Shared decision making: improving outcomes by changing relationships

Evidence tells us that shared decision making between clinicians and patients has the potential to deliver better health outcomes and a more efficient use of resources for healthcare commissioners and providers.

With insights from the Health Foundation’s Director of Improvement Programmes, Jo Bibby, we explore the topic and address some common misconceptions and barriers we need to overcome as a society to make shared decision making a practical reality in mainstream healthcare.

What is shared decision making?

Shared decision making is about the relationship between clinicians and patients and changing the consultation experience so that both parties share knowledge and expertise as equal partners and reach informed decisions about care and treatment, including the choice to manage their health themselves through self-management.

It recognises that, most often, it is the patient who best understands their healthcare needs and what is right for them in the context of their personal circumstances.

Jo Bibby says: ‘We’re all different and it should be our choice whether, for example, we learn to live with and actively manage pain or take the risks of surgery.’

Research shows conclusively that choice about treatment matters more to patients than the decision about where to receive treatment. Increasing choice for patients across our healthcare system must therefore be about all forms of choice and not just choice of provider.

Why does shared decision making matter?

It’s an anomaly that patients’ relationships with healthcare providers have remained so passive for so long. 

‘Where we are in healthcare still feels very outdated compared to the rest of our lives,’ says Jo.

‘We still have a cultural tendency to think that the doctor knows best. This is disempowering and makes people less likely to take responsibility for their own health. We know that if patients take a more involved and active role they tend to stick with a course of treatment and be more satisfied with the outcomes. And, interestingly, they often choose more conservative courses of medicine and self-care in preference to surgery.’

Can shared decision making deliver best value?

It’s easy to think that budgetary and time constraints are barriers to shared decision making. The reality is that better outcomes are achievable both in terms of patient satisfaction and the bottom line. And you may find the benefits are more persuasive than you’d thought...

Shared decision making does usually take more time in the beginning but, combined with good quality information and support, it can lead to patients becoming less demanding in the long term and to higher levels of satisfaction.

Jo believes that there is very little argument to support prescribing medicines or courses of treatment that patients would not have chosen if clinicians had truly engaged with them. ‘Currently huge amounts of prescribed drugs are not taken,’ she says, ‘and this represents both a waste of money and a failure to meet health needs.’ 

When people have the opportunity to play an active role in decisions about their treatment, it tends to lead to greater ‘buy-in’ and commitment from them and, in turn, improved outcomes and higher levels of satisfaction. 

How do we embed shared decision making in mainstream healthcare?

Jo believes that before we can truly embed shared decision making we need a radical redesign of our healthcare services, changes to the cultural expectations of the public and retraining of clinicians.

‘Current healthcare provision doesn’t facilitate these new types of relationships,’ she says. ‘We need to change how people can interact with services and clinicians.’ 

While the concept of shared decision making isn’t new, the practical arguments for change have become very strong and gained additional prominence through debates and consultations around the current NHS reforms, includingthe principle of ‘no decision about me without me’.

‘The government commitment to this agenda is very encouraging,’ says Jo. ‘It’s recognising that something that was seen as “nice to do” in the past now has a clinical and political imperative driving it and that doing nothing really isn’t an option anymore.’ 

Jo concludes: ‘The evidence is clear that shared decision making works. Now there needs to be a fundamental culture shift to make this happen. Collective voices are beginning to make an impact. But it will be strong leadership on the ground that makes the difference.’