Realistic Medicine: Survey Highlights

Future Priorities

The survey asked for views on key priorities for the future direction of Realistic Medicine. Respondents were able to select up to three options from the list provided, including a free text option. On average, respondents identified nearly three (2.7) key priorities, including free text responses.

Two priorities were selected far more than others: “wider engagement with the General Public to improve understanding of Realistic Medicine” (63%) and “detailed focus on how Realistic Medicine can be applied to specific areas of healthcare” (56%). More than a third of respondents (37%) saw the need to “develop and promote specific staff education training resources”.

Around a quarter of respondents identified “focus on optimising the wellbeing of the health workforce to enable the delivery of Realistic Medicine” (27%) as a key priority. Marginally fewer did so for “develop a suite of outcome measures to evaluate the impact of Realistic Medicine” (23%) and “widen the reach of Realistic Medicine to the work of non-medical health and social care professionals at a faster pace” (22%).

Again, divergence was evident across different professions. GPs and Consultants were more likely to cite wider engagement with the general public to improve understanding as a key priority (78% and 69% respectively). This priority though was the most frequently selected by six of the eight categorised professions. Resident Doctors (67%) and Nurses / Advanced Nurse Practitioners (62%) were most likely to identify detailed focus on how Realistic Medicine can be applied to specific areas of healthcare as a key priority.

Pharmacists and Pharmacy Technicians (50%) and Nurses / ANPs (46%) were more likely than other professions to identify, ‘develop and promote specific staff education training resources as a key priority’, whilst GPs (25%) and Consultants (27%) were less likely to.

Survey findings also show a clear correlation between responses given in relation to barriers and priorities. Of all respondents who cited criticism from patients for practising Realistic Medicine as a key barrier, 83% identified wider engagement with the public to improve understanding as a key priority, as did 75% of those who cited fear of litigation or other censure as a barrier. Furthermore, those who identified a lack of formal training as a barrier were more likely to select ’develop and promote specific staff education training resources as a key priority’ (51%).

Reflections

Public Engagement

Many of you are keen to see more engagement with the public on Realistic Medicine. There has already been significant engagement including a Citizens’ Jury on Shared Decision Making, the first on a healthcare topic in Scotland, which you may not know about.

The findings from the recent Citizens’ Panel 14 demonstrate the public’s desire to focus on achieving the outcomes that matter to them. Panel respondents rated their experience of conversations with their health and care professionals:

Opinions on Health and Care conversations

94% said they understood the information they were given

84% said they were treated with compassion & understanding

83% said they were listened to, and the healthcare professional understood what mattered to them

63% said they were given the opportunity to involve the people that matter to them in discussions

62% said they were involved in discussing what they can do to promote good health and prevent ill health in future

9 in 10 support discussing the outcomes that matter to them with their healthcare team and have them recorded to focus on achieving their goals (90%)

97% support/strongly support being involved in shared decision making with their healthcare professionals

88% would like healthcare providers to explain their condition and summarise the discussion and next steps in writing via letter or email after a hospital appointment

An overwhelming majority of the Panel participants expressed a desire to be actively involved in decisions about their care, with 93% agreeing that individuals should be encouraged to ask their health and care professionals the BRAN questions. The BRAN approach empowers people to make informed choices about their treatment, ensuring they receive care that they value while reducing unwarranted interventions and waste.

BRAN questions (B - what are the Benefits of this test or procedure? R - what are the Risks of this test or procedure? A - are there any Alternatives? N - what if I do Nothing?)

93% agreed that people should be encouraged to ask the BRAN questions to help them choose the treatment and care that is right for them

80% would use the BRAN questions with health and care professionals in future

1 in 5 were aware of the 'It's OK to ask' campaign (21%)

A significant majority of Panel respondents (84%) agreed that including a reminder of the BRAN questions on appointment letters and in waiting rooms would encourage people to ask them during their appointment. Despite low levels of awareness, 80% of respondents said they would use the BRAN questions with health and care professionals in future.

88% of Citizens’ Panel respondents also agreed that following a hospital appointment with a healthcare professional they would like them to write to them to explain their condition, summarise what they discussed and agreed, and potential next steps. They would like this to be done by letter or email.

NHS Scotland needs to take action to ensure every health and care professional is committed to and able to practise shared decision making. Alongside this, there is a need to improve public awareness that shared decision making is normal practice, for example by doing more to promote the “It’s OK to Ask” campaign and BRAN questions.

There is also clear public support for NHS Scotland to optimise its use of resources. 98% of respondents think it is important that NHS Scotland makes better use of its resources and reduces waste and potential harm.

Citizens’ Panel members said that NHS Scotland needs to take action to prioritise initiatives aimed at resource optimisation and waste reduction. Reducing wasted prescriptions was highlighted by Panel members. Implementing 7 step medicines reviews and the guidance on medicines of low or limited value would be a great place to start.

It is also important to note that as described in the Montgomery ruling, there has been a paradigm shift in the relationship between us as care givers and the people we care for. People are no longer passive recipients of care, and we must be aware of the individual’s situation. By using the BRAN questions as part of a shared decision making conversation and documenting that meaningful conversation, health and care professionals can be assured of meeting the principles of the Montgomery ruling and the current legislation on informed consent.

It is not appropriate to slavishly follow guidelines. Deviation from guidelines is acceptable so long as the rationale is clear and as long as we make sure people are fully involved in decisions about their care.

Senior leaders across our system must review the recommendations that accompany the Citizens’ Panel 14 findings and reflect on how your current and planned activities contribute to delivering them. It is what our population want and expect if we are to reduce harm and waste and deliver better value care.

Realistic Medicine Casebook

You also identified the need for a detailed focus on how Realistic Medicine can be applied to specific areas of healthcare as a future priority (56%).

The Realistic Medicine Casebook contains a variety of excellent case studies that demonstrate how teams across Scotland are achieving the outcomes that matter for people. My thanks go to all teams, who were willing to share the positive impact that practising Realistic Medicine is making to the people we care for and to our system. We should celebrate their success. We expect that these excellent examples of good practice will inspire you to innovate, adopt these approaches and deliver careful, kind, better-value care

We would be delighted if you would share your own case studies with the Realistic Medicine team with a view to including them in future editions. There can be no doubt that as it grows, the Casebook will become an invaluable tool in demonstrating the impact Realistic Medicine is having on outcomes and the positive difference it is making across all professions and care settings in Scotland.

Promoting Training

There is clearly more to do to promote the excellent training resources that NES has developed. Through shared decision making we can deliver personalised care and achieve the outcomes that matter for people. By identifying and tackling unwarranted variation in health, treatment and outcomes, we can reduce waste, ensure equity of access for those who need our help the most and ultimately, a fairer more sustainable system.

The Auditor General views Realistic Medicine as a key contributor to a more sustainable health and care system and has asked NHS Boards and Scottish Government to work together to implement the Value Based Health and Care Action Plan. Within the plan, NHS Boards are expected to support you to practise Realistic Medicine. Employer organisations and professional bodies must recognise the positive difference Realistic Medicine can make, help promote training and support you to complete it. If we really wish to achieve the outcomes that matter to the people we care for, completing the training available on TURAS will undoubtedly help.

Measurement framework

You also said that we should prioritise the development of a suite of outcome measures to evaluate the impact of Realistic Medicine (23%). We are working with Scottish Government analytical colleagues and our delivery partners to develop a framework that will help measure both progress with and the impact of the Value Based Health and Care Action Plan. The framework is expected to be ready by March 2026.

At an individual level, we need to capture the outcomes that matter to the people we care for and use them to drive improvements in the care we provide. That’s why the Action Plan commits us to supporting the development and use of Patient Reported Outcome Measures (PROMs, Action 5) and a Patient Reported Experience Measure (PREM, Action 4).

Evidence Based Practice

You identified the need for improved access to high-quality healthcare information for the people you care for. Putting high-quality evidence and knowledge in the hands of health and care professionals and the public will enable shared decision making and help optimise the use of resources. The VBH&C Action Plan sets out a number of actions to help support evidence based practice:

• SIGN guidelines will support shared decision making and provide evidence based guidelines. SIGN patient booklets will provide information on benefits and risks associated with treatment and care to help inform people’s choices.
• The Scottish Health Technologies Group’s independent evidence and advice will support wider use of health technologies that benefit patient care.
• HIS will support the Right Decision Service with continued development and maintenance of the suite of decision support tools which support safe, consistent, evidence based care when and where it is needed. This includes both professional and citizen-facing Realistic Medicine toolkit web and mobile apps.
• NES will continue to support, develop, and promote knowledge services through the knowledge network.
• NHS 24 will continue to develop NHS Inform to help people make informed choices about their treatment options.
• The Centre for Sustainable Delivery will continue to develop pathways of best practice in areas where existing guidance is limited.

Community of Practice

Many of you would also like to see a focus on optimising the wellbeing of the health workforce to enable the delivery of Realistic Medicine (27%), as well as further discussion around the philosophy and principles of Realistic Medicine (13%).

In Realistic Medicine: Taking Care, I discuss how collaboration is key to providing care that people value and greater job satisfaction. Healthcare is a vocational career, a “calling” for many health and care professions. The role of our heath and care organisations and our system leaders is to foster an environment where careful and kind care can flourish and where you are supported to enable your sense of service to thrive.

Awareness and knowledge of Realistic Medicine and Value Based Health and Care is key to creating an effective community of practice and changing the way we support each other to practise. We need a strong community of practice of professionals who foster a culture of stewardship, promote Realistic Medicine and deliver VBH&C for the people of Scotland.

I shall continue to host our annual Realistic Medicine conference which provides a collaborative forum where we can discuss the challenges our system is facing and explore innovative approaches to practising Realistic Medicine and delivering Value Based Health and Care. I know, too, that many NHS Boards also host local Realistic Medicine conferences to promote, support and encourage people to practise Realistic Medicine. I encourage you to get involved.

Through the VBH&C Action Plan (Action 9), Scottish Government, NHS Boards, HSCPs and professional bodies are committed to continuing to develop a strong community of educated and empowered multidisciplinary health and care professionals, who support each other to deliver better outcomes and experiences for the people we care for and a more sustainable health and care system. If you would like to get involved in a community of practice, please get in touch with the Realistic Medicine team who will be happy to help.

Support from peers and leaders

Around half of respondents feel that they have received limited (30%) or no support (20%) from leaders and peers to practise Realistic Medicine and Value Based Health and Care. Around one-in-ten feel very well supported (11%) and around four-in-ten felt some support had been received (40%). Resident Doctors (62%) and Pharmacists / Pharmacy Technicians (55%) were more likely to feel they had received “some support”.

Some variation was evident across territorial Boards; around a third of those based in NHS Fife (31%) and NHS Highland (33%) responded “very well supported” or “some report received”. This contrasts with around seven-in-ten from NHS Forth Valley (70%) and six-in-ten from NHS Tayside (60%).

* NHS Orkney, NHS Western Isles, NHS Grampian and NHS Shetland received fewer than 30 responses to this question, so results should be interpreted with caution.

Support from employer organisations

Around six-in-ten respondents felt that their employer organisation strongly (15%) or somewhat (46%) actively promotes Realistic Medicine and Value Based Health and Care. 15% felt that their employer organisation does not actively promote, whilst 24% were unsure about their employer organisation’s stance on Realistic Medicine and Value Based Health and Care.

Employer organisation support was uniform across the professions, while some variation was clear across different territorial Health Boards. Respondents based in NHS Borders (84%) were most likely to say that their employer organisation strongly or somewhat actively promotes Realistic Medicine and Value Based Health and Care, followed by those in NHS Forth Valley (71%). Conversely, those based in NHS Lothian (48%), NHS Fife (49%) and NHS Greater Glasgow and Clyde (54%) were least likely to say that their employer organisation strongly or somewhat actively promotes Realistic Medicine and Value Based Health and Care.

Respondents who said that their employer strongly or somewhat actively promotes Realistic Medicine and Value Based Health and Care were asked to tell us how they did so (from a list of nine options, there was no limit to the number of options that respondents could select). On average, respondents identified 2.6 things that their employer does to actively promote Realistic Medicine.

By a clear margin, the most commonly identified actions taken by employers was “encouraging shared decision making between healthcare professionals and patients” (63%), followed by “supporting multidisciplinary teamwork to deliver coordinated and person-centre care” (48%).

Employers encouraging shared decision making was the most commonly selected action across all professions, though this ranged from 76% of Pharmacists / Pharmacy Technicians to just 34% of GPs. On average, GPs and Dentists / SAS Doctors selected far fewer actions as being taken by their employer organisation (1.2 and 1.3 respectively), compared to Managers, Nurses / Advanced Nurse Practitioners and Pharmacists / Pharmacy Technicians (3.4, 2.9 and 2.9 respectively).

Support from Professional Bodies

Marginally more than four-in-ten respondents said that their professional body strongly (12%) or somewhat (32%) promotes Realistic Medicine and Value Based Health and Care. Nearly one-in-five (18%) reported that their professional body does not promote Realistic Medicine and Value Based Health and Care. A further 38% are unsure of their professional body’s stance on Realistic Medicine.

Of those respondents who said their professional body does not promote Realistic Medicine, the vast majority (91%) would like to see their professional body do more to actively do so.

GPs (61%) and Resident Doctors (60%) were most likely to say their professional body strongly or somewhat promotes Realistic Medicine. Conversely, this was only the case for around a third of Nurses / Advanced Nurse Practitioners (32%), Allied Health Professionals (36%) and Dentists / SAS Doctors (38%).

Support for and promotion of Realistic Medicine

Strong support for and promotion of Realistic Medicine among employers, professional bodies and peers / leaders is low (15%, 12% and 11% respectively).

”In principle, I think most people will agree with the message behind Realistic Medicine. However, in practice I think people do not feel supported to put it into practice and don’t appear to have time to have these conversations in an outpatient or ward situation and don’t feel supported enough to make these decisions.”

”Within in my Board some departments/teams adopt Realistic Medicine approaches really well, while others don’t. Some managers advocate and others don’t.”

”I think of the main barrier is that doctors do not feel able to make decisions in line with Realistic Medicine, because they will not be supported by management.”

”I have found that some medical staff still feel that they are in charge of the patient’s care and don’t listen to the MDT [multidisciplinary team] or the patient’s preferences. There is much inconsistency in who follows the principles and who doesn’t, and nobody challenges this if it is a medical consultant due to their status.”

However, where Realistic Medicine is promoted by employers, professional body, or by peers and leaders, respondents were more likely to:

• have completed Realistic Medicine and VBH&C training.
• feel confident in their understanding of Realistic Medicine principles.
• feel that Realistic Medicine has positively influenced their practice.
• identify fewer barriers to practising Realistic Medicine.
• report that practising Realistic Medicine has led to positive outcomes.

Figure 10 shows a number of key survey metrics, broken down by the level of employer support. There is a clear linear correlation between the extent of employer promotion and responses to the key metrics, with a stark disparity evident between those who feel their employer strongly promotes and those who feel their employer does not actively promote.

Furthermore, respondents who felt supported by their employer organisation were less likely to cite barriers to practising Realistic Medicine, compared to those where Realistic Medicine was not actively promoted by their employer.

Reflections

There is clear association between the level of local promotion of Realistic Medicine and more positive findings. It is also clear that as the level of local promotion of Realistic Medicine reduces, people are less likely to feel confident practising Realistic Medicine and identify more barriers to practising it.

Senior leaders and professional bodies must do more to promote and support people to practise Realistic Medicine if we are to achieve better outcomes for the people we care for.