Chapter 1 - Building A More Personalised Approach To Care With People Across Scotland
How do we know that the public really
wants “Realistic Medicine”?
Building a more personalised approach to care, in partnership with people through shared decision making, is perhaps the most important aim of Realistic Medicine, and perhaps one of our greatest challenges.
Evidence-Based Medicine remains at the core of informing best practice and guidance, but for it to truly take place, we must use best available evidence, clinical judgement and patients preferences together. This is especially true within our complex modern healthcare system and when applied to patients with multiple conditions. In chapter 6 this premise will be developed further.
Knowledge requires integration with personal values and preferences. As clinicians we can become very risk averse at a system level, over relying on scientific evidence to inform treatment choices. Through shared decision making we must get better at determining what matters most to patients. Practising Realistic Medicine requires care that is coproduced in partnership with the people receiving it – person-centred, holistic care. We need to readdress the balance.
People must be empowered to discuss their treatment fully with their healthcare providers including the possibility that a suggested treatment might come with side effects – or even negative outcomes. Everyone should feel able to ask their doctor why they have suggested a test, treatment or procedure, and all decisions about a person’s care should be made together.
But how do we know that patients and the public really want Realistic Medicine? Quite simply, we asked them. Several strands of work have already been commissioned that seek the public’s views on Realistic Medicine.
In NHS patient surveys, over one-third of respondents told us that they would like to be more involved in decisions about their care; furthermore, studies have shown that involving people, their families and carers in decisions about their care leads to safer care.  They have expressed interest in not only having their care discussed jointly, but being fully involved in the decision making process itself.
In Realising Realistic Medicine, we said that we’d consider the results from the Our Voice Citizens’ Panel to further understand public opinion on shared decision making, which we view as central to providing the person-centred care that people really value. The second Citizens’ Panel Survey results were published in August 2017, and the public agree. The results show that while 92% of people said they would feel comfortable asking their doctor about their treatment and care options, only 67% had actually spoken to their doctor about them.  Similarly, while 91% of people said they would be comfortable asking about the possible risks and benefits of their treatment options, only 64% had done so. 
When asked to expand on their answers, a number of people commented that the attitude of their doctor had an impact on their inclination to ask questions.
“The willingness to ask some of these questions depends on the behaviour/style of the doctor and how busy they are/or are perceived to be”
In Realising Realistic Medicine we committed to commissioning a “Citizens’ Jury”, to give members of the public an opportunity to consider Realistic Medicine in greater depth. 
We will hold the Jury in the autumn and expect that its conclusions will help us gain further valuable insight into how members of the public, with the benefit of evidence from experts, view and understand the principles of shared decision making and what might be done to foster it. The Jury’s recommendations will then be considered as part of our ongoing plans to embed Realistic Medicine across Scotland.
Many clinicians encourage patients to engage in shared decision making and to have a say. Similarly, most patients want to discuss options and share their opinions about treatment with their clinicians, and clearly many seek to be, or want to be, more involved in clinical decisions. Nevertheless, longstanding cultural norms can make it difficult for patients to speak up, ask questions, actively participate, or challenge clinicians’ expertise. Clinicians serve patients best when we frame treatment and care options in terms of the values and goals that patients and their families articulate.
It is also important to remember that doing less or no treatment can be the best option for some people. We know some patients later regret accepting treatment and that some treatments can add to the burden of illness, taking up time and energy, which could be devoted to other activities that offer more meaning to individuals; time spent with loved ones, or on cherished activities. This may partly explain why clinicians choose less healthcare intervention for themselves. 95% of doctors would not agree to have cardiopulmonary resuscitation at the end of their lives, and 88% would choose not to have haemodialysis.  We should aim to provide the kind of realistic care we would want for ourselves and our families.
As professionals, we must create a more open and trusting atmosphere that facilitates meaningful conversations. It may be that having discussed and weighed up the benefits and risks of the available treatment options, people will choose less treatment, or they may decide not to proceed. They may of course decide to go ahead. The important point here is that people should be guided and supported by us to make an informed choice based on what matters most to them.
Over the next few years we will continue to listen to what the public are telling us to further inform the development of tools and techniques that aim to encourage and promote more meaningful conversations between people and their healthcare professionals. Meanwhile we encourage everyone to consider what they can do to encourage, strengthen and facilitate shared decision making.
The next chapter sets out some of the thinking and work under way that aims to help make shared decision making “the norm” in Scotland.
Figure 1. Infographic of Citizen’s Panel Results
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