Implementing and evaluating care and support planning: a qualitative study of health professionals’ experiences in public polyclinics in Singapore

Abstract

Background

Two polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals’ perspectives on CSP to inform future developments.

Methods

Qualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them.

Results

Both polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP ‘going well’ all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals’ accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers’ person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals’ ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP.

Conclusion

Health professionals’ interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.

Background

Over recent decades, significant efforts have been made internationally to ensure that health services (and especially primary care) support the growing numbers of people with chronic diseases to manage these effectively in the context of their daily lives [1,2,3]. Increasing emphasis is also placed on the idea that such support should be ‘person-centred’ and oriented to enable people to live (and die) well with their long-term conditions [4, 5]. In part this reflects recognition that much of the value of support for self-management lies in its potential to improve the social and psychological aspects of life with long-term conditions. These aspects not only can significantly impact how well people manage those conditions, but also are important in their own right. At a population level, the effects of interventions on biomedical markers might be modest, especially over the short term [6], but respectful, responsive support can improve wellbeing more broadly and may mediate some biomedical improvement (or at least limit deterioration) over the longer-term [6,7,8,9].

The concept of person-centredness is variously explained and interpreted but includes notions of health professionals focusing on the person not just the disease, working respectfully with the person, enabling their agency, orienting to address the person’s own concerns and priorities for their wellbeing, and recognising the practical realities of their lives [5, 10]. The latter may be particularly important when poverty and social inequality constrain people’s scope to improve their health via lifestyle ‘choices’ [11, 12].

The implementation of person-centred support for self-management requires widespread adoption of person-centred values (including by institutional leadership); professional acquisition of relevant skills (including microskills of communication); and development of organisational structures (including information systems) to underpin delivery, including by preparing patients [9, 13].

One of the most established approaches to person-centred support for self-management, especially in the UK, is personalised Care and Support Planning (CSP) [13]. As developed by Year of Care Partnerships® (an NHS organisation dedicated to the implementation of personalised approaches to care), this approach emphasises the importance of a meaningful conversation between a prepared patient and a CSP-trained health professional. To help patients prepare for their CSP conversation appointment, they are sent a care planning letter in advance. This letter prompts them to consider any issues that they would like to discuss with the doctor or nurse. It summarises their biomedical test results (including past trends) before asking them to consider what they would like to work on this year. Health professionals are trained to actively listen to the patient’s concerns and perspectives on what is important before sharing any additional thoughts from their professional perspective, then collaboratively supporting the patient to prioritise and develop specific goals relating to what matters to them, and to formulate a realistic plan for achieving them [13].

In Singapore, CSP was first introduced for patients being treated for diabetes in a hospital setting in 2017. The endocrinologists involved recognised that the approach could also be appropriate for primary care, including within polyclinics. Polyclinics are multi-professional public sector organisations that (separately from private sector family doctors) provide a broad range of primary healthcare services at subsidised prices for many of the rising numbers of people with diabetes [9, 14, 15]. Singapore’s Ministry of Health funded a three-year trial of CSP using materials and processes adapted from the Year of Care Partnerships programme to suit the local context. The trial, Patient Activation through Community Empowerment/Engagement for Diabetes management (PACE-D), is set in four polyclinics. Two polyclinics each developed their systems and introduced CSP into the working arrangements of one or two professional teamlets (small groups of doctors and nurses that provide care for a panel of patients) [16, 17]. The PACE-D trial aims to recruit all adults with diabetes who can communicate in English, Chinese or Malay. The primary outcome is HbA1c levels (which the research team acknowledges fails to capture many potential benefits of CSP) [16].

We report here on a qualitative study of health professionals’ experiences of CSP, conducted to complement both the PACE-D trial and an associated study of patients’ experiences. We aimed to investigate professional perspectives on the introduction of CSP with a view to informing any more widespread adoption of CSP in Singapore. We were particularly aware, from research in UK and Australian settings, that health professionals can vary in their interpretations (including value emphases) and enactments of person-centred support for self-management [18,19,20] and can experience tensions when attempting to adopt such approaches [21, 22], so we were also interested in the potential of this study to further illuminate these issues, and in a South-East Asian context. Our findings and analysis have implications for the implementation and evaluation of CSP and similar approaches internationally.

Methods

This was a qualitative, interpretive study. We conducted individual interviews with health professionals working directly with patients for CSP. For context, we also observed the training session for doctors and nurses involved in PACE-D and team huddles convened to support CSP implementation.

Individual interviews

All doctors and nurses who conducted CSP conversations for PACE-D were invited to take part, as were PACE-D coordinators (a new teamlet role introduced to help recruit patients, arrange appointments, and collect data for the trial). Eligible staff were identified and approached by a PACE-D administrator and subsequently a PACE-D coordinator who also helped arrange interviews. Informed consent was documented before interviews commenced.

Participants were told that the study aimed to learn from their perspectives, including to identify any concerns or difficulties with CSP, to complement and inform the interpretation of the PACE-D trial data when it became available, and to inform decisions about whether and how CSP would continue beyond the trial. The interviewer (VAE) was introduced to health professionals during their CSP training and first huddles as a non-clinical Professor, new to Singapore, with an interest in person-centred care and self-management support.

We planned to conduct two face-to-face interviews with each health professional: one relatively soon after CSP conversations were initiated and a second at least 9 months later once they had more experience with the approach and had seen some patients for follow-up appointments. This reflected recognition that skills can develop with practice and that experience and perspectives can change with time. We were mindful that when interventions such as CSP are introduced, the health professionals who are expected to adopt new practices might benefit from some kind of support as they get used to them, and we thought that conducting two interviews rather than just one, when practices had become more settled, could be useful. In practice, first interviews started later than originally envisaged due to an initial delay in recruiting patients to the study and not all were completed before COVID-19 resulted in access restrictions. Further delays arose when VAE relocated, necessitating a revision to the study protocol and the securing of ethics committee approval to conduct interviews online and from overseas. Some health professionals’ first interviews thus did not take place until at least 12 months after CSP conversations were commenced, and in these circumstances, we judged a second interview unnecessary. To avoid confusion, we refer to the interviews as ‘wave 1’ (conducted relatively soon after CSP was implemented) and ‘wave 2’ (conducted at least 9 months after CSP was implemented). These are indicated as w1 or w2 after quotations. For health professionals who were interviewed twice, the minimum time between first and second interviews was 9 months (average 11 months). We note that the CSP experience levels of health professionals at the time of each wave varied because of a combination of leave and secondment arrangements and, to some extent, preferences for conducting CSP conversations.

The interviews were conversational in style, supported by a topic guide that (for doctors and nurses) prompted coverage of: their role in relation to PACE-D, how they had been introduced to CSP and what they had first thought of it; examples of occasions when they thought CSP conversations had gone more and less well; how CSP conversations went compared with previous consultations for diabetes; perceived advantages and disadvantages for patients and for health professionals; any challenges in delivering CSP well; and whether and why they would or would not be inclined to continue with CSP beyond the PACE-D study, or to recommend it to other polyclinics. The topic guide was modified for interviews with PACE-D coordinators and developed over time to reflect questions of interest identified from previous interviews (for example, whether and how CSP works differently for different patient groups). It was annotated for second interviews to pick up points raised previously by each participant, including to check whether and how experiences or views had changed.

Interview recordings were a mean of 48 minutes long (range 36 to 74 minutes).

Audio-recordings of the interviews were transcribed by medical students on a student work scheme. VAE checked and corrected the transcripts against the audio recordings.

Observation of training session and huddles

By invitation of PACE-D study leads, and with prior agreement from trainers, VAE was introduced to participating health professionals, as noted above, as one of several observers of the local CSP training session for health professionals and of the first lunchtime huddle sessions convened by the trainers to give the health professionals an opportunity to discuss how CSP was going and share concerns or practical tips. Participants were told that the observation could help provide background understanding for the interview study and help inform interpretation of PACE-D trial findings and decisions about the use of CSP beyond the trial. We explained that we were not analysing who said what in the training sessions or huddles, and that no quotations would be used. VAE interacted conversationally with health professionals and trainers during refreshment breaks and was included in lunch arrangements for the huddle. She also participated occasionally, for example, stepping in to make up a pair and play the role of a patient for a role play exercise during the training session, briefly confirming during an early huddle that health professionals in the UK also reported variation in how much preparatory thinking patients did ahead of CSP conversations, and (more significantly) presenting the preliminary analysis from the interview study for discussion at the final huddle observed.

A comprehensive set of slides and documents was provided for reference from the training. Note-taking from the huddles was handwritten, not formally structured, and brief. It focused on summarising topics of concern and key features of meetings (e.g. started late because clinics overran; some participants visibly very tired). Huddles were scheduled for an hour, but typically started late. In total VAE attended 7 of 11 huddles and watched recordings of 2 huddles that she could not attend in person. This amounted to approximately 6 hours of active meeting time observed.

The observations helped to inform interview questions (for example, prompting inquiry about how CSP conversations were documented in medical records) and provided context to support interpretive analysis of interview data (particularly confirming the nature and strength of concern about logistical challenges, including those associated with long patient queues in clinic).

We decided not to observe CSP consultations, both to avoid additional intervention in the context of the PACE-D trial and because the health professionals were already under significant pressure.

Analysis

Our qualitative analysis was broadly interpretive. It was practically oriented, but with awareness that theoretical development could also be practically useful. Primarily, we sought to complement and support interpretation of the PACE-D trial results, and to inform any plans to extend CSP beyond the trial period and initial polyclinic sites. To this end, we were sensitised by key ideas from Normalization Process Theory (including the relevance for implementation of actors’ views of intervention components, coherence with existing ideas and systems, cognitive participation, collective action and reflective monitoring) [23], although we did not use this formally as an analytic framework. An additional interest, as noted in Background, was in any variations in health professionals’ interpretations and enactments of CSP, and the potential significance of those for implementing and evaluating person-centred approaches to support.

We deployed multiple analytic strategies to develop our understanding of what was going on in this complex and dynamic situation. At a first, we might say surface level of analysis, we focused on what health professionals told us directly, and looked for similarities and differences in what they said, for example about what they saw as the main differences between CSP conversations and their previous approaches to annual review and “usual” consultations, the challenges they experienced with delivering CSP well, and whether they thought CSP should continue beyond the PACE-D clinical trial. We also compared health professionals’ self-reported interpretations and enactments of CSP with the person-centred principles, communication skills and goal-setting action planning strategies covered in the CSP training and envisaged in the broader literature. At another, we might say higher level of analysis, we considered how (sometimes subtly) different interpretations, enactments, experiences and evaluations of CSP were connected, attending not just to health professionals’ own reflections but also looking at how particular interpretations, enactments, experiences and evaluative judgements clustered within and varied across health professionals’ interviews.

In terms of tools used or processes followed for these analyses, after close reading and manual note-making on the early (wave 1) transcripts, VAE developed a ‘broad-brush’ set of codes to help organise the data. This reflected the research questions and interview structure as well as points of interest discussed with other authors. SM subsequently worked line by line through all the transcripts using NVivo software to apply these codes and collate data for further review. This ‘chunking’ allowed us to consider all responses to specific interview questions (for example inviting a description of a CSP conversation that had gone well, and asking for comment on how they found the training and huddles) and to bring together what was said about particular CSP processes (for example the care planning letter, or the goal-setting and action planning stage of the consultation) and more obviously evaluative judgements. It was particularly useful for supporting identification of the range of health professionals’ interpretations, enactments, experiences (including of challenges) and views about the purpose and success or otherwise of CSP. We also used it to start to identify potential shortfalls from CSP as introduced in training, coding data as relating to this either if health professionals themselves mentioned concerns or if researchers identified potential discrepancies on the basis of health professionals’ descriptions of what they did.

To support consideration of potential links between what each health professional said directly about the purpose(s) and value of CSP, their accounts of practical examples, the challenges they reported, and their evaluative reflections, we constructed analytic charts of a kind associated with a framework approach [24], although with relatively broad headings and thus relatively long cell entries. These were constructed on MS Word. VAE worked again through all the interview transcripts, reading each carefully in their entirety and summarising directly from transcript to chart row for each participant: evidence of their emphasis in interpretation and overall evaluation of CSP; the way they described challenges to CSP and their enacted responses to those; their accounts of working with patients with different characteristics, and connections drawn by the health professionals or researchers between these. Information from wave 1 and wave 2 interviews was recorded in different coloured text. An additional step of further analytic reflection, annotation of chart printouts and distillation from initial ‘long-version’ into ‘shorter’ summary charts helped develop an explanatory account of how what we loosely characterised as narrower and broader views about the purpose(s) of CSP, and narrower and broader initial skill repertoires, could interact with practical-situational challenges in the polyclinic to shape health professionals’ enactments, personal experiences and evaluative judgements of CSP. This analysis was credibility checked and clarified in discussion with all authors. Although it cannot be fully demonstrated via direct excerpts from interview transcripts alone, we developed summaries of four health professionals’ interpretations, enactments and evaluations of CSP to illustrate how these cluster (see Table 1 in Results below).

Table 1 Illustration of contrasts between health professionals’ interpretations, enactments and evaluations of CSP^a

Observations and documentation from the training, together with publications about CSP, were used primarily as a reference point against which health professionals’ accounts and reported enactments of CSPs were considered. Observations of the huddles were used primarily to summarise how these featured in the implementation process, but also reinforced what health professionals shared in individual interviews about organisational and logistic challenges of CSP, and allowed us to see that further input from CSP trainers was consistent with the original training in terms of the person-centred principles it emphasised and communication skills it sought to bolster.

A summary of the analysis reported here was shared with the PACE-D leads and presented to participants and others during a PACE-D huddle session, providing an opportunity for discussion and further comment and refinement before this manuscript was finalised.

In the Results and associated Tables, the names attached to quotations are all pseudonyms. To preserve participants’ confidentiality, we have not distinguished between doctors and nurses, we have sometimes changed the gender of pronouns, and we have not provided polyclinic affiliations. Quotations are verbatim but we have deleted hesitation sounds and spoken word repetitions. Where we have omitted words to improve clarity, this is indicated by ‘…’. Where we have added or condensed explanatory points they are within [ ]. Some Singlish constructions may look grammatically odd to readers more accustomed to British English, but the meaning should be clear. The expression “Lah” serves to add emphasis to a point.

Results

We interviewed 11 doctors, 2 nurses and 3 PACE-D coordinators. 7 doctors and 1 nurse were interviewed twice and 2 PACE-D coordinators asked to be interviewed together, so there were 23 interviews in total. 14 interviews (all in the second wave) were conducted online.

Our sample includes all but 2 of the health professionals trained to conduct CSP conversations within the PACE-D trial: 2 eligible nurses declined interviews because they conducted very few CSP conversations. 11 participants were from one polyclinic and 5 from the other, reflecting different staffing arrangements.

The interviews and huddle observations confirmed reports from PACE-D leaders that both polyclinics managed to establish a CSP system for people with diabetes, and to sustain this through the substantial disruptions of COVID-19 and introduction of a Next Generation Electronic Medical Record system. (At the time of writing CSP has been provided in these polyclinics for over three years – continuing beyond the trial). They also highlighted that the PACE-D coordinators came to play key roles in keeping key CSP processes going (not just supporting research components).

We report our findings in three main sections. First, we outline the understandings of CSP evident in doctors’ and nurses’ accounts, including the key contrasts they saw between CSP and their previous ways of working, and the range of benefits they attributed to CSP. Important variations in health professionals’ enactments of CSP are introduced within this section.

Second, we consider the challenges to CSP that participants reported as arising from (a) the situated characteristics of local patients and (b) organisational factors and policy pressures. This section also notes variations in health professionals’ interpretations of and enacted responses to these challenges. It indicates how both the external challenges and variations in health professionals’ enactments can impact the achievement and recognition of potential benefits of CSP.

Third, we examine health professionals’ overall evaluations of CSP and their inclination to extend its use beyond PACE-D. We show that these evaluations are somewhat contingent on health professionals’ interpretive emphases, experiences of challenges, and awareness of variations in their collective enactments.

In the Discussion, we develop our analysis of how variations in health professionals’ interpretive emphases and skill repertoires impact their enactments of CSP, scope to improve these with experience, evaluative judgements of CSP and motivation to continue with the approach.

The findings and analysis were endorsed by participants when presented to their team huddle. Health professionals particularly appreciated recognition of the challenges they faced and the recommendations for future organisational support for CSP.

Understandings and reported enactments of CSP

When CSP goes well: ‘ideal’ patient behaviours and outcomes

When asked early in their interviews for an example in which CSP went relatively well, participants gave strikingly similar responses. In both waves, all included most of the following elements: a patient comes to their CSP conversation actively ‘prepared’ (having read and reflected on their care planning letter), engages fairly readily in discussion, is willing to act to improve their health, proposes or works with the health professional to set relevant goals and a realistic action plan, leaves the CSP conversation motivated, sticks to their plan and sees (or would see) improvement in targeted biomedical markers at follow-up. A selection of these ‘good example’ accounts is provided in Additional Table 1.

In practice, of course, CSP did not always work along these lines. Participants consistently reported that only a minority of patients came to CSP appointments clearly familiar with their test results and able and willing to discuss ideas about their health, let alone set and stick to plans for health-related behaviour change that positively impacted their biomedical markers. Some participants seemed surprised by this and there was some variability in how and to what extent they became reconciled to it.

We will return shortly to consider variations in patients’ engagement with CSP. First, though, we continue this section with a description of how health professionals compared CSP with their previous practice. We note both common ground and variation in their understandings and their own contributions to enactments of CSP, as well as in their recognition of its advantages.

Commonality and variation in professional enactments of CSP conversations

Beyond ideas about how patients would ideally engage with CSP, there was much commonality in health professionals’ descriptions of how they conducted CSP conversations and how these compared with pre-PACE-D ‘usual’ consultations and annual reviews. Consistent features included CSP conversations: being allocated more time; being usefully supported by the visual (graphical) depictions of trends in patients’ biomedical markers that were shared in care planning letters (see Additional material); involving more listening to patients and less talking by health professionals; involving less issuing of ‘standard’ professional advice and more attention to patients’ daily lives; and (supposedly, but only occasionally) involving more leading by patients.

There were also, however, significant variations among professional accounts of their understandings and enactments of CSP. Some participants showed and developed a firmer grasp than others of values and communicative practices covered in CSP training, reflecting deeper commitment to the broad purposes and partnership ethos of CSP, following through more consistently on the recognition of patients as persons whose perspectives matter and the idea that the CSP conversation is a meeting between two experts, and describing more nuanced microskills of respectful, empathetic communication and collaboration. Table 1 summarises the accounts of four participants to give an indication of the range.

Benefits of CSP beyond improvements in health behaviours and biomedical markers

Between them, participants identified various benefits of CSP independent of (but perhaps intermediate to) changes in patients’ health-related behaviours and improvements in biomedical makers. Benefits identified by at least some health professionals included patients: being better informed; feeling less rushed, more listened to and better respected; sometimes appreciating that “the doctor is caring for them more, caring not for the disease but more emotionally” (HP Seow, w2); and sometimes being encouraged and enabled to feel and take more ownership of their conditions. Some health professionals also reported gaining a better understanding of each patient’s situation and perspective, which could in turn help them: (occasionally) solve previously baffling diagnostic puzzles; avoid unwarranted judgementalism; avoid alienating and demoralising patients; build rapport and trust; tailor suggestions more appropriately to patients and their situations; and “leave the door open” for people to come back for support in the future. Several doctors who stressed the value of these more emotional, relational and perhaps intermediate experiential benefits for patients also commented appreciatively on CSP as a better way of practising, an approach that reflected why they came into medicine, and one that could leave them feeling more satisfied with their encounters with patients and their work more generally (see Table 2).

Table 2 Broader benefits of CSP (beyond improvements to patients’ health-related behaviours and biomedical markers)

Variations in health professionals’ comments about these broader benefits of CSP seem to reflect variations in both their views of the purposes of CSP and their conduct of CSP conversations. It seems plausible at least that the broader benefits will be more readily realised and recognised when health professionals are more strongly committed, and have a deeper understanding of what it takes, to work in respectful partnerships, relate to patients as experts in their own lives, and take seriously patients’ own priorities for their health and wellbeing. The broader benefits will also carry more evaluative weight if these commitments are considered morally significant. We take the commitments to be consistent with the person-centred ambitions of CSP.

We will return to “Health professionals’ evaluations of CSP” below. For now, we consider the various challenges that health professionals experienced with CSP in practice.

Perceived challenges to achievement of CSP’s potential

We have grouped the challenges that health professionals reported as relating to (a) patients and their contexts and (b) clinic systems and policy priorities. Quotations illustrating the various challenges and some different responses to them are presented in Table 3.

Table 3 Challenges to health professionals’ enactments of CSP and achievement of CSP’s potential

Variations in patients’ ability and willingness to engage

Participants reported that many patients did not open or read, let alone reflect and write in care planning letters before their appointments. In the early stages of PACE-D they estimated that up to 30% of patients did not read the letter at all. They reported that this improved after it was agreed that PACE-D coordinators would check and provide more active assistance when patients came into the clinic (see below) and as patients became more familiar with the process.

Health professionals further experienced many patients as reticent or lacking confidence to engage in conversation about their diabetes in the context of their life. They mostly explained this with reference to some combination of language diversity, education and culture, although some somewhat judgementally also suggested a lack of interest on patients’ part, and some more sympathetically recognised that a long social history of medical practice not showing interest in patients’ perspectives was partly to blame.

Care planning letters were issued in whichever of three languages (English, Chinese or Malay) a patient preferred. However, many older adults in Singapore received little education and literacy rates among people over 55 are relatively low [25]. Health professionals reported that some patients struggled to understand the information provided - despite the visual depiction of trends and traffic light colour coding. A limited understanding of body and health concepts could reduce people’s scope to reflect on their test results and generate ideas for improving them. And although the additional time allocated to CSP conversations allowed health professionals to explain and discuss the information provided, CSP training had encouraged the view that the advance sharing of results should mean less consultation time was spent on this and more on hearing patients’ perspectives and supporting them to set goals and develop action plans.

All participants were used to conducting consultations in at least two languages, but several explained that language skills that sufficed for ‘usual’ consultations were not necessarily up to the more nuanced demands of open, broad-ranging and potentially emotional CSP conversations. Patients, too, might have limited ability and confidence to express complex thoughts and feelings in the language of the conversation, and the limitations of interpreters could be particularly problematic for CSP consultations.

Several participants commented that aspects of Singaporean or more broadly Asian cultures meant many people were not used to being asked for their opinion, particularly in healthcare contexts where (to a greater extent than in the UK or more broadly Western cultures within which CSP originated) doctors are deferred to as authority figures and families and family hierarchies are influential in healthcare decision-making. The CSP approach represented a big cultural-behavioural shift within polyclinic service provision. People with diabetes who had attended clinics for many years were likely to be strongly habituated to ‘usual’ consultation practices in which they were assessed quickly and sent away with medication and instructions. While all participants showed some awareness of the diversity of patients’ educational and cultural backgrounds and socioeconomic circumstances, some reflected these less clearly and sensitively than others in their accounts of CSP conversations. Not all recognised that patients might need substantial encouragement and experience of a few rounds of CSP to adapt to the expectation that they engage as ‘equal’ partners with the health professional in conversation. Not all seemed particularly able or willing to cede their biomedical priorities and authority to facilitate such partnerships.

The reticence and perhaps limited ability of many patients to engage in CSP recurred in participants’ accounts as a challenge that would tend to limit achievement of the approach’s theoretical promise, particularly in relation to biomedical health outcomes. Some participants quite quickly got “stuck” when patients volunteered little in the way of ideas and opinions (this was perhaps more likely if the health professionals were encouraging a focus on biomedical test results). These health professionals described often ending up with a CSP conversation that was more like a “usual consult”. Those who were also less inclined to recognise other potential benefits considered patients who were less able or willing to engage “less suitable” for CSP. Other health professionals, in contrast, were apparently more determined to hear and work with patients’ perspectives and persisted as constructively as they could with whatever little they could elicit from patients’ initial responses, expressing hope that patients would become more confident and open with more experience of the CSP approach. A few described developing and refining their questioning over time to help patients reflect on and express what was important to them.

Organisational arrangements and policy priorities shaping delivery of CSP

CSP training, professional huddles and PACE-D coordinator support

Health professionals spoke positively about the CSP training they received and the promise of the approach that it conveyed. Some described starting to use some of the ideas and techniques they learned immediately – before patients had been recruited for PACE-D. There were, however, some challenges associated with the training and support provided for health professionals which we note here.

For some participants, a time lag between the training and their first formal CSPs with patients meant they perhaps forgot some ideas and techniques and lacked confidence before they started in earnest. Several participants also reported “getting rusty” during periods of leave or secondment and having to rack their brains to remember what CSP entailed when they returned to the teamlet.

Some health professionals commented in interviews that the scenarios used in training were simpler than those encountered in the clinic where patients did not all follow an ideal kind of script. During the final huddle at which these findings were shared, members of the training team shared a reflection that perhaps they had painted too rosy a picture and so set up too high expectations during the first CSP training session.

The huddles, intended as supportive sharing and learning opportunities, were scheduled for lunchtimes, with food provided. Health professionals typically arrived late as morning clinic sessions ran over time, and they were often visibly tired. In the first huddles, a few practical challenges and questions were raised and addressed, including how to encourage patients to engage with their results information ahead of the consultation (which led to an arrangement that PACE-D coordinators could print a copy of the letter when patients checked in for their appointment and support them to review test results and think about questions or goals before seeing the doctor or nurse). In later huddles, partly in response to insights emerging from this study, CSP trainers shared short videos and presentations encouraging reflection on empathy and goal setting (including attention to goals beyond the biomedical) and examples of completed goal and action plan pages.

Appointment scheduling and clinic session pressures

Both polyclinics scheduled all CSP conversations for two specific weekdays, but routine consultations, including walk-in appointments, were also allocated to these clinic sessions. Some participants found the intermittency of CSP conversations within clinic sessions challenging because they needed to keep switching gears for the change from “usual” consultations.

The workload pressure generated by long patient queues was a strong theme in all interviews. In principle, more time was allocated for CSP conversations (fewer appointments were allocated to clinic sessions with CSPs). In practice, however, participants were often uncomfortably aware that their teamlet partner would be struggling with a long patient queue while they took 20-30 minutes for a CSP conversation – and they would also return to face the queue. All participants admitted at least minor shortfalls from what they understood to be good enactments of a CSP conversation when feeling this pressure. This was well summed up by HP Boon’s reflection that “We may short-change our CSP patients to a certain extent” (w1), but the shortfalls apparently varied in the extent to which they undermined the values and ethos of CSP. When keeping an eye on the patient queue resulted in sometimes rushing a bit, being less fully empathetic, or not working through the steps of goal setting and action planning with patients with well-controlled diabetes and no significant concerns, the shortfalls were arguably less significant than more routinely “cutting short” what patients were saying and “reverting back” to usual consults along the lines of telling patients what to do and being summarily dismissive of those not ready to act on their diabetes as health professionals would prefer.

Teamlet working and record systems: challenges to continuity

Patients’ CSP conversation appointments were to a teamlet clinic session, not to a health professional. Teamlets were notionally staffed by two doctors and a nurse, but various leave and secondment arrangements (especially through COVID-19 disruptions) meant multiple health professionals rotated through the teamlets providing CSP. PACE-D leaders had trained sufficient health professionals in CSP to cover staff movements, but staffing changes limited continuity of professional-patient pairings before and after CSP conversations.

Some health professionals thought the lack of relational continuity could contribute to patients’ reluctance to “open up” in consultations. It could also limit scope to build the kind of rapport that some participants considered necessary to enable them to challenge patients in ways consistent with the empathetic and collaborative ethos of CSP.

Challenges to continuity were exacerbated by limitations of the medical record-keeping system (including after the introduction of the new system). Although the records of patients enrolled in PACE-D were flagged, some participants found it hard to identify which of a patient’s previous appointments had been for a CSP conversation, so struggled to find notes about important information patients might have shared and goals and action plans agreed. Several participants admitted that appointments after the CSP conversation were not always recognised as follow-ups. This could limit continuity of approach as well as continuity of information: a few participants expressed concern that an ethos of empathic engagement with patients’ perspectives was not always sustained as not all colleagues were inclined to extend their use of open questions, affirmation and reflection to consultations other than CSP conversations.

In addition to potentially diminishing patients’ experiences and the effectiveness of CSP, limited relational and informational continuity also obscured health professionals’ view of how patients progressed, potentially depriving them of positive motivational reinforcement when their efforts with CSP were bearing fruit.

A systemic focus on biomedical markers and diabetes

Although CSP training emphasised working with patients as persons and stressed the value of health professionals attending to patients’ concerns and priorities relating to their diabetes and broader wellbeing, participants were aware that the primary outcome of the PACE-D trial was HbA1c, and that their teamlet and polyclinic performance was judged on HbA1c and other biomedical markers, with implications for salary bonuses. Some participants also recognised that several features of the care planning letter (which they often referred to as the “results letter”) tended to encourage patients to concentrate on biomedical markers.

Health professionals managed these potentially competing demands with different emphases. This had implications for their view of what was important for them to hear in CSP conversations as well as their assessment of what was agreed with patients and of subsequent outcomes.

Health professionals who conveyed a narrower view of the purpose of CSP worried that inviting patients to talk about their concerns could expose them to a long list of issues to be addressed, many of which would be irrelevant to the patient’s diabetes or were not things health professionals could help with. These health professionals sometimes acknowledged that it could be useful to find out about a person’s daily routine and key concerns to be able to tailor their professional advice about diet and exercise (to help ensure action plans to achieve biomedical goals were feasible), but their reasoning about this was somewhat narrowly instrumental.

In contrast, health professionals who put more emphasis on the idea that the CSP conversation should focus on the person and what mattered to them seemed also to value learning more about patients’ lives and perspectives. They appreciated getting to know people better and being able to empathise and allow a patient to feel “more human” in the conversation. Some reported a range of benefits of this broader understanding contingent on the situation. We noted above that some participants had developed strategies to “fish out” a sense of patients’ priorities even from those who seemed less able or willing to respond to unfamiliar requests to communicate their goals. A few of those with broader views of the purpose of CSP had explicitly formulated questions to encourage patients to think broadly about what mattered in their lives.

Another key point of variation was whether and to what extent health professionals saw a need for a clear action or action plan to conclude a CSP conversation – particularly to know or have evidence that they had done something to address poor diabetic control. Some participants seemed determined to have a professional or biomedical last word if a person appeared disinclined to do anything for themselves to improve on poor diabetes control, reverting to “usual” consultation practice with an emphasis on their own perspective and reiteration of their advice that the patient really should be taking action. For others, in contrast, CSP training had taught them or supported a previous view that it was not necessarily a professional failure to do nothing, or not emphasise a point that a patient already knew; in some circumstances the kinds of outcomes identified in Table 2 were all that could realistically be achieved at the time.

Health professionals’ evaluations of CSP

We have seen that health professionals varied in terms of how they interpreted and enacted CSP, including in response to the challenges posed in the polyclinic context. In this section, we examine their broader evaluative judgements.

When asked for their overall evaluations of CSP and thoughts about whether CSP should be extended beyond the PACE-D study or to other polyclinics, health professionals were generally cautious in their responses, expressing uncertainty and giving qualified “it depends” type responses. There were various reasons for this, not least that they all awaited the results of the PACE-D trial for evidence of any population-level effect of CSP on HbA1c. As noted, participants only saw clear improvements in biomedical markers in a minority of patients, and limited continuity of care obscured their view of how things went for many of the patients with whom they had CSP conversations. Their interpretation of the lack of evident quick biomedical wins varied, and although they often recognised some other benefits of CSP relative to “usual” consultations, they attached different, sometimes uncertain, levels of significance to these.

No participants expressed any concerns about patients being worse off for being offered CSP (except when considering what would happen if they persistently harangued reluctant patients for ideas and goals – which none of them reported doing). A few, like HP Wu, expressly noted that “there’s never been a case where it is worse than the normal consult” (w2).

For some health professionals, however, the benefits of CSP, whether narrowly or more broadly construed, came at the price of significant professional effort. It could be difficult to learn and remember how to conduct CSP conversations, some struggled to switch between CSP conversations and usual consultations, and the pressure of the patient queue added stress to a longer CSP conversation. Some health professionals became rather demoralised when they did not see many patients come as “prepared” for as hoped for CSP, when they kept getting “stuck” when patients’ engagement was limited, and when fewer patients than they had anticipated showed clear behavioural or health status improvement at follow-up.

Significant administrative and PACE-D coordinator resources were invested in producing and sharing care planning letters with patients and supporting CSP processes. CSP conversations also had opportunity costs in terms of the professional consultation time available for other patients. Resource considerations featured in several “I’m a fan of CSP, but” and “it depends” evaluative statements.

In addition to the proportionality of benefit and effort or cost, overall evaluations of CSP also depended on what health professionals used as their reference comparator. When compared with rare but striking best examples of patient behaviour change and biomedical improvement, health professionals’ more routine experiences with CSP could seem unsuccessful, especially if success was measured over a short time horizon from one CSP conversation. When compared with usual consults, however, they could seem significantly better – especially when richer enactments and a broader set of potential benefits were considered and a longer timeframe was allowed for the realisation of potential health benefit.

Opinions about whether CSP should be extended beyond the PACE-D trial could also depend significantly on which patient groups were considered (or proposed to be included in the future), and how situational challenges and variations in professional practice would be addressed. Some health professionals advocated offering CSP to a more limited group of patients, and perhaps concentrating its delivery among a smaller group of health professionals.

Discussion

The health professionals who participated in the PACE-D trial have contributed to the implementation of CSP in a busy public sector primary care environment, and they sustained it through COVID-19. This is a significant achievement, especially given the documented pressures of working in Singapore’s polyclinics [15, 26]. All health professionals experienced practical challenges associated with local patient demographics (including a significant inter-generational education gap) and features of healthcare systems and culture. They responded to these, and more generally enacted CSP conversations, with varying levels of adeptness and fidelity to the person-centred commitments of the CSP approach. Although all saw positives to CSP, the range of perceived benefits varied, and some were hesitant about the circumstances under which it would be appropriate to extend its use beyond the trial.

The experiences and insights that these health professionals shared allow us to extend theoretical understanding of the significance of health professionals’ interpretive emphases of CSP and the complex interactions of these with external contextual challenges. Our analysis of this, which we report below after a brief discussion of the strengths and limitations of our study methods, is particularly relevant for the development and evaluation of future efforts to introduce CSP and other forms of person-centred support for people with long-term conditions, especially in contexts where prevailing healthcare and broader social cultures include a strong deference on (bio)medical authority. Along with the more evident scope identified in the Results section to modify local systems to address some of the challenges participants in this study reported, this analysis informs the recommendations outlined in Table 5.

Strengths and limitations of methods

In the context of the PACE-D trial, we observed CSP training, interviewed all doctors and nurses who conducted more than a handful of CSPs (half of them twice) and observed a series of professional huddles. We generated a rich dataset that supported detailed examination of both commonality and variation in health professionals’ interpretations, enactments, experiences and evaluations of CSP, and enabled us to consider how these developed (or not) over time as familiarity with the intervention grew. What we heard from the health professionals involved in CSP conversations was consistent with what we learned from PACE-D coordinators and resonated for the CSP trainers (who also led the huddles). Our findings and key analytic points were endorsed by participants when we presented them at a PACE-D huddle.

Important limitations were that we did not observe clinical enactments of CSP and did not attempt to link our interviews with health professionals to interviews with patients. Because the interviews were conducted in the context of the ongoing PACE-D trial, experiences of trial participation inevitably overlay participants’ experiences of CSP in clinical practice. This might have increased some participants’ emphasis on biomedical markers and experiences of tension between biomedical and patient priorities. It does not, we believe, undermine the robustness of our analysis and recommendations.

Contribution to theoretical understanding

As briefly noted in Background and Methods sections, our attention to health professionals’ interpretive emphases and the implications of these for the success of CSP was informed by previous literature highlighting: variations in how health professionals interpret and enact ideas relating to patient empowerment and enablement [18, 19]; the significance of narrower and broader views of purpose in healthcare support for people with long-term conditions [4, 19, 20]; and the tensions that health professionals must somehow navigate when they try to work responsively with what matters to patients in the context of systems which prioritise biomedical outcomes and foster a professional reluctance to endorse behaviours that do not help with health conditions [21, 22].

Our study supports and enables us to extend this previous work with more attention to temporal and teamworking considerations and the operation of interpretive emphases within complex and value-laden systems of healthcare provision. We develop here an analysis of how the interpretive emphases, value commitments and skill repertoires that health professionals bring to CSP interact with practical-situational challenges external to the health professionals involved. We also outline the implications not only for how health professionals conduct CSP conversations and follow-up consultations, but also for their scope to develop their skills with practice, for their experiences of CSP and motivation to use it over time, for the overall impact of CSP, and for health professionals’ evaluations of the approach.

Table 4 identifies variants of some key features of health professionals’ interpretations, value commitments and skill repertoires that are less and more conducive to broadly effective enactments and positive evaluations of CSP among diverse patients. The two columns are not intended to characterise the full spectrum of possibilities within each row, and we are not saying that each health professional can be simply and confidently categorised in just one of the two columns. However, the features listed in each column were all illustrated in our interview data and tended to cluster within health professionals’ accounts (see also Table 1). We outline their implications here.

Table 4 Interpretations and skill repertoires that impact enactments and evaluations of CSP

We take the ‘less conducive’ side first. Health professionals who view improvements in the biomedical markers of diabetes as the ultimate purpose of CSP, and who expect CSP as an intervention to deliver those improvements as a result of patients conforming to expectations that they will actively prepare for and engage in consultations and make and follow through on plans to improve their health, will have relatively little scope to see their efforts with CSP as successful when CSP ‘works’ like this for only a minority of patients. If they further (perhaps relatedly) think that CSP will only benefit patients who come to a CSP conversation already motivated to act to improve their diabetes, health professionals can quickly become pessimistic about its prospects when relatively few people arrive having written in their care planning letter or otherwise willing, ready and able to contribute ideas about what they can do. The value of CSP for people whose diabetes is currently well controlled may also seem questionable.

If health professionals also consider what is unique or importantly different about CSP primarily in terms of process steps, they are less able to reason confidently about when it is appropriate to ‘skip’ certain steps – for example if goal setting and action planning is not a top priority given a patient’s current circumstances and concerns (a tick box process orthodoxy can work against the flexible responsiveness that CSP requires).

If health professionals think the main reason for listening to patients is to identify scope to tailor their advice and better persuade patients to change their behaviour to improve their diabetes, then other things that patients tell them, including about other conditions, financial worries or other social concerns, can seem irrelevant to their conversations. If health professionals feel obliged to address these concerns once raised, however, more open questioning risks adding to their workload or sense of failure. The investment of professional time and energy may not seem worthwhile, especially in busy clinics and amidst concerns about the opportunity costs of the approach.

If health professionals have little prior interest or learning to support their attention to patients’ psychosocial issues, they can get “stuck” quite quickly when patients are not very forthcoming in conversation. If they lack the foundation to develop their communication skills and approaches beyond those covered in the CSP training session, this can contribute to a downward spiral of professional enthusiasm and more negative evaluations of CSP.

In contrast, on the ‘more conducive’ side, health professionals have much more scope to see success if they have a broader and more flexible view of the purpose of CSP, including the idea that the focus of the CSP conversation and any resulting actions should be set or strongly influenced by the patient and what is important to them. Even if a particular CSP conversation cannot be considered an unequivocal success, a broad view of purpose and valuing of the emotional, relational and perhaps intermediate experiential gains from CSP can help health professionals to accept (rather than view as a failure) when CSPs result in little immediate action or evident progress on a professionally concerning health issue. If the patient’s concerns and considered priorities had been heard, the patient was aware of any serious professional concerns, and the door had been left open for further discussion in the future, agreeing to keep important issues in view might perhaps be as far as they fruitfully could go in that consultation.

If health professionals have more realistic expectations about the time frame over which any general, population-level health benefits of CSP are likely to emerge and if they recognise that these depend on multiple other influences beyond the CSP conversation (including follow-up consultations as well as patients’ circumstances and behaviours, and the not entirely linear causal connections between behaviours and health indicators) they are also less likely to be disappointed about what CSP achieves.

The scope to see some success even when patients do not engage with CSP as fully as hoped or do not achieve as much health improvement as the ‘best’ examples is more likely to keep health professionals enthusiastic and motivated to continue with the approach. A sense of potential to learn and improve on enactments of CSP can also help in that regard. In our study, health professionals who expressed strong interests in the psychosocial aspects of primary care or in “people more than disease”, and those with more advanced communication skills and familiarity with reflexive, practice-based learning were also more inclined and confident to develop and refine their enactments of CSP, for example by trying out different questioning strategies. A combination of a broad sense of purpose, commitment to be flexibly and respectfully responsive to patients, and good initial skill repertoire facilitated positive development of practice over time.

Our study demonstrates the complex interactions between health professionals’ interpretive emphases, value commitments and skill levels and the various challenges associated with diverse patient situations and organisational systems. It identifies potential for negative feedback loops to develop from narrow interpretations of purpose and limited initial skill sets, and for positive feedback loops to develop from broader interpretations of purpose, a stronger initial skill repertoire, and confidence and support for reflective learning and skill development.

In healthcare contexts in which there is limited relational continuity in care, significant variability between the various health professionals involved in a team providing CSP will reduce the chance of any one patient from benefitting richly from a CSP conversation and from effective follow through from that conversation. Limited relational and informational continuity also reduce the scope for health professionals to see benefit from their efforts with CSP and make it less likely that patients become more familiar and comfortable with CSP approach over time. Divergence from key CSP principles is thus likely to be particularly detrimental to the overall success of the approach in such circumstances.

Implications for policy, practice and research

There is clearly scope to address some of the challenges for CSP associated with organisational arrangements. Our analysis also indicates that implementation of CSP could be strengthened by constructive attention (and beyond initial CSP training) to those aspects of health professionals’ interpretive emphases that are less conducive to broadly effective enactments of CSP, and perhaps by ongoing support to foster the further development of communicative microskills. Constraints associated with patients’ educational levels and cultural backgrounds are less directly modifiable within health service provision. However, work on healthcare systems and professional skills and attitudes to help ensure patients are more consistently supported with flexible encouragement to ask questions, express their views and concerns, and experience positive responses to these might be beneficial for the longer as well as shorter term.

We have developed recommendations for organisational systems and policy development, for CSP leads and trainers, and for research. These are presented in Table 5, where we also note that informal sharing of findings from this study has already led to several recommendations being implemented in Singapore.

Table 5 Recommendations developed from this study

Conclusions

CSP has been implemented and sustained in two busy polyclinics in Singapore. Health professionals’ accounts have illuminated some important challenges and variability of enactments and experiences of CSP. They supported an analysis that highlights the practical significance of health professionals’ interpretations of the purpose of CSP and their valuation of relational, emotional and other perhaps intermediate experiential outcomes as well as the more typically considered behavioural and biomedical outcomes. Health professionals’ interpretations of CSP, along with their communication skill repertoires and support for reflective experiential learning, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.