What is shared decision-making?
Shared decision-making is a conversation that brings two kinds of expertise together. You know the condition, the evidence and what usually happens with each option. The patient knows their own life: their work, family, fears, and what they are willing to put up with. A good decision needs both.
NICE describes it as a joint process in which the person understands the risks, benefits and possible consequences of different options, and reaches a decision with their clinician. The result can be a decision to have no treatment. People can also choose how involved they want to be.
| Style | What happens | Problem |
|---|---|---|
| Paternalistic | The clinician decides and tells the patient | Ignores what matters to the patient and may not meet the legal test for consent |
| Informed choice only | The clinician lists facts and leaves the patient to decide alone | Patients can feel abandoned and confused |
| Shared decision-making | Balanced information, exploring values, a recommendation if wanted, then a joint decision | Takes some skill, but is the expected standard |
It is not only for major surgery. Starting a statin, choosing between physiotherapy and an injection, accepting screening, deciding where to give birth or whether to go to hospital after a fall are all shared decisions.
Why is shared decision-making required in the UK?
For many internationally educated professionals this is one of the biggest changes in practice. In the UK, involving patients in decisions is a legal and professional requirement, not simply good manners.
The Montgomery judgment
In Montgomery v Lanarkshire Health Board (2015), the UK Supreme Court held that clinicians must take reasonable care to make sure a patient knows about any material risks of a recommended treatment and any reasonable alternatives. A risk is material if a reasonable person in the patient's position would think it significant, or if the clinician knows, or should know, that this particular patient would. The focus moved from what doctors usually say to what this patient would want to know. The court also said the conversation should be a dialogue, not a pile of technical information or a signature on a form.
Professional standards and guidance
- GMC: Decision making and consent (2020) and Good Medical Practice (2024) expect doctors to share information patients want or need and to support them to make decisions.
- NMC: The Code requires nurses, midwives and nursing associates to respect people's right to make decisions and to communicate clearly.
- HCPC: The standards of conduct, performance and ethics require valid consent and appropriate communication.
- GPhC: The standards for pharmacy professionals require person-centred care.
- NICE NG197 (2021) sets out how organisations and professionals should put shared decision-making into practice, before, during and after appointments.
How do you do shared decision-making? The three-talk model
A simple structure that fits into a short appointment is the three-talk model, described by Elwyn and colleagues in the BMJ in 2017. It has three parts: team talk, option talk and decision talk.
- Team talk: say there is a choice: Many patients expect the clinician to decide. Say clearly that there are reasonable options and that you would like to choose together. For example, 'There are a few sensible ways forward, and the best one depends partly on what matters most to you.'
- Option talk: describe each option: Explain what each option involves, the likely benefits, the main risks and side effects, and what happens next. Always include doing nothing or watchful waiting where that is reasonable. Use a patient decision aid if one exists.
- Explore what matters: Ask open questions. What are you hoping for? What worries you most? How would each option fit with your work or caring responsibilities? The answers often point to the right choice.
- Decision talk: decide or agree next steps: Ask whether they are ready to decide, whether they want your recommendation, and whether they want to involve anyone else. Unless it is urgent, it is fine to agree to think it over and come back.
- Check understanding and record it: Use teach-back, then document the options, risks discussed, the patient's priorities and the decision.
The BRAN questions
Choosing Wisely UK encourages patients to ask four questions: what are the Benefits, what are the Risks, what are the Alternatives, and what if I do Nothing? A useful check on yourself is whether your explanation would let the patient answer all four.
How should you explain risk so patients understand it?
Explaining risk is where well-meaning clinicians most often mislead without meaning to. The same evidence can sound very different depending on how you frame it.
- Use absolute risk (for example, 4 in 100 people) rather than relative risk alone (for example, a 25% reduction). Relative figures sound bigger.
- Use the same denominator throughout, such as 'out of 100 people'.
- Give both sides: how many benefit, and how many have a side effect.
- Give a time frame, for example over the next five or ten years.
- Use pictures or icon arrays from a recognised decision aid when they are available.
- Do not invent numbers. Use the patient leaflet, a NICE patient decision aid or a validated risk calculator, or say you will find out.
This tablet cuts your risk of a stroke by a third, so I'd definitely take it. Side effects are rare.
Out of 100 people like you, about 6 would have a stroke in the next five years without treatment. With this tablet, it's about 4. So roughly 2 in 100 avoid a stroke by taking it, and for the rest it makes no difference either way. On the other side, a small number of people have a serious bleed. Some people feel that trade-off is clearly worth it and some would rather not take a daily tablet. How do those numbers sit with you? (Figures are for illustration only.)
Worked example: a shared decision about knee pain
Joyce has painful osteoarthritis in her left knee. She looks after her grandchildren three days a week and walks her dog daily. A first contact physiotherapist in her GP practice sees her. Reasonable options are a structured exercise programme, regular simple pain relief, referral to discuss knee replacement, or no change for now. The physiotherapist asks what matters most. Joyce says she cannot afford months off her feet because of childcare, but would consider surgery later if pain stopped her walking the dog.
OA left knee. Advised exercises and analgesia. Not for surgery. Patient happy. Review 6 months.
OA left knee. Discussed options: exercise programme, regular paracetamol and topical NSAID, referral to orthopaedics to discuss replacement, or no change. Explained exercise usually helps pain and function with few risks; surgery can relieve pain for many but has risks including infection, clots and ongoing pain for some, with a recovery of several months. Joyce's priorities: childcare three days a week, avoiding long recovery. Teach-back confirmed understanding. Chose exercise and analgesia; will reconsider referral if pain limits walking. Knows she can ask for referral at any time. Leaflet given. Review 3 months.
The first note reads as a decision made about Joyce. If she later found out surgery had been an option, nothing shows she was told. The second note shows the options, the risks, her priorities, her understanding and her choice, which is what a reviewer, a colleague or Joyce herself would need to see.
Adapting shared decision-making for different patients
Shared decision-making has to work for everyone, not only confident patients who are comfortable with numbers and fluent in English. NICE NG197 asks professionals to think about what each person needs to take part.
| Need | Practical adjustment |
|---|---|
| Limited English | Use a professional interpreter, not a relative, and allow more time |
| Low health literacy or numeracy | Plain words, one idea at a time, pictures, teach-back |
| Learning disability or autism | Easy read materials, reasonable adjustments, involve people who know them well |
| Hearing or visual impairment | BSL interpreter, large print or audio, a quiet room |
| Wants family involved | Include them if the patient agrees, while keeping the patient at the centre |
| Prefers the clinician to decide | Respect this, but still give the key information they need for valid consent |
How do you document a shared decision?
Good documentation does not have to be long. It should let anyone reading it later see that the patient was properly involved.
- The options discussed, including no treatment where reasonable.
- The main benefits and the material risks you explained, with numbers where you used them.
- What matters to the patient: their priorities, concerns and circumstances.
- Any decision aid, leaflet or interpreter used.
- How you checked understanding.
- The decision, or the agreed plan to decide later, and the safety-netting advice.
Busy clinics are the most common reason given for not sharing decisions. In practice, a structured conversation can be brief, and sending information before the appointment, using decision aids and booking a follow-up rather than forcing a decision on the day all help. Follow your organisation's consent policy and approved decision aids.
Developing your skills
Shared decision-making is a skill you can practise and reflect on, and it fits naturally into revalidation, appraisal and CPD records. If a complaint or concern about consent has been raised about your practice, take advice from your defence organisation or trade union before writing statements.
Our Shared Decision-Making course walks through the legal basis, the three-talk model, explaining risk with numbers, adapting for different patients and documenting decisions, with a reflective exercise. Breaking Bad News Training and Difficult Conversations with Patients and Families cover related communication skills.
Frequently asked questions
What is shared decision-making in simple terms?
It means the clinician and patient decide together. The clinician explains the reasonable options, including doing nothing, and their likely benefits and risks in plain language. The patient says what matters to them. Together they choose the option that best fits the patient's values and circumstances, and the patient can take time to think if the situation is not urgent.
What are the three stages of shared decision-making?
A commonly used structure is the three-talk model: team talk, where you explain there is a choice to make together; option talk, where you describe each option with its benefits and risks; and decision talk, where you explore what matters to the patient and reach a decision or agree next steps. Checking understanding and documenting the decision complete the process.
What does BRAN stand for?
BRAN stands for Benefits, Risks, Alternatives and Nothing. Choosing Wisely UK encourages patients to ask: what are the benefits, what are the risks, what are the alternatives, and what happens if I do nothing? Clinicians can use the same four questions to check whether their explanation has covered everything a patient needs to make a decision.
How did the Montgomery case change consent?
Montgomery v Lanarkshire Health Board (2015) moved the legal test for information disclosure towards the patient. Clinicians must take reasonable care to make sure patients know about material risks and reasonable alternatives. A risk is material if a reasonable person in the patient's position, or this particular patient, would attach significance to it. Consent should come from a genuine dialogue.
What is NICE guideline NG197?
NG197 is the NICE guideline on shared decision-making, published in 2021. It covers how organisations can embed shared decision-making and how professionals can involve people in decisions before, during and after appointments. It includes advice on using patient decision aids and discussing risks, benefits and consequences in ways people can understand.
Is shared decision-making the same as informed consent?
They overlap but are not identical. Valid consent requires that a person with capacity agrees voluntarily after receiving the information they need. Shared decision-making is the conversation that gets you there: exploring options and the patient's values so the decision fits them. Good shared decision-making usually produces valid, well-documented consent.
What if the patient wants me to decide for them?
Some patients prefer the clinician to decide, and you can respect that. However, you should still give them the essential information they need, including significant risks and reasonable alternatives, so that their agreement is valid. Record that they preferred you to recommend, what you explained and what was agreed.
Related courses
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Sources and further reading
- Shared decision making (NG197). National Institute for Health and Care Excellence.
- Decision making and consent. General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Montgomery v Lanarkshire Health Board [2015] UKSC 11. UK Supreme Court.
- Shared decision making. NHS England.
- Mental Capacity Act 2005 Code of Practice. Office of the Public Guardian.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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