What is informed consent?

#GPFUQ 166 How to question people in power? Tony Benn had five questions

What power have you got? Where did you get it from? In whose interests do you exercise it? To whom are you accountable? How can we get rid of you?

If you cannot get rid of the people who govern you, you do not live in a democratic system.

#GPFUQ 167 What is informed consent? Its not informed if the numbers that describe risk are a mystery to most people? Doctors usually don’t know the numbers needed to treat (NNT) and numbers needed to harm (NNH) and don’t explain the true benefits and harms of tests and treatments. Patients usually consent with only a poor understanding of their risks. Other numbers to explain overall benefits and risks like numbers needed to benefit (NNB) and numbers needed to damage (NND) are used even less.

Patients usually overestimate the benefit of treatments. For example, many people using statins or antihypertensive’s believe they are substantially reducing their risk of heart attack or stroke. Assuming that the treatment is safe and used for 5 years, only a few patients would take a drug if they thought that they had a 5% chance or less of benefiting (NNT 20). Half of the patients would take a drug if the chance of them benefiting was 20% (NNT 5). If the benefit was 5% or less then the number of patients willing to take a preventive drug was doubled if their doctor recommended the treatment. Most interventions are not that good.

Different doctors and patients cope with the same risk differently and the subsequent management of the same conditions varies widely.

#GPFUQ 168  How can risk and consent become better informed? GPs need to know and explain the frequency of benefits and harms of the tests and treatments that they recommend to patients. To be able to do this risk scores like NNT, NNH, NNB, NND for tests and treatments need to be easily accessible to inform everyday decision making and GPs need to benchmark their own understanding and tolerance of risk and make this clear when they make recommendations to patients.

If patients can make sense of their risk they will make more informed and personal choices about their care, and may not consent to overtreatments.

#GPFUQ 169 How do you reduce emergency hospital admissions? This should focus on all the people (patients, carers, and clinicians) at higher risk. Better care is needed outside of hospital for patients with chronic conditions. It is the weakest link in a chain of people at risk that’s important. Links are weak and the risk of emergency admission high when patients, carers, and clinicians struggle to cope with a mix of complex medical and social conditions, the plethora of services available, perverse incentives that confuse best practice, and the lack of effective feedback loops to inform choices about care.

For example, the GP is one of many factors in the mix. A series of studies of GP out of hours services in Bristol showed a fourfold variation in emergency referrals between the top and bottom quarter of referrers and a 10-fold difference between the top 10 and the bottom 10 referrers. A low “tolerance of risk” by the GP seemed to be the weak link that predicts emergency referrals. Weak links can be strengthened by making differences in behaviour visible through better feedback to patients, carers, and clinicians. Such an approach might reduce variation in performance and improve quality.