COMMENT
provide evidence-based information about options, outcomes, risks and uncertain- ties and they help promote a deliberative process in which patients are encouraged to think about what each of the different options might mean for them so they can reach an informed decision.
Patient decision aids take a variety of forms, from simple leafl ets through com- puter programmes, to DVDs or interactive websites that include fi lmed interviews with patients and professionals.
Decision support
Shared decision-making involves more than just signposting patients to a decision aid. Crucially it also requires clinicians to provide them with effective decision sup- port. Relevant support can be given in clinical consultations, but it can also be provided outside the consultation by offer- ing counselling provided by trained health coaches.
The aim of coaching is to help people to de- velop the knowledge, skills and confi dence to manage their own health and health care and to make treatment decisions and/or lifestyle changes accordingly.
Care planning
Collaborative care planning, in which peo- ple with long-term conditions are actively involved in deciding, agreeing and own- ing how to manage their condition can improve the effectiveness and effi ciency of healthcare delivery, leading to better health outcomes. Extensive evidence shows that shared decision-making and care planning leads to improved knowledge and under-
standing, more accurate risk perceptions, greater comfort with decisions, better treatment adherence, improved confi dence and coping skills, improved health behav- iours and outcomes and more cost-effec- tive use of services.
Shared decision making and health in- equalities
Most people value the opportunity to be in- volved in decisions about their care, yet it is not the norm in the NHS. Patients often want more health information than they are given and many are disappointed when clinicians assume the decision-making role without involving them. The desire for in- volvement is not restricted to the educated middle classes. Studies have shown that it is possible to encourage and support people from all walks of life to become knowledge- able, active partners in their care. Indeed, those with low levels of health literacy gain more than most when they are provided with well-designed information materials and given appropriate decision support by well-trained staff; hence shared decision making could contribute to a reduction in health inequalities.
Benefi ts for commissioners Personalised care
Shared decision making ensures that pa- tients choose healthcare interventions that are evidence based and that accord with their personal preferences. It is a proven method of personalising health services so that patients get ‘the care they need and no less, the care they want and no more’. Patients who share decisions with their clinicians tend to opt for less invasive (and
therefore less expensive) procedures. And if the treatment, care or support options that are chosen in shared decision mak- ing consultations are aggregated at a sys- tem level, the data can be used to defi ne a commissioning strategy that is informed by the needs and wishes of a population of informed patients, rather than by the per- sonal preferences of healthcare providers.
Managing ‘provider capture of the market’ and unwarranted variation
Jack Wennberg from Dartmouth Medical School has shown that there are a num- ber of factors that determine variation in healthcare delivery across health econo- mies, some warranted (such as variation in demography) and some unwarranted.
Clinician preference is the predominant factor driving unwarranted variation and can lead to enormous variations across health economies of as high as 30-40 fold. The recent NHS ‘Atlas of Variation’ shows us the variations in healthcare utilisation for many common conditions and proce- dures in the NHS. The Atlas should be used by commissioners to inform discussions with providers not just about intervention rates, but also about warranted and unwar- ranted variation in those rates and the role of shared decision making in reducing un- warranted variation.
Commissioning non-traditional services
Lastly, many people who live with long- term conditions are themselves experts in understanding and managing their own condition. Supporting them to articulate the care, support or treatment that they want in care planning consultations can lead to them opting for non-traditional providers of care. In the Year of Care pro- gramme for instance, people with diabetes have opted for cookery classes, and in the personal budgets pilot programmes, people with COPD have opted for singing classes. Care planning can therefore begin to help commissioners invest in support that peo- ple with long-term conditions want, rather than support that clinicians feel that they need.
Commissioning for shared decision making
Aligned drivers
Commissioners are likely to fi nd that shared decision making leads to more cost- effective and innovative ways of meeting patients’ needs, but they will need appro- priate performance measures and feed- back to monitor progress and incentivise
national health executive Sep/Oct 11 | 23
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