Decision making quality part two

Transcript

Introduction

Welcome to Neighborhood Health Conversations, where we explore how decisions made closest to people shape the future of the NHS. Today we’re unpacking a powerful idea from Professor Al Mulley, the five levels of decision quality. It’s a framework that helps us see why good medicine isn’t just about what science says, but about how wisely we apply that science together.

The Myth of the Single Answer (Level One)

First, let’s look at the myth of the single answer. This is where you start with level one quality decision-making, where many people think healthcare lives. It’s the level where science is assumed to tell us the right answer. In this world, there’s a correct diagnosis, a correct treatment, and a doctor who simply applies the rule. But as Al Mali points out, that’s rarely reality. The science can tell us what works on average, not what’s right for an individual. Yet this is the level many people expect from their doctor. Certainty, authority, and a clear plan. But what’s the problem with this?

Real life isn’t linear. Human biology, psychology, and context introduce variation and uncertainty. Level one gives comfort, but not necessarily quality. What about level two, the realm of clinical judgment?

Clinical Judgment: Weighing the Evidence (Level Two)

Well, moving up to level two, we reach the world most clinicians recognize, where there are four or five equally valid biomedical options. This is where the art of medicine begins, weighing the evidence, considering side effects, interactions, comorbidities, and professional experience. Doctors operate here every day, interpreting imperfect science and applying it to complex lives. But still, the focus remains biomedical. Choices between pills, procedures, and pathways that all set within the medical model.

Decision quality improves, but it’s still confined. We’re choosing between branches of the same tree, not yet looking at the forest.

Broadening the Frame: Non-Medical Solutions (Level Three)

At level three, we start broadening the frame. And this is where Al-Mulli’s thinking really challenges us. Here, the clinician steps back and asks, are there non-biomedical options that could achieve the same or better outcome? Could the answer lie in diet, movement, sleep, connection, purpose? Or in addressing housing, income or loneliness?

These aren’t soft alternatives. They’re often more effective and more sustainable than medication alone. At level three, decision quality expands from treatment choice to life choice. This is where integrated neighborhood care truly comes alive, because professionals work alongside community and voluntary partners to support health creation, not just disease management.

Identifying and Reducing Bias (Level Four)

At level four, we start to confront the bias in some of that medical decision making. So once we’ve explained the full range of options, it’s important to identify and to reduce bias. Every decision carries bias, professional bias, institutional bias, and even emotional bias.

Doctors may prefer the intervention they’ve trained in. Systems may reward activity over value. People may assume more treatment means better care. And if people come to see a doctor expecting treatment and feel they’re then being denied that treatment, that can create a very difficult relationship and decision-making process.

It’s the relationship that people have with their professional that builds trust, that allows time for the professional to listen to the person and to truly understand the importance of alternative decisions to what might have been perceived to be what science says is best.

This requires trust and relationships and continuity and is one of the reasons they add so much value to healthcare. The high quality decisions at this level require reflection and transparency. They rely on data, peer discussion and humility. The willingness to see where our preferences or incentives might distort the choice. Level four is uncomfortable but essential. It’s where we move from what we like to do to what’s right to do. So what about level five, the voice of the person?

The Voice of the Person: True Shared Decision-Making (Level Five)

This is the highest form of decision quality. At level five, it’s not the clinician or the science that has the last word—it’s the individual’s own values, goals, and context. What are they trying to achieve? What risks are they willing to take? What trade-offs make sense in their life?

Level five transforms medicine from something done to people into something done with them. It’s the true expression of shared decision-making and the foundation of person-centered care.

So how do we pull this all together? Well, when you look across the five levels, a clear pattern emerges. Each step upward moves us from certainty to curiosity, from control to collaboration. At level one, science dominates.

From Certainty to Collaboration

When you look across all five levels, a clear pattern emerges: each step upward moves healthcare from certainty to curiosity, from control to collaboration. At level one, science dominates. By level five, humanity does.

And here’s the miracle: when we reach level five, outcomes actually improve. Value improves. Professional experience improves. People are more likely to follow through, less likely to regret decisions, and far more likely to feel seen and heard. For the NHS, this framework reminds us that true value lies not in doing more, but in doing what matters most

Conclusion

Al-Molly’s five levels of decision quality give us a roadmap for the next 25, 50, 75 years of the NHS. They invite us to honour science, but also to recognize its limits, to combine data with dialogue and expertise with empathy.

Because every health system, however complex, still comes down to one timeless question. How do we side together what’s right to do? Thanks for joining Neighborhood Health Conversations. If you’ve enjoyed today’s episode, please share it and join us next time as we explore how better decisions made closer to home can secure the NHS for generations to come.