Offering patients true choice in healthcare means giving them the right information at the right time and providing them with the skills and support to make informed decisions
Imagine a healthcare system in which patients at the point of initial diagnosis in primary care are given the right clinical information in a patient friendly format that includes feedback from those who have been in the same situation. Imagine if they could take this information away, reflect and then access support to make sense of what they had learnt, while identifying their own values and given skills to articulate their choices.
For how many of us have at some point felt overwhelmed with emotion, overloaded with information and pressurised when faced with a choice over a treatment path or care decision?
Planning for change
The migration from choice of provider to choice of treatment is a huge journey and can have a major impact on the healthcare system. Planning for this change needs to happen now, so that as patients gain confidence and accept their new responsibilities for choice the NHS can respond in a way that is empowering. Supporting patients to make choices that are right for them and at a time that is right for them is a vital piece of infrastructure for co-production.
Would the sale of council houses during the 1980s have been such a successful policy for the Conservatives if the independent financial market had not responded to the opportunity with a prolific range of services?
We cannot expect people to seize major new policy initiatives without route maps and skills transferred to support them. So if patients are to make fully informed choices, they need to be able to access unbiased, evidence based clinical information. The National Institute for Health and Clinical Excellence and the NHS Choices website both do a good job of putting this in the public domain. As access to information becomes less of an issue, we should now be providing the skills and support needed to understand this information alongside personal preferences and values. What is important to one person now is not necessarily what will be important to them next year. And herein lies one of the major challenges.
Massachusetts General Hospital general medicine chief Al Mulley, an expert in the field of decision making, refers to "mis-imagining the future". Professor Mulley and the US Foundation for Informed Medical Decision Making argue patients need to be supported to imagine their future state as it might be if they were to use one treatment option or another. They advocate the idea that patients should be supported by the use of decision aids. They say this is especially important for "preference sensitive conditions", that is, those where there is no clear clinical evidence of one treatment being superior to another (back pain, for example).
This is where the power of patient choice can be maximised. What impact might we have on back surgery rates and outcomes if we said no patient could have surgery without first being coached in their choices?
Arguably, no patient can be said to have truly informed consent or make fully informed choices without support. If we think back to the council house purchase boom, we are reminded of the mis-sale of endowments as purchasers rushed into decisions, sometimes without the right information and/or the skills to make sense of them.
Yet is it reasonable to expect NHS staff to undertake the role? How many have the skills required or the time to help patients identify their values and preferences and then follow this discussion up with them? How rich are the libraries of decision aids? And are health professionals in the mood to move away from professional control and comfort to patient and public power and value?
Many readers might also be concerned about the potential impact on NHS resources. In fact evidence shows that where patients have more information they choose less treatment and that providing them with health coaching type support can result in significant reductions in hospital use.
This approach is not new and has been operating in the US for over 10 years, with major healthcare insurers having health coach support for patients as an integral part of their patient care programmes.
In the UK, patients in Norfolk and Surrey with long term conditions and those facing elective treatment decisions have been receiving this kind of support, with positive results. Usage rates go down while patient satisfaction and their feelings of control go up.
The challenge for the NHS, if it wants to move co-production and personalisation forward, is to ensure people not only have the right information at the right time, but also become skilled in decision making so they have the optimum opportunity for choosing well.