Dr Jenni Naisby from the Personalised Care Institute (PCI) caught up with Professor Alf Collins, NHS England’s Clinical Director, Personalised Care Group, to discuss shared decision making and the recently developed Decision Support Tools. Professor Collins has researched and published widely on self-management support, shared decision making, care planning, co-production, patient activation and patient engagement and his views are informed by his work as a community consultant in pain management and his more than a decade working with the Health Foundation. He has honorary fellowships from the Royal College of Physicians and the Royal College of General Practitioners and is a Visiting Professor at Coventry University.
Shared decision making involves collaboration between a person and their health and care professional. Both the person and health and care professional have expertise to bring to the decision-making process, which is why health professionals must be willing to involve patients in decisions and have the skills to be able to have the right kind of conversations. It was great to have the opportunity to discuss this with Professor Collins and so I asked them what they would describe as key for successful shared decision making.
‘Shared decision making requires three key things – relational skills, risk communication and an attitudinal/mind-set shift.’
Numerous relational skills, including developing trust and rapport, being present, and coaching not telling are important for shared decision making. Inviting the patient to tell their story, acknowledging, and affirming, whilst also honestly and compassionately offering alternative explanations or courses of action can empower people to have more control over their health.
Risk communication is key; however, this is not just communicating risk but inviting the patient to tell their story of how they have made sense of the risk. Communication style is important, but this can be enhanced by ensuring patients are systematically prepared, and that tools or resources are available before, during and after the consultation.
Finally, an attitudinal/mind-set shift ‘from fixer to facilitator’ is needed. We should acknowledge that medicine has only so much to offer. It is important to acknowledge that patients and communities are innately resourceful. We can be curious about the person, including their life, their social and cultural context, their beliefs and having the attitude of ‘non-judgemental positive regard’.
A recent article, ‘Presenting complaint: use of language that disempowers patients’, gained a lot of interest in the media. The impact of clinician language on attitudes is highlighted and the authors discuss how this may impact shared decision making and the therapeutic relationship. I asked Professor Collins how clinicians could be supported to understand the impact of their language in shared decision making.
‘If we use medical terminology (a deficit model) to help patients manage their health, it’s less helpful than using a more asset/strengths-based approach.’
The article is a brilliant starting point to consider the role of language. Some further consideration for health and care professionals could focus around the ‘common sense model’ of health/illness. Through many years of research in common-sense work in health psychology, we know if we use medical terminology (a deficit model) to help patients manage their health, it’s less helpful than using a more asset/strengths-based approach. A simple example is that people with angina who believe their symptoms are caused by ‘furred up arteries’ fare less well than people who believe that the pain of angina is being bought about by the heart improving its own blood supply (which is what it is).
Professor Collins co-authored a paper focusing on the progress of implementing shared decision making to date. This piece highlighted that there have been many positive advancements over the last five years in relation to leadership, infrastructure, and practice. I was interested to explore how services and clinicians could develop shared decision making. An area highlighted by Professor Collins was a national collaborative to help teams learn more from each other. The PCI is exploring the potential for a community of practice. Watch this space!
Decision Support Tools have recently been shared by NHS England and have generated a lot of discussion and interest across professional groups. I asked Professor Collins about the role of these Decision Support Tools to support shared decision making.
‘Decision support tools ensure that there is informational continuity across that pathway.’
Well-designed Decision Support Tools can help both patients and clinicians understand and make decisions informed by the evidence and, if used across pathways of care, ensure that there is informational continuity across that pathway, no matter who is the provider.
Tammy Hoffman has shown that patients and clinicians can underestimate harms and overestimate benefits of medical/surgical interventions. Alex Freeman (and others) have found that clinicians can find risk communication challenging (but can be trained to improve).
My take home message from this insightful Q&A is ‘inviting the patient to tell their story’. This allows the person to discuss what matters to them and to direct the conversation. However, it is important to consider that health and care professionals require a range of skills to support successful shared decision making. In turn, opportunities for development and support for health and care professionals are required.
It was wonderful to get the chance to talk with Professor Collins about this important subject and both I and the PCI wish to thank them for their time and a thought-provoking interview. For further information and training on shared decision making please see the free Personalised Care Institute e-learning https://www.personalisedcareinstitute.org.uk/2022/08/18/free-shared-decision-making-refresher/
References
Breland, J.Y., Wong, J.J. and McAndrew, L.M., 2020. Are Common Sense Model constructs and self-efficacy simultaneously correlated with self-management behaviors and health outcomes: A systematic review. Health Psychology Open, 7(1),
Coulter, A., Collins, A., Edwards, A., Entwistle, V., Finnikin, S., Joseph-Williams, N., Thomas, V. and Thomson, R., 2022. Implementing shared decision making in UK: Progress 2017–2022. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen
Cox, C. and Fritz, Z., 2022. Presenting complaint: use of language that disempowers patients. bmj, 377.
Hoffmann, T.C. and Del Mar, C., 2015. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA internal medicine, 175(2), pp.274-286.
Hoffmann, T.C. and Del Mar, C., 2017. Clinicians’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA internal medicine, 177(3), pp.407-419.
NHS England ‘About Shared Decision Making’ [Online] Available at: https://www.england.nhs.uk/shared-decision-making/about/
NHS England ‘Decision Support Tools’ [Online] Available at: https://www.england.nhs.uk/shared-decision-making/decision-support-tools/