Shared Decision Making – the response of a whole health economy

Hi all haven’t blogged for a while… here’s one we made earlier. I wrote this with Ewan King from the Office for Public Management (OPM)….not sure if he’s published it yet?

Presented increasingly as the way care should be delivered – not least in the NHS England CCG Assurance Framework and the National Patients in Control Programme, Shared Decision Making’s (SDM) time has come. Defined as ‘an approach where clinicians and patients make decisions together using the best available evidence’ (Elwyn et a BMJ 2010), SDM can be associated with a narrow set of skills and tools (in particular patient decision aids [PDAs]) used by doctors with patients rather than something that requires the whole NHS system response.

It is however, increasingly accepted that in order for wider system reform goals such as integrated /pathway commissioning or commissioning for outcomes, SDM provides a valuable framework to work within. SDM is now being seen as an integral part of a treatment pathway stretching from primary care through acute and back into the community.

It was exciting therefore to have the opportunity this week to speak about shared decision making to senior health system reform leaders – 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 – from a single local health economy – Wirral.

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. This group of senior leaders were brought together by a local GP with an interest in SDM. Our presentation covered findings from recent Wirral –based research we have conducted on SDM (in the sponsoring GP s practice), and nationally for Health Foundation: our slides are attached.

The discussion was fascinating and 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 and patients themselves. For instance, there was a lively debate about how the growing tide of patients – sometimes needlessly – being referred into secondary care 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.

One 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 their GP without a good understanding of what the alternatives are to surgical (and often very expensive) care options.

The discussion went on long into the evening and were greatly supported by academic and Med school colleagues  one of whom had undertaken a study tour on SDM at a renowned US treatment centre which fully embraces SDM as a critical part of the patients planned recovery.

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.’

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.

OPM are hosting a seminar: Realising the power of patients to produce tangible and radical reforms: Moving from the possible to the essential in the new NHS on the 27 of March