Realising the power of patients to Realising the power of patients to produce tangible and radical reformsproduce tangible and radical reformsShared Decision Making – MAGIC or Shared Decision Making – MAGIC or
not?not?Dave Tomson Primary Care lead for MAGIC – North East GP and Freelance consultant in patient centred primary care
Preliminary thoughts/ context
Mainly focussing on service/ individual level – background in general practice and life long interest in the pivotal function of the consultation
Getting less keen on idea of ‘patient engagement’ – like ‘collaborative practice’ better
- similarly moving away from ‘patient activation’ towards – patients having right skills knowledge and confidence to manage their conditions effectively (thanks to Simon Eaton for this)
Will also talk about some of work in my own practice Will talk about Shared decision Making SDM & MAGIC
10 mins – lay out the territory – rest of the time lets discuss the issues!
Practice activity Getting the most out of your consultation leaflet Early adopters of PILS patient information leaflets Research in copying letters to patients Patient participation group Pioneer for MAGIC First wave Year of Care Skills development programme for all staff
including video review Redesigning supported self management
Not sure how much difference all this is making?
NewcastleRichard Thomson
CardiffGlyn Elwyn
Acknowledgements: The Health Foundation, Cardiff and Vale University Health Board, Newcastle upon Tyne Hospitals NHS Foundation Trust, and most importantly all staff and patients involved across both sites
MAGIC – MAking Good decisions In Collaboration
• Evidence-based patient decision support
PLUS
• Social marketing
• Clinical skills development
• Organisation and clinical team engagement and leadership
• Measurement and rapid feedback, action learning, quality improvement cycles
• Patient & public engagementSenior Management Clinical Leadership
Social
Marketing
Breast Surgery
ENT
Urology
Primary Care
Obstetrics
Indicator
Feedback
Project
Start
MAGIC Making Good Decisions in Collaboration with PatientsThe MAGIC Framework: Action learning with indicator feedback, located in a social marketing context
and supported by organisational level leadership.
Focusing on implementation
Paternalistic Informed ChoiceShared Decision Making
Patient well informed (Knowledge)
Knows what’s important to them (Values elicited)
Decision consistent with values
SDM is an approach where clinicians and patients make decisions together using the best available evidence. (Elwyn et al. BMJ 2010)
Models of clinical decision making in the consultation
Model of SDM consultation
I think I prefer this option…
Posters, leaflets, calling cards Questionnaires DVD – JUST ASK
3 Questions approach Based on original Australian research, adapted after an iterative
approach with patients (Shepherd et al, University of Sydney): What are my Options What are the possible benefits and risks? How can we make a decision together that is right for me?
collaborative practice (we called it Patient Activation at the time)
•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’
Acknowledgement to Shepherd et al, School of Public Health, University of Sydney
Ask 3 Questions
A True story! Small surgery – 3000 and two main GPs A great DVD A brand new screen in a small waiting room Looped showing every 10-15mins Leaflets on the chairs every morning 3 months
WHAT HAPPENED?
Triangulation – inviting more involvement AND Skills development
Clinicians need to meet patients half way – it takes at least two to change the dynamic Trained lots of people, detailed educational programme
Increasingly focused on attitudes
KEY debate: Rolling out skills training for all or nudge the whole
curve Design for the multiple ways of increasing the chances of collaborative practice
YOC – giving patients results ahead of appointments
Using Brief Decision Aids (BDAs) and Option Grids
Parkinsonnet ( BMJ this last week)
SDM or patient centred practice
Currently lots of silos – Supported self management, care planning, end of life care, motivational interviewing and shared decision making
Skills for 21st Century practice? Continuum
TO
OL
S
SK
ILL
S
Episodic - SDM
Lifestyle and LTC
Challenges
Different patients want different styles of working at different stages of illness trajectory
Mistaking choice for collaboration Measuring what makes a difference Sustaining program across all levels and for sufficient time Power, knowledge and attitudes remain significant issues
Realising the power of patients to produce tangible and radical
reforms- moving from the possible to the essential in the new NHS
Realising the power of Patients to Produce Tangible and radical
Reforms- moving from the possible to the essential in the new NHS
Governing Body Community Forum
Council of Members
Community Forum
Council of Members
Older People
Disabilities & Mental
Health
Unscheduled Care
Planned Care
Women and
Children
Prescribing &
Medicines
Wellbeing &
Prevention
CCG Governing Body/Partnership Board
Coming together is a beginning; keeping together is progress; working together is success.-Henry Ford
OPM Breakfast Seminar
27th March 2014
Dr Tim Williams MA MBBSCo-founder & Director
@t1mwilliams
Helps patients to measure their clinical condition throughout their care & share progress with those involved
Started with a clinical need to respond to outpatients department capacity / demand mismatch (I)
1,200 hip and knee replacements per year
Best practice: review at 1yr, 3,yr, 5yr, and every 5 years
BUT… real financial pressures sometimes restricts ideal practice
Royal Cornwall Hospitals, 2011
An emerging need for clinicians to be increasingly accountable (II)
Revalidation Publication of clinician-level data
While the commissioning & provider landscape rightly increases emphasis on transparency and improved outcomes (III)
Everyone Counts, NHS England, 2013-14
We think that allowing patients to monitor the outcomes that matter to them throughout their care is essential
PROMs are clinically-validated condition-specific questionnaires
Quantify symptoms
Inform clinical decisions
Overview of quality of care
Used in clinical trials… cost has limited clinical use
Our focus is on making collection engaging and reports useful and useable for patients and doctors
Overview
The National PROMs Programme was introduced in 2009 to begin to compare and improve quality
4 procedures
Condition-specific & generic well-being scores
Pre-op and 6 months
c. 250,000 pts/ yr = c. 3.5% elective admissions
Organisation level reporting
Pen, paper and post
c. £4 - £6.50 per patient
Reports published c. 6/12 later
No primary use - individual patients do not benefit
What? How?
PROMs Programme Overview
But five years on comprehensive data collection is still an issue
1. Source: www.hscic.gov.uk1. Difference includes cancellations and deaths2. Acknowledged as underestimate due to time delay
Overall linkage, Apr – Sep 2013 (published 13th Feb ‘14)
Pre-op returns
Eligible procedures
Post-op sent out1
Post-op returns2
122,571
89,157
37,278
13,690
11% linked pre and post-op (by 5 months)
What happens to patients who aren’t faring so well?
Improvement rate by procedure & measure, Apr – Sep 2013 (published 13th Feb)
Source: www.hscic.gov.uk
When do those who are faring well deteriorate, and what’s the cause of that variation? Improvement rate by procedure & measure, Apr – Sep 2013 (published 13th Feb)
Source: www.hscic.gov.uk
1. Pts < 50, 90% chance of revision before death (>70, 90% chance of dying first).Pts with post-op OHS <27 7.6% chance of revision within 2 years; >34 it’s 0.7%. Rothwell et al. JBJS, March 2010
Patient sign-up
@myClinOutcomes
Patient sign-up
@myClinOutcomes
Patient sign-up
@myClinOutcomes
Patient sign-up
@myClinOutcomes
Score completion
@myClinOutcomes
@myClinOutcomes
Patient Dashboard: Your progress
@myClinOutcomes
@myClinOutcomes
Developing the system with a mix of clinicians at different sites has produced a highly flexible platform
12 hospitals, 1 CCG so far
94 registered clinicians
> 5,500 registered patients
> 42,00 assessments
Orthopaedics & trauma
Cardiology
NPP PROMs module
Oncology / palliative care in development
Progress to date
Consider patients according to needs
Co-define and measure outcomes that matter to those groups throughout the full care cycle
Align all parts of patient pathway to provide the highest quality of care
Commission services around outcomes rather than volume delivered (ultimately at the lowest cost)
“The central goal in healthcare must be value for patients, not access, volume, convenience or cost containment” – Prof Michael E. Porter
Value Based Healthcare
Source: The Strategy That Will Fix Healthcare. Michael E. Porter & Thomas H. Lee; Harvard Business Review, Oct 2013
[email protected]+44 777 999 0276
@t1mwilliams@myClinOutcomes
Thank you!
1. ISPOR.org2. Illustration by Jill Dawson, BMJ 2010;340:c186
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