Saturday, 15 October 2011

Shared Care Decision Making in the NHS

Kevin Pho was kind enough to post a piece I wrote several months ago and which I originally posted here on my blog. It has provoked alot of interest and comment most of which has not quite been complimentary!
I was pleased that two experts on Shared Decision making were able to leave comments - one unflattering  from Angela Coulter and the other, considered from Glyn Elwyn.  Both  have written extensively on the subject and on the Salzburg statement.  I myself have written on SDM previously, specifically with respect to medical notes.

Shared decision making is about how we as doctors, interact with patients. It is integral to medical professionalism . Many would say it is about the new professionalism.  But in my eyes it was always thus. The expression 'Doctor knows best' has always been a caricature to me  - which is why I know I have always practiced 'participatory medicine'. Over nearly thirty years of interacting with thousands of patients in the NHS, I just know the right way of interacting with patients - (in answer to a Tweet asking me how I knew I practiced participatory medicine), I get it.
Shared decision making is about a conversation between 2 responsible adults about the treatment of one of them. One individual, the doctor has the experience, knowledge and the legal right to treat patients, the other, the patient, has increasing knowledge (from the web) and an inalienable sense of what's right for her/him.
The dynamic of that conversation depends on many things - not least of which is the type of health system(s) that provides that treatment. The conversation in the US will be different from that between British (or should I say English) patient and doctor or between French patient and doctor or even between the Greek doctor and patient.  In the UK, the NHS has totemic status and patients have a sense of entitlement to comprehensive free treatment. There is no requirement for responsibility in this conversation . I do not mean to imply that most patients are irresponsible - the vast majority in my experience are not. There are however a significant few that are and  that makes shared care decision making very difficult.  I will give an example from my own personal experience - I accepted a patient with severe coronary artery disease for a coronary artery bypass operation. I explained the possible alternative treatments and the risk associated with all of them. The patient accepted the need for surgery. I explained that after 5 days, if medically fit and as long as there was a fit accompanying adult at home, the patient would be discharged. The patient accepted this. The surgery and postoperative recovery were uncomplicated. On day 5, the patient mentioned that he/she could not go home as their relative had gone aboard for 5 days and would not return for another 2 days. They might as well spend a further 2 days in hospital - which he/she did. There was no obligation in that shared decision making conversation we'd had earlier,  to leave after 5 days  - so why should they.  The same applies to losing weight or stopping smoking - there is no obligation to do so and no comeback if they don't.
As I mentioned in my original piece, responsible input from the patient is explicitly taken into account in the new Patient Protection and the Affordable Care Act in the US. (PPACA). It is this piece in the New England Journal of Medicine that prompted me to write the post in the first place.
I might have overstated the point that SDM was not possible in the NHS - however within that system, one participant in that sharing agreement has one arm tied behind his/her back!
I was also criticised by many by stating that all the good ideas in health care are coming from the US. There is a sense amongst British medics that everything about US healthcare is grossly unfair and very expensive. It is precisely because of the expensive inequity of the US healthcare system, that the very urgent need for reform and the realisation that quality in healthcare was crucial, have created so many good healthcare ideas in recent years - including the 'saving 10,000 lives' campaign borne from 2 Clinton era reports (here and here) which led to the development of bundles of care to prevent ventilator associated pneumonia and line associated infections, the publication of operative outcomes (the cardiac surgeons were first), and many many others  - most of which have migrated eastwards across the Atlantic. One should only inquire how many NHS executives have travelled to California to see the Kaiser Permanente system or to Boston and Harvard University, where the Institute of Healthcare Improvement is based to realise how much of the provenance of the English NHS lies in the USA.  There are many more healthcare ideas (such as the one highlighted above) that are included in the PPACA and that I predict will also find themselves over here in near future. Health care reform, shared care decision making and the need for deficit reduction are closely intertwined and are crucially important there as they are here.