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

HP Eng gave a limited account of the purpose and ethos of CSP: “let patient talk a bit more… so that we can understand the patient more” and so “help them manage their chronic condition better than the usual approach”. He saw CSP as “quite similar” to usual care but with less reliance on medication and more attention to diet and exercise.

In both interviews, HP Eng referred to CSP as “patient-centric”. In w1 he explained this meant “patients realize that all this is for their own good” and that “they also had to take care of their own health”. In w2, he linked the concept to listening to patients’ concerns and giving advice relevant to their situation.

HP Eng valued the graphs in the CSP letter as making it “easier for [patients] to understand” “the target we are aiming for”. He said in w1 “one of the things I’m hearing about the idea of the CSP is perhaps that it’s the patient’s ideas about what they can do” but had no examples of this. In w2 he more confidently described going through each indicator in the letter, using the graphs to give patients “a clearer picture” and provide a focus for goal setting. HP Eng routinely asked patients about their “diet, exercise and then whether they comply with the medication, any side effect or not”.

HP Eng thought the few patients he had seen by w1 were “not that interested”, because they had not completed the results letter. At w2, he still found most patients “not interested”, perhaps because they had financial worries with which “we can’t help the patient”.

HP Eng thought CSP could help him understand a patient’s situation and so tailor advice-giving. However, it was “not so helpful” if patients “don’t give you much” or “are not so willing to work with you”.

HP Eng saw no impact of CSP on empathy, rapport or respect in his communication with patients. He said he rushed CSP conversations because “the queue builds up and we can’t afford” 30 minutes.

HP Eng saw it as a limitation of CSP that patients were often not motivated to modify their diet or exercise to improve diabetes control.

HP Eng did not directly answer questions about continuing with CSP but emphasised that it was difficult given clinic time pressures.

HP Chen regarded improvement of diabetes control, and especially HbA1c, as the purpose of PACE-D and focus of the CSP conversation. He thought CSP could be “quite helpful” for patients with poorly controlled diabetes who come prepared and motivated. However, he “rarely” saw such prepared and motivated patients, especially through to follow-up. At w1, HP Chen had not seen any clear examples of improvement in HbA1c. By w2, he had seen one or two patients “that really achieve their goal” of improved sugars or weight.

HP Chen found CSP “tough” and “tiring” in the busy polyclinic with the stress of the patient queue and the challenge of changing pace between usual and PACE-D consultations. This did not improve with experience. HP Chen admitted “cut[ting] patients short” in the telling of their concerns, finding mentions of non-life-threatening problems an unhelpful diversion. He sometimes skipped to goal setting.

When reviewing CSP letters with patients, HP Chen prioritised blood sugar, blood pressure and cholesterol levels. When the patient queue allowed, he tried to “pause a little” to ask patients about family, work and what is important to them before sharing “some sad stories” about patients with uncontrolled diabetes who didn’t listen to advice and suffered complications. Although some patients would “just keep quiet” he could “try to push” those “able” to say “of course they wanted to be still independent” to help them set goals and achieve targets for sugar control. If time allowed, HP Chen would ask about their routine so his advice could be more practical for their situation.

HP Chen thought patients could feel more respected when given time to share their concerns but saw the time it took to hear these as a disadvantage for staff.

HP Chen favoured the faster resolution and lower resource use of usual consultations but thought neither these nor CSP made much difference for patients with poorly controlled diabetes who did not take prescribed medicines.

For HP Chen, the main challenges of CSP were time constraints and patients’ lack of motivation. With uncertainty about CSP’s impact on diabetes control and concern about staffing levels and resources, HP Chen was not inclined to recommend continuing CSP for all people with diabetes but perhaps not averse to continuing with a more select patient group.

HP Ho talked very positively about CSP training as having “opened up” for him a new way of consulting. He saw CSP as an approach that could help him “understand the patients better”, work “together” with them “toward a common ground” and so improve their care.

It took time for HP Ho to get beyond consciously telling himself to “change mode” for CSP and get comfortable using the approach. He also needed to remind himself about CSP after time away from the Teamlet. His self-reminding focused primarily on “shared decision-making” the “OARS” skills and “patients’ goals”.

HP Ho found some patients were reluctant to say much, perhaps because they were not used to the CSP approach. However, he could usually “fish out” something useful in a conversation and valued coming to understand the patient even a bit better. With CSP, HP Ho heard things that he didn’t used to hear, including what people were concerned about and why. If he learned about a difficult home or work situation, he could at least show empathy and not suggest or expect impossible diet or exercise changes.

HP Ho used CSP type questions in other consultations as well as designated CSP conversations. His reflections on goal setting with patients who found this difficult led him to suggest that sometimes “starting” something might be an appropriate goal.

HP Ho thought CSP gave health professionals a better chance of improving healthcare and outcomes (he had a keen interest in reducing cardiovascular risk). CSP could help him increase patients’ motivation – for example supporting someone to lose weight because they wanted to feel better about themselves. He also appreciated that CSP could ensure patients felt more listened to and respected. Even if the agreed action was only to keep medications at the same dose, he could be more confident that was what the patient wanted.

HP Ho was not sure that CSP had benefitted all the patients he saw (he lacked evidence, including about patient satisfaction) but he was confident it benefited some. He would “strongly encourage” continued use of CSP and the incorporation of its principles into daily consults. He stressed that the CSP system depended on the ongoing support of PACE-D co-ordinators and extended consultation times.

HP Wu stressed the collaborative aspects of CSP. It “made a lot of sense” to her that patients got their lab results before consultations, and she valued how CSP “flipped” the conversation to ask what was important to the patient. HP Wu had started using what she learned from CSP training immediately and found patients responded positively to open questions about what they thought. She now finds it “difficult to not” use this approach in her consultations.

HP Wu emphasised a need for the collaborative ethos of CSP to be followed through between the main CSP conversations. She prepared carefully for CSP conversations and follow-ups and had found a way to search medical records for panels of lab tests to help find notes from the CSPs that followed.

HP Wu admitted struggling with long patient stories that she thought she could predict the end of. “Speed is a thing” in the polyclinic and professional training had taught her that good doctors diagnose and act quickly – but she had learned to listen and see where the story took her. HP Wu gave detailed examples of different kinds of benefit derived from hearing what a patient would have been less able to share in usual consultations

HP Wu appreciated that various forms of progress might be made in a CSP conversation even if no goals were set or actions plans made. She stressed a need to avoid imposing a tick-box process orthodoxy for CSP on health professionals: sometimes, for example, goal setting and action planning was less necessary or appropriate. HP Wu also reflected that as a deeply personal process, goal-setting could make patients feel vulnerable so needed to be supported carefully.

HP Wu considered CSP beneficial for both patients and health professionals. Even at its worse a CSP conversation would be no worse than a usual consultation for patients. She favoured continuing with the approach but noted that while some health professionals spent time on CSP with some patients, others would be working with a queue of patients who would receive less contact time.