Realising the power of patients to produce
tangible and radical reforms
Shared Decision Making – MAGIC or 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?
MAGIC – MAking Good decisions In Collaboration
Newcastle
Cardiff
Richard Thomson
Glyn 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
Focusing on implementation
• Evidence-based patient decision
support
MAGIC Making Good Decisions in Collaboration with Patients
The MAGIC Framework: Action learning with indicator feedback, located in a social marketing context
PLUS
and supported by organisational level leadership.
Indicator
ENT
• Social marketing
Feedback
Breast Surgery
Project
• Clinical skills development
Primary Care
Start
Obstetrics
• Organisation and clinical team
engagement and leadership
• Measurement and rapid feedback,
action learning, quality
improvement cycles
• Patient & public engagement
Social
Urology
Marketing
Senior Management Clinical Leadership
Models of clinical decision making in the consultation
SDM is an approach where clinicians and patients make
decisions together using the best available evidence.
(Elwyn et al. BMJ 2010)
Paternalistic
Shared
Decision
Making
Informed Choice
Patient well informed (Knowledge)
Knows what’s important to them (Values
elicited)
Decision consistent with values
Model of SDM consultation
I think I prefer this option…
collaborative practice
(we called it
Patient Activation at the time)

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?

Ask 3 Questions
•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
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
SKILLS
TOOLS
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
Council of
Members
Governing Body
Community Forum
Wellbeing
&
Prevention
Prescribing
&
Women Medicines
Planned
and
Care
Children
Disabilities
& Mental
Council of Health
Members
Older
People
Unscheduled
Care
Community
Forum
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 MBBS
Co-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)
Royal Cornwall Hospitals, 2011
 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
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
Overview
 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
The National PROMs Programme was introduced in 2009 to begin to
compare and improve quality
PROMs Programme Overview
What?
How?
 4 procedures
 Pen, paper and post
 Condition-specific & generic wellbeing scores
 c. £4 - £6.50 per patient
 Pre-op and 6 months
 c. 250,000 pts/ yr = c. 3.5%
elective admissions
 Organisation level reporting
 Reports published c. 6/12 later
 No primary use - individual
patients do not benefit
But five years on comprehensive data collection is still an issue
Overall linkage, Apr – Sep 2013 (published 13th Feb ‘14)
122,571
11% linked pre and post-op (by
5 months)
89,157
37,278
13,690
Eligible
procedures
1.
Pre-op
returns
Source: www.hscic.gov.uk
1. Difference includes cancellations and deaths
2. Acknowledged as underestimate due to time delay
Post-op
sent out1
Post-op
returns2
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
@myClinOutcomes
Patient sign-up
@myClinOutcomes
Patient sign-up
@myClinOutcomes
Patient sign-up
@myClinOutcomes
Patient sign-up
@myClinOutcomes
Score completion
@myClinOutcomes
Patient Dashboard: Your progress
@myClinOutcomes
@myClinOutcomes
Developing the system with a mix of clinicians at different sites has
produced a highly flexible platform
Progress to date
 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
“The central goal in healthcare must be value for patients, not
access, volume, convenience or cost containment” – Prof Michael E. Porter
Value Based Healthcare
 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)
Source: The Strategy That Will Fix Healthcare. Michael E. Porter & Thomas H. Lee; Harvard Business Review, Oct 2013
Thank you!

1. ISPOR.org
2. Illustration by Jill Dawson, BMJ 2010;340:c186
tim@myClinicalOutcomes.co.uk
+44 777 999 0276
@t1mwilliams
@myClinOutcomes