This article from the Bevan Commission look at how, “The NHS in Wales, like other healthcare systems around the world, is facing the twin challenges of rising costs and increasing demand, while continuing to improve the quality of care .”
The article examines how healthcare organisations around the world are applying principles similar to the central themes of prudent healthcare that have been developed in Wales. It includes examples from Brazil, Canada, Holland, New Zealand, Sweden, and the USA, drawing out key points that could be applied by NHS Wales.
Prudent: a system-wide response to cost, demand and quality
“The NHS in Wales, like other healthcare systems around the world, is facing the twin challenges of rising costs and increasing demand, while continuing to improve the quality of care.”
In response to the growing and well-recognised challenges facing the NHS in Wales, including reducing costs, addressing rising demand and improving quality, the Bevan Commission set out its initial thinking on a new approach to healthcare, in a paper called Simply Prudent Healthcare[i].
Recognising other countries were also confronting these challenges, the Bevan Commission has now drawn on research, practice and experience from around the world, for this online resource.
A variety of different approaches were found to help tackle these challenges. Although successful, they are often restricted to services or setting that were not delivered system-wide. In contrast, Wales intends to take a unique, holistic and system-wide approach in the development and adoption of prudent healthcare.
The overall objective will be to co-produce better health, more equitably across the entire healthcare system. This will be done in partnership with the public, professionals and wider communities, recognising health is everyone’s responsibility, not just the responsibility of one system, one initiative or one service alone.
Canterbury District Health Board, New Zealand[ii]
Canterbury District Health Board in New Zealand offers a good example of how a more equal relationship between patients and professionals can be achieved. For more than five years the health board, which covers the South Island’s largest and most populous region, has been redesigning services to achieve better integration with enhanced community care. Its main achievements include:
- moving from hospital gridlock to reduce delays and pressure on the system
- lower rates of acute medical admissions
- low rates of both average length of stay and readmissions in acute care
- fewer cancelled planned admissions
- more conditions treated out of hospital
- saving patients more than a million days of waiting for treatment, in just four clinical areas
- fewer people moving into care homes
- transformation of a NZ$17millioin deficit in 2007, on a turnover $1.2billion, to an NZ$8 million surplus in 2010–2011
- recognition as one of the top-performing public services in New Zealand
Some of this transformation was precipitated by the Christchurch earthquake disaster in 2011 when several healthcare buildings were damaged, destroyed or rendered unusable. But while the earthquake created a pressing need for changing the location and delivery of healthcare, Canterbury had already started to make changes in the location of its services before the disaster.
“As in other transformation programmes, the stimulus for what happened was the perception of a health system that was under pressure and beginning to look unsustainable.” (The King’s Fund 2013)
The improvements in Canterbury have been aided by redesigning services with an emphasis on:
- system improvement at the heart of strategy
- investment in developing skills and capacity
- prioritising primary care, including IT support, education, strong engagement with secondary care, and poly-clinics
- HealthPathways – a shared electronic referral tool to enable integration of community, primary care and hospital services and shared care records across services
- emphasis on the individual, reducing delays and wastage in the system
- being bold and assertive – putting patient experience before targets and measures
- collective leadership – staff at all levels expected to take the lead when needed to bring about change
- emphasis on one budget, one system, to pool budgets across the health board
Canterbury has not significantly reduced the number of hospital beds but it has reduced pressure on them, while delivering improved services and increased volume of activity. The need for hospital beds is expected to increase in the future but a lower rate than had been predicted before the transformation programme was introduced. The increase in bed numbers is estimated to be less than half what would otherwise have been needed.
One of the approaches used was extensive engagement with staff which included a series of workshops. The outcomes of these workshops identified how to improve patient care by reducing delays and unnecessary treatments, secured ownership by the staff of the work needed to be taken forward and facilitated the acceptance of the pressing need for change and its more effective implementation.
Wales can learn from Canterbury about applying prudent healthcare. In particular:
- adopt similar engagement approaches to improve patient care, co-creating health and improved ways of working with staff, patients and other partners
- put the needs of patients first, making sure resources are pooled most effectively
- identify and eliminate measures which add no value to patient outcomes or experience
- strengthen collaborative leadership within and between health boards and at all levels of management to ensure prudent healthcare is everyone’s responsibility
Choosing Wisely, USA[iii]
Involving patients in their care is essential to achieve high-quality care with optimal patient outcomes which are of relevant and important to individuals. To achieve this, information for patients about their treatment and care needs to be readily available and easy to understand. It also needs to be used effectively by patients and healthcare professionals, so they can make the best choices for the individual’s own preferences and circumstances.
Choosing Wisely is an initiative that started in the United States (US) to help provide safer and better quality patient care and also tackle overuse and unnecessary waste of healthcare resources[iv].
Choosing Wisely is an initiative by the American Bureau of Internal Medicine (ABIM) Foundation to help healthcare professionals and patients take part in conversations about the overuse of unnecessary tests and procedures, and help patients make effective care choices. The ABIM estimated that in some cases as much as 30 per cent of care delivered was unnecessary duplication of earlier treatment or unnecessary itself.
American specialty associations and organisations supporting Choosing Wisely were asked to create a ‘things-to-question’ list, giving specific, evidence-based recommendations for each item. These lists can be used to prompt discussions between doctors and patients, helping them to make prudent decisions about their healthcare. The lists can be downloaded from www.choosingwisely.org/doctor-patient-lists and have helped to stimulate much wider discussion about the need for many tests and interventions.
Choosing Wisely is now being adopted in 12 countries, including Japan, Germany, Italy, Australia, and New Zealand.
In the US and Canada, an ABIM Foundation survey found doctors taking part in Choosing Wisely were more likely to have reduced the number of times they recommended a test or procedure, because they learned it was unnecessary.
Wales is planning to adopt Choosing Wisely to help reduce unnecessary tests and procedures. Steps are being taken to find out how best to do this. We need to make sure that:
- patients are encouraged to discuss their needs and the outcomes they expect
- patients have reliable information to help them make informed decisions about their treatment and care
- there is wider public debate and discussion about Choosing Wisely and unnecessary treatments and medication
The Nuka system of care, Alaska USA[v]
The Nuka system of care, developed by Southcentral Foundation in Alaska, is recognised as one of the most successful and innovative primary care systems in the world. Southcentral Foundation administers federal funds to provide healthcare services on behalf of First Nation people under the US government’s Indian Self-determination Act.
Notably, the Nuka system has benefitted from extensive investment of federal funds at a level which on current forecasts will not be available for investment in NHS Wales. Nevertheless the innovative models adopted by Nuka and the essential elements of the approach chime well with principles of Prudent Healthcare and provide sterling examples of the benefits gained by their system-wide application.
Southcentral Foundation has achieved its success by delivering a community-led model of “customer-ownership” for the care services it delivers, particularly in primary care. Those relying on services, set priorities for those services. The use of a new terminology – “customer-owner” instead of patient or service user – emphasises the organisation’s commitment to listen to people and act on their feedback. The executive team must also seek approval from tribal leaders of the decisions it makes. As well as many positive organisational outcomes, including raising the quality of services and levels of staff engagement[vi], the health outcomes of the community have been significantly improved[vii]. The orientation of services around the customer-owner has proved positive and is cost-effective. The chief executive hosts an open mic session where any customer-owner can approach and ask questions which have to be answered.
Although Southcentral Foundation spends more of its budget per person on primary care, it spends less on healthcare overall per person and delivers higher quality healthcare than that experienced in most other parts of the US[viii].
Through the Nuka system of care, access to primary care medical advice, similar to visiting a GP, has been reduced from an average of four weeks to same-day consultations. Previously, the majority of admissions to the healthcare system were through the secondary care emergency department. The service delivered through Nuka emphasised ‘same day’ consultations. This has reduced the pressure on emergency departments and resulted in people receiving treatment more quickly, often in a more suitable environment that the emergency room at the hospital.
Wales must look more carefully at how it can apply the learning from the Nuka, in particular:
- identifying opportunities to strengthen patient and public engagement and accountability at local and national levels
- finding ways to give the patient’s voice more weight: centrally, in acute and primary care discussions about services
- using community health councils more effectively to involve people in planning, delivery and accountability of health services
- engaging the communities and patients in service design and delivery and securing ownership as customer-owners.
Participatory democracy in healthcare, Brazil[ix]
In 2013 the Bevan Commission investigated participatory democracy and received a presentation from a physician working in this system in Brazil.
Brazil’s constitution, inaugurated in 1988, includes considerable scope for participatory democracy. The establishment of municipal health councils in the early 1990s allows for direct citizen influence over healthcare delivery models. Although there have been some flaws in the process, the health councils allow local people to approve the budgets, accounts and spending plans presented by the executive team of regional health organisations.
The composition of health councils is outlined in statute as:
- 50 per cent usúarios (health service user representatives)
- 25 per cent health workers
- 25 per cent health managers (including private sector providers who have been commissioned to deliver services).
The councils meet monthly. Federal money is not released to the organisations delivering care until the health council approves plans and budgets. Many usúarios are appointed rather than elected and there have been some concerns of cronyism and people being selected to rubber stamp decisions. However, the system generally works well and ensures the wishes of the wider community are heard and acted on.
Wales has made some steps to improve its engagement with the public, particularly through the South Wales Programme and Bevan Commission public meetings[x], but there remains a pressing need to improve involvement, particularly in the ownership, design and delivery of services and to redraw the relationships between the citizen and NHS Wales. Opportunities exist to do this in Wales, through community health councils and may increase through formation of the new GP clusters and local integrated community teams.
QUEST® – a Premier healthcare alliance collaborative[xi]
QUEST® – QUality, Efficiency, Safety and Transparency – is an American collaborative designed to help hospitals “reliably deliver the most efficient, effective and caring experience for every patient, every single time.”[xii]
It uses a variety of different improvement methods, many of them drawn from industry, to improve quality across the organisation, including clinical quality, patient experience and business processes from the supply chain to the workforce.
More than 350 hospitals were involved in the collaborative for more than five years. During the programme, QUEST participants:
- increased service provision of evidence-based care to approximately 109,000 additional patients
- prevented an estimated 136,375 deaths (14 per cent lower than the national average)
- reduced inflation-adjusted healthcare spending by nearly US$11.65 billion
- prevented 17,991 instances of potential harm, with a particular focus on hospital-acquired infections
- reduced hospital readmissions by more than 40,000, over the five year period
There are many aspects of the QUEST® initiative that link closely with the prudent healthcare agenda in Wales:
- resource utilisation, to deliver reductions in the cost of care
- medicines standardisation
- improving internal processes, particularly in the supply chain
- case managers working with patients to make sure they receive the best care possible in hospital and when they leave – resulting in reduced length of stay and fewer readmissions
- ensuring evidence-based medicine is implemented in practice.
Prudent healthcare has identified these in its principles but there is still a struggle to ensure that this happens in practice. Some NHS Wales organisations are already exploring the application of the QUEST® model, for example opportunities to develop standardised quality measures.
Kaiser Permanente, USA – applying evidence-based medicine and embedding quality improvement[xiii]
Evidence-based medicine is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” [xiv]
Kaiser Permanente, the largest American not-for-profit health insurance company, launched a national guidelines programme in 2005, to ensure healthcare providers were consistently implementing evidence-based medicine. A web-based data dashboard called Big Q was created, which tracked the performance of each medical centre and service area against external benchmarks and internal goals. Between the second quarter of 2008 and first quarter of 2009, performance across all Kaiser Permanente medical centres improved.[xv]
The programme of work ultimately resulted in people receiving more appropriate and effective care and healthcare professionals taking ownership of the guidelines programme.
Based on the programme, Kaiser Permanente claimed: “By following the recommendations contained in our cardiovascular guidelines, a high-risk Kaiser Permanente member has a 60 per cent lower chance of dying from stroke or heart attack than does a non-member.”[xvi]
Kaiser Permanente is recognised as leading on evidence-based healthcare. This has been attributed to three practices:
- emphasis on preventive care to deliver sustainable cost reductions
- doctors are salaried rather than paid per service, removing incentives for selection of unnecessary procedures
- planning hospital stays and shifting care to outpatient clinics, resulting in lower insurance premiums, cost savings for Kaiser Permanente and a better patient experience. In comparison patients in the UK NHS spend two to five times longer in hospital than a similar patient in a Kaiser Permanente
Kaiser Permanente’s healthcare system presents a number of opportunities for prudent healthcare and further consideration in Wales to:
- apply a more systematic approach to evidence-based medicine
- put in place information systems to monitor and account for evidence-based care and patient experience as identified in the Bevan Commission data and information report
- further explore opportunities to support preventive and self-care at every opportunity
- make prevention a central requirement of NHS Wales, supported by training at all levels and recognition of success
- incorporate some salaried GP services and identify the benefits of salaried GPs, build on the experiences of Cwm Taf University Health Board and others
- further explore new models in primary care, as identified in the Bevan Commission draft primary care report
- adopt a similar approach to Kaiser Permanente to embed learning and strong leadership.
The Esther Network, Sweden[xvii]
The Esther Network is part of the healthcare system in Jönköping, Sweden, widely recognised as a world leader in patient-centred care. The network appoints healthcare workers and other carers to scrutinise and assess services through patients’ eyes. The network started as a single project in 1997 and was restructured into a network that today covers a population of 110,000 service users.
Elderly people, with experience of using the healthcare system, have been recruited to provide insights into how the healthcare system works. Often referred to as ‘Esthers’, they have become valuable partners in shaping services.
The Esther Network has helped to focus service providers on patient value – the aspects of the service patients value most, this can be different to what clinicians and managers think is important. More efficient and improved prescription and medication routines have been designed, based on feedback from patients and staff. Other benefits attributed to the Esther Network include increased patient and staff satisfaction, greatly reduced waiting times, more effective treatment and reduced costs.
Some NHS Wales organisations have developed their own patient-focused programmes, using profiles of typical patients and working out how those people would view the system. Examples include Megan in Aneurin Bevan University Health Board, Wyn in Cardiff and Vale University Health Board and Freda in Betsi Cadwaladr University Health Board.
Buurtzorg, district nurse model, the Netherlands[xviii]
In 2006, community nurses started a new concept in the Netherlands: Buurtzorg, which in English means ‘Neighbourhood Care’. It is a not-for-profit provider of care through care homes and in community settings. The experience of Buurtzorg shows how understanding demand in human terms and supporting self-help are fundamental prudent improvement principles.
Most traditional home care in the Netherlands has been based on an approach similar to that in the UK. This model views home care as a product that can be delivered most efficiently when divided up into separate component processes. These processes can then be delivered by different individual specialists, for example, those who administer pills and injections, those who dress wounds and others with more specialist skills who, for example can connect morphine drips.
The Dutch organisation found any savings made in cost per hour from specialisation were lost when the cost of managing a complex and fragmented process was also factored in. A better system, one that put patients’ needs at the centre of care, was needed. Buurtzorg decided to revitalise the district nurse role. The care provided by its generalist district nurses is to build a relationship with the client, solving problems and rebuilding their self-confidence as part of recovery. The organisation has shown that a single, unhurried visit by a highly-trained district nurse is more effective than several visits by specialised care workers, each performing their allotted tasks.
This way of working has increased the unit cost of interventions but this is compensated for by a 50 per cent reduction in total demand. Nurses serve neighbourhoods of 10,000 people in self-managing teams of ten. Working with GPs, they see themselves as community builders, developing neighbourhood-level support for their clients from friends, families and volunteers and they even have a weekly slot on local radio they can use to advertise events and services, provide advice and put people in touch with one another.
Preliminary findings show that Buurtzorg’s patients use 40 per cent of the care they are entitled to. Half of patients receiving care do so for less than three months and patient satisfaction scores are now 30 per cent higher than the national average. With no managers, communication lines are short and employees report greater work satisfaction. In 2011, Buurtzorg was chosen as the Dutch employer of the year.[xix]
Wales needs to build on this model of home care more systematically, avoiding unnecessary delays for patients, fragmented care and duplication in the system. It should also capitalise on local examples such as Monmouthshire adult services, redesigned to meet the needs of its clients at first request.
Applying the world’s learning in Wales
If prudent healthcare is to flourish in Wales we need a bold, radical and enduring commitment to change. We need to change our thinking and our culture in the health and social care systems. We need to change the way we work and how we gain acceptance and commitment by the people of Wales for prudent healthcare principles.
How often have we heard similar sentiments expressed about previous attempts at transformational change, which have failed to gain traction and withered on the vine? This must not be allowed to happen to prudent healthcare, which offers real benefits to the NHS not only by delivering a safe and high-quality service, but also by transforming the fundamental relationship between each one of us and NHS Wales.
Time is critical. To gain acceptance from those whose commitment is essential for success, we need to demonstrate further evidence from around the world about the very real and tangible benefits that adopting a prudent approach can deliver. We do not have to reinvent the wheel, but we do need to ensure that the wheel is crafted to successfully traverse the unique landscape of NHS Wales.
By drawing on the examples highlighted in this chapter we can gain valuable insight about how we might fruitfully continue this exciting journey. Some of the examples cited here are more radical than others, but they all offer clear and consistent messages about how we can take prudent healthcare forward. We can learn from others and import, adapt and adopt innovative good practise, as appropriate for Wales. Most importantly we can gain confidence that where others have succeeded, so too can we.
[i] Aylward, M., Phillips, P. Howson, H. (2014) Simply Prudent Healthcare – achieving better care and value for money in Wales – discussion paper. Cardiff: Bevan Commission. [Available online at http://www.bevancommission.org/sitesplus/documents/1101/Bevan%20Commission%20Simply%20Prudent%20Healthcare%20v1%2004122013.pdf]
[ii] Timmins, N. & Ham, C. (2013) The quest for integrated health and social care A case study in Canterbury, New Zealand. London: The King’s Fund
[v] Hussey, R. & Gottleib, K. (2014 – forthcoming) Redesigning healthcare: Learning from the Nuka System of Care to inform the development of healthcare in NHS Wales. Cardiff: 1000 Lives Improvement (Publication date October / November 2014)
[vi] Gottlieb, K. (2013) The Nuka System of Care: improving health through ownership and relationships. International Journal of Circumpolar Health 2013
[vii] Gottlieb, K. (2014) Southcentral Foundation Nuka System of Care [Presentation at The Nuka system of care: Lessons for healthcare redesign in Wales, 13 February 2014.] Available from www.1000livesplus.wales.nhs.uk/nuka
[viii] Gottlieb, K. (2013) The Nuka System of Care: improving health through ownership and relationships. International Journal of Circumpolar Health 2013; Porter, P. and Cook, B. (2014) The Nuka System of Care for chronic conditions. Qementum Quarterly, Spring 2014. Ottawa: Accreditation Canada
[ix] Cornwall, A. (2007) Deliberating Democracy: Scenes from a Brazilian Municipal Health Council. Brighton: Institute of Development Studies; Cornwall, A. et al (2010) Engaging Citizens in Governance: Lessons from Brazil’s Democratic Experiments. London: Department for International Development
[xii] Premier Inc (2014) QUEST: High-performing hospitals Year 5 collaborative findings, February 2014. Charlotte, North Carolina: Premier Inc.
[xiv] Sacket, D et al (1996) Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71
[xv] Schilling, L, Chase A, Kehrli S et al (2010) , Joint Commission Journal on Quality and Patient Safety, Volume 36, Number 11, 2010, 489 – 498 (15)
[xvii] Davies, J. (2012) Person Driven Care. Cardiff: 1000 Lives Improvement.
[xviii] Sinclair, A. (2011) A life worth living. Edinburgh: Scottish Council for Voluntary Organisations (SCVO)
[xix] De Blok, J. (2013) Buurtzorg: better care for lower cost. [Presentation to The King’s Fund. Available from http://www.kingsfund.org.uk/sites/files/kf/media/jos-de-blok-buurtzorg-home-healthcare-nov13.pdf]; KPMG (2012) Netherlands: Buurtzorg empowered nurses focus on patient value (online). Available from http://www.kpmg.com/global/en/issuesandinsights/articlespublications/value-walks/pages/netherlands.aspx