2. My role Being part of the core MAGIC team for primary care Imbedding shared decision making into the culture of the surgery Writing patient decision aids(PDAs) Developing confidence in using PDAs in my own consultations

3. Statements Decide the extent to which you agree with the following statements where 1 = completely disagree and10 = completely agree In the end it is MY job to advise a patient on the best treatment and encourage them to choose this

4. What percentage of patients say they were involved as much as they wanted to be in decisions about their health care? 1.10% 2.30% 3.50% 4.75% 5.85%

5. Are patients involved?

7. Poor decision quality Patients: unaware of treatment or management options and outcomes Clinicians: unaware of patients’ circumstances and preferences The Clinical Decision Problem

8. UK Policy: UK Government Shared decision making will become the norm: “No decision about me without me” 8

9. What is shared decision making (SDM) ?

11. Paternalistic Informed Choice Shared Decision Making “When we want your opinion, we’ll give it to you”

12. Paternalistic Informed Choice Shared Decision Making “I’m sorry doctor, but again I have to disagree”

13. Definition of SDM SDM is a process whereby a patient, expert in their own lives, and a clinician, expert in evidenced based medicine, come together to make a decision. Patient and clinician, collaboratively, understand that there are choices, present options and evidence, explore these together in the light of the patient’s personal preferences and beliefs, before arriving at an appropriate decision.

14. Cochrane Review of Patient Decision Aids(O’Connor et al 2014): Improve knowledge More accurate risk perceptions Feeling better informed and clear about values More active involvement Fewer undecided after PDA More patients achieving decisions that were informed and consistent with their values Reduced rates of: major elective invasive surgery in favour of conservative options; PSA screening; menopausal hormones Improves adherence to medication (Joosten, 2008) Better outcomes in SSM/long term care SDM – evidence

15. So why aren’t we doing it? Multiple barriers - “We’re doing it already” - “It’s too difficult” (time constraints) - Accessible knowledge - Skills & Experience - Decision support for patients / professionals - Fit into clinical systems and pathways Lack of implementation strategy

16. Core skills in SDM

17. SDM Consultation skills Choice talk Introduce preference sensitive decision. Respond to patient’s reaction Option talk Introduce options, detail pros and cons, check understanding, introduce decision support Deliberation Help patient to deliberate about options, could be supported by decision specific / generic decision support tool Preference/decision talk Establish patient’s personal preferences Decision Immediate or delayed SDM consultation skills

18. Some thoughts about micro skills practice Some useful questions to keep in mind: How much am I talking, compared to how much is this generating a two way conversation?? Am I using the decision support as a script or as a way to stimulate dialogue? Might it be worth trying just using a blank decision aid and writing things down as we go? Do I know what matters most to the patient in making this decision?

20. Shared decision making – support for HCPs and patients 10 Brief Decision Aids (BDAs) available now on patient.co.uk Around 15 more in development Inform patients (and clinicians!) In consultation/take home On-line Patient Decision Aids http://sdm.rightcare.nhs.uk/pda/

21. Patient Decision Aids – key messages Have much value, but need to be accessible at the right time and designed for purpose We will never have enough PDAs for all decisions PDAs are an adjunct to good clinical practice BMJ recently made clear that…. you can have PDAs available, and clinicians trained to use them but this does not necessarily change patient experience – the challenge of the ‘black box’

22. What proportion of people take their treatments as prescribed? a)35% b)50% c)65% d)80%

23. What proportion of people take their treatments as prescribed? a)35% b)50% c)65% d)80% Multiple sources. DARTS Study group – only 35% of people on more than one medication for diabetes cashed in sufficient prescriptions for full daily coverage.

25. What difference has SDM made to my practice Consistency in message when options available Patient centred care moved a step forward Change in culture for the surgery and consultation skills Range of PDAs avail with some still to develop A useful tool when needing to address changes with QIPP

26. What difference has SDM had to patients Better informed ?improved adherence Confidence their values/concerns addressed Written material to share/reflect on AN option to do nothing Improved quality of care

27. Statements Decide the extent to which you agree with the following statements where 1 = completely disagree and10 = completely agree In the end it is MY job to advise a patient on the best treatment and encourage them to choose this

28. http://www.health.org.uk/areas-of-work/programmes/shared-decision-making/