Table 5 Recommendations developed from this study

Recommendations for organisational systems and policy development:

• Investigate scope to improve language matches between health professional and patient for CSP conversation appointments

• Review appointment systems to improve relational continuity through CSP consultations and follow ups

• Consider establishing dedicated clinics for CSP conversations or clearly demarcating and protecting a block of time for these within mixed clinic sessions.

• Review the medical record system for scope to facilitate identification of notes about CSP conversations and follow-up (progress review) discussions

• Review Key Performance Indicators and associated incentives to reduce emphasis on biomedical markers and reflect commitment to person-centredness and broader wellbeing^a

• Strengthen post-training support for health professionals delivering CSP (see below)

• Perhaps consider staff assignment to CSPs to reflect interests and skills^b

Recommendations for CSP leads and trainers

• Review the CSP letter as modified for Singapore with a view to more clearly encourage patients and health professionals to reflect on what matters in the patient’s life and for their health and wellbeing (including psychosocial issues beyond the biomedical markers for which test result trends are provided)

• Refer to the CSP letter as a ‘preparation’ or ‘planning’ letter or similar, rather than as a ‘results’ letter to help encourage preparation and with a broader focus.^b

• In training and follow up support for health professionals who deliver CSP:

 ◦ Prepare health professionals more explicitly and practically for some patients coming to CSP conversations ‘unprepared’ and, for various reasons, being not very forthcoming with their ideas^b

 ◦ Encourage health professionals to check and reflect on their interpretive emphases and if necessary consider whether a shift to positions more conducive to broadly successful enactments of CSP would be appropriate. Table 4 could be the basis for a tool to support this. Meanwhile we note it might be particularly important to:

  • Debunk expectations that CSP will mostly go according to the ‘ideal’ model with quick wins in biomedical improvements^b

  • Encourage health professionals to keep in sight a bigger picture of how diabetes impacts patients, to adopt a broad view of the purpose of CSP (enabling people to live well with their condition)

  • Encourage recognition and appreciation of the ‘softer’ relational and experiential benefits of CSP – both in their own right and as possibly intermediate to longer term health benefits.

  • Promote the underlying ethos of CSP as valuable in its own right and attend to this as the basis for the ‘usual’ process steps (a hollow or inflexibly dogmatic tick box approach to CSP steps may be counterproductive, there needs to be an underpinning interest in the person’s wellbeing and life and orientation to a collaborative and continuing supportive approach)

  • Discourage viewing the CSP conversation as a ‘one-off’ intervention

  • Encourage recognition that one can do ‘a good job in the circumstances’

• If possible, offer occasional ‘peer review’ by a skilled trainer who can observe consultations and support individual health professionals to reflect on and improve their practice

Recommendations for interpretations of trial findings and further research

• Be aware of outcomes (including experiences that may mediate longer term health outcomes and are broadly relevant for wellbeing) that are not assessed

• Be aware of varying fidelity to the intervention (and recognise that the adverse effects of some shortfalls in fidelity may be compounded in some circumstances)

• Be aware of potentially modifiable systemic challenges and shortfalls in some professional enactments of CSP conversations and follow up that have likely limited the impact of CSP on health outcomes.

• When inviting or interpreting health professionals’ evaluative comments and thoughts about whether an approach they have tried should be extended, check their reference comparator (an unrealistic ideal or previous usual practice?). If possible elicit and bear in mind how they have understood and enacted the approach, and in what circumstances.

• Be aware that simple rating questionnaires about the value of CSP are potentially misleading if health professionals are making different assumptions about patient populations, working contexts (including organisational support) and the skills of the health professionals involved.

• Qualitative studies of health professionals’ perspectives can add value