News and Comment

Shared Decision Making – the response of a whole health economy

Wednesday 12 February 2014

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Noises being made by the likes of NHS England, the CCG Assurance Framework and the National Patients in Control Programme seem to confirm it: Shared Decision Making (SDM) is an idea whose time has come. Defined as ‘an approach where clinicians and patients make decisions together using the best available evidence’ (Elwyn et al BMJ 2010), SDM is unlike many of the other NHS reforms currently gaining pace in that it is an approach not reliant on a whole system response, but rather one characterised by a narrow set of skills and tools (in particular patient decision aids) used by doctors with patients.

It is however increasingly accepted if the wider system reform goals such as integrated and outcomes-based commissioning are to be achieved, SDM will have an important role to play as part of the treatment pathway stretching from primary, through acute care, and back into the community.

It was therefore very exciting to have the opportunity this week to speak about Shared Decision Making with senior health system reform leaders an event on the Wirral hosted by Dr Shyamal Mukherjee MBE, who practices at Central Park Medical Centre, Wallasey, Merseyside.

Wirral has been at the forefront of patient engagement and patient involvement for some years – and many of its local hospitals and GP practices are seen as innovative leaders. The audience for this event included a number of senior GPs, leaders of the CCG, acute sector managers, a regional NHS England representative and those from the Academic Health Science Network and the local Medical School.  In our presentation we outlined the findings from recent Wirral–based research we have conducted on SDM (in the sponsoring GP’s practice), and nationally for Health Foundation. You can view our presentation slides attached here.

The discussion moved from initial scepticism and challenge into broad acceptance of the principles and that more could and should be done to promote SDM in clinical interventions. But perhaps more importantly the group reflected on how SDM should feature much more in pathway design – as clinicians need to share clinical decisions across disciplines and with service providers from the voluntary and community organisations as well as patients themselves. There was for instance, a lively debate concerning a growing number of patients who – sometimes needlessly – are referred into secondary care. It was felt this practice could be stemmed somewhat by the introduction of intermediary expert advisors who would see patients referred into secondary care before they see a consultant to explain the full range of options available to them, including less expensive community based options that might prove just as effective.

Another suggestion was that there needed to be ‘expert intermediaries’ between the GP making the referral into secondary care and consultants who are often have little time to fully explore care options with the patient. At the moment, the argument was made, too many patients arrive to see a consultant having been referred by their GP without a good understanding of what alternatives exist to surgical (and often very expensive) care options.

The barriers to system implementation are however myriad and complex: the lack of consultant and GP time to fully embrace SDM; the capacity of some patients to consider complex information or too much information; the lack of focus in commissioned contracts on SDM; and the difficulty of layering SDM into complex care pathways.

The lack of evidence to inspire doctors to adopt SDM was also a hurdle: “Is there any evidence that this will save money, and if so, in which areas, for what conditions, and over what time period?”, as one attendee put it.

Overall however there was immense potential in some of the ideas that were discussed to overcome these hurdles. We hope to do some further work on exploring potential for SDM in the Wirral and will keep you posted on developments.

Next month OPM will be hosting a seminar on realising the power of patients to produce tangible and radical reforms in the NHS. You can find out more details and RSVP here