Involving patients more closely in decisions about their treatment is a key strategy for GP commissioning consortia wanting to reduce unwarranted variations in healthcare. Alisdair Stirling reports
Back in 1938, NHS medical officer Dr James Alison Glover noticed a 10-fold variation in tonsillectomy around England and an eight-fold risk of death with surgical treatment. His analysis of the tonsillectomies found many were not related to clinical need, but rather reflected the clinical culture of the areas where they were taking place.
More than 70 years on, there is still massive unwarranted variation in levels of treatment for many conditions across England – a fact amply illustrated by the NHS Atlas of Variation in Healthcare published in November last year.
Unwarranted variation means one of two things. Either some patients are receiving treatment they don't need, so that money is being wasted – or that some patients aren't receiving treatment they do need, which means extra costs somewhere down the line that could be avoided.
Atlas of Variation
Based on 2009 data, the new Atlas of Variation assesses what 152 PCTs across England achieve with the money spent on services for their local population. Consisting of 34 maps, the atlas aims to stimulate awareness of the need to focus on appropriateness of a clinical service.
For example, one map shows musculoskeletal expenditure per 1,000 population per PCT. The variation among PCTs is almost three-fold, ranging from just over £40,000 per 1,000 population to almost £120,000 per 1,000 population. The atlas concludes such variation in investment does not reflect the variation in incidence, prevalence or severity of osteoarthritis or rheumatoid arthritis.
The atlas also reveals a four-fold variation in expenditure between PCTs for knee replacements. And with each replacement costing £5,808, potential savings are £39m. Further, it suggests that the most deprived patients have the lowest number of groin hernia and hip and knee replacements and the worst pre-treatment health status for hip replacements.
The variation solution
According to Dr Steve Laitner, a GP in St Albans and one of the team working with NHS chief knowledge officer Sir Muir Gray on the atlas, the key to reducing variations such as these lies in clinicians giving patients more information about their treatment options and setting out to share decision making with patients: ‘Where there is too much intervention, shared decision making reduces it and where there is unmet need, shared decision making increases the rate of intervention.
‘The process is known to reduce unwarranted variation because it means the influence of different clinical decision making processes is reduced.'
Dr Laitner, who is also national clinical lead on shared decision making at the Department of Health, cites Canadian researcher Professor Annette O'Connor of the University of Ottawa, who claims: ‘Shared decision making gets the decision right.'
The shared decision process can be facilitated using decision support aids such as software and DVDs that clarify the problems and the goals and identify possible solutions. Dr Laitner believes the evidence for the success of these is strong. He cites Professor O'Connor again, whose research suggests decision aids reduce rates of discretionary surgery. Findings from
a 2009 study suggest shared decision making cut prostatectomy rates in cancer from more than 75% to around 60% and also substantially reduced orchiectomy, coronary bypass and mastectomy rates.
Take prostatectomy: the safest option in prostate cancer is for GPs to refer to avoid recurrence. However, patients will often choose not to have the operation when it is explained to them that although recurrence rates are high, the death rate as a result of recurrence is not as high as is often thought and that treatment carries the increased likelihood of impotence and incontinence.
The shared decision making process can be time consuming because it means spending more time with patients at least initially (see case study) but the time spent is repaid by more efficient use of services.
NHS Direct
Dr Laitner has already begun making information available to patients via NHS Direct. The initiative is a part of the Department of Health's ramped up QIPP programme and is managed and delivered nationally by NHS East of England, of which he is an associate medical director.
NHS Direct has been commissioned to develop, pilot and deliver a suite of decision aids with telephone support when required.
Decision aids for arthritis of the knee, benign prostatic hyperplasia and localised prostate cancer are already available under phase one of the project and phase two covering concern about prostate cancer, breast cancer and pregnancy with a high risk of Down's Syndrome is under development.
Dr Laitner sees shared decision making as being absolutely central to the work of the new GP consortia: ‘Shared decision making is going to be an essential tool for consortia because it's going to help improve the value we get from scarce healthcare resources.
‘There is a role for GPs not only in their own practices but also in their commissioning functions. We all need to think about commissioning care with shared decision making at its heart.'
Alisdair Stirling is a freelance journalist
Shared decision making is used to get the decision right on whether an intervention is appropriate Shared decision making is used to get the decision right on whether an intervention is appropriate What is shared decision making?
Shared decision making is a process whereby the patient is made fully aware of the causes of their disease and all the treatment options available to them.
Risks are clarified and the effect on their quality of life from different treatments explained so that patients become active partners in their care and how it is managed.
Patients in turn share their experience of illness, their social circumstances, attitude to risk, values and preferences.
It is used when people face major medical decisions, where there is more than one feasible option and when people with long-term conditions want to plan their care, adopt healthier lifestyles and enhance their ability to self-manage.
Case Study: managing angina
Dr Clare Hawley, a GP in Chesterfield, Derbyshire, has been running a shared decision-making scheme for her local PCT for the past two years.
The scheme is a satellite of the National Refractory Angina Centre service in Liverpool run by Professor Mike Chester.
Dr Hawley, explains: ‘The patients we see are the frequent flyers into hospital, people who are listed for surgery, patients without a surgical option and those with anxiety about their condition. We first see the patient for about two hours on their own to discuss their condition and the treatment options open to them.
‘We assess their individual symptoms, establish their beliefs and misconceptions, explain collateral development, pre-conditioning and pain and nerve pathways, help them control angina with relaxation and give lifestyle advice.'
‘We then have four two-hour group sessions, a one-hour follow-up session and a one-hour annual follow-up.'
‘Questionnaire results show that among the patients we've had for a full year some 76.2% say they have a good quality
of life compared with only 47.6% before.'
‘The Liverpool angina pathway found that 80% of patients on the programme there felt they did not need an intervention.'
‘In Derbyshire, our set-up costs were about £100,000 but we've saved £31,900 so far. The team consists of myself – an associate specialist in cardiology at Chesterfield Royal Hospital NHS Trust – three other GPs and a cardiac rehabilitation specialist.'
‘As a clinician, it's a true joy to come to work. You start out with a patient terrified by their condition and after two hours you get the lightbulb moment where they realise they don't have to be scared, that they have some control.'
‘It's such a satisfying thing. You can't beat it. And these are skills you can apply to everything else you do.'
