COMMENT
Angela Coulter, visiting fellow at the King’s Fund, Director of Global Initiatives at the Foundation for Informed Medical Decision-making and Senior Research Scientist at the Department of Public Health, University of Oxford, and Alf Collins, Clinical Lead of the Somerset Community Pain Management Service, examine shared decision-making.
T
he debate about whether greater com- petition and more choice will lead to improvements in healthcare continues to rumble on, with proponents and opponents as far apart as ever.
Evidence to support or refute the Govern- ment’s faith in provider choice as a mecha- nism for raising standards is sparse. Mean- while most patients remain indifferent to the arguments, preferring familiar local organisations where possible. But the op- portunity to have a greater say in how their care is managed is much more appealing. Most people place far greater value on hav- ing a choice of treatments than on shopping around for providers.
The Government’s NHS White Paper recognised this, announcing that shared decision-making was to become the norm throughout the NHS. The Secretary of State, Andrew Lansley, articulated this vi- sion in the phrase ‘nothing about me, with- out me’. But the White Paper gave only sketchy details about what shared decision making means, and the phrase is rapidly becoming a catch-all to cover almost every type of involvement.
This is not helpful, so in a report for the King’s Fund we embarked on a mission to rescue the term and bring some clarity to the debate before it becomes completely opaque. In ‘Making Shared Decision-Mak- ing a Reality’, we defi ned shared decision making as ‘a process in which clinicians
22 | national health executive Sep/Oct 11
and patients work together to select tests, treatments, management or support pack- ages, based on clinical evidence and the pa- tient’s informed preferences’.
But why is shared decision making impor- tant, what are the benefi ts for patients and for commissioners and how can we ensure that health services embed the principles of shared decision making?
Benefi ts for patients Clinical evidence plus personal preferences
All of us face decisions about our health or healthcare from time to time and the deci- sions we face are often quite complex.
For example, we may need to decide wheth- er or not to undergo a screening or diag- nostic test, whether to take a medication or undergo a medical or surgical procedure, whether to attend a self-management or education programme or accept a psycho- logical intervention, or whether to attempt a lifestyle change.
At most decision points there are a number of options, each carrying a range of possi- ble outcomes. The decision we make will be informed by what we know about the options and the possible risks, benefi ts and consequences of those options and by our personal preferences (including our per- sonal attitude to risk and uncertainty and our personal preferred outcome).
Shared decision making is a legal and eth- ical imperative
Shared decision-making explicitly recog- nises a patient’s right to make decisions about their own health and healthcare, en- suring they are fully informed about the op- tions they face. It is an ethical imperative, supported by the General Medical Council, and also a legal imperative, supported by the principle of autonomy upheld by com- mon law.
Shared decision making involves providing patients with information about all the op- tions available to them, the possible ben- efi ts and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. There are three essential components: • Provision of reliable, balanced, evidence- based information outlining treatment, care or support options, outcomes and un- certainties; • Decision support counselling with a clini- cian or health coach to clarify options and preferences; • A system for recording, communicating and implementing the patient’s prefer- ences.
Decision aids
Decision aids have been developed to pro- vide patients with the information they need to make these types of decisions. They
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