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

tim@myClinicalOutcomes.co.uk+44 777 999 0276

@t1mwilliams@myClinOutcomes

Thank you!

1. ISPOR.org2. Illustration by Jill Dawson, BMJ 2010;340:c186