News and Comment

Handing over power – How shared decision making can give patients a greater say in their care

Tuesday 15 October 2013

This week I had the pleasure of speaking at the annual ISQua event in Edinburgh: the most beautiful city in the world…does growing up their make me biased?! I was part of a three person team presenting insights on patent-centred care and particularly how Shared Decision Making can help transform patient care by shifting the power from clinicians to patients and creating a less paternalistic NHS.

Our presentation looked at the impact of the MAGIC programme – Making Good Decisions in Collaboration – a Health Foundation funded project that aims to support clinical teams in primary and secondary care to embed shared decision making with patients in their everyday practice. To remind readers:

Shared decision-making is a process where patients and clinicians work together to come to an agreement on a particular course of action, ensuring health services respond to what matters to the patient.

Adrian Sieff from the Health Foundation set the scene by discussing he history of patient-centred care and the Foundation’s rationale for funding the MAGIC programme, I described the findings of our evaluation of MAGIC, and Dr David Tomson, a GP working in Newcastle and primary care lead for the MAGIC programme, talked about his experience of implementing SDM in primary care.

As with any discussion about radical change in organisations as large, complex and rigid as the NHS, the starting point for our presentation was on the challenges that stand in the way of implementing SDM: the culture in GP practices which can be resistant to change; the difficulty of collecting consistent data from patients about their experiences of decision making; the difficulty faced in engaging patients when many prefer to defer to the doctor.

But as David Tomson started to expand on what has been achieved in his practice over the last three years, it becomes ever clearer that the benefits far outweigh the negatives if you are persistent and courageous in pursuing shared decision making. Starting with patients themselves – David was able to point to real stories of patients feeling that they have regained control by being asked to participate in decisions about their health. They spoke about feeling listened to, feeling better for being involved in decisions about what operation to have or drug to take, and feeling ultimately less anxious and more positive about their health.

Then there are the system improvements that result from SDM. David gave the example of the huge number of people who never ‘cash’ antidepressant prescriptions at the pharmacy. Through engaging patients in decisions about their care – looking at the pros and cons and consequences of different care options – SDM is more likely to encourage patients to think and act more responsibility about their own care. Good SDM reduces waste and increases self-care.

The techniques that work in encouraging clinicians to become involved in SDM are wide-ranging and need to be pushed constantly on many fronts. However, it is not about unpicking the way clinicians currently work and starting from scratch, but more about a series of ‘nudges’ to improve on what most clinicians already do. First there are the tools that support SDM and make practice consistent – such as option grids and brief decision aids – which guide clinical encounters and provide patients with information on the pros, cons and risks associated with different care options. Our evaluation showed that these tools, if short, easy to follow and not too prescriptive, are welcomed by clinicians. Then there are the culture changes required – here good, focused, and supportive skills development is crucial as long as it includes a large dose of peer support and encourages whole teams to work together – doctors, nurses, clinic managers and receptionists. Patients also need to be taken on the journey towards SDM – by encouraging them to ask questions about their care, by selling SDM at every available opportunity, and by encouraging patient groups to demand SDM.

David spoke of being inspired to become involved in SDM because of his concern about how power is constructed within the NHS: a place where doctors know best and where people imagine signs above doors that say ‘enter at your peril’. SDM demystifies the NHS through honest dialogue between the patient and the clinician and helps break down the one-sided power relationship which can often feel frightening and disempowering. At a time when some people are beginning to worry that the NHS may not be on their side, could SDM be a way to rebuild trust and support for this vital institution?