Terms of engagement for working with patients in a
person-centred partnership: A secondary analysis of qualitative data

1 | INTRODUCTION
Person centredness is currently promoted across international health
systems as part of a turn towards more participatory health care
(Castro et al., 2016). This approach proposes a model of personhood
beyond the biomedical features embodied in the role of ‘patient’.
Personhood values the individual’s capacity, preferences, assets
and their power to co-create their own health (Ekman et al., 2011;
Sen, 2002). Self-responsibility in the management of long-term illness is viewed as an antithesis to patients as passive recipients of
care. Definitions of PCC and participation have evolved and converged in recent years (Castro et al., 2016; Fumagalli et al., 2015).
However, in the United Kingdom, the concept of person centredness
has been introduced within the context of fiscal constraint in statutory services. This has led some patients to believe changes in their
care represent the neoliberal shrinking of public services in light of
the costs incurred by growing numbers of people with long-term
conditions and multi-morbidity.

2 | METHODS
2.1 | Secondary analysis of qualitative data
Primary data were collected between 2014 and 2018 during mixed
methods formative evaluations of five primary care interventions, which
aimed to promote PCC for individuals with multi-morbidity living in the
community. The evaluations assessed patient outcomes in health and
well-being, implementation barriers and facilitators and addressed
the research question of whether the interventions were aligned with
the GPCC routines (Close et al., 2019; Lloyd et al., 2015; Sugavanam
et al., 2018). Approval was obtained from the Health Research Authority
to integrate and publish work from the five evaluations as part of our
programme of work (Ref: 18/NE/0143, Tyne and Wear). Individual participants gave written informed consent for their data to be collected
and to be used in scientific publications. The original qualitative data set,
used here for secondary analysis, is described in Table 1.

2.2 | Step 1: Emergent PT
A process of retroduction (Pawson, 1997) was used to build initial
theories about contextual factors that influenced how the projects
did, or did not, fulfil their aim of working in a PCC way and the mechanisms that were operating on this process. Specifically, we identified that some individuals failed to fully engage in PCC programmes,
and it was this common finding across all of the evaluation projects
that led us to generate an emergent PT (the terms of engagement).
The theory constituted a precondition for person centred routines
to commence. Without engagement, defined by our analysis, PCC
would fail to initiate.
2.3 | Step 2: Secondary analysis of primary
evaluation data
The emergent PT was tested by developing “If–Then” statements
(Pearson et al., 2015) from the primary data reports and researcher
reflections. These ‘micro-theories’ express a relationship between
context and mechanism that lead to a particular outcome. The statements were organised into nodes in QSR Nvivo 12 and coded against
a sample of the primary evaluation data to test researchers’ interpretations (Dalkin, 2015). Data were coded both deductively (from
the initial PT) and inductively (exploring new aspects of meaning).
This was refined until we had identified enough nodes to establish a
framework to identify relationships that would later inform development of CMO configurations. The relationships were tested against
the other data sets as described below, to reflect any disconfirming
examples and ensure no relationships were missed.
2.4 | Step 3: Stakeholder workshops
Two stakeholder workshops were conducted to build co-produced
“If–Then” statements. The first comprised six people with long-term

2.5 | Step 4: Testing of consolidated “If– Then” statements
Consolidated “If– Then” statements were then back- tested against a set of previously un- sampled primary evaluation data (Gwernan- Jones et al., 2020). This allowed direct validation against the complete and original data source. Sampling of the evaluation data was purposive, with respondent cases selected to provide information about contexts, mechanisms and outcomes of interest and to test specific aspects of PT. Additional cases were sampled theoretically on the basis of their potential for confirming or disconfirming emerging statements.

2.6 | Step 5: Consolidated “If– Then” statements developed into explanatory CMOs: Building the final Pt
A process of constructing, exploring and refining led to a consolidated set of ‘If– Then’ statements (n = 87), which identified relationships between CMOs. These CMOs were then cross referenced with original source material (primary data, theory building workshops, researcher reflections) see Table S2. Working through this process, we identified a number of new CMOs. Each element of the configuration was assigned a letter (i.e., C = context, M = mechanism, O = outcome) and a numerical label to ease retrieval, based on their function within a causal chain. These are reported in findings as the below example (mechanism no. 13) in which a statement from a practitioner workshop was coded as a ‘shared understanding of purpose’ (M #13):
If the practitioner is skilled and sensitive (M1 = mechanism of programme resources) [they] make things manageable and achievable (M2 = mechanism of reasoning) then patients are more likely to move towards their aims (O = outcome).