SHARED DECISION MAKING - USING A CAPABILITIES APPROACH AND RELATIONAL THINKING

1. SHARED DECISION MAKING - USING A CAPABILITIES APPROACH AND RELATIONAL THINKING Hereford and Worcester Sub-Regional Trainers’ Workshop November 2013 “No decision about me, without me”

4. Short exercise • What are the essential ingredients of Shared decisions?

7. The empowered patient http://www.youtube.com/watch?v=RK8dMRLVWvg

10. Policy makers today often look to the sciences, including the social and psychological sciences, for support, but they look to philosophy rather less often. This is perhaps because requirements for ‘evidence-based’ policy making reflect and encourage a strong focus on questions about effectiveness or, in crude terms, ‘what works?’ Philosophy can make very important contributions to the development of policy and practice by checking and improving the quality of our understanding and reasoning. It can be compared to a (sometimes annoying) critical friend who asks uncomfortable questions about the assumptions we are making and whether we know what we are doing or talking about.

11. Some studies that I like to quote.. http://www.youtube.com/watch?v=Ij8bPX8IINg

12. Relational autonomy • Diana Meyers suggested that • ‘we should understand personal autonomy as the possession and exercise of skills related to self-discovery, self-direction and self-definition, and the use of these skills to achieve an integrated but dynamic authentic self.’ • She stressed that the ‘repertory of skills that make up autonomy competency’ are developed through socialisation (for example under the influence of parents and teachers) and then shaped by social experience in a broad range of interactions.

13. More recently, Catriona Mackenzie proposed that • we should understand a person’s autonomy not just as a matter of them having a sense of who they are and of what matters to them, but also as a matter of them having a sense of themself as the legitimate source of normative authority over their life. This sense, which is associated with attitudes of self-respect, self-trust and self-esteem, is developed and sustained in part by other people’s recognition of the person’s claim to normative authority.

14. It is therefore also dependent on social attitudes and other people’s behaviours towards the person. • Mackenzie builds on this point to argue that clinicians might be obliged to promote patients’ capacities for autonomy, including if necessary by working to shift patients’ attitudes so that they can see themselves as a source of normative authority over their lives.

16. What goes wrong when clinicians claim to use collaborative approaches but control the agenda to pursue biomedical targets? Sometimes clinicians who claim to use collaborative approaches ‘involve’ people with long-term conditions in discussions, for example about how and when they will take particular medications and/or adopt particular lifestyle changes, but seem somehow to fall short of what experienced advocates think matters for collaborative approaches. The good intentions of these clinicians need not be doubted, and what they do might be consistent with published models of collaborative approaches and with notions of patient activation. A few more details can start to reveal how they might fall short of more demanding aspirations. Sometimes clinicians can be seen to be ‘managing’ patients’ involvement to support the pursuit of biomedical treatment targets

17. FACILITATING SHARED DECISION MAKING Shared decision-making requires three essential components – • Health literacy • Appropriate communication • ‘Activated’ patients

18. Core Skills used in Shared Decision Making

20. Short exercise • Short case scenarios

22. WHAT MIGHT A‘SHARED DECISION-MAKING II’ TEACHING RESOURCE LOOK LIKE?

24. ‘Three questions’ – • What are my options? • What are the possible benefits / risks of these options? • How likely are the risks and benefits of each option likely to occur? • Whose responsibility are the options? – • Exclusively mine? • Mine but with support? • Beyond me? • Combined with the impact on capabilities in the following dimensions - • Physical environment • Behaviour and roles – what are the important functions / tasks that I need / wish to keep doing? • Skills and capabilities – what will be the impact on my abilities to do them? • Values and Beliefs – How important is my health in this context? • Identity – How will affect my view of my ‘self’ • Aspirations / Spirituality - Where does it fit in the wider scheme of my life?

25. Short exercise • Short case scenarios

26. Suggested Scenarios • Managing LTCs; • End of Life; • Personalised care planning; • Mental Health conditions that overlap with lifestyle / personality; • Role of screening eg. dementia; • Telehealth; • Ill-defined conditions eg. CFS; • Commissioning health care for local people; • Commencing COC for first time; • Lifestyle changes in obesity / Exercise; • Making every contact count ( ? too ambitious); • Planning residential care for competent elderly

27. WHAT MIGHT A‘SHARED DECISION-MAKING II’ TEACHING RESOURCE LOOK LIKE? The following principles might apply – • It should be a toolkit for development, not only at an individual level, but also at a practice and community level. • It looks beyond the communication and consultation model • It should encourage and change in culture not simply technique. • It shows examples of ‘capability approaches’ which describe important quality of life preferences • It includes ‘relational thinking’ to exemplify issues of autonomy through genuine choice rather than a restricted selection of options offered by the professional • It could be multi-disciplinary rather than a medical model – but would need to retain it’s primary care focus • It should maintain the identity and ‘house style’ of Dialogues in Decision making’ but will have a significantly different content. • It should have an interactive and expandable format • We might consider collaboration with other organisations eg. The Health Foundation, which is a registered charity, offers funding for innovation in Shared Decision Making.