My role

• Being part of the core MAGIC team for primary care

• Imbedding shared decision making into the culture of the surgery

• Writing patient decision aids(PDAs)• Developing confidence in using PDAs in my

own consultations

StatementsDecide the extent to which you agree with the following statements where 1 = completely disagree and10 = completely agree

In the end it is MY job to advise a patient on the best treatment and encourage them to

choose this

What percentage of patients say they were involved as much as they wanted to be in decisions about

their health care?

1. 10%2. 30%3. 50%4. 75%5. 85%

Patients who would like more involvement in decisions about their care (source: NHS Inpatient Surveys 2002 - 2011)

45 46 47 47 48 49 48 48 48 48

0

10

20

30

40

50

60

70

80

90

100

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Per

cen

tag

e

Poor decision qualityPoor decision quality

Patients: unaware of treatment

or management options and outcomes

Clinicians: unaware of patients’ circumstances and

preferences

The Clinical Decision Problem

UK Policy: UK GovernmentShared decision making will

become the norm:

“No decision about me without me”

8

What is shared decision making What is shared decision making (SDM) ?(SDM) ?

Paternalistic Informed ChoiceShared Decision Making

“When we want your opinion, we’ll give it to you”

Paternalistic Informed ChoiceShared Decision Making

“I’m sorry doctor, but again I have to disagree”

Definition of SDM

• SDM is a process whereby a patient, expert in their own lives, and a clinician, expert in evidenced based medicine, come together to make a decision.

• Patient and clinician, collaboratively, understand that there are choices, present options and evidence, explore these together in the light of the patient’s personal preferences and beliefs, before arriving at an appropriate decision.

Cochrane Review of Patient Decision Aids(O’Connor et al 2014):

Improve knowledgeMore accurate risk perceptionsFeeling better informed and clear about valuesMore active involvementFewer undecided after PDAMore patients achieving decisions that were informed and consistent with their valuesReduced rates of: major elective invasive surgery in favour of conservative options; PSA screening; menopausal hormones

Improves adherence to medication (Joosten, 2008)

Better outcomes in SSM/long term care

SDM – evidence

So why aren’t we doing it?• Multiple barriers

- “We’re doing it already”

- “It’s too difficult” (time constraints)

- Accessible knowledge

- Skills & Experience

- Decision support for patients / professionals

- Fit into clinical systems and pathways

Lack of implementation strategy

Core skills in SDM

SDM Consultation skills

Choice talkIntroduce preference sensitive decision. Respond to

patient’s reaction

Option talkIntroduce options, detail pros and cons, check

understanding, introduce decision support

DeliberationHelp patient to deliberate about options, could be

supported by decision specific / generic decision support tool

Preference/decision talkEstablish patient’s personal preferences

Decision Immediate or delayed

SDM consultation skills

Some thoughts about micro skills practice

Some useful questions to keep in mind:

• How much am I talking, compared to how much is this generating a two way conversation??

• Am I using the decision support as a script or as a way to stimulate dialogue?

• Might it be worth trying just using a blank decision aid and writing things down as we go?

• Do I know what matters most to the patient in making this decision?

Shared decision making – support for HCPs and patients

•10 Brief Decision Aids (BDAs) available now on patient.co.uk

•Around 15 more in development

•Inform patients (and clinicians!)

•In consultation/take home

•On-line Patient Decision Aids•http://sdm.rightcare.nhs.uk/pda/

Patient Decision Aids – key messages

• Have much value, but need to be accessible at the right time and designed for purpose

• We will never have enough PDAs for all decisions

• PDAs are an adjunct to good clinical practice• BMJ recently made clear that…. you can have PDAs available, and

clinicians trained to use them but this does not necessarily change patient experience – the challenge of the ‘black box’

What proportion of people take their treatments as prescribed?

a) 35%b) 50%c) 65%d) 80%

What proportion of people take their treatments as prescribed?

a) 35%b) 50%c) 65%d) 80%

Multiple sources. DARTS Study group – only 35% of people on more than

one medication for diabetes cashed in sufficient prescriptions for full daily coverage.

What difference has SDM made to my practice

• Consistency in message when options available

• Patient centred care moved a step forward• Change in culture for the surgery and

consultation skills• Range of PDAs avail with some still to develop• A useful tool when needing to address

changes with QIPP

What difference has SDM had to patients

•Better informed ?improved adherence•Confidence their values/concerns addressed•Written material to share/reflect on •AN option to do nothing•Improved quality of care

StatementsDecide the extent to which you agree with the following statements where 1 = completely disagree and10 = completely agree

In the end it is MY job to advise a patient on the best treatment and encourage them to

choose this

http://www.health.org.uk/areas-of-work/programmes/shared-decision-making/