From words to action: time for Australia to take shared decision making implementation seriously

Why is embedding shared decision making within the Australian health care system essential and urgent? Shared decision making is a process of engagement and partnership between a patient and their clinician that enables a collaborative decision to be made based on the best evidence, individual circumstances, and what matters most to the patient.¹ Patient involvement in making informed health decisions is a fundamental right² and is central to safe and quality health care. Shared decision making represents the highest standard of informed consent³ and is a cornerstone of value-based health care. As well as benefitting individual patients and clinicians, shared decision making also has an important role in addressing unwarranted variations in health care and has the potential to contribute to health system sustainability by reducing the overuse of low-value care (where the benefits do not, or hardly, outweigh the harms) and increasing the uptake of care that is known to be effective but is underutilised.^{4, 5}

Shared decision making can contribute to achieving the quintuple aim of health care improvement,⁶ by improving patient care experiences, informed decision-making, care efficiency, the wellbeing of clinical teams, and contributing towards reducing health inequities.^7-12 However, shared decision making is not widely adopted in practice in Australia and requires urgent scaling up so that more individuals and the health system can benefit from it.

In 2013, the inaugural national Shared Decision Making Symposium was hosted by the Centre for Research in Evidence-Based Practice (now the Institute for Evidence-Based Healthcare) at Bond University, in collaboration with the Australian Commission on Safety and Quality in Health Care (ACSQHC). One outcome of the symposium was identifying that clinicians’ low awareness of shared decision making, misperceptions about it, and limited training opportunities were among the barriers hindering its implementation in Australia. Following the symposium, we published an article in the Medical Journal of Australia¹ (MJA) to increase broad awareness about shared decision making, providing a brief explanation and example of the process, and refuting some of the common misperceptions. To address the barrier of limited training opportunities, the ACSQHC developed an online training module in shared decision making for clinicians (Box 1).

The 2014 MJA article noted that “In the absence of a coordinated national effort, we encourage individual clinicians to begin incorporating shared decision making into their consultations…”.¹ In the eleven years since the article’s publication, numerous initiatives led by local champions across Australia have promoted and facilitated implementation of shared decision making. Box 1 lists examples of some of these initiatives. Although this represents some progress, implementation has been ad hoc, mostly driven by individuals or teams championing its implementation, and some initiatives were only funded via research grants¹³ or were pilot projects, which limits sustained practice change.

This ad hoc approach to advancing shared decision making uptake in Australia is problematic. Concerns include a duplication of efforts and resource development, limited learning from others’ experiences, widely inconsistent resource access with no awareness of or access to resources in many health services, over-reliance on the enthusiasm and advocacy of individual champions, lack of monitoring of impact, and challenges with scalability and sustainability. The only national policy leadership for shared decision making in Australia has come from the ACSQHC. Notably, shared decision making was included in the second edition of the Australian national safety and quality health service standards, which was released in 2017.² Two of the eight standards include items relating to shared decision making: Standard 2 (“Partnering with consumers”) and Standard 5 (“Clinicians working collaboratively to plan and deliver comprehensive care”). Similarly, the second edition of the Australian charter of healthcare rights, which was released in 2019, includes explicit reference to the core components of shared decision making.¹⁴

In general, there is now more visibility about shared decision making and it appears more frequently in health policy documents and on health service websites. However, its inclusion in documents is not sufficient for shared decision making to occur in clinical practice. There must be active large scale implementation strategies and a coordinated and resourced plan to ensure that patients who attend any health service across Australia are offered the opportunity to make collaborative and evidence-informed decisions with their clinician.

In the absence of any coordinated efforts to measure shared decision making in clinical practice, we do not yet have reliable and specific health service data about how often patients experience shared decision making during consultations. Questions in patient experience surveys are usually not sensitive enough to provide accurate information about whether shared decision making occurred. Some general indication of Australia’s performance comes from an analysis of health system performance in ten countries, where for the domain of care process (which contains two elements relevant to shared decision making: patient engagement and sensitivity to patient preferences), Australia was not considered to be among the high performers.¹⁵ Data from the few small Australian research projects that have specifically measured the extent of shared decision making or gathered clinician or patient self-reported information suggest that levels are low.^{16, 17} Data on the teaching and assessment of shared decision making in Australian university medicine and health curricula are also lacking and difficult to gather, which hinders the identification of gaps and opportunities for improvement in its teaching.

Eleven years on and there has been disappointingly little progress towards this. The lack of coordinated and sustainable activity, with little focus on implementation and research funding, means that Australia¹⁸ is lagging behind many other countries (eg, Taiwan, Netherlands, Germany) who have committed to large scale implementation of shared decision making. In such countries, a combination of initiatives that target patients, clinicians, and the health system is typically used. For example, initiatives in the Netherlands include accredited shared decision making e-learning for clinicians; national promotion of the Ask 3 Questions to patients (including emails when a clinic appointment is booked); national governance of patient decision aids, quality criteria for these aids, and integration with guidelines; introduction of a specific billing code to finance the time for shared decision making conversations; legislation that empowers patients, such as the right to audiotape conversations, and that informed consent must cover the right to abstain from treatment; and explicit support and funding from the Dutch government and the ministry of health equivalent.^{19, 20} There is an increasing evidence base to guide shared decision making implementation, much of it generated in other countries.^21-27

A national symposium on advancing shared decision making was held in September 2024, hosted by the Australian Shared Decision Making Network and the Institute for Evidence-Based Healthcare. The symposium included presentations from international and national speakers who have led implementation activities and was attended by researchers, clinician–researchers, and representatives from various state and federal health organisations and departments. Among the topics presented and discussed were the current barriers to shared decision making in Australia, learnings from other countries (particularly about large scale/national level implementation), and practical strategies that could be used to progress uptake (Box 2).

Barriers to the implementation of shared decision making occur at the level of individual patients and clinicians and at the health organisation and system level.^{1, 39} Patients may face challenges such as low health literacy, cultural expectations, emotional distress, or a lack of confidence in participating. At the clinician level, some of the known barriers include low awareness of and access to shared decision making tools and resources, time constraints, insufficient training, concerns about professional autonomy, limited recognition of the compatibility of shared decision making with clinical practice guidelines, and the misbelief that simply providing a decision aid is enough to facilitate shared decision making.^{39, 40} System-level barriers to the implementation of shared decision making include limited access to decision aids, misaligned performance incentives, fragmented care, and policy or legal uncertainties.^{1, 39} The strategies suggested in Box 2 are primarily aimed at helping to mitigate some of these system and clinician-level barriers. However, it is acknowledged that for certain conditions (eg, chronic pain), the complexity of the information and the decision, along with gaps in the evidence, means the shared decision making process can be more complicated.^{41, 42} In such situations, addressing barriers needs to include ensuring that a broader atmosphere of care, concern, supportive communication and trust has been established; that goal-setting is incorporated; and there are coordinated efforts across clinical, organisational, and policy domains.

Implementing shared decision making requires a universal approach to ensure equity and access to inclusion in decision making, not just for those with high health literacy and access to care.⁴³ Adults with lower literacy can use tools to support shared decision making and are willing participants in health decisions.⁴⁴ Shared decision making can be most effective in supporting vulnerable populations.⁴⁵ In Australia, projects to improve shared decision making in specific communities have been developed⁴⁶ and with considered implementation and national support, could avoid widening inequities.

In Australia, there has been a notable change over the last decade and the term “shared decision making” is now used widely and appears frequently in health policy documents. But this is not enough and is not sufficient to ensure that shared decision making becomes standard practice in Australian health care. Many countries have recognised the importance of actively implementing large scale shared decision making. These international examples provide evidence of the feasibility of bridging the gap between policy and action and provide opportunities for Australia to learn from other countries. Various strategies have been used elsewhere, such as developing national guidance and strategy, establishing a centre focused on implementation, creating a national portal to provide easy access to shared decision making resources, developing targeted legislation (particularly around informed consent), requiring training and assessing clinician competency in shared decision making, funding implementation research and projects, and promoting shared decision making in guidelines and clinical pathways. Not actively leveraging this knowledge about shared decision making for Australia is a missed opportunity. Australia has been a leader in shared decision making research and policy over the last 20 years; however, we continue to lag behind in clinical practice. Widespread implementation of shared decision making is needed to support safe, high quality, sustainable and patient-centred health care in Australia. This is the right action to take for patients and will help to sustain an increasingly strained health care system. Scaling shared decision making for all in Australia should be a national priority.

Open access publishing facilitated by Bond University, as part of the Wiley - Bond University agreement via the Council of Australian University Librarians.

No relevant disclosures.

Not commissioned; externally peer reviewed.

Hoffmann TC: Conceptualization, writing – original draft, supervision, project administration, writing – review and editing. McCaffery KJ: Writing – original draft, writing – review and editing. Légaré F: Writing – original draft, writing – review and editing. Bakhit M: Writing – original draft, writing – review and editing. Tracy M: Writing – original draft, writing – review and editing. Australian Shared Decision Making Research Network: Writing – review and editing.