passenger seat, patients are invited into early conversations, their insights shape solutions, and their presence is expected rather than exceptional. But the organisation still sets the parameters, agenda, and pace.<\/span><\/p>\n

Co-production models consistently highlight the importance of shared values, transparent communication, inclusive processes, and attention to diversity of voice. Narrative reviews indicate that although partnership models are growing, many still lack the deeper attention to power and agency required for full co-production. <\/span>[Robert et al, 2024]<\/span><\/a>\u00a0<\/span><\/p>\n

This seat represents genuine involvement but also the limit of many current approaches.<\/span><\/p>\n

Driver\u2019s Seat – True Co-Production<\/b>
\nThe driver\u2019s seat represents shared work and shared power. Patients help define the problem, shape data collection priorities, codesign solutions, and participate in governance. The healthcare coproduction literature describes this not as a luxury but as the natural form of service creation: health services are, by definition, jointly produced by professionals and those who use them. <\/span>[Robert et al, 2024]<\/span><\/a><\/p>\n

Leading co-production is complex work requiring investment in practices such as power-sharing, trust-building, communication, and co-implementation. But leaders who embrace this discomfort often find that early involvement prevents rework, accelerates adoption, and produces solutions more aligned to what matters. <\/span>[Boam et al, 2026]<\/span><\/a><\/p>\n

Not Every Journey Needs the Same Driver<\/b>
\nOne of the most helpful insights the model offers is that the driver\u2019s seat is not always the right seat. In safeguarding, regulatory response, or emergency redesign, the expertise and accountability of clinical teams may need to lead. Conversely, tasks like redesigning letters, deciding meaningful outcomes, or shaping digital tools are often best driven by patients.<\/span><\/p>\n

The goal isn\u2019t to put patients in the driver\u2019s seat <\/span>everywhere<\/span><\/i>. It\u2019s to develop leadership discipline around asking the right questions:<\/span><\/p>\n