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.