Person-centred approaches: emerging theories of terms of engagement

Abstract

Background: The growing number of people living with multiple long-term conditions is increasing demand on Global Health Systems at a time of fiscal constraint [1]. To meet this challenge, new models of primary care aiming at enhanced coordination and person centred care have been proposed to improve efficiency and patient outcomes by breaking with paternalistic models of health and encouraging increased self-management within the community [2]. Lack of implementable evidence and guidance has led to the development of local ‘implementation experiments’. We evaluated a number of these ‘experiments’ across southwest England against four routines for practice developed by the Gothenburg centre for person centred care [3]. Methods: To develop theory about how best to engage people in new interventions for the development of person centred coordinated care we conducted a secondary, inductive analysis of qualitative data. This comprised of data generated from structured interviews, focus groups and observations with patients and practitioners that formed part of our service evaluations. Theory was co-produced in workshops involving patients and practitioners. Results: Our data revealed that initially some patients were suspicious of the motives for their inclusion in novel interventions, or did not understand the new model’s rationale. In these cases participants found it difficult to develop a narrative routine one and some individuals declined participation. This was due to underdevelopment of programme theory and inexperience of practitioners in articulating programme aims when introducing the intervention. Evidence suggested that older individuals with more complex care needs may find it more difficult to engage with the new approach, resulting in lack of shared decision making during subsequent goal setting and care planning routines two and three. Co-production was an unintended consequence of bringing participant groups together which produced mechanisms reframing interactions and further developing participants’ narratives. Developing a trusting relationship with practitioners over time also promoted engagement and was more likely to result in development of authentic, holistic narratives and goals. Discussion: Evidence shows that person centred care increases wellbeing and self-management in patients and co-production supports personalised practice [4]. This study gives exemplars of how these principles operate in practice. Personal narrative development is a significant departure from traditional health service encounters in which topics and solutions are defined by practitioners. It may be challenging for patients and practitioners. Conclusions: The establishment of a meaningful patient narrative depends on clear explanations of new interventions and the formation of relationships with practitioners trained in eliciting these conversations. This ‘pre-context’ is fundamental to person centred care since it establishes rules of engagement for the subsequent routines of decision-making and care planning. Lessons learned: Clarity of programme theory and staff training on effective communication and narrative development are imperative to the delivery of person centred care. Limitations: Data was limited to those agreeing to be interviewed, observed, or take part in focus groups; the views and experiences used to develop theory may not be wholly representative of more marginalised individuals. Suggestions for future research: Testing the developed theory in controlled or other well-designed research programmes.