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Ask three questions

Donal O'Donoghue
Donal O'Donoghue
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Sometimes there will be choices to make about your healthcare. If you are asked to make a choice, make sure you get the answers to these three questions:

  • What are my options?
  • What are the benefits and possible risks?
  • How likely are these risks and benefits?

These are the three questions that the MAGIC projects are promoting. MAGIC stands for 'making good decisions in collaboration' and is a Health Foundation implementation programme for shared decision making that has been running in Newcastle and Cardiff over the last year.

There is lots of evidence from many different countries and across many clinical areas that patients want more involvement in decisions about their care and that greater involvement results in better experience and outcomes. Recently, the Care Quality Commission in England patient surveys have shown that 48% of inpatients and 30% of outpatients want more involvement in decisions about their care. A Cochrane review in 2009 found that decision support improves knowledge and leads to a more accurate understanding of risk perception as well as increasing participation and comfort with the decisions. Such an approach leads to fewer patients being undecided and improves adherence to medication.

I was privileged to be invited to the Health Foundation MAGIC site visit to Newcastle last week. Driving to Piccadilly station I was thinking 'it’s nice to be on a different train'. Views across the North Yorkshire moors, Northumberland and the Angel of the North are gorgeous. I assumed I would be spending the journey doing battle with my inbox when to my delight I bumped into Sir John Oldham who is a general practitioner from Glossop but also much more.

John is the Department of Health Quality, Innovation, Productivity, Prevention lead for both long term conditions and acute care. We travelled up together with Alf Collins (Consultant in Pain Management & Vice Chair Clinical Ref Grp for NHS SW). Alf had driven up to Manchester from Taunton the evening before! 'Making Shared Decision Making a Reality, no decision about me without me', the publication by Alf and Angela Coulter, was released the day before and was receiving quite a lot of media attention. So we had a great journey up, fruitful conversation and lots of learning. A great way to start the day.

The highlight without doubt was, however, the visit to Dave Tomson’s surgery where I saw the 3 questions in use and sat in on a shared decision making skills workshop. It struck me how far ahead primary care is of hospital practice in terms of ensuring the skills needed to talk, understand and listen to patients are well taught. Clinical encounters may only be 10 or 15 minutes, or 7 minutes, but they’re full of body language, unsaid messages, anxiety and anticipation in addition to the dialogue. They can also result in confusion and misunderstanding. Offering choice, explaining options, providing decision support, eliciting preference and achieving good decisions is a real skill. Like all skills it needs practice before it’s added to our repertoire of 'automatic' skills that 'just happen'.

Back at the Royal Victoria Infirmary in Newcastle we heard from Richard Thomson (Professor of Epidemiology and Public Health) about shared decision making in breast surgery, obstetrics and urology and discussed the importance of leadership, learning sets and team engagement in addition to the clinical skills. The emerging lessons from the Newcastle micro-system highlighted some of the NHS wide barriers and disincentives that need to be addressed if we are to build on these achievements and to secure sustainability.

Shared decision making is much more than patient decision aids. We need to embed shared decision making within clinical pathways and to demonstrate the value to both patients and clinicians. The Health Foundation projects are using shared decision making with quality improvement methods to drive up patient activation, measure patient experience and improve quality. I am looking forward to my next visit already. I don’t think we need to wait until then to make the three questions OK in every surgery and clinic in the land.

Dr Donal O'Donoghue is the National Clinical Director for Kidney Care and was appointed the first Renal Tsar for England in 2007. This blog post first appeared on http://renaltsar.blogspot.com





 
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Comments
Empathy is an essential component to a wise decision - there is another and that is evidence. The one is subjective, the other is objective. The problem is that evidence derived from research trails, not matter how well conducted, is a necessarily arttificial distortion of reality. Research is necessary but it is not sufficient - the lessons of research need to be implimented in practice and the effect measured - in practice - in order to provide evidence that can be used for individualised decision support. The method required to measure the impavct of a change-over-time is not the same as research and it is not audit either - it sits between the two and is called Improvement Science. The problem is that no clinicians or managers are taught the basics of improvement science. That is the gap that we will need to fill to deliver the promise of actuality-based-collaborative-decisions (ABCD).
A 4th, 5th, and 6th question are needed;
How much does each option cost?
How quickly is each option available?
How far do I have to travel (and how much will that cost me in time and money) for each option?

Applying these (e.g.) to NICE guidance on skin cancer treatment produces some interesting patient responses
Thanks Tony , i agree with 5 and 6 but i dont think its streching it to far to consider these aspects of convience as part of the benefit arm of the Q 2 and 3 of the magic questions .
Costs are i think more difficult for a number of reasons - not a direct cost to the patient , costs need to be seen across a pathway of care rather than a single interventon to consider value , it might be best to consider costs for populations rather than individuals and our costing information in the UK is pretty poor .
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