Can shared decision-making reduce health inequalities?

The fact that the health of the general population seems to be on an upward curve masks the significant health inequalities that persist in the UK. A recent analysis by the Equality Trust found that in the past twenty years the gap between the health of the richest and poorest members of society has increased significantly.

For example, there is now an 18 year gap in the “healthy life expectancy” between women living in Richmond (72) and Tower Hamlets (54) (Equality Trust, 2014). The link between poverty and ill-health is one of the most widely researched areas of public social policy.

In addition, recent research shows that the level of inequality in a society is a factor in determining health outcomes. This is still the case in wealthy countries such as the UK. Inequalities not only affect access to healthcare but also the other wider determinants of health.

Since the 1980s, the UK has an unprecedented growth in levels of inequality. The Office for National Statistics ONS (2012) calculated the wealthiest tenth of households owned more than 40% of overall wealth and were over 850 times wealthier than the least wealthy tenth of households (ONS, 2012).

The impact of these wider policies on people with severe mental health problems is particularly acute. Kelly’s 2005 paper entitled Structural violence and schizophrenia (Kelly, 2005) discusses the complex ways in which social factors such as stigma, racism and poverty can combine to marginalise and exclude people with severe mental problems.

The ladies of Richmond have a healthy life expectancy 18 years longer than their counterparts in Tower Hamlets.

The new systematic review that I am blogging about today (Durand et al, 2014) has to be seen in the wider context of health inequalities. It is not specifically concerned with mental health services but there are wider lessons to be drawn. I would argue that some of these, about the need to develop approaches that foster the genuine involvement of patients in decisions about their care, are particularly relevant to mental health services. One of the frustrations of modern health and social care service provision is the consistent parroting of phrases such as “No decision about me, without me” which do not then result in real change in the organisation and delivery of services.

This paper explores the impact of “Shared Decision Making” (SDM), which is now widely considered one of the goals of healthcare services; to encourage patients to take greater responsibility for their own health, which has two elements: lifestyle choices and private insurance. In addition, policy makers seek to ensure that patients are more heavily involved in decisions about their treatment. The positives of this approach are that patients will increase their knowledge and therefore be in a position to make more informed choices. A more collaborative approach should also lead to a reduction in conflict between medical staff and patients and their families. One can see that these issues are very relevant to decisions in mental health care, where the Mental Health Act (MHA) allows for compulsory treatment.

Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.

Shared decision making is a collaborative process that allows patients and their providers to make health care decisions together.

Methods

This systematic review and meta-analysis examined 19 studies which looked at a variety of tools to aid SDM. The study included research from USA, Australia and Nicaragua (84% of the studies were from the USA).

Results

One of the issues that the authors seek to explore is the impact of SDM on health inequalities. The concern here is that SDM is a model that works well for already advantaged groups, i.e. wealthier, more educated citizens who demand that they are involved in decision making in a whole range of areas. More marginalised groups will find it more difficult to be involved in these processes. Thus one paradoxical outcome of SDM might be there is an increase in health inequalities as the health of more advantaged groups improves whilst that of poorer groups does not.

The paper identifies different approaches to SDM, these include:

Communication skills works
Computerised decision making programmes
Videos
Counselling

This shows the potential for disparity in the effectiveness or uptake of such schemes. They are based on assumptions such as the fact that patients will have access to a computer and a level of computer literacy. This is simply not the case in many cases.

Ten of the interventions or approaches were specifically designed to meet the needs of disadvantaged groups. When one probes this issue further, one sees that such studies are focusing on some key themes:

The use of plain language
Not using complex technical language and medical jargon
Avoiding the passive voice
To these can be added a need to produce information resources in clear simple formats with user-friendly designs

Conclusions

Such approaches will benefit all patients. By assisting in the process of engaging more marginalised patients more effectively in the decision making process, they can help to contribute to reductions in health inequalities.

However, the wider message of research in this field is that the real solution to health inequalities lies in a more equal society.