Shared decision making in MSK services
Spring 2019, the Sussex MSK Partnership (Central), proudly delivered by Here in partnership with Sussex Community NHS Foundation Trust (SCFT), was awarded the “Best Educational Programme for the NHS” at the HSJ Partnership Awards 2019. The awards recognise efficient use of NHS resources and ‘inspirational’ innovation in services that make a tangible difference to people’s lives. The partnership received the award for their Shared Decision Making project, which is all about putting people in control of their healthcare journeys. This would not have been possible without the collaborative efforts of teams from Here and SCFT.
Our clinical lead for our Upper Limb team Helen Patten shares about the journey within the service of developing a clinical culture focused around Shared Decsion Making.
One of our core values at the Sussex MSK Partnership is ‘Putting patients in control’ and ensuring care is tailored to their needs, which is at the heart of the shared decision making (SDM) process. We have over 100 clinicians in our service including physiotherapists, nurse specialists, podiatrists, osteopaths and orthopaedic surgeons, and 2 years ago we embarked on a training programme to educate clinicians to align our patient consultations to this value. The programme aimed to improve our understanding and delivery of Shared Decision Making to put people at the centre of decisions about their own treatment and care.
We know that patients want more involvement in making decisions about their healthcare (CQC inpatient survey, 2016) and also that both clinicians and patients overestimate the benefits and underestimate the harm of treatment interventions (Hoffman, 2017) so we have a responsibility to present clear risks and benefits of treatment keeping what is important to each individual in mind. This is also part of the NHS England Long Term Plan.
Many of us as clinicians feel we have a good understanding of SDM, however through the training process clinicians realised that the depth of understanding required a significant cultural shift in communication. We are generally competent in offering informed choice (i.e., treatment options) and less competent as understanding a patient’s preference diagnosis (i.e., what matters to them) There is a fundamental difference between offering informed choice and in involving patients at all stages of their health journey, ensuring that treatment options align with their preferences and values and that they feel involved in decisions about their care. To truly put a patient at the centre of their treatment we need to make them aware of their role in a collaborative way, viewing them as an expert of their own health journey asking not ‘What’s the matter with you?’, but ‘What matters to you?’ This is a significant move away from the paternalistic medical model that has dominated medicine for so long.
We are fortunate enough to have a self-care lead in our service, Chloe Stewart, who as a health psychologist was able to give a unique and expert perspective in leading our training programme. Chloe has been a consistent and valued voice for the project. We took a multifaceted approach to our education strategy ensuing that we engaged with our clinicians in as many ways possible to bring people on-board with the process. Firstly we held expert led training in SDM and motivational interviewing for all clinical staff. We supported a group of self-selecting clinicians to complete a train the trainer programme, resulting in a team of ‘clinical champions’ who were able to offer peer support and tailored observation feedback to colleagues within their teams. This allowed staff the opportunity to identify strengths and areas for improvement in a practical way using reflective practice and peer support. We have realised through the SDM journey that the process takes time – firstly to on-board and engage with staff.
Another shift in our process has been to engage patients in their health journey through the development of a patient outcome letter to outline individualised care plans. We now write directly to the patient, rather than sending them a copy of a letter about them written to their GP. This patient outcome letter acts as a summary of their consultation, and includes: i) self-management information, ii) their treatment options in accordance with their preferences and values; and iii) the relevant harms and benefits of relevant treatments. We developed this letter with our patient partners and we believe this connects the patient to their consultation and reflects the conversations had within the clinical setting.
The impact of our programme has been demonstrated in many ways. We have seen improvements in patient experience measures of SDM using the SureScore over the past 2 years; There has been a significant reduction in referrals to secondary care since 2015 suggesting patients are opting for conservative management over surgical intervention which is also reflected in a reduction in secondary care spend. We also strive to integrate the SDM process into our organisation as a whole through the interactions we have with colleagues as well as the leadership teams. We have a strong presence from our patient partners, administration as well as leaders in our meetings and projects on SDM to ensure every voice is heard and to embed the culture of SDM within our organisation.
We are keen to share our learning further and Chloe Stewart spoke recently at an NHS England webinar for SDM and has just last week been recruited to be on the panel for the new NICE guidelines for SDM. Our highlight of the project so far was entering the HSJ Partnership awards category for education and training which we subsequently went on to win. This has felt like a reflection of the hard work and collaboration of our whole team in sharing this journey and will be a great opportunity to spread the developments in SDM further to encourage a cultural shift in the way we communicate.
Access the full HSJ Partnership Awards 2019 Projects Showcase “Showcasing the Most Effective Partnerships with the NHS“