Editor’s blog Tuesday 7 September 2010: Shared decision-making in healthcare

The Social Market Foundation held an interesting event this morning, on 'shared decision-making in healthcare'.

Paul Streets, DH director of public and patient experience and engagement, emphasised that DH policy and politicians are genuinely committed to the principles of 'nothing about me without me and nothing about us without us'. He outlined the known improvements to services and reductions in cost that can follow from meaningful sharing of decision-making, observing in response to comments that though the NHS's progress is  deemed slow in this area, it is at least now mainstream thinking, which was not the case a decade ago.

Henriette Coetzer, VP and medical director of BUPA Health Dialog, warned of the risk of supplier-sensitive variations as all UK providers become foundation trusts, citing the famous US Dartmouth Atlas showing variations in healthcare activity to be related much more to suppliers than to communities and their health needs. She noted that even in the NHS, there are wide differences between GP practices in the same PCT on referral rates for hip replacement surgery.

Decision aids have, Coetzer added, a demonstrable track record in improving the quality of the shared decision between clinician and individual. She suggested that primary care was the logical level at which this should happen, and that another crucial factor was to locate the 'decision window' - the point at which the information will be most meaningful. Effective population segmentation and understanding of continuity of care would be vital to locating the 'decision window'.

Angela Coulter, director of global initiatives for the Foundation for Informed Medical Decision-Making, felt that despite much lip service, little real progress on shared decision-making had been achieved in the last decade. She cited inpatient surveys regarding information and involvement having made virtually no change in six years' iterations, and also referred to international studies which indicated that the NHS is more paternalistic in shared decision-making than other systems.

Coulter emphasised that decision support aids have good evidence of effectiveness and may also contribute to cost-effectiveness (although this is not a prime reason to do it) - as well as simply being part of doing the right thing in involving individuals more in decisions about their care, which she suggested also has good evidence that it improves services and outcomes.

She agreed that primary care was probably the sector where shared decision-making could have the greatest impact, and suggested that referral management centres would currently be the logical place for it to be done, noting that the recent Kings Fund report had shown RMCs not to be effective because they were not constraining activity.

Questions and comments discussed the need to involve the whole primary care team, rather than focusing on 'GP' commissioning; the role of markets in reducing variations and increases in activity levels; the challenges to medical custom and practice; understanding how and when patients want to be partners; perceived loss of clinical autonomy; and challenges in being on top of innovations in healthcare.

An anecdote about medical paternalism
The brilliantly-named Elston Grey-Turner, an ex-BMA secretary, chaired a conference on the doctor-patient relationship, and concluded with the remark “well this has all been very interesting especially for those who want to know more about the doctor-patient relationship. For my part I’ve never been interested in it over-much: I sit at my desk, and think, 'I’m the doctor, and you are the patient'.”