There are no easy solutions for the challenges faced by NHS Wales. Without strong leadership from LHB and trust chief executives to implement prudent healthcare the NHS will not be able to achieve the excellent standards, or offer many of the services, people need.
The challenge for leaders is to embed prudent principles in decision making at all levels in NHS Wales. Prudent healthcare invites every member of staff to stop and think about the value of what they are doing. Leaders need to have the courage to stop services or activities that cause harm or are ineffective. They must also lead the way in the change of culture in the organisation to develop a new relationship between patients and the NHS.
Times have changed, the NHS must too
Since its conception more than 65 years ago, the health service has continued to work using broadly the same models and principles in its relationship with patients.
Despite dramatic changes and developments in society, which has seen demand for healthcare reach record levels, it’s still the case that the NHS, and its partners, absorb almost all society’s responsibility for keeping people well.
Through developments in technology and a broadening of the services and treatments on offer, public expectations about what the health service can deliver have, just like demand, reached high levels – sometimes to the point of being unrealistic.
At present we have a health service with few limits for determining treatment for an individual’s condition, no matter the cause. This way of working has without a doubt been important in the huge improvements made in survival rates of several chronic and acute conditions, there has been little open discussion and debate about the sustainability of this kind of approach. We now need to consider if this approach, which sees the NHS taking significant responsibility for the management of health and illness, is always right for the individual or society as a whole.
The NHS has a long history of clinical freedom to practice. This means the decision about who receives care and what type of care they receive, has been a decision that has remained almost exclusively with the treating clinician. This has often resulted in significant variation in clinical interventions. Variation in which drug is prescribed; who receives what type of surgery; what implant is used; and even whether an individual receives treatment at all. This kind of variation can create even greater variation in the cost of treatment. There is often no evidence to support arguments that increased cost improves quality or patient outcomes.
Prudent healthcare – a necessary philosophy for change?
Since the intention to introduce the principles of prudent healthcare into the Welsh NHS was first made by the Minister for Health and Social Services, there have been a range of views expressed about our potential to deliver the significant service redesign needed to achieve prudent healthcare.
At one end of the spectrum of opinion, prudent healthcare could be criticised as a tool for rationing access to healthcare while reducing clinical freedom to decide what is best for individual patients. At the other end of the spectrum prudent healthcare could be viewed as a tool to systematically drive evidence-based clinical practice and reduce variation across the NHS.
As health service professionals and leaders in Wales, we remain wholly committed to the founding principles of the NHS. We firmly believe that decisions about treatment should be based on need and efficacy of the intervention. Cost alone should never be a key determinant in patient care.
However, we also have a responsibility to deliver services with the resources available and this means spending money wisely – eliminating waste; ensuring everything we do is high quality; and interventions are both clinically and cost effective.
We strongly believe prudent healthcare provides boards, clinicians, NHS staff and the people of Wales with a powerful set of principles to help us make better decisions about how we deliver health services in the future.
The real leadership challenge is how we embed prudent principles in our governance and decision making at all levels in the NHS and, at the same time, co-create a new relationship with the people of Wales so they become partners in creating their own health.
The challenges ahead
The challenges faced by NHS Wales are well known. We are experiencing record levels of demand on services which, due to an ageing population and soaring rates of chronic diseases, are only going to increase.
The Welsh NHS Confederation, which represents leaders and seeks to provide an independent voice, recently, published a briefing paper, From rhetoric to reality – the NHS in ten years’ time. This outlined the challenges facing NHS Wales in the next decade, including an ageing population, public health, workforce and finance.
The service changes being driven forward by health boards and NHS trusts will help us to deal with some of the longstanding issues raised but, at a time of austerity, it is important we now go beyond this. We must fundamentally examine what we do, how we do it and the relationships between our health service and the public.
A different approach
Previously, during times of recession and public service contraction, the health service worked to continue doing everything it was doing, but at a lower cost. Reducing management costs; rationalising estate; more effective procurement; and reviewing the skill mix all contributed to this cost-saving approach. Now, cost-saving opportunities are becoming exhausted – driving those delivering health services to look more fundamentally at the shape of health services.
A new approach shaped by the principles of prudent healthcare must question:
- Clinical effectiveness – are services delivering best outcomes for patients; do they need to change or be delivered at all?
- Waste – are interventions unnecessary, repetitive or generating unproductive work?
- Variation – can the degree of variation be justified in terms of patient outcomes?
- Thresholds for intervention – are thresholds understood and consistently applied?
- Relationships with patients – are individuals helped to take more responsibility for the choices they make in life which affect their health; is the NHS seen as a partner helping individuals to support good health and not a safety net when people become ill?
All NHS staff will play an important role and chief executives and boards must lead the way in delivering this new approach. It will involve changing NHS culture. The responsibility for spending precious NHS resources must be something everyone, including patients, takes seriously.
Every decision NHS leaders make should be grounded in the principles of prudent healthcare together with every decision clinicians and patients make together about patient care.
However, this is only part of the story – the full potential of prudent healthcare will only be realised when the NHS supports the people of Wales to adopt a different set of responsibilities and behaviours in managing their own health and how they access health services.
How prudent healthcare can secure the future of NHS Wales
If we are to deliver the health service we want and need in the future, we must find new ways of prioritising services. The prudent healthcare principles, as articulated by the Bevan Commission, must be embedded in the NHS in such a way that they are meaningful for boards, staff and patients alike.
Arguably, what the system needs and what individuals need are the same. However, the language is important in this context so that engagement of everyone in the pursuit of better more prudent healthcare is meaningful and authentic.
The following charts put forward a suggested construct for the alignment of system and individual need to generate the greatest impact on the delivery of prudent healthcare.
Prevention and early intervention
If we assume that prevention and early intervention are the most prudent of all healthcare activities, there needs to be a new contract between public services and the individual where we all play an active role in this endeavour.
In this context, public services are wider than the NHS alone. They are about realising the real potential of the regional collaboratives where the NHS, local authority, police, fire service and key voluntary sector organisations build community resilience and agree priorities together. It is about having a social construct where education, leisure and all care services focus on maximising the potential of an individual to take care of their own health and wellbeing.
The principle of prevention is one without question – but it is the potential for incentives and sanctions that always causes alarm for people.
Case Study 1
Jamie is 26 years old and has been drinking heavily since the age of 11. Despite significant health problems needing 24 hospital admissions for bleeding oesophageal lesions in the last six years he has refused all offers of help to enable him to stop drinking. He argues that he should be able to live his life as he chooses and the NHS is there to patch him up every time he becomes acutely unwell.
Where does personal responsibility sit in a prudent healthcare system?
Case Study 2
Sylvia is 63 and weighs 19 stone. She is having terrible problems with her hip and has been referred for a joint replacement. She is also getting quite depressed because her mobility is restricting her ability to get out and about. As part of the musculo-skeletal pathway, before making it onto the orthopaedic waiting list she is referred to a local exercise and weight management scheme. She loses three stone, and her pain is alleviated. She has decided she no longer needs the surgery and has the added bonus of a new circle of friends she met while on the exercise and weight management scheme.
The exercise referral scheme costs less than 5 per cent of the surgery. Is this prudent healthcare at its best where the system and the individual is better off?
It is down to us all, as leaders, clinicians and all staff in the NHS, to have a full grasp of the services we are providing and make sure they are organised in the most efficient way.
For example, w care pathways must reduce the numbers of steps it takes to get to the end-point of treatment. Access to diagnostics can be enhanced so the right decision for the right intervention can be made as quickly as possible and people who do not need treatment can be reassured and removed from waiting lists.
Case Study 3
Dr S is a consultant in emergency medicine. After several years of referring people for a routine ultrasound to eliminate certain diagnoses, she determined it would be quicker, more cost effective and better for patients if she became trained in a limited number of scanning procedures and the department bought a portable scanner.
Is this a good example of empowering staff to innovate, driving prudent practice?
These actions will also help to deliver another key principle of prudent healthcare – carrying out the minimum intervention possible. For too long the traditional response in the NHS has been to offer every possible treatment to a patient all of the time.
Case Study 4
Emily is 84 years old, has very high cholesterol level and is taking statins to reduce her risk of heart attack and stroke. One of the side effects of the tablets is that she gets leg cramps which means she is prone to falling when she gets out of bed at night to use the toilet. Emily also has bowel cancer and has a poor prognosis. A fall and a fracture in her current state of frailty could severely affect her quality of life and hasten her demise.
Are we doing more harm than good in continuing to prescribe Emily her statins?
Prudent healthcare invites every member of staff to stop and think about the value of what they are doing. Whether it is the type of cleaning fluid that is used on the floors to the drugs prescribed or the prosthesis used in the operating theatre, the same question should be asked – ‘What is the most cost-effective procedure or product I can use that will give me the desired quality outcome?’
This is not advocating that cheapest is best; this is about rationalising for quality and cost effectiveness.
Case Study 5
Mr T is an orthopaedic surgeon working in a team of nine consultants. He and his colleagues have been through a process of testing and rationalising implants which has enabled the health board to negotiate better prices and annual savings of approximately £300,000. The surgeons are happy that patient outcomes for the new products (which have now been in use for two years) are excellent, but Dr T refuses to switch claiming he prefers the older products. His decision is costing the Health Board £50,000 per annum.
Where evidence of equivalent quality is clear, should clinicians continue to be able to exercise product choice?
Sometimes, the potential for substitution is even more fundamental. The question is whether any healthcare intervention is appropriate at all.
Case Study 6
David is 58 years old. He was made redundant two years ago and can’t find work. His marriage has broken down; his self-esteem is at rock-bottom and he is very lonely. He saw his GP because his mood is very low and has been prescribed anti-depressants.
Are we treating the symptom here and not the cause? Would a more prudent healthcare system direct David to a local voluntary sector service to help him engage in community activities, address his social isolation and improve his self-esteem?
Elimination of waste
From wasted resources to wasted time and wasted opportunities, prudent healthcare challenges everyone working for the NHS to seriously question the value of what they do.
Current levels of expectation of the NHS in themselves are leading to significant amounts of waste and is resulting in reduced benefit or even harm to patients.
Case Study 7
A recent survey commissioned by charity Nesta asked 1,000 GPs about prescribing antibiotics. More than a quarter (28 per cent) said they prescribe antibiotics ‘several times a week’ even when they were not sure they were medically necessary; and almost all GPs surveyed, 90 per cent, said they felt pressure from patients to prescribe.
Waste is not always obvious but surely prescribing in this way cannot continue in a system built on prudent healthcare principles?
Prudent healthcare should never mean that people do not receive the treatment they need. It will require a change in relationship between the patient and the NHS. In trusts and health boards, chief executives and board members have to lead by example and all our decisions should be made in line with prudent principles.
A new relationship between NHS staff and the public
It is vital we get into the mindset that the NHS is free from charge but not free from obligation. Prudent healthcare will not work without prudent patients and the NHS must help people make this shift in thinking.
This means leading organisations to redress the balance by increasing both the accountability of staff for their own actions and supporting greater involvement of patients in their own healthcare. It is also about striking a new bargain where patients are encouraged to take responsibility for their own actions by understanding the impact their choices have on their health and wellbeing.
The NHS can offer support to people to make changes to their lifestyles to support better health. In many cases, these initiatives can result in savings to the NHS because interventions are made earlier, and services are more effective and efficient.
It is this combined responsibility which has the potential to lead to reduced costs and improved outcomes.
We know a shift in culture will not happen overnight. Wide and deep changes are needed to make sure that every aspect of every organisation and every service in the NHS in Wales is working prudently. While change on this scale may not be rapid, at the same time, we cannot afford to waste more time.
Leaders need to start considering what can be done in the short term and plan for the long term to make sure we are meeting this vision.
A change in culture starts with trust boards and chief executives, and both must lead by example.
This means improving patient flow, waiting times and follow-up processes. We will also have to break the cycle of allegiances to buildings and traditions. Transport and technology open the door to new systems of care. Access to definitive treatment will need to be the currency of success not how long it takes to travel to the hospital.
Early intervention includes better uptake of services such as screening or immunisation programmes and ‘finding’ the people who may be most at risk of developing certain conditions.
On an individual level, it is about using the health service wisely and not abusing what it can offer. It is about taking responsibility for the consequences of our lifestyle choices. It is also about knowing when to use the health service and where to go to seek medical treatment or advice. Self-help and prevention will be key to driving this forward.
The reasons behind the need for change in the Welsh NHS are well versed. But we should not underestimate the challenges they pose. As austerity continues to take its toll, our ability to live up to public expectations when demand is at record levels is compromised. It is clear we need to be more radical when making decisions about how we will shape our future.
The principles of prudent healthcare provide the opportunity for us to improve the quality of services, provide better outcomes for patients and get better value from the billions invested in the NHS every year in Wales.
Our success in leading these changes will be seen in more positive outcomes for patients, a reduction in health inequalities, a highly-trained workforce working to the best of its abilities and helping more people avoid hospital admissions through improved services and an increased ability to manage their own healthcare needs.
There are no easy solutions for the challenges we face in the health service. But we know that, without radical change of the kind that prudent healthcare advocates – and strong leadership in its implementation – the NHS will not be able to achieve the excellent standards, or offer many of the services, people need.
Wales has been at the forefront of many innovative health movements in recent years. Prudent healthcare can be at the heart of a new joint contract between public services and the people of Wales. The NHS in Wales can lead the way in developing this new movement and creating a new culture of working that will help us address the challenges we face. Together, using prudent principles we can make the NHS in Wales the best it can be now and for future generations.
As we move ahead with the implementation of prudent healthcare, there are three things that we should be keeping in mind in our decision making. We should always be asking ourselves whether the actions we decide to take, meet the prudent healthcare principles.
There are five practical steps to introducing prudent healthcare from a leadership perspective:
- Simply stop those services or activities which may be causing patients harm or are of little benefit.
- Make sure all staff understand they have a personal responsibility to work prudently.
- Organise services so staff are consistently working to their highest competencies.
- Lead the way in the change of culture in the organisation to develop a new relationship between patients and the NHS.
- Make sure all future decisions for organisations are made on a basis of the prudent healthcare principles.
- Welsh Government. Delivering Prudent Healthcare in Wales. [Written Statement]. 2014. Available at http://wales.gov.uk/about/cabinet/cabinetstatements/2014/prudenthealthcare/?lang=en
- Bevan Commission. Simply Prudent Healthcare. 2013. Available at http://www.bevancommission.org/document/226538
- ‘Benefit of the doubt’ is the basis for prescribing antibiotics, finds Longitude survey. [Internet]. 2014. Available at http://www.nesta.org.uk/news/%E2%80%98benefit-doubt%E2%80%99-basis-prescribing-antibiotics-finds-longitude-survey