As generalists, the volume of guidance that affects our day-to-day practice can be overwhelming, even more so over the last 18 months as our inboxes have been filled to bursting with ever-changing COVID-19-related updates.
It may be, then, that you missed, or at least did not fully appreciate, two important pieces of new guidance that impact the fundamentals of how we practise medicine. The GMC guidance on decision making and consent and the NICE guidance on shared decision making are both relevant to everything we do in healthcare. Now is an opportunity to evaluate how we incorporate them into our practice.
What is shared decision making?
Shared decision making is not a new concept. It describes a process of ensuring that a patient’s individual preferences and values are combined with the best available evidence to ensure that they are making the decisions that are right for them.
It is our job to support this process by laying out the options, carefully describing the potential risks and benefits of each, and then supporting the patient in incorporating what is important to them in the decision being made.
However, shared decision making is an advanced clinical skill and our systems don’t always support the process. Sometimes protocols and guidelines may impede the discussion of options, or the relevant information may not be easily available.
The new guidance from the GMC and NICE are a clear indication that shared decision making is no longer a ‘nice to have’ but must be business as usual in the NHS; a message that reinforces the commitment to personalised care within NHS England's Long Term Plan.
The GMC makes it clear that shared decision making applies to every patient and for every health and care decision that is made.
Due to the conflation of ‘consent’ with ‘consent forms’, we sometimes only considered the process of consent when discussing procedures or surgery. But of course, consent relates to every decision in healthcare, including ordering investigations, prescribing medication or making referrals.
Consent is given at the end of the process of decision making, and is only valid if that process is personalised to the individual patient through shared decision making.
How to implement shared decision making
Helpfully, both the GMC and the NICE documents go beyond the usual ‘what to do’, and actually describe ‘how to do it’.
The NICE guidance unpicks the process of shared decision making and explores the steps that can be taken before, during and after discussions with patients to put it into practice.
It introduces models for decision making, strategies on how to encourage patients to express their preferences and values, as well as practical tips on how to communicate information on risk. The mechanics of shared decision making are laid bare, but the challenge of going from knowing to doing is not underestimated.
NICE also make recommendations at an organisational level so that clinicians are supported to practise in a patient centred way. The guidance challenges organisations to take responsibility for leading and enabling change in their culture, training and systems so that patients are put at the heart of decision making.
Truly adopting personalised care through shared decision making is much more difficult than the application of protocols and processes. Organisations can and should do their part in making the right thing to do; the easy thing to do.
Involving patients in discussions
Some clinicians feel that their patients don’t want to be more involved in discussions, instead preferring to be told what decision is ‘best’.
However, patients sometimes find themselves unable, rather than unwilling, to participate as much as they want in decision making. Many of us would say we are already practising shared decision making, but sometime it helps to take a step back and reflect on the habits and heuristics that we have developed over the years.
This is not straightforward. It requires us to question the foundation of our consultations and our relationship with patients. We need to fully understand what shared decision making is, and what it looks like when done well. The guidance from the GMC and NICE are good places to start, and further elearning is available through the Personalised Care Institute, but, like any advanced skill, mastery takes practice, reflection and responding to feedback from patients and colleagues.
Shared decision making is not only a necessary part of medical practice, but it also makes healthcare work better for patients, healthcare professionals and the wider system. Being truly patient centred is a challenge, and I don’t claim to have mastered it yet, but ultimately it is the very core of good general practice so support from the GMC and NICE is very welcome.
- Dr Pauline Foreman is a GP and clinical director of the Personalised Care Institute