Care and support planning for people with long term conditions: a realist evaluation

Brown, Sarah (2019) Care and support planning for people with long term conditions: a realist evaluation. Doctoral thesis, Northumbria University.

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Abstract

Background: An increasing prevalence of long term conditions (LTCs) and multimorbidity is challenging the sustainability of the National Health Service. There is a major focus in policy to change the dynamics in healthcare systems so that people with LTCs are recognised as equal experts in the consultation. Care and support planning (CSP) has been described as a “better conversation” that supports this and promotes self-management, however, evidence suggests that CSP implementation and impacts are inconsistent. The purpose of this research is to close the gap in knowledge regarding the specific underlying mechanisms and related contexts needed for the effective operationalisation of CSP.

Methods: This study used realist evaluation, which contends that underpinning mechanisms of action are triggered under key conditions, leading to observable outcomes. Context-Mechanism-Outcome configurations provide explanatory statements, which are developed, refined and empirically tested. This was operationalised in three overlapping phases:

1) Programme theories were developed through a rapid realist review of 51 peer reviewed articles. 2) These were refined through a focus group with 5 CSP leaders. 3) They were tested through interviews with 9 CSP implementers and 11 people with LTCs.

Data analysis: Mind maps were used to decipher between contexts and mechanisms and formulate explanatory theories.

Findings: CSP is detailed and explained through 6 programme theories, articulated around preparation, quality conversations, goal setting, shared decision-making, conversation summaries, and communication. Together these explain how, for whom and in what circumstances CSP works best.

Discussion: This study challenges the idea of CSP being a healthcare practice taking place in statutory organisations only. It highlights how people with LTCs are an inherent part of the CSP team, who implement and normalise changes within their own contexts, and therefore inherently challenges the boundaries of what is considered “practice”, and where it is operationalised. In a context of ageing demographics, rising multimorbidity, and strained public finances, the potential relevance and application of this understanding is wide ranging.

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