It is considerably less than 12 months since the discussion of prudent healthcare in Wales began with a piece of work led by the Bevan Commission. During this short period, there has been a lively debate in which both scale and scope has exceeded expectations. In the space of nine months prudent healthcare has gone from being a concept shared by only a few keenly-interested individuals to a topic widely discussed and disseminated. It appears in health board papers; features in the work of our Royal Colleges; whole conferences have been devoted to it and it has even been mentioned in the British Medical Journal.
This period has been devoted to the refinement of the idea itself – what exactly do we mean by prudent healthcare? – and by an effort to agree and codify a set of core principles on which it can be taken forward.
My own view has been that we have to be patient with this process. The debate is a necessary and worthwhile investment in the long-term viability of the project. To an outsider – such as me – the health world can appear dominated by the search for an elusive and, in some important ways, spurious appearance of certainty. While the need for the practice of healthcare to be evidence-based is essential, this has to be accompanied by a more nuanced understanding of the nature of evidence: its contestability, the iterative relationship between evidence and application and so on. This is especially important during the formative phase of any new idea or exploration and confirms our wish to resist a rush to over-systematise prudent healthcare in this early period because we are certainly not yet in a position where we can afford to side line any contribution to the debate.
There are dangers in this open approach – we will have to be watchful of the way any pre-existing system responds to new thinking by discovering it was doing this all along. Just applying the label of prudent healthcare in a post-hoc fashion to the world as it has always been would be a very disappointing outcome.
Moving from principles to practice
Prudent healthcare has to be more than an idea and more than a set of principles. It has to change the way health services are used and provided. It has to make a real practical difference to the broad sweep of those millions of encounters which take place every year between Welsh people and their health service. The strongest case for making such a difference is that, if we get it right, it offers a way of allowing the founding principles of the National Health Service to be sustained into the future.
My own advocacy of the prudent healthcare approach begins and ends with that ambition. The health service remains a modern miracle. It is the greatest achievement of practical socialism – an organisation we pay into in the hope we will be fortunate not to need its services; an organisation in which we pool our risks and share the results on the basis that those with the greatest need and not the fattest wallets will be the first to receive attention.
But it is also a system under continual stress and strain as demands rise and the resource from which to meet them stands still.
A social foundation
Let us remember that for the founders of the NHS – and as I would argue, even more significantly today – the importance of the NHS was as much social as it was economic and clinical. In 1945, T H Marshall’s notion of “social” citizenship was rooted in the shared experience of warfare. Today we live with the effects of increasing spatial segregation, which has been a characteristic of the UK for nearly 40 years, together with other forms of intensifying inequality. We work alongside people like ourselves; we live in neighbourhoods which share our own economic and social circumstances; children are sent to school to meet other children like themselves.
Wales has, by and large, avoided the worst excesses of the self-excluding society. We have little private education and less private medicine. Gated communities are so rare as to be practically invisible. Yet, as far as public services are concerned, the NHS remains a great democratic meeting place. The hospital outpatient clinic remains one of the diminishing contexts in which people will find themselves sitting next door to others from very different social circumstances but facing similar personal challenges.
The experience of being present at birth and death takes place every single day in our hospitals. The sharing of such profound moments makes a fundamental contribution to a live sense of common humanity and shared solidarity. That is why, if our healthcare system is able to embed the notion of prudent medicine as part a set of specific practices, it will have achieved something important. To go beyond that, however, to be part of the broad sweep suggested earlier, will require a much more substantial cultural shift in the way we use and provide public services.
And, in the current state of development, this is a possibility which, in the minds of many, still seems implausible or difficult to achieve. Indeed, in the large number of chances I have now been given to address audiences of health professionals, the notion of cultural change is the point at which scepticism begins to get the upper hand. The proposition that our healthcare system should aim to eliminate treatments for which there is no evidence of efficacy is a difficult one to take issue with in principle – even the notion that intervention should always be pitched at the minimum necessary level to obtain the desired result is hard to resist. Who could argue the opposite proposition – that we should regularly over-treat patients, beyond their clinical need? The principle that no health professional should routinely undertake work which does not require that person’s level of clinical competence is one which quickly enough secures general consent.
None of these ideas are uncontroversial. The eminent Italian epidemiologist Gianfranco Domenighrtti has argued that only 11% of 3,000 common health interventions have good evidence to support them , but many will be in everyday use in the Welsh NHS. Over treatment is one of the sins of the advanced healthcare system. And the principle that any health professional should only do work which requires that level of professional competence soon comes under strain once its implications for previously taken-for-granted professional fiefdoms are understood. But at the level of proposition, as opposed to practice, all have a broad level of support.
The idea of co-production is today one which is widely and approvingly quoted. That is not to say that everyone uses the term in an identical way. Here in Wales, the dominant strand is that which draws on the highly-influential work of Edgar Cahn. At its ethical core lies the notion of reciprocity – the give and take which creates the social bonds that hold us together in a common life and which relies, for its vitality, on the innumerable individual encounters in the services we use. The purpose of those encounters has to be emancipatory – always aiming at fostering and promoting the autonomy and capacity of the individual, rather than undermining it.
This sense of shared and joint decision-making is the opposite of the cold managerialism which has played its part in the history of social democracy, as well as being the dominant strand amongst the privatising and marketising right.
In his recent Hugo Young lecture, Labour leader Ed Miliband quoted two authorities to underscore the rebalancing which co-production brings about it. Looking back to the work of Michael Young, the author of the 1945 Labour manifesto, he quotes the American community organiser, Saul Alinsky, who said: “Self-respect arises only out of people play an active role in solving their own crises and I’m not helpless, passive, a bit like the recipients of private or public services.”
In more challenging terms, he also quotes Professor Richard Sennett’s revival of the term first coined by anthropologist Mary Douglas: “compassion that wounds”. The well-intentioned, properly motivated, but ultimately destructive compassion which strips away the ability of individuals to exert the maximum influence of their own lives stands at the opposite end of the spectrum from the emancipatory co-produced practice, as understood in prudent healthcare.
As we develop our thinking about prudent healthcare further I believe the collective nature of co-production will also become more apparent. In health, in particular, we need to call the force for change, which comes through the positive encouragement of communities of interest. Co-production is achieved by amplifying the collective voice of users as well as by the choices each of us makes. No user of public services ought to be left as an isolated individual but should be enabled to link with others. We have given insufficient attention so far to the contribution the third sector, user-led, organisations can bring to the practical delivery of the co-production principle.
This is particularly important because it is when the prudent healthcare discussion turns to co-production in practice that the journey of persuasion becomes even more challenging. “That’s all very well in theory,” I see people’s eyes saying to me, “But you’ll never make it happen.” I see patients thinking that about doctors. And I see health workers thinking it about patients.
Making it happen
It is for this reason I devote the rest of my contribution to explaining why I believe the change implied in these aspects of the prudent healthcare prospectus can be made to happen.
The most powerful evidence comes from our own recent past. When Barbara Castle, the non-driving Minister for Transport in the 1966 Wilson government announced new laws were to be introduced to limit drinking and driving and the introduction of a new breathalyser system (invented by Dr Tom Parry Jones, from Menai Bridge and Bangor University) she ran into a storm of protest.
It is quite difficult to think of two more entrenched lobby interests than the alcohol industry and motorists. While even they felt unable to defend the indisputable connection between excess consumption of alcohol and death on the roads, they focused on the cultural right – as they saw it – to the enjoyment of leisure without interference in an essentially private activity through the infringement of personal liberties.
Here is an extract from an interview broadcast on the BBC’s flagship radio news programme, The World This Weekend, on October 1, 1967:
Interviewer: “Minister, this is a rotten idea. You’re spoiling my fun as a motorist. So Minister, what’s the idea behind it?”
Mrs Castle: “The idea is to save your life, not mine. I don’t drive, you do. I am ready to risk unpopularity to save you, perhaps, from yourself.”
Interviewer: “You’re only a woman, you don’t drive, what do you know about it?”
Changing cultural assumptions
Despite the controversial nature of the new legislation it very quickly proved its worth. In the first year of breathalysers being introduced road accidents where alcohol had been a factor fell from 25% to 15%. There were 1,152 fewer recorded deaths; 11,177 serious injuries and 28,130 fewer slight injuries caused by road traffic accidents. By 2012, the number of people killed in road accidents in Wales in which alcohol was involved had fallen to just 280. The following year, the lowest ever number of deaths on the roads in Wales was recorded since figures were first collated in 1926.
The impact of the breathalyser and compulsory seat belt wearing (introduced at the same time) was immediate and has lasted ever since. It was a cultural shift, which was widely described at the time as being impossible to bring about, but rapidly became irreversible. Who today would imagine the argument in favour of the”freedom” to drink and drive or to add to the harm from motor vehicle accidents winning the day? We understand the co-productive bargain in which avoidable harm is avoided by individuals taking responsibility for the contribution they must make to secure that result.
My second example of cultural shift has taken place more gradually but with equally profound results. As I write these paragraphs, I have just returned from a visit to one of Cardiff’s recycling centres. On a warm Sunday afternoon I joined a queue of other Cardiff residents – men and women, young and old, black and white – in an activity which, at a distance, would have been indistinguishable from an ant colony in the intensity of its organisation. Once parked, the inhabitants of each car leapt into rapid activity, conscious of others waiting to do the same thing – sorting, delivering and tidying an enormous range of recyclable products into one of 14 different categories.
When I came to live in Cardiff, in 1979, if I carried the weekly rubbish bin to the gate for collection, I felt as if I had discharged my obligation as a concerned and engaged citizen. Today things are very different – we identify our rubbish; divide it into categories; put it in different containers; check to see which collection takes place each week and make our active contribution to the co-production of solutions to the shared environmental challenges we face. And it works. The Welsh reuse, recycling and composting rate for 2013-14 currently stands at 54% compared to 42% in England. This is a remarkable improvement from a rate of just 37.5% in 2008-09.
Protecting people from harm
My final example is the only one to come directly from the field of health and refers to the revolution in smoking, which has been such a striking achievement of the past 30 years. Here, is evidence of the need to remain optimistic about the possibility of cultural shift.
The first clear research to demonstrate the danger tobacco posed to human health emerged 60 years ago but the early years were characterised by ferocious attempts by tobacco companies to evade and deny the damage their activities were creating. As late as 1978, nearly 30 years after the first scientific experiments demonstrating the harmful effects of tobacco reported, 45% of adult males in the UK were smoking. Another 30 years later and the rate had more than halved to 21%. This is still far too many but we are on a steadily declining trajectory. Fewer than 10% of the population of California now smoke at all and New Zealand has a realistic ambition of becoming the first smoke-free nation within the next 10 years.
Professor Simon Chapman put it in this way: “A Rip van Winkle awaking from a 20-year sleep would be astounded by the cultural transformation of the status of smoking from pleasant, mannered past time to a badge of low education, social disadvantage and ostracism. Cigarette packets have metamorphosed from elegant boxes to pathology museum exhibits.” And here, in Wales, of course, they will be museum exhibits when plain packaging is introduced.
As Chapman suggests, we must not underestimate the cultural shift which underpins the change in smoking habits. In July this year, I spent a fine Saturday afternoon at the final, major, event of the Ely Festival in my own Cardiff West constituency. As usual, I joined others in running the Labour party stall. Half way through the afternoon, someone came to see what we had on offer and was smoking! It caused consternation among all of us. In a highly unscientific way we then carried out an eye-level survey of the festival field and we couldn’t see anyone else smoking. Even within the limitations of such an approach it told us something striking. Ely is an area with real economic and social challenges. People live hard lives, often with unrelenting pressures of simply putting food on the table and keeping life-line services, such as electricity, from being taken away. These pressures erupt into smoking levels well above the Welsh average. Twenty years ago, that propensity to smoke would have been entirely apparent on the festival field – people would’ve been smoking everywhere, regardless of whether children were present or food was being served. In 2014, people who smoke at home have absorbed the cultural message that it is not socially acceptable to do so in public places.
The transformation may not be absolutely universal – as our one visitor demonstrated – but it is overwhelmingly true and, as far as prudent healthcare is concerned it shows, alongside the other examples cited here, that the cultural shift it relies on is not only real but achievable too.
Making hope possible
R H Tawney, the famous socialist thinker, described the demise of the 1931 Labour government as one which happened “not with a crash” but with a “slow crawl to its doom”. In equally challenging financial times, we are not prepared to allow the same fate to befall the NHS in Wales, even as the slow doom of its basic principles is played out elsewhere.
That process means that the fixed frame through which the National Health Service is discussed and reported in the United Kingdom is one designed to make despair convincing. It takes exceptional failure and tries to make that emblematic of the service as a whole. My job, as a Minister for Health and Social Services in a nation which has unparalleled affection and regard for that service, is to provide a counter narrative.
In the words of Raymond Williams it is to demonstrate, in our own times, that “to be truly radical is to make hope possible rather than despair convincing”. That’s why the prudent healthcare agenda is so important. It shows how, even in the hardest of times, we can go on shaping and providing a National Health Service, which is not only as good as it ever has been but better than we have ever imagined.
- Smith R. The Case for Slow Medicine (BMJ Blogs)
- Cahn E. No More Throw-Away People: The Co-Production Imperative
- Miliband E. Hugo Young lecture. February 10, 2014
- Miliband E. Hugo Young lecture. February 10, 2014
- Local authority municipal waste management statistics http://wales.gov.uk/statistics-and-research/local-authority-municipal-waste-management/?lang=en
- Welsh Health Survey http://wales.gov.uk/statistics-and-research/welsh-health-survey/?lang=en
- Chapman S. Risks of Smoking: All Done and Dusted. In: Medical Milestones, Celebrating Key Advances Since 1840
- Tawney RH. The Choice Before the Labour Party. 1932
- Williams R. Resources of Hope. 1988