Implementing shared decision making in the UKImplementierung von Partizipativer Entscheidungsfindung in Großbritannien
Introduction
At least ten pre-requisites must be in place before shared decision making will become the norm in clinical practice. These include a) a favourable policy climate, b) appropriate regulatory, professional and legal standards, c) availability of decision support, including information and tools, d) training for clinicians, e) patient champions, f) clinical champions, g) evidence of clinical and cost effectiveness, h) metrics for monitoring progress, i) financial and other incentives, and j) a feasible implementation plan. The current position in the UK in respect of each of these aspects is briefly reviewed here.
Section snippets
Policy climate
Most UK citizens depend on the National Health Service (NHS) for all their healthcare needs. Funded out of taxation, the NHS covers primary care, hospital care (inpatients and outpatients), community care (including home nursing and other out-of-hospital services), mental health care, dental health care, community pharmacies and associated services. About 10 per cent of the population has private health insurance, but this is mostly used to cover specific services such as elective surgery,
Standards
The NHS Constitution, published in 2009 and supported by the three main political parties, made the following commitments to patients:
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You have the right to make choices about your NHS care and to information to support these choices
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You have the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this
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You have the right to be given information about your proposed treatment in advance, including any significant risks and any
Information and support
In 2008 the government established NHS Choices, a public website to help people make informed choices about their health and healthcare (www.nhs.uk). The website includes detailed information about conditions and treatments, and a guide to decision points along a care pathway. Other developments in the field of patient information included NHS Direct, incorporating a public-facing website, email and telephone advice line (www.nhsdirect.nhs.uk); Information Prescriptions, a series of links or
Training
The GMC is responsible for setting educational standards and approving curricula for both undergraduate and postgraduate medical training, so the inclusion of the above-mentioned statement in Good Medical Practice, the GMC's set of standards for doctors, implied that shared decision making should be incorporated into training courses at appropriate points, with the relevant competencies being subject to assessment. However, despite the fact that all medical and nursing undergraduates now
Patient champions
The government is not the only body calling for greater patient engagement. National patient surveys, carried out on an annual basis in every hospital in England since 2002, show that around half of all patients admitted to hospital would have liked more involvement in decisions about their care [7]. Several organisations representing patients have lobbied for greater involvement in treatment decisions. For example, National Voices, an umbrella group representing more than 100 patient
Clinical champions
A number of clinically-led projects have focused on encouraging patient engagement. Most of these have been introduced to assist patients with chronic diseases and other long-term conditions to self-manage their treatment. For example the Expert Patient programme offers six-week courses designed to give people the confidence, skills and knowledge to manage chronic health conditions such as arthritis, asthma, diabetes, epilepsy, heart disease and multiple sclerosis (www.expertpatients.co.uk).
Evidence
A number of UK-based academic groups have secured funding for studies of shared decision making and decision aid evaluations, with particular strengths in the universities of Bristol, Cardiff, Dundee, Leeds, Manchester, Newcastle, Oxford, Sheffield and Stirling [11]. The 2009 update of the Cochrane Review of decision aids included eleven trials conducted in the UK, including three with economic analyses. One of these suggested that use of decision aids plus coaching support could be highly
Metrics
Following the incorporation of shared decision making in the health bill, the Department of Health has started to develop plans to monitor progress and outcomes of the policy, but these plans are at an early stage and details of how this will be accomplished are not yet available. Efforts are under way to pilot the use of decision quality measures, currently in development in the US. In the meantime the regular national patient surveys include simple questions about involvement in decisions
Incentives
There are trade-offs to be made when considering changes to clinical practice and clinicians often face time constraints, system barriers and cultural obstacles that inhibit their desire to engage patients [13]. Motivating factors can include development and application of new consultation skills for shared decision making, knowledge that shared decision making will benefit their patients, that it can be introduced with minimum disruption, and that they themselves, or the service they run, may
Feasible implementation plan
Another project aimed at promoting the use of shared decision making in clinical practice was launched in 2010 by the Health Foundation, a well-endowed charity. Entitled the MAGIC Programme (MAking Good decisions In Collaboration), it is led by teams at Cardiff and Newcastle Universities, working with NHS partner organisations in both secondary and primary care. The project is funded for eighteen months from August 2010 to January 2012. MAGIC aims to explore how shared decision making can be
Conclusion
Shared decision making is firmly on the policy agenda in England and there is evidence of progress since we last reviewed the topic [17]. Legislation has been introduced to require healthcare commissioners to promote it and professional regulators have underlined its importance. Patient information has been made available, together with some locally developed decision aids. Many patients appear to have an appetite for greater engagement in decisions about their care, some clinicians want to
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