Angela Coulter: Please stop muddling shared decision-making and provider choice

Government departments are barred from making policy announcements during elections, so there’s always a flurry of them after the purdah period has ended. The aftermath of the recent local government elections was no exception. Hot on the heels of the publication of the long-awaited NHS Information Strategy came a document entitled No decision about me without me: further consultation on proposals to secure shared decision-making. As a long-time advocate of shared decision-making, I leapt on this as soon as it appeared on the Department of Health’s website, but was astonished to see that, despite its title, it wasn’t about shared decision-making at all, but about provider choice.

Now I’ve got nothing against offering patients more say about from whom, when, and where they receive services. Indeed, as The King’s Fund study led by Anna Dixon showed, this type of choice is quite popular. Anna and her colleagues found that most patients were keen on being offered a choice, even if they chose to remain at their local hospital, but many GPs were ambivalent or antagonistic to the idea, with the result that less than half of eligible patients were offered the choices they were entitled to. No doubt this is why the government keeps plugging away trying to remove the barriers to implementing their provider choice strategy, in the hope that this type of competition will help to raise quality standards. But this has nothing at all to do with shared decision-making, which is an entirely different concept.

Shared decision-making, which has been researched and written about in this country and internationally for more than two decades, has a very specific meaning. In a recent report by The King’s Fund, Alf Collins and I explained that it is a process in which clinicians and patients work together to select tests, treatments, management, or support packages, based on clinical evidence and patients’ informed preferences. It involves the provision of evidence-based information about options, outcomes and uncertainties, together with decision support counselling and systems for recording and implementing patients’ treatment preferences. Unlike provider choice, it’s well-supported by evidence of beneficial effects, and it’s even more highly-rated by patients.

A new report from The King’s Fund by Al Mulley and others outlines how clinicians’ failure to involve patients in decisions about their care amounts to “a silent misdiagnosis.” They argue that the failure to diagnose patients’ treatment preferences is every bit as dangerous as failing to diagnose disease correctly. Pointing to examples of “breathtaking gaps” between what patients actually want and what doctors think they want, they call for a co-ordinated effort across the NHS to tackle this serious defect in clinical decision-making.

It is therefore a huge pity that the government has chosen to ignore the large and important body of evidence about the rationale for engaging patients in decisions about their clinical care, which is almost totally absent from its “shared decision-making” report. This is particularly disappointing given the emphasis placed by the prime minister and the secretary of state for health on the importance of the concept “no decision about me without me” prior to and post the last election. They have unhelpfully muddled two entirely different topics, creating confusion at a time when NHS staff are crying out for greater clarity. And in doing so, they have ignored a crucial clause in the Health and Social Care Act that places a duty on commissioners to ensure that individual patients are involved in decisions about their treatment.

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This blog also appears on the King’s Fund website at