Choosing Wisely and Shared Decision Making

August 2018

Four questions to ask my doctor or nurse to make better decisions together:

What are the Benefits?What are the Risks?What are the Alternatives?What if I do Nothing?

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Choosing Wisely is an initiative which aims to reduce unnecessary intervention and improve outcomes by promoting conversations between doctors and patients to choose care that is:

— Supported by evidence — Not duplicative of other tests

or procedures already received — Free from harm — Truly necessary — Consistent with patients’ values.

The Academy’s Choosing Wisely initiative consisted of inviting suggestions from each of the medical Royal Colleges on procedures or practices of low clinical value. Another key component of the initiative is to use these recommendations to focus on shared decision making with patients.

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Shared Decision Making involves the provision of evidence-based information about options, outcomes and uncertainties, together with decision support counselling and a systematic approach to recording and implementing patients’ preferences.1 Evidence-based patient decision aids have been developed to support the process for some conditions and illnesses.

Shared Decision Making is appropriate for patients facing treatment decisions where there is more than one feasible option (including the ‘no treatment’ option) such as:

— Decisions about diagnostic and screening tests

— Selecting maternity care and delivery plans

— Determining appropriate care and support packages for long-term conditions

— Advance care plans for mental health and end-of-life decisions

— The NHS Constitution tells patients that they have the right to be involved in planning and making decisions about their health and care and to be given information and support to enable this2

What is Shared Decision Making? Shared Decision Making (SDM) is a collaborative process in which clinicians and patients work together to select tests, treatments, management and/or support packages, based on clinical evidence and the patient’s informed preferences. It explicitly acknowledges that that there is usually more than one way to treat a problem and that patients may require help to weigh up the benefits and harms of the options in order to determine the best choice for them.

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Involving patients in their care and treatment and empowering them with all the information to make informed decisions with their healthcare professional is the right thing to do. It is now seen as both an ethical and a legal imperative, supported by evidence that most patients want it.

Why is Shared Decision Making important?

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It is enshrined in policy in a number of ways:

— The NHS Constitution tells patients that they have the right to be involved in planning and making decisions about their health and care and to be given information and support to enable this2

— The General Medical Council’s guidance on informed consent makes it clear that patients must be told about their treatment options and actively involved in decisions.3 This has recently been strengthened following a landmark ruling by the UK Supreme Court4

— NICE quality standards emphasise the importance of SDM as a key component of a high quality service5

— The government’s Mandate for the NHS says it should become ‘dramatically better at involving patients and their carers, and empowering them to manage and make decisions about their own care and treatment’6

There is good evidence that SDM benefits patients, improving the quality and appropriateness of clinical decision making. A Cochrane review of 115 randomised control tests found that the use of patient decision aids leads to improved knowledge and more accurate risk perceptions among patients, greater participation in decision making and more appropriate treatment decisions. These included reduced demand for screening procedures such as PSA tests and also surgical procedures such as hysterectomies and knee replacement operations.7

Shared Decision Making is an effective strategy for tackling over-diagnosis and overtreatment.8,9 For example, interventions to promote SDM, including skills training, have been shown to lead to reductions in inappropriate antibiotic use in acute respiratory infections10 and better understanding of the risk of overdetection in breast screening.11

As part of a systematic approach to collaborative care and support planning for people with long term conditions SDM often leads to better health outcomes, including improvements in physical health indicators (HbA1c), psychological wellbeing (depression), and confidence for self-management.12

Many patient complaints about care arise from a lack of information and involvement in decision-making. Following the Supreme Court’s decision in Montgomery v Lanarkshire Health Board,4 the importance of ensuring that patients are fully informed and given a choice about their treatment, where there is one, is more important than ever before. Doctors must ensure that the benefits and harms of each option are clearly understood by patients and that the chosen treatment is consistent with their values. This ruling applies to all countries within the UK, and means that clinicians who do not adopt a shared decision making approach will put themselves at legal risk in the event of outcomes which patients have not been informed of.

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Many medical royal colleges have explicitly acknowledged the importance of patient involvement in decision making and continue to develop this theme within their educational and training strategies. However, there has been little improvement in the proportion of patients who report satisfactory involvement in decisions about their own healthcare in the NHS inpatient surveys over the last decade, with only about half of patients reporting they were sufficiently involved in decisions about their care.13

Choosing Wisely UK, led by the Academy, want to go beyond the initial principles of the initiative and promote shared decision making so that it becomes part of everyday practise. In doing so, it acknowledges the need to recognise and promote existing models of good practice, and to listen carefully to the voices of patients and of practising clinicians.

This will require a change in behaviour and practise from clinicians, who will require support in the form of training, resources and practical help to embed SDM into clinical care in effective and time-efficient ways. Strong leadership is essential to support this culture change, particularly from colleges and specialist societies. The Health Foundation has outlined the steps healthcare leaders can take to implement SDM, including tools and techniques, practical support, and change management.14

Encouraging the use of existing resources to support SDM is a short-term goal, but the long-term aim must be to promote SDM from the very start of clinical training and to continue this development throughout a clinician’s professional life. The medical royal colleges will be key to achieving this by ensuring that SDM theory, skills and competencies (including risk communication, options appraisal, goal setting, care planning and outcomes assessment) are taught in medical schools, in post-registration training, and in continuing professional development. A useful set of training resources is available at person-centred care resource centre.

The Choosing Wisely team at the Academy will collate a selection of relevant SDM resources and work with colleges to ensure that these are readily accessible to all those wanting to make use of them.

What can Medical Royal Colleges and the Academy do to promote SDM?

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1. Coulter A, Collins A. (2011) Making shared decision-making a reality. www.kingsfund.org.uk/publications/nhs_decisionmaking.html

2. Department of Health. (2015) The NHS Constitution.. www.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/NHS_Constitution_WEB.pdf

3. General Medical Council. (2008) Consent: patients and doctors making decisions together. GMC

4. Edozien LC. (2015) UK law on consent finally embraces the prudent patient standard. BMJ 2015 May 28;350:h2877

5. NICE. (2012) Patient experience in adult NHS services. https://www.nice.org.uk/guidance/cg138

6. Department of Health. (2015) The Mandate: A mandate from the Government to NHS England - April 2015 to March 2016. www.gov.uk/government/uploads/system/uploads/attachment_data/file/48681mndate-NHSE-15_16.pdf

7. Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. (2014) Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;1:CD001431

8. Mulley AT, Trimble C,Elwyn,G. (2012) Patients’ preferences matter: stop the silent misdiagnosis.www.kingsfund.org.uk/publications/patients-preferences-matter

9. McCaffery KJ, Jansen J, Scherer LD, Thornton H, Hersch J, Carter SM, et al. (2016) Walking the tightrope: communicating overdiagnosis in modern healthcare. BMJ. 2016;352:i348

10. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. (2015) Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;11:CD010907

11. Hersch J, Barratt A, Jansen J, Irwig L, McGeechan K, Jacklyn G, et al. (2015) Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. Lancet. 2015;385(9978):1642-52

12. Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. (2015) Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev [Internet]. 2015 Mar 3;(3):CD010523 www.ncbi.nlm.nih.gov/pubmed/25733495

13. Wood S CA, Taylor A. (2015) Is the NHS becoming more person-centred? I=The Health Foundation. www.health.org.uk/sites/health/files/IsTheNHSBecomingMorePersonCentred.pdf

14. Health Foundation. (2014) Ideas into action: person-centred care in practice. The Health Foundation www.health.org.uk/sites/health/files/IdeasIntoActionPersonCentredCareInPractice.pdf

References

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Where can I find out more? Health Foundation’s Person-Centred Care resource centre www.personcentredcare.health.org.uk

Practical implementation advice and research on SDM from the Informed Medical Decisions Foundation www.informedmedicaldecisions.org

Patient decision aids designed for the NHS Right Care programme www.sdm.rightcare.nhs.uk/pda

International databases of patient decision aids Canada: www.decisionaid.ohri.ca Netherlands: www.med-decs.org

If you have any questions about this leaflet or would like further information, please email choosing.wisely@aomrc.org.uk or call 0207 490 6819