Shared decision making improves outcomes and patient satisfaction while reducing costs and unwarranted variation in intervention rates.
Shared decision making provides an approach to delivering ethical, high-quality care that offers patients 'the care that they need and no more, and the care that they want and no less' as articulated by Dr Al Mulley1
Reasons for incorporating shared decision making into the way individual clinicians and services work include:
- Patients want more involvement in decision making
- Shared decision making improves outcomes for patients
- Shared decision making is recognised as good clinical practice
- Shared decision making reduces inappropriate interventions and unwarranted variation
- Shared decision making can improve value and cost effectiveness
- National policy promotes shared decision making
National patient surveys show that 48% of inpatients and 30% of outpatients wanted more involvement in decisions about their care than they had2 and 24% of patients in primary care did not feel their GP was good at involving them.3 This is not unique to people of a particular age, ethnicity or other demographic. Recent research from America showed that older people and people with lower health literacy particularly value support to be involved in decisions about their own care.4
Evidence shows that providing patients with decision support improves their knowledge of their condition and treatment options, increases their participation, gives them a more accurate perception of risk, improves match between values and choices, and helps them feel more comfortable with decisions about their care.5
In addition, research shows that patients who are actively involved in managing their own health and in making healthcare decisions have better health outcomes than patients who are passive receivers of care.6
Despite this desire from patients to be more involved, we know that how much people are involved in decisions about their treatment and care varies from clinician to clinician and from CCG to CCG as the map below shows:
The map is based on data from the GP Patient Survey (GPPS) asking patients to describe how good the last GP they saw or spoke to at their GP surgery was at involving them in decisions about their care. CCGs are split into four quartiles of performance: the darker the shade of blue, the higher the proportion of patients that rate their GP positively at involving them in decisions about their care.
The professional regulatory bodies back shared decision making and see it as an ethical requirement. They expect clinical staff to inform and involve patients as partners in care whenever possible.
For example the General Medical Council (GMC) Guidance on good practice sets out principles for good practice in making decisions. It explicitly states that the principles apply to all decisions about care: from the treatment of minor and self-limiting conditions, to major interventions with significant risks or side effects.
The guidance requires doctors to
- Listen to patients and respect their views about their health
- Discuss with patients what their diagnosis, prognosis, treatment and care involve
- Share with patients the information they want or need in order to make decisions
- Maximise patients’ opportunities, and their ability, to make decisions for themselves
- Respect patients’ decisions.
Other professional regulatory bodies share this view and set out similar requirements within their own guidelines and codes.7 8
There are signficant variations in the rates of intervention for different conditions even after adjusting for need. For an individual patient, this means that some people might be receiving treatments that other clinicians would regard as unnecessary and that the patient would not choose if they understood the risks, benefits and alternatives.
An international Cochrane Review in 2011 showed that demand declined by 20 per cent after patients became well informed. The review reported consistent evidence that as patients became better informed, they made different decisions and felt more confident.9 A more recent study in 2013 compared the effects on patients of receiving a usual level of support in making a medical treatment decision with the effects of receiving enhanced support. It found that patients who received enhanced support had 5.3 percent lower overall medical costs than patients who received the usual level of support. The enhanced-support group had 12.5 percent fewer hospital admissions than the usual-support group, and 9.9 percent fewer preference-sensitive surgeries, including 20.9 percent fewer preference-sensitive heart surgeries.10
Within a local health economy, where there is a comparatively high rate of a particular intervention relative to the population served, the benefits gained from the additional cost of funding that activity may be lower than if the same amount of resource were to be invested in another type of treatment, or preventive intervention, for people with the same conditions or to meet unmet needs in another group of patients.
At the level of the individual patient, examples of increased cost effectiveness include patients being more likely to stick with treatment plans, such as taking their prescribed medication11
Policy and legislation across the four countries of the UK are promoting shared decision making. For example, the 2011 Patient Rights (Scotland) Act encourages participation in decisions and the 2012 Health and Social Care Act (England) includes a duty on NHS England and Clinical Commissioning Groups to 'promote the involvement of individual patients, and their carers and representatives in decisions about their treatment and care.
2CQC patient surveys 2010
3 The GP Patient Survey July – September 2011, ipsos MORI