The development of a prototype measure of the co-production of health in routine consultations for people with long-term conditions

Highlights

• Co-production of health (CPH) could improve healthcare communication in long-term conditions.

• A new measure of co-production of health to observe patient and clinician behaviours is presented.

• Increasing CPH will increase patient-centeredness and communication control in consultations.

• Increasing CPH will decrease clinician verbal dominance.

• CPH can be used to assess decision making about self-management in consultations.

Abstract

Objectives

(i) To develop a prototype measure of co-production of health (CPH) in consultations for people with long-term conditions (LTCs); and (ii) to undertake initial validation of it, using a measure of patient-centred care, as defined by the Roter interaction analysis system (RIAS).

Methods

Mixed methods were applied. A qualitative study gathered 11 experts’ views on what comprised CPH behaviours. These were operationalised and a prototype measure applied to a convenience sample of 50 video-recorded consultations involving clinicians trained in self-management support and patients with LTCs at health services in six UK locations.

Results

Twenty-two CPH behaviours were identified. High frequencies of CPH behaviours in consultations were associated with greater patient-centeredness, less clinician verbal dominance, and more patient communication control in comparison to consultations where CPH behaviours were less frequent.

Conclusion

Although the CPH tool is promising, further testing is required in order to improve reliability and validity.

Practical implications

In the future, the measure could be used to test interventions to promote patient participation in decision making about self-management.

Introduction

The prevalence of long-term conditions (LTCs) reflect changing patterns of health and illness worldwide, and of healthcare delivery [1]. According to the Wagner chronic care model [2], in order to cope with demand, health care systems should adapt to support patients, and there is evidence that one-to-one consultations are effective interventions to facilitate the management of LTCs [3], [4], [5]. In the USA for example, provision in primary care settings is changing to focus on patient-centred medical home models in which front-line clinicians and patients are the main decision makers guiding access to services [6]. Prepared and proactive clinicians could encourage their patients to make healthier choices and stay in good health for longer in each contact with the healthcare system [7], [8], [9]. Peer reviewed evaluations of patient-centred medical models confirmed this strategy increases satisfaction, reduces errors and improves quality of care overall [6], [10].

In the UK, improving the quality of life for people with LTCs has become a mandate for the National Health Service [11]. Co-production, as a service delivery model in which the service user is an active contributor in the delivery of that service, has often been cited in UK health and social care policy as a way forward [12], [13], [14], [15], [16], [17], [18], [19], [20].

Co-production emerged as a critique of the lack of recognition of service users’ input in the successful delivery of a service [21]. As a delivery model for health services, it is based on sharing information [22] and decision making between service users and providers [23]. Co-production is expected to result in the empowerment of front-line staff and in increasing levels of confidence in service users to find suitable solutions to their concerns [16], [23].

Furthermore, the process of co-production aims to obtain highly individualised solutions [22]. This, together with the promotion of long-term relationships between users and providers [15], are two aspects of co-production that can improve the care of people with LTCs [13], [24], [25]. But there is little known about what, in behavioural terms, is expected from the clinician and the patient in a co-productive consultation. Patient-centred care, shared decision making and research into patient participation are well-known approaches to studying healthcare communication that inform the development of a measure of CPH in the context of routine LTC consultations.

According to the patient-centred approach, at a basic level, a consultation is a negotiation between the doctor’s bio-diagnostic agenda and the patient’s psychosocial agenda [26], [27]. The explicit collaborative element of patient-centred care and its emphasis on patient activation and empowerment makes this model an obvious comparator to CPH. However there is a multitude of definitions and measures devoted to patient-centred care [28], [29], which tends to obscure its utility to guide practice. Alternatively, shared decision making (SDM) is an evidence-based approach that built on patient-centred care [30], [31], [32] but which emphasises implementation, as difficulty in adopting new ways of interacting with patients in routine care has been widely reported [33], [34]. Efforts to facilitate implementation are reflected in studies such as Elwyn et al. [35] in which a three-step delivery of SDM: choice, option and decision talk, is recommended. Originally developed in the context of life-threatening disease [30], [31], [32], the potential of SDM in facilitating self-management support is an emerging field of study [31], [36], [37], [38]. Developing a measure of co-production requires integrating SDM as a core principle and learning from the advances made into implementation to practice.

The study of patient involvement in consultations provides resources to observe the interaction from the patient’s point of view. By definition, the patient’s contributions to the consultation are key indicators as to whether co-production has taken place. Street and Millay [39] have extensively researched this aspect of healthcare communication and proposed that patients showed their engagement by expressing concerns, asking questions and making assertive statements [39,p. 63]. People’s behaviours within the consultation are part of their response to perceived health threats and symptoms, as well as help seeking actions, undertaken in order to restore health [40].

This paper presents a prototype of a measure that aims to fill the gap between co-production of health as a service delivery policy and a process that can be observed and measured in the interaction between clinicians and people with long-term conditions. The CPH measure was developed over three phases that are described in the following sections. The first phase comprised a qualitative study designed to gather key informants’ views about what constitutes a co-productive consultation. These results guided the next phase in which the co-production components were operationalised as a measure and its reliability tested. The final phase aimed at assessing the concurrent validity of the CPH measure. Hypotheses were developed to explore whether the engagement of patients and clinicians, through the use of the CPH behaviours, was associated with signs of patient-centred care, as it would be expected We adopted the code combinations of the Roter interactional analysis system [RIAS, 41] employed in previews research aimed at assessing self-management support for people with long-term conditions [42], [43], [44] and the level of patient participation and clinician task-orientation vs. socio-emotional behaviours in the medical encounter [45], [46], [47]. This group of studies defined concepts such as patient centeredness, partnership building, positive non-verbal engagement, clinician verbal dominance and patient communication control, based on RIAS coding. The results provided evidence of interactions in which patients were actively involved in making decisions [42], [45], discussed relevant socio-psychological issues within the consultation [46], [47] and reported having fewer functional limitations due to their illness [43], [44]. These aspects of the consultation were expected in an ideal co-productive interaction and therefore we selected these concepts as comparators to the CPH measure in the validation process. Further details about how these variables were calculated are presented in Section 2.3. Based on this previous work, we hypothesised that increases in co-productive behaviours would be associated with:

• A decrease in clinician verbal dominance;

• An increase in patients’ communication control of the consultation;

• A higher rate of patient-centeredness;

• Increased partnership building; and

• Positive non-verbal engagement.