1. 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

2. 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

3. Model of regulation Four components of regulation:
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

4. 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)

5. 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?

6. 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)

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

8. 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

9. 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?

11. 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

12. 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

13. 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)

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

15. 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

16. 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

17. 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.

18. 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

19. Thank you
If you are interested in finding out more about our project or have any questions, please contact:
Guy Rubin:
Professor Stephen Tyreman:
Fiona Browne:
Stacey Clift: