Shared decision making is impossible in a government run health system

The relationship between doctors and their patients has changed dramatically over the past few years. Medical beneficence became paternalism and is now near obsolete. Shared decision making is the new lofty ideal we should all be striving for. It is guiding new health policy both in the UK, with the new mantra “nothing about me without me,” and in the US.

We are at the start of the Century of the Patient. New appropriate societies have been formed such as the Society of Participatory Medicine and the Foundation for Informed Medical Decision Making.

This is all excellent stuff. As a doctor, I’d like to think that I have practiced so called participatory medicine all my life.

There are caveats with all of this. In a universal health service such as the British NHS, funding is through general taxation and whose levels are determined by politicians, albeit elected. Because of this, the NHS will always, whatever the protestations of different health secretaries, be controlled from the top.  Shared decision making, which surely also means an input into how much I want spent on me as a patient,  is clearly not possible.

With shared decision making must come the counterbalance of responsibility and accountability on the part of the patient.  Without this,  patient involvement becomes a sham. This has been recognized in the Affordable Care Act, the Health Reform Act introduced by the current administration in the United States. This will allow “rebates” for good behavior – and good healthy behavior can easily be measured by weight, markers of smoking, etc.

In the UK, we have the Downing Street Nudgers who will “nudge” all of us into behaving in a way that will not break the NHS bank in a few years. It does not need a Committee in the House of Lords to tell us that Nudge alone will not work. Being nudged itself is anything but being involved in decision making.

All the good ideas in health care are now coming from across the pond.

You just cannot have your cake and eat it and you just cannot have meaningful true shared decision making in the British NHS and the way it is currently funded.  The two are incompatible.

Norman Briffa is a consultant cardiac surgeon practicing in Sheffield, Yorkshire, England, blogs at Thinking Allowed – Conversation with a Chestcracker and can be found on Twitter @chestcracker

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  • Anonymous

    Wake up and smell the statism. PPACA is The Matrix – There is no spoon.

  • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

    Thanks for sharing your thoughts. I really don’t feel that any current health system or health reform bill places nearly enough emphasis on patient responsibility and patient self-efficacy. Good behavior by not smoking is only the tip of the iceberg. In order to obtain optimal health, patients (all of us) need to make great nutritional choices, exercise consistently, take high quality nutritional supplements and think positive thoughts. Encouraging a patient to seek out doctors and providers who can help them in these efforts should be encouraged and the current reform bill does the opposite–treats everyone as the same and reinforces the mantra that health is achieved through “health care”. That couldn’t be farther from the truth.

    The sooner we move towards a system where patients do put their time, energy and money into their actual health is the time that we will truly see shared decision making. RIght now (and with the thrust of the reform bills) patients make decisions based upon their health coverage, not on what it means to be healthy. There is a huge difference and it is worth distinguishing.

  • http://profiles.google.com/dr.rich.olson Rich Olson

    Yeah I’m thinking the most paternalistic doctor won’t be even in the same league with the nanny state rules & regs. (I won’t even try to recast that thought with gender neutral language)  ;)

  • Anonymous

    And it’s so fabulously possible now in the US with just the three of us in the room: me, my doctor, and my insurance company. Or, if it’s a drug question (I don’t have drug coverage), it’s me, my doctor, and my lack of money. On the bright side, since I won’t be stopping off at the drug store on the way home, go ahead and tell me to take a lap.

  • Anonymous

    There’s not enough detail here about why the NHS stops shared decision making. Can you explain please? Maybe give an example?

  • http://twitter.com/acpatient Angela Coulter
  • Howard Luks

    Really?  Perhaps I’m being naive… I do not see how a government run hcr system precludes a physician from being able to enter into a shared decision making process with a patient?  How does such a system prevent you from educating your patients about the alternatives/ lifestyle changes available— to the point where they are capable of making an informed choice???  What am I missing?  
    HJL

    • http://www.facebook.com/brianpcurry Brian Curry

      Short answer? It doesn’t. But it sure makes for senSATional headlines.

  • http://twitter.com/christianmunthe Christian Munthe

    A very simplisticly argued piece, I would say. The author assumes that SDM, patient participation, collaborative models of clinical planning, et cetera have to take the form of a purely consumer driven system where professional responsibility has been completely dismantled. For more nuanced treatments of this area, acknowledging the tensions touched on here but also pointing towards ways of resolving them in a less black-or-white fashion (and giving further references, these two recent publications from University of Gothenburg Center for Person Centered Care (GPCC), are worth checking out:

    http://gu-se.academia.edu/ChristianMunthe/Papers/326375/Person_Centred_Care_and_Shared_Decision_Making_Implications_for_Ethics_Public_Health_and_Research

    http://gu-se.academia.edu/ChristianMunthe/Papers/421523/Adherence_Shared_Decision-Making_and_Patient_Autonomy

  • http://twitter.com/drsuparnadas Suparna Das

    Interesting point of view Mr Briffa. As a consultant anaesthetist in the NHS, there have certainly been a few occasions where both surgeon and I have had a detailed discussion of risks/benefits with a patient/family to jointly arrive at a decision about an elective/emergency procedure. On one or two occasions, the joint decision was to have a less invasive procedure or none at all. Surely you must have experienced this in cardiac surgery too?

    As for ‘All the good ideas in health care are now coming from across the pond’ – I’m not so sure. The US spends 17% of it’s GDP on healthcare and yet, doesn’t have the outcomes to match this level of investment. The Sep 2011 issue of the Harvard Business Review has a Big Idea on containing healthcare costs by Profs Michael Porter and Robert Kaplan of Harvard Business School. In many ways, their theory is already being implemented in the NHS but, curiously, they fail to make any reference to the NHS financing system. You can read more here http://e3intelligence.com/2011/09/counting-the-cost-a-medics-take-on-healthcare-finance/

    @drsuparnadas:twitter 

  • http://www.nervenstark.net Tobias Müller

    Shared decision making depends on the doctor’s mindset not on the health
    system

     

    As a
    psychiatrist in an own practice in Nuernberg, Germany, and a founder of an
    psychiatrists’ network (www.nervenstark.net)
    I am well acquainted with that all repeating and tiring arguments of colleagues:

    1. Since our very first beginning we’ve
    already practiced SDM, that’s nothing new – yeah, we’ve already done it
    for decades.2. SDM is impossible because of the system.

    But ask
    your patients and those of your colleagues: 
    are they really well informed, do they have the chance  to participate?

    Of course,
    there are limitations/ restrictions (due to budget etc.) – in every health care
    system on earth. This is a fact we and our patients have to acknowledge. Maybe
    these limitations are narrow or wide, but we and our patients have to cope with
    that.

    If we regard
    these limitations in our health care systems too narrow, we have to address the
    policy makers, we have to tell our patients to increase political pressure.

    These are
    the lessons learned in Germany during the last years.

    So: SDM or
    not?  The answer depends not on the money
    but on our mindset. It’s our (the doctors’) choice! Of course, we have to leave
    our comfort zone and the planet of helpless lamentation …

     

  • Anonymous

    “Shared decision making, which surely also means an input into how much I want spent on me as a patient,  is clearly not possible.”
    I have a question: Why? because you have so many patients and are busy to do it?

    I don´t understand this post. I think this is the worst post I´ve ever read on Kevin MD

  • Peep_Stalmeier

    Certainly, turning the right switches to incite players towards SDM will help. The quality assurance audit here in the Netherlands contains 2 questions on patient-doctor communication. Too little to cover SDM competences. In the meanwhile, internet, e.g. http://www.thedecisionaidcollection.nl,, a multilingual comprehensive collection of decision aids, can be used to support shared decision making.

  • http://twitter.com/kgapo Kathi Apostolidis

    Although I agree that it’s up to the physician to go into shared decision making (provided he knows what it is and what it takes to perform it!) as many here say, the reality is that in many healthcare systems this might be possible only in private/concierge healthcare, and only if the physician decides to see less patients for longer time resulting in less income.
    In the public health care system, at least in Greece, the majority of physicians do not have control on how many patients they will see in any given day since the appointments are fixed by an independent organisation at 10min interval for all specialties (25patients in 5hours, including doctor’s coffee break). In this respect, I will agree with Dr. Briffa that unfortunately still in many European countries the reality that patients experience is that “In a universal health service……. funding is through general taxation and whose levels are determined by politicians, albeit elected. Because of this, …… (healthcare) will always, whatever the protestations of different health secretaries, be controlled from the top”. This is all the more true for countries in economic crisis where healthcare and education are the first victims to succomb to drastic state budget cuts and further reductions of public expenditure.
    The policy makers at the Ministry make decisions on healthcare delivery purely on economic considerations disregarding excellence in healthcare delivery. These people simply consider shared decision making, even in oncology, as a superfluous luxury, since doctors “explain everything” to the patients. The reasoning is that SDM delays health care delivery so the waiting times for patients will increase further! This is not an excuse definitely!
    Doctors also do not understand the value of SDM for all involved: the patient, the physician, the healthcare system and therefore, they have never asked for it in their negotiations with the Ministry of Health. On the other hand, physicians at the best, consider that presenting to the patient their option among one-two they have in mind,  is shared decision making, while it is simply sharing their own option! As for the patients and patient organisations, very few know concretely about shared decision making and participatory medicine, so that they might include it in their advocacy, but also it is not considered a top priority for them when drugs disappear from the market, are suddenly not reimbursed any more, the waiting times for specialists may go to three months, hospitals are closing, hospitals ask patients to bring their medicines and common disposables that are not available any more……