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Confidential: For Review O

nly

Implementing shared decision making in routine NHS

settings - lessons from the MAGIC Programme

Journal: BMJ

Manuscript ID BMJ.2016.033197

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the Author: 26-Apr-2016

Complete List of Authors: JOSEPH-WILLIAMS, NATALIE; Cardiff University, College of Biomedical Life Sciences Lloyd, Amy; Cardiff University, College of Biomedical Life Sciences, Centre for Trials Research Edwards, Adrian; Cardiff University, College of Biomedical Life Sciences,

Division of Population Medicine Stobbart, Lynne; Newcastle University, Institute of Health & Society Tomson, David; Collingwood Surgery Macphail, Sheila; The Newcastle Upon Tyne Hospitals NHS Foundation Trust Dodd, Carole; The Newcastle Upon Tyne Hospitals NHS Foundation Trust Brain, Katherine; Cardiff University, College of Biomedical Life Sciences, Division of Population Medicine Elwyn, Glyn; Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice Thomson, Richard; Newcastle University, Institute of Health & Society

Keywords:

Shared Decision Making, Patient centred care, Implementation, Patient

involvement, Quality improvement, Patient participation, Physician-patient relations

https://mc.manuscriptcentral.com/bmj

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BMJ Analysis

Implementing shared decision making in routine NHS settings –

lessons from the MAGIC Programme

Implementing shared decision making is challenging, but possible, argue Natalie Joseph-Williams and

colleagues. A multi-level approach targeting organisations, clinicians, and patients is needed.

Natalie Joseph-Williams, Research Fellow 1

Amy Lloyd, Research Fellow 2

Adrian Edwards, Professor 1

Lynne Stobbart, Senior Research Associate3

David Tomson, Executive Partner and Freelance Consultant in Patient Centred Care4

Sheila Macphail, Consultant in Obstetrics and Fetal Medicine and Assistant Medical Director5

Carole Dodd, Programme Manager5

Kate Brain, Reader1

Glyn Elwyn, Professor6

Richard Thomson, Professor 3

1 Cardiff University, College of Biomedical and Life Sciences, Division of Population Medicine,

Cardiff, UK

2 Cardiff University, College of Biomedical and Life Sciences, Centre for Trials Research,

Cardiff, UK

3 Newcastle University, Institute of Health & Society, Newcastle upon Tyne, UK

4 Collingwood Surgery, North Shields, Tyne and Wear, UK

5 The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK

6 Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, New

Hampshire, USA

Corresponding author: Natalie Joseph-Williams

[email protected]

Current word count: 2084

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Adoption of shared decision making (SDM) into routine practice has been remarkably slow, despite

forty years of research and considerable policy support. We need to move away from the traditional

research settings to learn from implementation work at the coalface, in collaboration with clinicians and

leaders responsible for routine healthcare. We need to identify what is and is not going to work in

reality. The MAGIC (Making Good Decisions in Collaboration) programme was commissioned by The

Health Foundation in 2010 to design, test, and identify the best ways to embed SDM into routine

primary and secondary care settings (see Box 1 for summary of MAGIC).[1 2] Here we draw upon our

overall learning from the three-year MAGIC programme, discuss the key challenges of implementing

SDM, and offer practical solutions to address them (See Table 1 for summary of solutions).

Key Challenge 1: “We do it already”

Attitudes are a key challenge facing any change programme. Introducing routine SDM and patient

choice requires both structural change, in terms of healthcare pathways and delivery, and culture and

attitudinal change amongst clinicians. Many clinicians feel that they already routinely involve patients

in decisions about their care, so often do not see how SDM differs from their usual practice. A minority

sees their role as ‘decision maker’ to act in the best interests of their patients. Clinicians’ long held

commitment to doing what they perceive to be the best for their patients is a key barrier to attitudinal

change. This is well intended, but fails to recognise that the individual patient’s values, opinions or

preferences might differ markedly from theirs.

An essential step in implementing SDM is to increase understanding of what it entails – that is,

‘building coherence’.[3 4] Clinical teams need support to review current practice, to build a shared

understanding of how SDM differs from their current practice, and to decide how they want to make

decisions with patients. Interactive skills training workshops using the SDM Model for Clinical

Practice[5] (Figure 1) were essential for building coherence, improving skills and promoting positive

attitudes (a slight variant of this model is also available).[6] Workshop feedback indicated that role-play

based training, with an emphasis on practical skills, worked better than theory-heavy presentations. We

increasingly included exercises that challenged embedded attitudes and promoted discussion around

them. The teams were generally already good at recognising options and discussing them with patients,

but risk communication and the task of ‘exploring what matters’ to patients, needed improvement. The

SDM skills training helped clinicians understand the key aspects of SDM and how it differed from

current ways of working. Some clinicians reported ‘light bulb’ moments, changing their view from ‘we

do this already’ to ‘we could do this better’.

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Key Challenge 2: “We don’t have the right tools”

SDM is sometimes seen as giving patients decision aids (materials that help patients through the steps of

the decision making process). Many clinicians believe they cannot deliver SDM if they do not have a

‘tool’ to give their patients, or that a tool itself will enable SDM. One of the key learning points from the

MAGIC programme was that ‘skills trump tools, and attitudes trump skills’. It is therefore important to

build coherence of attitudes and understanding. Then, clinicians need to consider their approach to

communication skills to engage patients in decision making. Only then can timely access to evidenced-

based tools help to support the SDM process, but they are not an essential element. There will never be

decision support tools for every decision, nor will every patient find them acceptable or helpful. The

skills to have different types of conversations with patients are paramount, with or without an available

tool.

In the skills training workshops, role-play was particularly effective for showing that tools may support

the process, but do not replace SDM communication skills. Traditional outside-consultation tools, such

as websites, are costly and time consuming to develop and keep updated. Developing brief decision

support tools helped overcome this challenge.[7-11] Clinicians readily designed brief evidence-based

tools to use inside the consultation, such as Option Grids TM in the Cardiff sites[7] and Brief Decision

Aids in the Newcastle sites.[11] These provide short (1-3 pages) summaries of the treatment choices, the

likely outcomes, and the factors that patients might consider when making their decision. These brief

decision support tools assist with information sharing, providing risk and benefit data that are accessible

to both the clinician and patient together. Experience from MAGIC also suggested that in-consultation

tools were often better at facilitating discussion between patient and clinician than those used outside

the consultation. Some patients used the tool’s content to guide their own questions for the clinician and

it prompted them to ‘discuss what mattered to them’ – the nub of SDM. However, using such tools in

the consultation does not equate to SDM. The main danger is clinicians using brief decision aids to

enhance information transfer and their ‘talking at’ patients skills, rather than improving their ‘working

with’ patient skills – success depends more on skills and willingness of the patient and clinician to

contribute to the conversation, rather than use of decision aids.[12]

Key Challenge 3: “Patients don’t want shared decision making”

Clinicians often report that their patients ask ‘what would you do, doctor?’ and conclude that their

patients do not want to be involved in making healthcare decisions. The question is perfectly valid in the

context of SDM, and is one way of seeking the clinician’s expert opinion. It is different to the question

‘what should I do, doctor?’, which suggests a desire for a paternalistic approach. Indeed, it is worth

remembering that ‘shared’ in SDM recognises the value of two sources of expertise in the discussion.

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Many patients feel unable, rather than unwilling, to share in decision making.[13 14] Some patients

think they will annoy clinicians by trying to be more involved,[15] and their desire to be a ‘good’

patient over-rides their desire for sharing decisions. Often this emerges from long standing experience

and expectations of a paternalistic approach and is more common in older people.[16 17] This can be

mistaken for lack of interest in engaging in decision making. Clinicians’ misconceptions about what

they think patients want must be addressed. They cannot make every patient be more involved, but more

can be done to make patients feel included and respected, and clinicians can often make more effort to

understand what is important to the patient. However, patients may also need support and preparation to

take part in a different type of consultation.

Patient activation and preparation are potentially valuable, and can increase the likelihood of patients

and clinicians being involved in mutually useful conversations. Patient activation campaigns focus on

changing patients’ attitudes about involvement in healthcare decisions, explaining what SDM involves,

why it might help, and provide interventions such as question prompt lists. Some patients do not know

what SDM is, or what an SDM consultation is like; activation interventions such as the ‘Ask 3

Questions’ campaign used in the MAGIC programme can help patients know what to expect, and give

‘permission’ and encouragement to be involved (See Figure 2).[18-20]. These can be operationalised in

a variety of ways such as leaflets, posters, clinic letters and video. Interventions promoted from within

healthcare organisations are better received and convey that the organisation and clinicians support

SDM.

Successful implementation also needs wider patient and public involvement. In the MAGIC programme

we included both condition specific representatives for local interventions, and a wider user panel to

guide the broader implementation process. The lay panel was crucial in identifying areas for

improvements in the implementation work, providing users’ perspectives (i.e. identifying needs), and

aiding intervention development and testing.

Key Challenge 4: “How can we measure it?”

Clinicians and managers implementing SDM want to know what difference it makes to their patients,

and to clinical practice. In the MAGIC programme we found it difficult to identify or develop suitable

patient-reported measures to capture experience of SDM. Patient-reported measures are hampered by

ceiling effects, or social acceptability bias (wanting to give high ‘satisfaction ratings’), and patients may

also not fully understand and identify SDM when it occurs if they have not experienced it

previously.[21] However, the short three-item CollaboRATE measure (used in over 40 studies

worldwide) shows promise in addressing these issues.[22]

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Tensions exist between desires for validated, reliable measures (measurement for research), and

measurement for quality improvement. Focusing on the latter helped embed SDM more readily with

some clinical teams. When measures directly informed practice and improved patient care, in real-time,

we witnessed greater motivation to improve and to sustain the improvement (e.g. Decision Quality

Measure in breast cancer, see Table 1).[23] Linking with local quality improvement expertise and

resources, where available, was valuable. For example, the 1000 Lives Plus national improvement

service for NHS Wales had supported QI skills development within the Cardiff site, which could be

utilised within the implementation of SDM.[24]

Key Challenge 5: “We have too many other demands and priorities”

Changing attitudes and behaviours involves effort at micro and macro levels. Clinical teams face many

competing demands and priorities, some of which are compulsory, some even incentivised (whether

financially or by targets). For example, there are tensions between the SDM approach and the Quality

and Outcomes Framework, where GPs are financially rewarded for behaviours that are evidence-based,

but not necessarily about what matters most to the patient. There are also increasing tensions between

SDM and clinical threshold guidelines or referral management schemes, which are widely applied

within commissioning in England. Similarly, for cancer treatment time targets current emphasis is on

time to treatment, but patients may prioritise time to make the decision.

Visible organisational buy-in and support are essential. This may be at Executive Board or middle

management level (or equivalent level in primary care). During the MAGIC programme, key

organisational leaders showed the clinicians that SDM was an important organisational priority to drive

improvement (see Table 1), and clinical leadership was key for driving implementation. SDM should be

framed as adaptation of existing clinical practice, not as a new and additional element of practice.

Framing interventions as healthcare organisation priorities that improve current practice, rather than

new additional tasks, also led to greater engagement. Clinicians then saw SDM as something the

organisation does, rather than another ‘initiative’ being ‘done to them’ and competing with other

demands. Teams sometimes needed support from the organisation to adapt clinical pathways to support

effective SDM; the SDM ‘tasks’ can also be distributed among different clinical team members e.g.

midwifes support decision making about mode of delivery, rather than a doctor. Many teams also have a

strong clinical identity, which can lead to insularity or, more positively, self-reliance. Shared learning

about ‘what works’ was essential and avoided ‘reinventing the wheel’.

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A ‘shared decision making bundle’ – recommendations for implementation

We have discussed the key challenges faced during a SDM implementation programme in varied

clinical settings, across primary and secondary care, and in different healthcare organisations, including

commissioners in England. This summary is inevitably oversimplified, and cannot capture every

nuanced problem or barrier encountered during the programme. [14 25] We worked in complex settings,

with complex relationships (see Figure 3 for an outline of key factors influencing SDM

implementation).

We offer some solutions to these, from our experience. Many other factors also affect implementation

attempts, which are beyond the remit of a localised learning programme. In the real world, finance,

resources and time are all scarce. Although SDM is mentioned in key policy documents, such as the

NHS Constitution 2015 (see pages 4, 15),[26] it is not incentivised at national, regional or organisational

levels. These wider aspects need policy changes and the input of professional bodies. Furthermore, we

need to focus on cultural change among clinicians and patients, and this is a momentous challenge. A

receptive culture will only truly exist if clinicians view SDM as usual practice and as a fundamental

component of safe, effective and compassionate healthcare for patients, not as an optional style of

communication if we have time. It needs to be embedded in the medical and nursing curricula, and

inter-professional training programmes. Similarly, much health policy and professional practice has led

to feelings of powerlessness and passivity for many patients. Increasing patient agency and health

literacy is going to be equally important.[27]

Implementing SDM is challenging, but possible. It requires interventions targeted at organisations,

clinicians, and patients: a ‘shared decision making bundle’. No one intervention in isolation will succeed

alone. It requires the bundle of interventions working together at the different levels to achieve SDM

across the board.

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Table 1 – Recommended solutions to key shared decision making implementation challenges*

Intervention /

approach

What it involved* What it helped with

Interactive

SDM skills

workshops

Two to three-hour session.

Based on SDM model for clinical practice.[5]

Interactive session using clinical scenarios and role play with actors or other

participants.

Focus on practical skills, less on theory of SDM.

When feasible, used existing training / meeting structures (e.g. MDT) and

processes (e.g. CPD); more likely to engage senior clinicians with this

approach.

Examples of the SDM skills workshops are available from -

http://personcentredcare.health.org.uk/resources/shared-decision-making-

skills-training-workshops

Challenging clinicians’ attitudes.

Differentiating SDM from current practice.

Developing shared understanding of the approach to decision

making.

Improving SDM micro-skills.

Overcoming the belief that SDM is only about tools.

Demonstrating the critical nature of understanding what is

important to the individual patient (values).

Development

of brief SDM

tools

Facilitating teams to identify key decision points suitable for SDM.

Mapping care pathways to agree on point of delivery.

Developing brief evidence-based in-consultation tools (1- 3 pages), e.g.

• Option Grids – available from The Option Grid Collaborative

website (http://optiongrid.org)

• Brief Decision Aids – available from the Patient website

(http://patient.info/decision-aids)

Developing tools that are locally relevant and fit with care pathway.

Patient representative involvement in design and user testing to refine tools.

Making reliable information available at the time of the

consultation for both patient and clinician.

Information sharing between clinician and patient about options.

Facilitating a SDM discussion between clinician and patient

(more than information transfer alone), by changing the dynamics

of the consultation.

Getting clinicians to support and engage with the SDM approach.

Increasing likelihood of implementation (when developed

locally).

Patient

activation &

preparation

Dedicated panel of patient and public representatives (general or clinical

team specific) to guide development and testing of interventions, and guide

implementation plans.

User panel helps to identify areas for improvement, identifying

user needs, and intervention design and testing.

Changing clinicians’ perceptions that patients do not want SDM.

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Patient ‘activation’ – preparing patients to participate in SDM. This includes

raising awareness of the approach, explaining what it involves, and

providing tools/skills to help with engagement (e.g. ‘Ask 3 Questions’

campaign). A mix of elements e.g. posters and videos in waiting areas and

on web sites; flyers; launch event. Sent ahead of consultations with

appointment letter.

Examples of the Ask 3 Questions materials are available from:

http://personcentredcare.health.org.uk/resources/ask-3-questions-materials

Increasing patient awareness of SDM.

Promoting positive attitudes among patients about SDM

Preparing patients ahead of time to become more engaged in the

decision making process.

Measurement Measurement for improvement for driving change in clinical teams.

Clinically useful measures that have a direct impact on practice

e.g. Decision Quality Measure for breast cancer. Measures patients’ knowledge and

preferences. Breast care team use the tool to identify knowledge gaps and

demonstrate improvements in knowledge, and to elicit patients’ preferences (for

further discussion during SDM process).

Link to healthcare improvement programmes, when possible (expertise and

resources).

Utilise existing routine data collection systems, when available.

Engaging organisations and clinical teams.

Demonstrates improvement / change associated with SDM.

Belief that SDM is an organisational priority and a valued

activity.

Reminds clinical teams that they and the organisation is interested

in SDM.

Collaborative

& facilitated

approach

Dedicated clinical lead.

Regular contact.

Clinical team mapping care pathways and identifying areas for

improvement. Also assessing fit with current pathways and other objectives

/ priorities.

Regular shared learning opportunities (e.g. clinical lead meetings, learning

sets), including top-up learning sessions where clinicians could bring real

world challenges back to the SDM trainers.

Clinical leads help to drive the work forward in each clinical

team.

Understanding clinical teams’ priorities / demands and making

sure SDM fits in with these.


Motivation to engage with and sustain implementation.

Organisation

buy-in / senior

level support

Visible organisational buy-in and executive / senior level support of SDM

For example


Belief that SDM is an organisational priority and a valued

activity.

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Walk-arounds (clinic visits) by Executive Board members

Internal Board reports identifying shared decision making as an

organisational priority

Grand Rounds presented by senior clinicians

Dedicated Executive Board member working with implementation team

“Board check list”

Framing interventions / approaches as healthcare organisations initiatives

(internally promoted).

Patients’ perceptions that the organisations and clinicians want

them to become more involved.

Structural

considerations

Supportive policy context i.e. making sure broader healthcare policies align

with the principle of SDM.

Encouragement and support from professional bodies of SDM approach.

Integration of patient-centred care / SDM into undergraduate medical /

nursing curriculum and continued inter-professional development.

Ensuring other systems / targets are compatible with SDM approach e.g.

Quality Outcomes Framework, criterion based systems of referral

management and guidance

Incentivisation at national, regional and organisational level.

Role of commissioning in England e.g. inclusion in CQUIN

Enabling clinicians and managers to see SDM as part of what

they already do – linking to other aspects of patient centred

practice.

Gradually moving SDM from ‘project’ to something that is part

of the organisation’s core function.

* A wide range of the MAGIC resources / interventions listed in this table can be found on The Health Foundation’s Person Centred Care Resource Centre:

http://personcentredcare.health.org.uk/ All materials are available open access.

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Box 1 – A summary of the MAGIC programme commissioned by The Health Foundation

Cardiff

Sites

• Cardiff University (lead)

• Cardiff and Vale University Health Board

Clinical areas

• Four general practices

• Breast cancer (surgical options for early

stage breast cancer)

• Chronic kidney disease (treatment for end-

stage renal failure)

• Head and neck cancer (treatment options for

head and neck cancer)

• Paediatric ears, nose and throat (surgery for

recurrent tonsillitis)

Phase 1 (August 2010 – February 2012) Aim - design and test the best ways to implement SDM into routine clinical settings

Quality improvement methodology

Primary and secondary care settings

Multi-centre programme based in Cardiff and Newcastle (UK)

Newcastle

Sites

• Newcastle University (lead)

• The Newcastle upon Tyne Hospitals NHS

Foundation Trust

• Northumbria Healthcare NHS Foundation Trust

Clinical areas

• Four general practices

• Breast cancer (surgical options for early stage

breast cancer)

• Maternity (options relating to mode of delivery

after caesarean, place of birth, and screening for

Down’s syndrome)

• Urology (treatment options for prostate cancer)

Phase 2 (February 2012 – October 2013)

Aim – demonstrate that SDM can become part of routine clinical care (wider dissemination,

implementation and sustainability) and build practical and transferable knowledge about the conditions for

success.

Cardiff

Summary

• Work with up to 10 clinical teams

across the Cardiff & Vale University

Health Board to involve more patients

in shared decision making (spread from

Phase 1)

• Underpinned by a nine-step consultancy

model and the Model for

Improvement[1]: moving from

expression of interest, establishing team

readiness and priorities, action planning,

to implementation & sustainability

• Teams had access to support and

interventions/ approaches developed

during Phase 1: SDM skills, decision

support tools, patient participation,

quality improvement support

Newcastle

Summary

• Provide tools, materials and resources to enable

clinical implementation teams from MAGIC 1 to

continue their plans for sustainable change

• Engage with four new clinical teams (two each

from primary and secondary care)

• Engage with third sector organisations, providing

versions of skills training workshops to service

users and advocates

• Work closely with organisational strategic groups

and with emerging commissioning organisations

• Continue to support clinical teams that are not

part of the MAGIC programme per se, both those

who have already expressed an interest and begun

implementation of SDM and new teams that make

an approach

• Further develop a range of tools, materials and

processes to facilitate spread of SDM and to

demonstrate sustainable change.

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Figure 1 – Shared Decision Making Model for Clinical Practice (from Elwyn et al 2012)[5]

Choice

Talk

Option

Talk

Decision

Talk

Decision support

Brief or extended

Initial preferences Informed preferences

Decision

D E L I B E R A T I O N

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Figure 2 – Examples of the ‘Ask 3 Questions’ campaign posters used in MAGIC

a) Cardiff general patient poster b) Newcastle children’s services poster

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Figure 3 – Summary of key factors influencing SDM implementation

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Contributors and sources:

This paper originated from the learning from the Making Good Decisions in Collaboration (MAGIC)

Programme, funded by The Health Foundation. NJW drafted the manuscript, and all authors worked collaboratively to contribute to the content, edit, and agree the final version. All authors were involved

in the MAGIC programme and contributed to the learning that is described throughout this manuscript.

NJW is a Research Fellow conducting patient centred care implementation research at the Division of

Population Medicine, Cardiff University. NJW was the Cardiff-based Programme Manager for MAGIC.

AL is a Research Fellow working on the design and implementation of interventions to improve clinical

practice. AL was the Cardiff-based SDM facilitator for MAGIC. AE is Professor of General Practice at

the Division of Population Medicine, Cardiff University, with research and teaching interests in

healthcare communication and quality improvement. LS is a Senior Research Associate and was the

Newcastle-based SDM facilitator for MAGIC. DT is a full time GP with long term interest in patient centred practice and training. He took a lead on the training programme in MAGIC. CD is an NHS

manager with broad experience in quality improvement implementation programmes. CD was the

Newcastle-based Programme Manager for MAGIC. SM was a Consultant Obstetrician and Fetal Medicine Specialist who facilitated the project with the Newcastle Upon Tynes Hospitals NHS

Foundation Trust, and took a lead in developing the training tools and delivering training to clinical

teams in secondary care. KB was PI in Cardiff for Phase 2 of MAGIC, and is a registered health psychologist with expertise in psychological aspects of cancer early diagnosis, prevention and

screening. GE was PI in Cardiff for Phase 1 of MAGIC and co-led the development of the programme.

GE oversaw implementation of SDM in Cardiff during Phase 1. RT was PI in Newcastle for Phases 1

and 2 of MAGIC, and co-led the development of the programme, and oversaw implementation in

Newcastle during Phases 1 and 2.

Competing Interests:

We have read and understood the BMJ Group policy on declaration of interests and declare that we have no competing interests.

Exclusive Licence:

The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all

authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and

media (whether known now or created in the future), to i) publish, reproduce, distribute, display and

store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints,

include within collections and create summaries, extracts and/or, abstracts of the Contribution and

convert or allow conversion into any format including without limitation audio, iii) create any other

derivative work(s) based in whole or part on the on the Contribution, iv) to exploit all subsidiary rights

to exploit all subsidiary rights that currently exist or as may exist in the future in the Contribution, v) the

inclusion of electronic links from the Contribution to third party material where-ever it may be located;

Key Messages

• Skills trump tools, but attitudes trump skills - shared decision making is

about more than tools

• Preparation before enablement, in a supportive clinical team - successful implementation relies on a combination of interventions targeted at the

organisation, clinician, and patient level

• Organisational support and local ownership are vital for engagement

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and, vi) licence any third party to do any or all of the above. All research articles will be made available

on an Open Access basis (with authors being asked to pay an open access fee). The terms of such Open

Access shall be governed by a Creative Commons licence—details as to which Creative Commons

licence will apply to the research article are set out in our worldwide licence referred to above.

Acknowledgements:

This paper originated from the MAGIC programme, funded by The Health Foundation. This programme involved collaboration between the following organisations: Cardiff and Vale University Health Board,

Cardiff University, the Newcastle upon Tyne Hospitals NHS Foundation Trust, and Newcastle

University. We are grateful to all of the MAGIC contributors, including the organisational

representatives, clinical teams, and patients for their contribution to the learning.

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References

1. The Health Foundation. Implementing shared decision making: clinical teams' experiences of

implementing shared decision making as part of he MAGIC programme. London: The Health

Foundation, 2013

2. The Health Foundation. The MAGIC programme: Evaluation. London: The Health Foundation, 2013.

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