Table 3 Examples of data extracts coded to NPT constructs

Coherence

Examples of views about whether or not SSME was seen as distinct from routine care

• “It was different from previous reviews with the GP—it included action planning and goal setting.” (Recipient; DESMOND Ongoing; ID 1.01.030)

• “The feedback I got back from patients was fantastic. They all really loved it. […] They found it so helpful. It was the first thing really that people had ever had access to so we were very keen to get DESMOND up and running here because there was not very much that people could access in [location]” (Practice nurse; DESMOND Ongoing; ID PS-A-021)

• “I don’t think it was that different really. I mean I think we do really try and give people responsibility. Plus we do have a lot of support because we have a diabetes specialist nurse who will come in and also give people support”. (GP; DESMOND Ongoing; ID PS-B-023)

Cognitive participation

Buying into the idea of SSME and what it involves

• “I would like to see more GPs come to observe it […] I have had one or two practice nurses [observe], some do but again it’s time constraints. But I have never had a GP […] I personally think that would help them and some commissioners to see what it’s all about.” ([role?], PDG, 020,101)

• “I think the two primary factors behind [low referral] are possible ignorance as to what is involved in the process and secondly lack of local resources so that if you refer and the patient has to wait for weeks or months, which is locally our case, they [don’t attend] and therefore don’t engage in the process and there is nothing coming back to us about the useful impact of SSME. (GP; DESMOND Ongoing; PS-B-019)

• “It pushed you to think more about how you can take responsibility and help yourself & to set goals” (Recipient: DESMOND Ongoing; ID 1.01.024)

• “I am self-employed so when work comes in you have to do the work. You know these things [SSME] take a long time and you have got to take a day off work so it costs me a day’s money […] so it has to be a relative benefit and to be honest after the first ones that I went to, I was not getting any benefit from them at all.” (Recipient: DESMOND Ongoing; ID 1.01.029)

Collective Action

Debates about funding and delivery of SSME

• “Time and resources would be need to implement [SSME] in primary care… you couldn't fit these activities into a normal practice”. (Educator; DESMOND Ongoing; ID ES-A-017)

• “I think the fact that practices are seeing diabetics, the nurses are spending quite a lot of time with patients already, it probably would be a better model if they were formally trained to deliver [SSME], partly on a one-to-one and some of it in a group in the practice. I think that would be a far more cost effective way of doing it. And probably better because the people who are providing the ongoing care, if you like are brought into those messages as well. I think it’s a far better model rather than sending someone on a [course].” (Commissioner; PDG; ID 020,104)

Reflexive monitoring

Views about effectiveness and impact of SSME and suggestions for improving it

• “[SSME] needs to be constantly evaluated to be cost effective”. (Frontline Delivery Staff, PDG, 020,101)

• “Needed to be prepared and to have done some thinking before the care planning appointment, so that you are not put on the spot and come up with goals that you are pulling out of thin air, needs to be explicit that people need to be prepared”. (Recipient; DESMOND Ongoing; ID 1.04.005)

• “I suppose it is too expensive to tailor it to each person, but maybe have different options for people because people are at different stages [of T2DM duration]. People who are retired can perhaps attend any time. They might have different barriers of access or being able to get somewhere or health problems or just simply not being able to drive, but then you get the younger people who are working five days a week and […] it is a drain on resources to keep having half days off.” (Recipient; DESMOND Ongoing; ID 1.01.067)