How are standards interpreted by health professionals when interacting with patients? Guy Rubin, General Dental Council Professor Stephen Tyreman, British School of Osteopathy Professionals Standards Authority Conference: 10 March 2017

Aim for the session Explore patient and professional values and how standards can be embedded This presentation will: Set the academic and policy context Explain what are the issues that this project aims to address Outline what the project involves and the next steps

Model of regulation Four components of regulation: www.gdc-uk.org Model of regulation Four components of regulation: Setting and promoting professional standards Ensuring skills are kept up to date Taking people off the register where necessary Ensuring those qualified are taught the right skills Checking people meet requirements to be on the register

What does the evidence say? Regulation framed by social and professional institution and norms (Black and Baldwin 2010) and behaviour influenced by external factors with regulation some way down the list (Quick 2011) Compliance more likely when promotes good professional practice (Quick, 2011) Early intervention and proactive approach to identifying and tackling harm (Sparrow 2008) Understanding the ‘why’ not just the ‘what’ enhances compliance (McGivern 2015) Focusing on patient and clinician values can support the application of a tool supporting patients and professionals in decision making about their care and treatment (Fulford)

Does regulatory expectation match clinical experience? The problem of Medically Unexplained Symptoms Complexity due to multi-factorial causation, patient idiosyncrasy and multiple morbidity How is professional practice to be regulated when much decision-making falls outside standardised protocols, guidelines and algorithms?

Medically Unexplained Symptoms in primary and secondary care WARNER, A., WALTERS, K., LAMAHEWA, K. & BUSZEWICZ, M. (2017) How Do Hospital Doctors Manage Patients with Medically Unexplained Symptoms: A Qualitative Study of Physicians. J R Soc Med, 110, (2) 65-72.

https://sites.google.com/site/ranilillanjum/research/causehealth Medically Unexplained Symptoms Complexity and Multiple Causation (CAUSEHEALTH) https://sites.google.com/site/ranilillanjum/research/causehealth

Cynefin Framework (Dave Snowden) Complex and Uncertain Complicated but Knowable Emergent Practice Guidelines – Good Practice Disorder Probe-Sense-Respond Sense-Analyse-Respond Chaotic Simple and Known Novel Practice Protocols – Best Practice Act-Sense-Respond Sense-Categorise-Respond

Clinical decision-making Following a map or charting a course? Aporia The Pathless Path through uncertainty and complexity … with different values and expectations How to regulate good practice in uncertain and complex situations?

Osteopathic context Osteopathic and dental practice have very high levels of patient satisfaction Limited evidence (small numbers) that osteopathy patient values are scored less highly, when measured with the Care and Relational Empathy Measure. Scores less than excellent include: Really listening Explaining things clearly Helping you take control Making a plan of action with you

Dental context Patient satisfaction with dentistry and with dental regulation is generally high, however some issues reported with confidence to ask questions and clarity of information and costs particularly in relation to: Treatment options and Informed consent

Some still feel unclear about costs though I didn't receive any information about the treatment options or costs. I paid for the treatment in instalments, but wasn't sure what the total would be, just hoped that what I'd been paying each week would cover it, and it did. Some still feel unclear about costs though (Male, over 45, social grade C2, 2015) (Male, over 45, social grade C2) I basically just go in and pay what is necessary at the end of the session. I'm not too clued up on what things should cost. I basically just go in and pay what is necessary at the end of the session. I'm not too clued up on what things should cost (Male, over 45, social grade C2, 2015)

Upstream – Shifting the balance www.gdc-uk.org Point of harm ‘Upstream’ preventing harm Fitness to practise after harm occurs Developed from a diagram originally created by Malcolm Sparrow, Harvard University

What do we mean by values based practice ? Focusing on patient and clinician values to support decision making Values – what matters or is important to you Patient values – “the unique preferences, concerns and expectations that each patient brings to a clinical encounter and which must be integrated with clinical decisions if they are to serve the patients” (Sackett) Montgomery judgement (2015) – Clinicians engage in dialogue with patient to enable sufficient understanding of risks and benefits of treatment option that take into account patient values

The project: who, what and how Overall objective: developing and testing a decision making tool that supports ‘good consultation’/shared decision making A partnership project drawing together health regulators, academics working with patients and health professionals The project is being managed by the Collaborating Centre for Values Based Practice (Oxford University), the General Osteopathic Council and the General Dental Council Co-production model involving patients and health professionals in developing and testing the tool

Research design and methodology Stage One Date: Summer 2017: A workshop with patients and health professionals to understand patient and professionals values and to explore what kind of decision- making tool could explicitly tap into patient and practitioner values to support shared understanding and decision-making. Stage Two Date: Autumn 2017: Developing a tool that could be tested with Osteopathic and Dental patients and health professionals. Stage Three Date: (tbc) Seek ethical consent. Pilot the tool with patients and health professionals in a clinical context.

Evaluating the tool Administer CARE Measure Ask groups to use decision making tool, Administer CARE measure again to see if any difference Seek feedback Evaluation

Thank you If you are interested in finding out more about our project or have any questions, please contact: Guy Rubin: grubin@gdc-uk.org Professor Stephen Tyreman: s.tyreman@bso.ac.uk Fiona Browne: fbrowne@osteopathy.org.uk Stacey Clift: sclift@osteopathy.org.uk