Shared Decision Making in Practice: An Overview of MAGIC Richard Thomson

1. Shared Decision Making in Practice: An Overview of MAGIC Richard Thomson On behalf of MAGIC Cardiff and Newcastle

2. CardiffGlyn Elwyn/Maureen Fallon NewcastleRichard Thomson Acknowledgements: TheHealth Foundation, Cardiff and Vale Health Board, Newcastle upon Tyne Hospitals NHS Foundation Trust, staff and patients involved across both sites.

3. What is shared decision making (SDM) ?

4. Models of clinical decision making in the consultation SDM is an approach where clinicians and patients make decisions together using the best available evidence. (Elwyn et al. BMJ 2010) Shared Decision Making Informed Choice Paternalistic Patient well informed (Knowledge) Knows what’s important to them (Values elicited) Decision consistent with values

5. Examples of preference –sensitive decisions • Breast conserving therapy or mastectomy for early breast cancer • Repeat c-section or trial of labour after previous c-section • Watchful waiting or surgery for benign prostatic hypertrophy • Statins or diet and exercise to reduce CVD risk • Diet and weight loss or medication in diabetes

6. TOOLS SKILLS Spectrum of SDM to SSM “Shall I have a knee replacement?” “Shall I take a statin tablet for the rest of my life?” “I would like to lose weight” “I would like to eat/smoke/drink less” “Shall I have a prostate operation?” “Should I use insulin or an alternative?”

7. SDM – evidence Cochrane Review of Patient Decision Aids(O’Connor et al 2011): 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 long term care

8. Are patients involved?

9. 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

10. Key features of the MAGIC programme

11. Key elements: Phase 1 • effective engagement of multidisciplinary clinical teams through clinical champions, skills development, trained facilitators, and embedding change into clinical pathways and practice • Awareness, attitude,, skills development • drawing upon what we know works in change management and professional behaviour change, whilst testing some additional innovative elements • used decision aid tools both decision-specific and generic tools • rapid action learning and feedback (implementation monitoring) • patient and public engagement

12. MAGIC – Phase II • Moving implementation from pilot departments and general practices to hospitals and health communities: embedding and sustainability • Leadership and organisational engagement, including working with new commissioning structures (Newcastle) and Welsh Govt (Cardiff) • Expanding and accelerating clinical engagement and impact, by testing learning from Phase 1 • Enhanced patient and public involvement, including an emphasis on patient activation and the wider community. • More efficient ways of delivering education and training • Quality metrics: demonstrating value to commissioners and primary and secondary care organisations.

13. Key learning from the MAGIC programme: headlines. “When we want your opinion, we’ll give it to you”

14. Evidence-based decision support • Timely and appropriate access for clinicians and patients • Needs facilitation • In consultation or outside? • Value of brief in-consultation tools (Option Grids and Brief Decision Aids) • Fit to clinical pathways • Adapt pathway or tools? (VBAC, BPH)

15. Brief Decision Aids/Option Grids • Heavy Menstrual Bleeding (Heavy Periods) • Management Options[1] • A Brief Decision Aid • There are four options for the management of heavy menstrual bleeding: • Watchful waiting - seeing how things go with no active treatment. • Intrauterine system (IUS)– a hormonal device placed in the womb that lasts five years. • Medication - tablets taken before and during periods, the combined oral contraceptive pill, or progestogens either as tablets or a 3 monthly injection. • Surgery - endometrial ablation or hysterectomy. These are hospital procedures that are usually considered only if other options have not worked well or have been unacceptable. [1] Only for use once other causes of HMB such as fibroids or polyps have been excluded

16. Benefits and Risks of Intrauterine System (IUS) Menorrhagia BDA

17. Option Grid

18. Measuring impact of change in clinical practice (Option Grid) Patients’ knowledge post diagnostic consultation

19. Clinical skills development • Cornerstone of implementation • Attitudes and awareness critical • Interactive, advanced skills-based training is core • Eye opening and valued – moving from “we do this already” to “I think we do this, but we could do it better” • What is important to patient (values) is key learning • Challenge of getting senior clinicians to attend • Role of the model of the consultation • Attitudes and skills trump tools • Needs resourcing - MAGIC-Lite model: possible to deliver more efficiently

20. SDM model for clinical practice 20

21. Clinical team engagement • Leadership and champions • Team of champions (including non-clinical) • Learning sets (in primary care) • Importance of medical leadership & role of nurse specialists • Different facilitators for different teams • Keeping SDM on the agenda of the team • Patient experience – decision quality • Support new developments (place of birth) • Support for model of delivery (MDT in head and neck cancer) • Practice payments • Peer pressure/CCG and national initiatives (1000 lives)

22. Measurement & rapid feedback • Action learning model • Regular meetings to share good practice and experiences • Measurement for monitoring, research or QI? • History and experience • Local skills • Driver diagrams and PDSA in Cardiff • Role of rapid testing locally and ownership • Patient experience data a challenge • Validity, reliability, social acceptability bias • Role of decision quality measures

23. Measuring patients’ readiness to decide Readiness to decide, using DelibeRATE (Feb 2011 – Jan 2012)

24. Measuring patients’ choice of treatment Choice of treatment (Feb 2011 – Jan 2012)

25. Quality Improvement & MAGIC Cardiff used the model for improvement (known as QI) as the basis for implementing SDM. This methodology is adopted on a pan-Wales basis. The PDSA (Plan, Do, Study, Act) cycle is ideally suited to SDM implementation as it allows you to test a change in the work setting by planning it, trying it, observing the results and acting on what is learned e.g DQM changes in Breast; Surescore use in Mental Health

26. Patient and public involvement • Role of patient narratives/stories • Role to challenge • “Patient activation”: PPI role • Patient materials design and content – MAGIC or SDM • Ask 3 questions –well received and adaptable • How to better support activated patients? • Challenge of PPI in clinical teams • Wider bi-directional PPI – range of stakeholders – External Advisory Group (Newcastle)

27. A6 flyer for use in appointment letters, waiting areas, consulting rooms. Posters for use in waiting areas and consulting rooms. Short film to encourage patient Involvement: ‘So Just Ask’ Ask 3 Questions Acknowledgement to Shepherd et al, School of Public Health, University of Sydney

28. Commissioning • Challenging in rapidly changing systems and new organisations alongside efficiency savings!! • MAGIC Lite: possible to deliver training to large numbers quickly • Link to other priorities – e.g. referral management, long term conditions

29. Key learning: Summary • SDM is so much more than tools; more to do with skills and new ways of consulting (aided by decision support) • Complex PDAs have a role, but also need simpler in-consultation support (Option Grids/Brief Decision Aids). • Need to embed within clinical pathways (or adapt) and show value to clinicians • Need for wider PPI at all levels

30. Key learning: Summary • Important emerging role of patient activation (provided service is ready to respond) • Measurement of patient experience hard at local level, but local measures likely to be of value if they stimulate change and inform clinical practice (e.g. DQM) • Link to QI/service improvement – local context

31. Wider policy and systems issues • SDM needs to be incentivised within the system (e.g. key metrics/performance management; national/ professional body support; commissioner buy in; board buy in) • Tensions exist • Rapid progress through cancer care pathways • QOF ( e.g. for hypertension treatment targets) • Tendering processes within the English market • Criterion based models of referral management and NICE guidance may create tensions with SDM

32. Wider policy and systems issues • Need for national coordination around education and training • Coordination nationally between patient experience/SDM and LTC/SSM • Access to resources at the time needed – e.g. within info systems • Use of routine data for monitoring and QI • Research needed (e.g. NIHR) to develop valid and reliable measurement of SDM

33. THANK YOU richard.thomson@newcastle.ac.uk