Shared decision making: skills trump tools, attitudes trump all

Two weeks ago we brought together over 100 people to mark the end of our MAGIC programme, which supported teams to embed shared decision making in everyday clinical practice. There were some great insights throughout the day, but I wanted to share a few that particularly stayed with me:

'Skills trump tools, attitudes trump all'
Many at the event were talking about the importance of embedding training in shared decision making into all levels of education for doctors, nurses and other healthcare professionals. This training would equip them with a range of tools and techniques, including decision aids and options grids to use in consultations with patients, and decision quality measures to help them test if they are getting it right. But this is only a part of it.

A GP told me that, while it was important to learn about the tools (the patient decision aids and option grids), the most valuable thing he had gained from training in shared decision making was the mindset and the confidence to have different conversations with his patients, and the knowledge and skills to support these conversations.

'Remember – it’s not what matters to the clinician, it’s what matters to the patient'
The day started with four different perspectives on shared decision making: a patient, a nurse, a commissioner and an organisational view. The patient representative, Jacqui, set the tone for the day and reminded people why we were all there.

There are many potential benefits of shared decision-making, from making clinicians' jobs easier (as several commented) to the holy grail of saving money. But these mean nothing if they do not ensure that health services are responding to what matters to the patient (rather than what is the matter with them). As Jacqui said so succinctly:

If I feel in control, I’ll feel much more positive generally and I think I will be able to cope with my life better which will have an impact on how I manage my health. Hopefully this will prevent my health from getting worse and that has got to be a good thing!

'Simple ideas can be effective and not expensive...'
This was the key message from Lucy Craig and Ruth Wylie from the Paediatric Rheumatology department at Great Northern Children’s Hospital, who set out to try and involve young people more in decisions about their care.

They started by developing ‘a spoonful of questions’ – 15 top questions young people said they wanted to ask about their condition or treatment, to help them think about what to focus on in the consultation.

After being introduced to the work of the Newcastle MAGIC team, they refined this to five key questions and also introduced ‘Ask 3 Questions’. Within a year, they had successfully implemented shared decision making in all of their outpatient clinics.

Now most young people are happy to go into the consultation with their doctor alone and are confident in feeding back to their parents about the treatment options and decisions. Ruth and Lucy are now in the process of launching ‘Ask 3 Questions’ to all children’s departments in the hospital.

'The system shouldn’t dictate how I do my job'
The challenges of commissioning and the complexities of how contracts, payment systems and incentives worked was another theme of the day.

I heard about the challenges people were facing and ideas for how to address them. For example, in England, locally developed CQUINs were seen as an option by some but others commented the annual CQUIN cycle made it difficult to sustain change.

On a positive note, there were some great examples of success in commissioning shared decision making by clinical commissioning groups in Newcastle. In South Tyneside, they used shared decision making training as a tool with their clinical teams to drive up the quality of GP referrals in three areas – general surgery, orthopaedics and gynaecology – and across six conditions. Results included GPs being more confident in their referrals, improved patient satisfaction and savings of approximately £500,000 in first outpatient referrals.

'It is surprising how difficult it is to measure SDM'
As part of the session on measuring shared decision making, we were asked to play the role of a patient and to score two videos of a consultation between a GP and a patient with high blood pressure, for how well they demonstrated shared decision making in practice.

This really brought to life the challenges of measurement – the general consensus from my group was that it was much easier to judge when it isn’t happening, than to assess what a good shared decision making consultation looks like from the patient's perspective.

As I walked home from the event over Tower Bridge, I was struck again by the ‘attitude trumps all’ comment and the need for a shift in mindset to truly achieve change in this area. In the wrap up for the day, it was suggested we should start talking about conversations instead of consultations. What do you think?

Suzanne is a Policy Manager at the Health Foundation.