Context for NHS Wales - 1000 Lives Improvement

8th November 2011

MAGIC - Shared Decision Making in the Cardiff and Vale University Health Board Natalie Joseph-Williams Mike Spencer Insert name of presentation onand Master Slide

• Shared decision making what is it and why do we do it? • MAGIC programme what are we doing? • Spread and sustainability SDM in the Cardiff and Vale University Health Board

I think I prefer this option…

Shared Decision Making is an approach that ensures all patients understand the key features, risks and benefits of treatment options and make a decision that is aligned with what is important to them

What health care professionals think…

What proportion of your patients do you believe actually want more information than they currently receive on their treatment and its management?

Which of the following do you think is the biggest barrier to increased patient engagement?

What patients want…

Patientexpectation expectationabout about involvement decisions Patient involvement in in decisions

Doctor sole decision maker 10%

Patient sole decision maker 5% Patient decides after consultation 18%

Doctor decides after consultation 16%

Source: Coulter & Jenkinson “European patients’ views on the responsiveness of health systems and healthcare providers” (2005) European Journal of Public Health, Vol. 15, No. 4, 355–360

Shared decision 51%

Are Patients involved ? Percentage of patients who wanted more involvement in treatment decisions

Source: Care Quality Commission Inpatient Survey

What patients say… “I would like to be more involved in decisions for me to pick the right treatment for myself…” “Doctors don’t always explain the side effects possible…I might have preferred a different option if I’d known…” “I don’t normally ask about options as I assumed the doctor would know better for me, but now I would like to understand the pros and cons so I can decide what I would like…” “Who knows me better than me?” “Doctors rush you in and out of the consultation…I would like to but they don’t give you the time”

Evidence • Cochrane Systematic Review of patient decision support (O’Connor, 2011): • Improves knowledge and more accurate risk perception • Increases participation and satisfaction with decision • Fewer undecided • Reduces uptake of elective surgery

• Improves adherence to medication (Joosten, 2008)

So why aren’t we doing it? Multiple barriers – “We’re doing it already” –

“It’s too difficult” (time constraints)

–

Accessible knowledge

–

Skills & Experience

–

Availability of decision support tools for patients / professionals

–

Fit into clinical systems and pathways

Lack of implementation strategy Multiple levels

What are we doing in MAGIC ?

MAGIC • The Health Foundation - 2009 call for “SDM Design Team” • 18 months programme: started August 2010 • Design and test the best ways to overcome the barriers and embed shared decision making in mainstream health services • Implementation not research

MAGIC teams Currently working with:

Spreading to:

• Breast cancer

• Urology

• Head and neck cancer

• Mental Health

• Paediatric ENT

• Sexual Assault Referral Unit

• Renal

• Pharmacists

• 4 primary care teams

• Further primary care teams

What are the key interventions being used in MAGIC ?

Decision support tools

Measurement tools • Decision Quality Measure (DQM) assesses patients’: – Knowledge about the key features of the available treatment options – Preferences (what is important to them) – Readiness to decide (using the DelibeRATE scale) – Preferred choice of treatment • Teams using the measure to inform consultations • “This isn’t for MAGIC now…this is for us”

Knowledge – Breast Team Knowledge post home visit (DQM2)

100

100

90

90

80

80

70

70

60 50 40 Unsure 30

Correct

20

Incorrect

Percentage of Patients

Percentage of Patients

Knowledge post diagnostic consultation (DQM1)

60 50 40 Unsure 30 20

10

10

0

0

Question Topic

Correct Incorrect

Question Topic

Choice of treatment – Breast Team Intention post home visit (DQM2)

100

100

90

90

80

80

70

70

Percentage of patients

Percantage of patients

Intention post diagnostic consultation (DQM1)

60 50 40 30

60 50 40 30

20

20

10

10

0

0 Strong Leaning preference towards for mastectomy mastectomy

Not sure

Leaning towards lumpectomy

Strong preference for lumpectomy

Strong Leaning preference towards for mastectomy mastectomy

Not sure

Leaning towards lumpectomy

Strong preference for lumpectomy

“Ask 3 Questions” Campaign • Patient Activation – bottom-up approach • 3 questions to help patients become more involved in healthcare decisions

So just ask…

Embedding Shared Decision Making in Cardiff and Vale University Health Board

Context for Cardiff and Vale Statement of intent…………. ..…..for our patients to ensure they are involved meaningfully in their care

Context for NHS Wales • Healthcare Standard 9 • Health Boards…..address the needs of patients…by providing opportunities to discuss and agree options

Delivery • Can we demonstrate to what extent patients are involved in decisions? • Can we show that we are actively doing something to change the baseline?

Delivering the Intent • Can we demonstrate to what extent patients are involved in decisions? - Not really • Can we show that we are actively doing something to change the baseline? - Not really

Patient Context - what patients tell us: What problems do you have with health professionals? • • • • • • •

Don’t listen to what I’m saying Uses words I don’t understand Decide on treatment without explaining or discussion Think they know how I am feeling Reach for the prescription pad before I’ve finished speaking Condescending/ patronising /talks down to me Being treated as if you know nothing about your condition and how it affects you / not acknowledging your experience and knowledge

So how can we change that? Source: Comments from patients as part of the Expert Patient programme, Cardiff and Vale of Glamorgan

It’s MAGIC……………..

XXX



How have we gone about it? • Board commitment – Clear part of the Patient Experience agenda – Reported through Quality and Safety Committee

• Divisional Engagement – Presentations at Quality and Safety meetings – Spread of clinical teams for phase 2

• Clinical Team Engagement – Clinical leads meetings

How have we gone about it? • Public engagement – Use of media – Use existing public/patient networks

• Link with Innovation and Improvement – Use of Quality Improvement techniques

• Link with strategic priorities – Clinical direction – Patient Information

Future Directions • Links to – – – – – –

Work with Minority Ethnic Communities Health Literacy Strategy Patient feedback framework Carer involvement and engagement Patient resource centre development Patient and public engagement

Future Directions • Links to – web site development – continued shared learning with others – Development of the Ask 3 approach

• Measurement for assurance and improvement

Thank you – any questions? [email protected] [email protected]