Given that there are so many reasons in favour of shared decision making, and given that so many policy documents and national publications support it, why is it not yet common practice?
Low health literacy
One reason is the low level of health literacy in England. Health literacy is important because 43% of working age English adults do not understand health information. This rises to 61% if there is any numerical component to the information.
People with lower levels of health literacy are less likely to be confident about talking to health professionals, less motivated to engage in decisions about their health and less willing to let clinicians know when they haven’t understood what they have been told. At the same time clinicians are not always likely to spot people with lower levels of health literacy, which means they do not adjust their practice to take account of it. The written information given to people is also less likely to be understood by those with lower health literacy.
The effect of this is that those with higher levels of health literacy both expect and receive shared decision making while those who are less health literate neither expect or get it.
The professional perspective
To a large extent, health professionals are committed to a shared decision making approach, but it is not consistently and comprehensively applied and there can be both practical and organisational pressures which are perceived as making it harder.
In 2010, the Health Foundation in the UK commissioned the MAGIC (Making Good Decisions in Collaboration) programme. Its aim was to design, test, and identify the best ways to embed shared decision making into routine primary and secondary care. The programme report was published in 2017. It identifies and responds to five key challenges:
- We do it already
- We don’t have the right tools
- Patients don’t want shared decision making
- How can we measure it
- We have too many other demands and priorities.
In summary, the three most commonly stated issues, and the response are shown below:
We don’t need to change our practice – we’re already doing shared decision making
That’s fantastic – let’s look at how we can make sure you have consistent, high quality practice across all decisions, simple and complex. Let’s review how you document what you are already doing, so we can share your learning and spread best practice.
We don’t have time to go through all the options with patients
It can take a bit more time to go through all the options but you need to have that conversation with patients. You might save time long term too, as patients will be making better decisions and getting the best care for them first time. Let’s look at what tools we can use, or how we can help provide the information to patients in a time-effective way.
Patients don’t want to be involved – they always say: “You know best, what would you do?
Patients might not have the confidence to speak up about what they want, or how much involvement they need – we need to help them get that confidence, then we can support them in making a decision together. For those patients who still ask for your recommendation, you need to have understood their own preferences to help them decide what’s best.