Making prudent healthcare happen

Focusing primary care services on people by applying prudent healthcare

  • Dr Sally Lewis, Interim Assistant Medical Director and Primary Care Clinical Director, Aneurin Bevan University Health Board

Summary

This article recognises the value that prudent healthcare can add to primary care services. There is a growing burden of chronic disease combined with new innovations in healthcare. Primary care clinicians will need to become more skilled at making treatment decisions with patients.

Clinical guidance for primary care can no longer be ‘single issue’ as that is unhelpful when working with an ageing population with increasing co-morbidities. Primary care clinicians also need to know where to direct people for information and support to maintain healthy behaviours and manage long term conditions as effectively as possible.

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What is prudent healthcare?

Prudent healthcare provides a philosophy and sets out principles to guide our work that will sustain the NHS in Wales for future generations. It is not unique to Wales; it is part of a global movement to make sure we use healthcare resources wisely. It aims to minimise harm to patients, focus on those treatment and systems that add real value to individual patients and deliver the health outcomes that matter to patients and communities. Prudent healthcare is especially relevant to primary healthcare. Primary care is the first point of contact people have with health services, where day to day health concerns are addressed and where access to more specialist care is brokered when it is needed.

Three things you may not know about prudent healthcare

  • It directly involves patients in designing their own care and participating in co-creating services
  • It focuses on obtaining the best outcomes for patients, discarding practices which are of marginal or no benefit, or may even cause harm
  • It is allied with a global movement seeking to reduce harmful over-medicalisation
Goldilocks care

For individuals accessing NHS services, prudent healthcare aims to reduce over-medicalisation and unintended harm. It also aims to reduce unnecessary investigations and the treatment burden patients often experience as a result. It encourages us to embark only on those interventions of maximum benefit and value to the individual. We can do this by tailoring evidence-based practice into individual management plans; helping people set realistic health goals and supporting them achieve them. This is what is meant by taking the “minimum appropriate intervention”. It has also been described by Dr Jessica Otte as “Goldilocks care”, in other words, care that is just right for the individual and their own circumstances.[1]

Shared decision making

This is an area in which primary care physicians excel and we are often advocates for our patients’ care. However, as we face a growing burden of chronic disease and many new innovations in healthcare, we need to make more decisions about interventions. General practitioners (GPs) will need to become more skilled at sharing treatment options with patients, along with their risks, benefits and likely outcomes. In addition, there is recognition that single condition clinical guidance is of limited value for an ageing population with increasing co-morbidities. We will need updated guidance to reflect the needs of patients and enhanced support in primary care in order to do that well. This may include a range of community services which offer alternatives for patients to seeking information, wanting to learn or maintain healthy behaviours and manage long-term conditions as effectively as possible.

For health boards, who manage primary care as part of integrated health services in Wales, the prudent approach should allow the development of services delivering outcomes important to patients and the rebalancing of services towards the interventions known to deliver the greatest health benefits. Many of these interventions take place in primary care and have an impact on health at a population level.[2-5]

The practical application of the principles of prudent healthcare in primary care are numerous and varied. Although to describe all approaches in primary care is beyond the scope of this chapter, the next section gives examples of holistic management of healthcare with patients and the co-design of primary care services to give maximum benefit to the populations we serve.

Implementing prudent healthcare in primary care
  1. Greater focus on prevention, promoting wellness and healthy behaviours, improving community cohesion

GP clusters are small groups of GP practices working together and with partners to develop services to meet local need. They are perfectly placed to help people with health issues as diverse as smoking cessation, weight management, dementia, befriending and mental health.

Often the best solutions are locally grown, and it will be important for health boards to consider how innovative services built on prudent principles are incorporated into cluster plans and health board-wide delivery plans.

People are experts on their own lives. Health and social care professionals are guided by prudent healthcare towards a facilitation role and away from the traditional ‘fixing’ role. This means a shift of power and everyone will need the skills to take part in shared decision making. This shift in power is the foundation of co-production and for this approach to really work primary care will need information to support collaboration with a wide range of partners, community leaders and groups. Co-production has the potential to unlock community assets which can encourage the development of healthier environments and result in healthier behaviours.[6,7]

Example: collaborating for smoking cessation

Improving access for people with chronic obstructive pulmonary disease (COPD) to smoking cessation services by increasing the range, type and setting of service available. Improving access to pulmonary rehabilitation, as well as linking up with Breathe Easy groups that provide education and support to patients who may not be able to access formal pulmonary rehabilitation. The aim of this collaboration is to provide patients with a menu of easily accessible community resources which enable them to maximise their potential to quit smoking based on their own particular circumstances.

  1. Prudent prescribing

Arguably one of the greatest impacts we have in general practice is through safe and effective prescribing.

The evidence-based medicine revolution continues to develop guidelines for us to follow and there is a steady stream of new innovations in healthcare, not least in prescribing. This therefore will lead to rapid growth in the amount and diversity of medicines we will prescribe for our patients.

Is this bad? Not necessarily, but only if we have assured ourselves that every time we prescribe a drug it is a valuable addition to an individual’s management and will do no harm. This is the basis for prudent prescribing and makes it imperative we determine the true value of the medicines we prescribe to each of our patients.

Value-based healthcare is defined as “an approach to providing care that maintains or improves quality while restricting growth in cost”.[8] I believe it is an essential approach if we are to preserve and maintain the central ethos of the Welsh NHS.

In order to decide if something has value we need to look at the outcomes an intervention delivers in relation to its cost. When we are considering a prescription, we need to get much better at shared goal setting with our patients and not assume what it is that they want and need. This requires a more nuanced and individualised approach to evidence-based medicine.

We must give clear advice at the outset about risks and benefits and manage expectations that we will be reassessing the effectiveness of the drug and its side effects at a given interval. We must be bolder in tackling polypharmacy to prevent the harm that this can cause.

As prescribers, we aim to relieve symptoms and prevent complications through treating disease. We do not set out to do harm. Experience tells us that when issues of quality and patient safety are at stake, prescribers step up to the plate and quickly change prescribing patterns. This has been particularly evident with the prescribing of non-steroidal anti-inflammatory drugs in recent years following developing evidence on the relative safety of different agents.

(This section was first published as a 1000 Lives Improvement blog)

  1. Shared goal setting and shared decision making

By providing patients with relevant and clear information about treatment options, it’s possible to make decisions that meet patients’ needs and take into account personal preferences and priorities. For the professional this means communicating the potential benefits and risks of an intervention honestly and transparently. For the patient or service user, discussing options creates an opportunity and expectation to participate more fully in decisions about their health and treatment and take greater responsibility for them.

Better outcomes

Patients who feel they have been listened to and understood and involved in deciding the most appropriate management plan for their condition are more likely to adhere to the plan, have better outcomes and be satisfied with their care. For healthcare professionals, this may mean difficult conversations with patients, giving them an honest appraisal of what “heroic” treatments can really offer them in terms of benefit and allowing them to make the decisions that matter to them. This becomes particularly relevant to end-of-life care.

While we know well-informed patients are more likely to decline some interventions, sharing options and ensuring understanding takes time. To support shared decision making it will be important for health boards to ensure primary care possesses the necessary tools and resources.[9,10]

Using evidence well

Now guidelines support professional practise, we must ensure we do not fail to individualise care in the pursuit of practising evidence-based medicine.

Evidence-based medicine is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”[11]

 A common failure in individualising care is to over-emphasise the importance of research evidence, or to act as if evidence-based medicine is only right or wrong.

Sally Lewis Primary Care funnels pic

For example, research has shown that treatment “A” reduces the risk of condition “B” and therefore all patients at risk of condition “B” should be offered treatment “A”.  An example of how this evidence can be over-emphasised, is when an 80-year-old patient who has had a heart attack must be offered a statin because that is good evidence-based medicine. The Quality and Outcomes Framework (QoF) has undoubtedly raised the level of care in many aspects but it has also encouraged this type of misrepresentation of evidence-based medicine.[12]

Supporting shared decision making

Examples of how shared decision making can be supported in primary care include:

  • use of audio/visual resources to give consistent, high-quality advice and information that can be repeated as many times as needed
  • enabling contact with support groups
  • anticipatory care plans to reinforce patient control over what happens to their future care in a range of different circumstances
  • encouraging patients to ask three questions[13]:
    • What are my options?
    • What are the benefits and possible risks?
    • How likely are these risk and benefits?
  1. Working with secondary care colleagues and patients to explore alternatives to traditional referral, improving access to specialists and the patient experience.

This work needs to be facilitated by health boards. There is an imperative in primary care to look at how we order diagnostic tests and the impact this has on access to radiological tests in particular. We know some types of imaging are not indicated in certain conditions and yet they are still regularly requested. We need to understand why that is, and work with colleagues in secondary care to make best use of specialist advice and radiological tests to avoid diagnostic delay.

Example of pathway redesign: epilepsy

Redesign of neurology outpatients in Gwent included providing an email advice line and redesign of the follow-up process for patients with epilepsy. Patients were able to access the service when they needed to instead of waiting for arbitrary follow-up intervals and experiencing difficulty accessing a consultant when they had a problem.

  1. There will be an expectation primary care refrains from interventions of low clinical value and for which there is not a robust evidence base.

In some areas of practise this may mean abandoning treatments and procedures which have been undertaken historically. This may provoke opposition and debate. In other areas we should be seeking to reduce potential harm, for example by reducing the incidence of community-acquired Clostridium difficile by avoiding prescribing broad spectrum antibiotics where possible and a reduction in the amount of antibiotics prescribed overall, in line with evidence.

There is a preference towards quantitative research in medicine, as opposed to qualitative, and this bias is reflected in the evidence base. The relative undervaluing of data best researched using qualitative methods, such as values and preferences, tends to distort what we consider to be important.

Next steps
  1. Creating the opportunity and resources to deliver shared decision in practice will need an initial increase in capacity in the system to allow this new way of working to become established.
  2. Current guidelines may be of limited use in patient populations with more complex health needs. Our evidence base needs to reflect the more complex co-morbidities of elderly patients and the challenges of polypharmacy to allow GPs to achieve appropriate decisions with these patients about the risks and benefits of interventions.
  3. Co-production has the potential to help create healthier environments to support healthier lifestyles. To engage fully in co-production, primary care will need to be supported with information and resources to support collaboration with a wide range of partners.
  4. Prudent prescribing may have the greatest impact on prudent healthcare in practice. GPs are well placed to deliver prudent prescribing practice. We must be bolder in tackling polypharmacy to prevent the harm this may cause.
  5. We all need to know how to use evidence effectively. By supporting understanding of evidence and how to use it well, shared decision making has the potential to raise the quality of debate when more challenging decisions are made about healthcare interventions, such as abandoning ineffective treatments.

 References

  1. Otte J. Less is more medicine [Internet]. [cited 2014 August 16]; Available at http://www.lessismoremedicine.com/
  2. Declaration of Alma Ata World Health Organisation [Internet]; [cited 2014 August 16] Available at http://www.who.int/publications/almaata_declaration_en.pdf
  3. Primary Care: Now more than ever The World Health Report WHO 2008 [Internet]. [cited 2014 August 16]; Available at http://apps.who.int/iris/bitstream/10665/69863/1/WHO_IER_WHR_08.1_eng.pdf?ua=1
  4. Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. J Public Health Sept 2011:1-9. doi:10.1093/pubmed/fdr075.
  5. Elwood P, Galante J, Pickering J, Palmer S, Bayer A, Ben-Shlomo Y, Langley M, Gallacher J. Healthy lifestyles reduce the incidence of chronic diseases and dementia: evidence from the Caerphilly Cohort Study [Internet]. 2013. [cited 2014 August 16]; PLoS ONE 8(12): e81877. doi: 10.1371/journal.pone.0081877. Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0081877
  6. Co-production Wales. All in this together. [Internet]. [cited 2014 August 16]; Available at
  7. www.allinthistogetherwales.wordpress.com/…/aitt-5-coproducing-resilient- communities
  8. The ALISS project – a local information system for Scotland [Internet]. [cited 2014 August 16]; Available at www.aliss.scot.nhs.uk/index.php/753-2
  9. Porter ME. What is value in healthcare? N Engl J Med 2010; 363:2477-81. [cited 2014 August 16]
  10. option grid [Internet]. [cited 2014 August 16]; Available at http://www.optiongrid.org/optiongrids.php
  11. Mulley A, Trimble C, Elwyn G. Patients’ preferences matter. The King’s Fund; 2012; Available at
  12. www.kingsfund.org.uk/publications/patients-preferences-matter
  13. 11. Sackett D, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson, WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312-7. [cited 2014 September 16].
  14. 12. Melzer D, Tavokoly B, Winder RE, Masoli JAH, Henley WE, Ble A, Richards SH. Much more medicine for the oldest old: trends in electronic medical records [Internet]. 2014 [cited 2014 August 16]; Available at
  15. http://ageing.oxfordjournals.org/content/early/2014/08/07/ageing.afu113.abstract
  16. 13. National Voices. Ask 3 questions [Internet]. [cited 2014 August 16]; Available at www.nationalvoices.org.uk/ask-3-questions
Further reading

Edwards RT, Burrows JR.  Transitioning from hospital-based to Enhanced Care at Home (ECH) for older adults in rural areas – a case study from the National Health Service (NHS) in Wales, UK, as an example of prudent healthcare. [Conference paper] The Commonwealth Fund, Harkness Alumni Health Policy Forum, Washington DC, July 2014.


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3 Comments

  1. This is a MUST read for any practitioner across the health and social care community. It is clear, concise and absolutely demonstrates the importance of shared decision making to really drive forward the prudent healthcare agenda. To date it could be argued that innovation is a poor traveller. We must make sure that good prudent healthcare outcomes are not only celebrated but embedded across Wales! Sally Lewis is clearly an ambassador for this. Great article!

  2. A good overview of the concept of prudent healthcare as applied to primary care. Facilitation of shared decision making is clearly the cornerstone of developing prudent healthcare in primary care, and something GPs and primary care staff already do well. However, the increasing emphasis on individualised interpretation of the evidence base presents its own challenges. For frontline clinicians, being able to interpret and recall the nuances of the evidence base and applying it to numerous subpopulations (eg the strength of evidence for certain interventions for under 65s vs over 80s) is difficult. For this to be done well will require support and resources, and a rethink on how eveidence for interventions is presented to patients AND health professionals.

  3. A beautifully clear explanation of the direction in which we must travel.

    Your next steps’ point 3 is an absolute. “3….To engage fully in co-production, primary care will need to be supported with information and resources to support collaboration with a wide range of partners.”

    We have to mature as a health service from talking the talk on co-production to walking the walk, and this requires data systems, feedback mechanisms and genuine engagement at the start of projects, to make this happen.

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Watch Dr Sally Lewis talk more about her article, click on the video.

“Three things you may not know about prudent healthcare:

It directly involves patients in designing their own care and participating in co-creating services

It focuses on obtaining the best outcomes for patients, discarding practises which are of marginal or no benefit, or may even cause harm

It is allied with a global movement seeing to reduce harmful over-medicalisation.”

Making it happen

  1. Primary care can deliver prudent healthcare through greater focus on prevention, promoting wellness and healthy behaviours and improving community cohesion.
  2. Prudent prescribing – one of the greatest impacts on prudent healthcare will be through safe and effective prescribing in primary care.
  3. Shared goal setting and shared decisions – discussing options with patients creates an opportunity and expectation for patients to participate more fully in their health and treatment and take greater responsibility for their health.
  4. With the support of health boards, primary care can work with secondary care colleagues and patients to explore alternatives to traditional referral, improve access to specialists and improve the patient experience.
  5. Primary care can reduce interventions by refraining from interventions with a low clinical value without a robust evidence base.

Innovation is one of the key drivers for prudent Healthcare. #ConnectNHS

Prudent Healthcare - collaboration leads to increased sustainability in patient care. #ConnectNHS pic.twitter.com/C33lMtboqH