Compartmentalised policy The distinct roots of shared decision making and self-management support can help us understand why they have developed separately in policy, regulation and professional practice. Shared decision making is rooted in sharing evidence-based information and patients2 having the ability to understand and trade-off between risks. Self-management support is built upon coaching with support for incremental achievements towards life goals and patients having the knowledge, skills and confidence to enact and sustain behaviour change. Where shared decision making is grounded in information being the foundation for making specific and discrete choices, self-management support is more grounded in the capabilities and resourcefulness of patients to problem-solve. However, in practice, decision making and support are often part of the same encounter. Many encounters will demand of clinicians the ability to flex between the different tools, techniques and skills that have historically been compartmentalised into these disconnected spheres. Bringing together our thinking and learning on shared decision making and self-management support can help join up policy and its support for practice. Both seek to understand the patient’s perspective; both demand that health services engage with a person not their illness or condition; both see patients as assets, with their own unique strengths and resources whose application will determine the outcome of health care.  Simple approach to a complex issue Person-centred care is a complex arena. It pivots around a relationship between parties with their own histories, identities and purposes. It takes place in an interconnected set of organisations and communities with distinct cultures and social norms. The capacity for a person to participate in decisions, set and achieve goals or manage their health is therefore not a choice they can enact alone. But the research highlights that policy makers and services have focused their energies on seeking to equip patients to take on a more active role. 2 What we call people who use health services raises hackles: patients, service users, people with lived experience, clients, consumers, all have connotations they may reflect our understanding of person-centred care. This In brief uses patient, recognising that it has inherent within it a history of passivity and disempowerment. Person-centred care is a factor and consequence of the dynamic created by the way care is provided. For people to be more active in their care, more attention therefore needs to be paid to ensuring clinicians, managers, services and systems invite, enable and support an active role. Knowledge, experience and expertise A broader focus is beginning to emerge. Health Education England’s strategy, Framework 15, begins to draw attention to the importance of supporting health care professionals to have the skills and confidence to engage in more collaborative approaches to care.3 The Care Quality Commission (CQC), NHS England and Monitor are increasingly turning their attention to developing the NHS’s infrastructure, capacity and capability to support this new approach. However, these are tentative first steps. These organisations are on their own journey to developing their knowledge and skills in these areas – and do so while being pulled by many other competing demands, facing their own financial constraints and where the pool of expertise to help them on this journey is limited. Tension in purpose: ethical and instrumental The research draws our attention to the tension between a rhetoric of person-centred care and support being the right thing to do and its instrumental goal of delivering both better clinical outcomes and less costly health care utilisation. This tension may be inevitable and even healthy in a publicly funded NHS. But a focus on instrumental aims alone can lead to shared decision making, care planning and self-management support being adopted in ways that retain clinical and service control, and so defeat its own purpose. Tension between complementary purposes in health care The NHS was set up largely to meet health needs that were out of people’s control. In part due to its success in keeping us alive when previously we would have died and in part due to ‘lifestyle’ diseases, the demands on the NHS today are very different to when it was established. The role of the NHS can no longer solely be to heal us, remove disease and infirmity. Rather, it can help to mitigate the impacts of disability, illness and disease upon our lives and support us to adapt to live our lives optimally.4 3 http://hee.nhs.uk/2014/06/03/framework-15-health-education-englandstrategic-framework-2014-29/ 4 See www.bmj.com/content/343/bmj.d4817 IN BRIEF: PERSON-CENTRED CARE: FROM IDEAS TO ACTION 5 This requires interventions that work within and are coordinated around people’s social context from a psychological as well as biomedical standpoint. It means starting with the question ‘What matters to you?’, rather than ‘What’s the matter with you?’ These sorts of changes in equilibrium don’t happen on their own. They need an injection of energy to break the chemical bond which binds a passive patient to paternalistic medicine. More broadly, it means moving away from an orientation in which the habits and rules of providers and professions come first, to one in which the world is seen through the eyes of the person. It is a radical reframing of roles in which, for example, the clinician’s role is to fix to one which builds upon people’s strengths and capabilities (see Table 1). Self-management and shared decision making are at the heart of this change. What are the implications for policy and system stewards? The challenge that now faces system and professional stewards and regulators is to translate their commitment to person-centred care into specific actions that will create an appropriate and supportive infrastructure, which will in turn facilitate and guide change in practice. While not easy, putting the levers for change in place is an essential step. It will require doing different things as well as doing things differently. What these different things are and how to do things differently are questions we are all grappling with. Drawing on the research, we set out below our reflections on what actions we think are needed. These thoughts are intended as pointers for deeper exploration: there is no blueprint, no off-the-shelf set of system tools. Table 1: Shared decision making and self-management support: the changing roles of patients and clinicians Current practice Person-centred care Roles and beliefs Patients passive, believe clinician has the answers and will improve their health People active partners and managers of their health Clinical expert gives advice, fixes, cares for and promotes dependency Clinician cares about, listens and uses expertise to support and enable patient as a partner in decision making and management of their health and care Policy and practice assume knowledge creates behaviour change Policy and practice recognise that knowledge, skills, confidence, self-efficacy and motivation create behaviour change Model Primarily medical Biopsychosocial Values clinical outcomes Values outcomes that matter to people Who Workforce = clinicians Workforce = clinicians + peer support workers + navigators + health coaches + ... How Clinician shares results and information during consultation Person receives results and information at appropriate time to enable them to set their agenda and make their decisions Clinical training in ‘communication’ skills used to enable them to get patients’ agreement to clinician determined goals Clinical training in skills to support people to determine and enact their own goals Compliance with clinically determined goals and treatment plans Collaborative care and support planning with adherence to co-produced goals