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.