With more than 60% of the 422 million persons living with diabetes mellitus, Asia is poised to be the global epicentre of this long term condition (LTC) in this century [1, 2]. Inhabited by 5.7 million residents and nestled within Southeast Asia, the multicultural city-state of Singapore is a microcosm of the sociocultural norms of the region. Given a prevalence of 11.3% among adults in 2010, Singapore has one of the highest rates of diabetes worldwide [3, 4]. Current estimates predict that one million residents will have diabetes in 2050 compared to 440,000 in 2014 [5, 6]. Healthcare cost-wise, USD 1.9 billion will be spent on diabetes in 2050 compared to USD 790 million in 2010 [7]. In response to these projections, Singapore declared a nationwide, long-term “war on diabetes” in 2016 [8]. Support for active self-management of persons living with diabetes was identified as a key focus of the campaign [5].
Over the past decade, it has been increasingly recognised that outcomes for persons living with diabetes and for the healthcare system, are better when persons with LTCs are empowered to take charge of their condition [9, 10]. In Singapore, however, the public primary care clinics (polyclinics) have been designed mainly for efficient medical problem solving rather than for systematic engagement of patients in long-term self-care. As an illustration, a typical consultation for an LTC at the polyclinic lasts 8–12 min, usually used to address new complaints, explain investigation results, problem-solve, provide patient education, and plan subsequent steps. The presence of comorbidities compounds the time-pressure. Most patients and doctors would find it difficult to consider the significance of adopting any positive health behaviour within the time constraints. Given that the bulk of patients with LTCs including diabetes are managed at the polyclinic, there is value in learning and adapting from best practices elsewhere [4].
Personalised care planning
Persons with LTCs have important roles in managing their own health in the context of their daily lives, but often need support, including to develop the confidence and skills to adhere to medications, adopt and maintain healthy lifestyles, and know when and how to seek medical advice. Personalised care and support planning (CSP) has been proposed as a means to provide support from healthcare providers (HCPs) that is individualised to the needs of specific persons with LTCs and oriented to enable them not just to manage their LTCs well in biomedical terms but more broadly to live well with those LTCs [11, 12]. Personalised CSP entails a conversation or a series of conversations between the patient and the HCP when they jointly agree on goals and actions for managing the patient’s health problems [11, 12]. Evidence shows that personalised care planning, most effective when integrated in routine clinical practice, leads to improvements in certain indicators of physical and psychological health status of patients, and their capability to self-manage their condition as compared to usual care [11, 12].
The care and support planning model
Year of Care Partnerships (YoC) in the United Kingdom (UK) has implemented and made iterative changes in the use of CSP for over a decade [11, 12]. The personalised CSP has been conceptualised as a meaningful conversation between partners that occurs within a “house of care” [13] with four components: The prepared person living with diabetes and the trained CSP practitioner form each of two walls of the house, the organisational processes that operationalise the CSP form the roof, while institutional support forms its foundation.
YoC’s experience over the past decade has shown that personalised CSPs have resulted in positive outcomes for patients, HCPs and healthcare organisations. Patients experience improved clinical outcomes in terms of glycated haemoglobin (HbA1c) and blood pressure within 3–5 years of enrolment, in parallel with increased engagement with positive health behaviours. Explicit orientation of care to support personal goals in CSPs was observed to raise practitioner morale and strengthen the practitioner-patient relationship; ripple-effects have been seen at the organisational level with improved levels of productivity at zero additional cost [7, 13]. As a further badge of its success, CSP practice has spread to multiple sites across England and Scotland, [11] and CSPs have been adopted as part of the core curriculum in General Practice training in the Royal College of General Practitioners (RCGP) since 2019 [14].
In Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D), the model of care from YoC has been adapted for the Singapore polyclinic context. Structured on the blueprint of the chronic disease model, [15] it places self-management at the forefront of diabetes management. The programme builds on the clinical experience in the management of chronic diseases in the polyclinic setting and on YoC’s extensive experience with the use of care plans. It is underpinned by the conceptual frameworks of the patient-centred consultation, the theories of adult education and self-efficacy, the concepts of self-management and self-empowerment, [9, 16,17,18,19,20,21] and has been described in terms of six programme theories in a recent realist evaluation [22].
This paper describes the design and significance of PACE-D, a pragmatic controlled trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in the public primary care setting in Singapore.
Primary objective
The primary objective of this study is to examine the effects of personalised CSP (Intervention) compared to the standard model of care (Control) on glycaemic control, as measured by HbA1c.
Secondary objectives
The secondary objectives include investigating the change in patient activation [23], measured by Patient Activation Measure-13 (PAM-13), and the difference in healthcare utilisation and cost between the Intervention and Control.
The selection of the primary and secondary objectives reflects strong health policy interests in Singapore. The intervention designers and research team are aware that they can be in some tension with the idea that CSP involves working responsively with each patient to help them manage their life with the condition rather than (more narrowly) to manage the biomedical aspects of the condition well. To elucidate this further, the qualitative experiences of the participants and HCPs will be researched in parallel with this study.