Shared decision making: making assumptions?

Shared decision making (SDM) impacts practice across all sectors and specialisms. It is a golden thread in organisational strategies, a driver in national health policy across all four UK countries, a focus of the HCPC (The Health and Care Professions Council) standards of proficiency update, as well as a cross-cutting theme in the CSP’s 2023-27 corporate strategy.

The Patients Association recently reported that 50 per cent of patients surveyed did not feel involved in their treatment and care decisions. Not being properly informed about their condition and their options for treatment is the most common cause of patient dissatisfaction. 

Evidence shows that SDM improves quality of care, improves patient satisfaction, greater patient motivation to actively manage their health - leading to a more effective use of healthcare services, greater job satisfaction for healthcare professionals, and ultimately better health outcomes.

It is an essential component of evidence-based practice and a vital tool in tackling health inequity, with the greatest improvements in health outcomes reported by the most disadvantaged groups. 

There is comprehensive, free and easily accessible training to develop our knowledge and skills in SDM, but in our busy and challenging work environments are we successfully translating SDM into practice to optimally support our patients and develop our practice? How are we evaluating its impact on our services, patient care, and our wellbeing? 

How should SDM look?

SDM is a process in which clinicians and patients collaborate to select tests, treatments, management or support packages, based on evidence and the patient’s informed preferences. 

It involves the provision of evidence-based information about options, outcomes and uncertainties, together with decision support counselling and a system for recording and implementing patients’ informed preferences’(NICE/NHS Consensus Statement 2016).

Does SDM defer all decisions to the patient?

No. Rather it is a conversation between two experts; the clinician’s expertise, such as treatment options, evidence, risks and benefits and what the patient knows best: their preferences, personal circumstances, goals, values and beliefs. NHS England Shared decision-making. 

Discussing the same evidence with people with different values might lead to different decisions.

When should SDM be applied?

SDM should be an on-going conversation - not a tick box exercise. It should be an integral part of all health conversations and used in any non-life-threatening situations when there is more than one reasonable course of action and to aid obtaining informed consent or communicate risks.

What about the barriers?

There are barriers, including individuals and organisational culture and attitudes, resources and perceived time constraints limiting the effective application of SDM.

However, SDM is an approach not an additional task and evidence shows that when healthcare professionals are routinely implementing SDM within their practice, it takes no extra time. 

So how can you reduce the barriers to optimise SDM?

Reflect on your last three interactions with patients with marginalised protected characteristics. How effectively did you use SDM? Consider:

• Your skills – are you confident in your SDM knowledge and implementation? The Personalised Care Institute offers free training and new virtual patient simulations to test your SDM skills.
• You – are you making conscious or unconscious assumptions about patients based on their characteristics or diagnosis? For example, in arthritis management, you may assume pain management will be a patient’s top priority. But patients report a multitude of other priorities, for example returning to work or exercise. Explore your unconscious biases.
• Your organisation – do its policies and pathways support effective SDM? Discuss this at your next supervision or team meeting. If SDM is not already included in your clinical supervision discussions or linked to your competencies request that it is
• Your patients – are your patients prepared for SDM? Whilst SDM can empower patients it may take encouragement to get some patients fully involved. What information could you supply before appointments to support patients to actively participate for example BRAN leaflets or ‘Ask 3 Questions’ resources.
• Evaluation -– how do you know if your SDM is effective? Consider the evaluation tools being used (examples include CollaboRATE or SDM-Q9) and what data is being collected. Is SDM activity being captured and its impact clear?