Making prudent healthcare happen

Establishing prudent principles across the public sector

  • Paul Matthews, Chief Executive, Monmouthshire County Council


Healthcare organisations don’t exist in a vacuum. They are surrounded by other organisations that also contribute to health through improving the wellbeing of society. Loneliness is a major factor in health and social connections and interactions are therefore crucial in helping people attain and maintain good health.

Instead of focusing on medical approaches that often render people reliant on the system, prudent healthcare could look holistically at the services that are provided. This article proposes the health benefits of many council services that are often regarded as ‘discretionary’, should be taken into account when making funding decisions. Healthcare organisations may feel it is worth investing in discretionary services if councils can no longer afford them.

Image copyright: © GeeHock

Almost everybody, at some time or other, has stood on the side of a riverbank with the flattest stones they can find and thrown them to see how many times they bounce off the surface of the water before they sink. The goal – seldom achieved in my case – is to get them over to the other side. The reality – in my case – is that they usually disappear into the depths after a bounce or two, lost from sight. It’s more appealing to grab the next one and try and do better, than to worry about the one that’s disappeared.

Success is a combination of velocity, the right angle of approach and the right stone – not too heavy, not too light and flat enough to skim. If these things come together well then the rotation of the stone is rapid enough to cause enough lift to bounce off the water, and continue to move forwards, albeit with decreasing energy, and reach the other side. You can’t see the lift from the stone’s rotation, or how the water repels the stone, but you know they’re there – crucial forces invisible to the eye. Without these invisible forces, the game would be lost no matter what you did to try to compensate.

It’s a while since I’ve skimmed a stone and my analysis makes it obvious I don’t hold a PhD in the natural sciences, but the point I’m trying to make is this – building a sustainable and reliable system of prudent healthcare is not a technical challenge, even though there are a range of technical changes to make. It’s more an adaptive leadership challenge. We’re looking for solutions that go beyond those we’ve found before, although some components of new solutions may well be things we know have worked before.

Prudent healthcare and the principles that underpin it have been laid out in earlier contributions. The science and practice of healthcare has also been talked about by some of the nation’s leading practitioners. My offer, over and above that of my colleagues, is to connect the debate to the wider social systems we are all part of – our families, our neighbourhoods, our villages, towns and cities. Human beings are innately gregarious and we tend to succeed or fail together.

I believe that the cohesive strength to allow our well-meaning actions have the desired effect, will come from the invisible force of social capital that exists beyond our structured healthcare system. Just like the physical forces allowing the stone to skim the surface of the water, social capital can make a contribution to bringing together the elements of prudent healthcare. My understanding of social capital and its potential to support change, gives me, a Chief Executive of a County Council with no healthcare credentials, a reason to take part in this important debate.

Organisations like mine – councils – are charged with caring for both the people who live in the local area and the place itself. We’re not only service providers, we also have powers and duties to act for, and represent the interests of, our administrative areas. These are responsibilities councils take very seriously indeed. I think this bridge – the duty of care for people and place – allows us to interpret what could easily be seen as a health challenge more accurately as a public service challenge. That’s something we, as public servants, have a moral imperative to act on together.

Prudent healthcare is about designing a great system to create public value – an open system that everyone can contribute to, if they have an offer and a desire. Prudent healthcare not only about those on the public service payroll, it’s about all of us and the contributions we can make if we are prepared to engage with this opportunity. Where we sit and what we are called becomes less important than what we can offer; prudent healthcare is a vocational public service calling.

If you accept this argument or are inclined to at least think about it a little more, I’ll expand on my stone skimming thinking.

Imagine, like skimming stones that people are the stone, their independence is the air, and our care services are the water.

Too often, in my experience, people present to the health service and disappear into it. They seem, to me, to be more brick shaped than missile shaped. They enter the water so deeply and quickly that many are lost. If they are not lost, it takes a hell of an effort to get them back out and back on a journey to good health – the river bank on the other side. The energy to retrieve people from the depths of care is in short supply.

This may be because, at least in part, we focus the system to deal with ‘the next one along’ rather than combine our forces to mobilise an escape into the air for those lost in the water. And because these people don’t escape the water and make it to the river bank, they often quickly consume resources. Our ways of working are well intentioned, but do sometimes fail to deliver the outcomes we desire.

Prudent healthcare is the antithesis of this. It’s about being quick, light and appropriate. It’s about recognising that success involves the person getting to the opposite riverbank and walking off into the distance. It serves little purpose if one part of the system is strong enough to keep someone alive, if other parts are not strong enough to help the person live their life.

It’s undeniably right that we are trying to remodel our healthcare system so we do more in the community and less in hospital. It’s not easy, but it is right. Without this approach our health services would probably just seize up or consume an unaffordable proportion of the nation’s wealth.

Most, but not all of healthcare is episodic; you need something, you get something, you go. Life, on the other hand is not episodic; it’s a continuum of experience. The person who became a patient when admitted an hour ago, was a person before they were a patient. They were also a person when they were a patient and they will remain a person when they are no longer a patient. Movement through these states is really important – it’s not desirable to lock anybody into the patient state for any longer than they need to be there.

Our goal should be to help all people to lead their good life. I’m not going to attempt to define what a good life looks like because that’s inherently a personal set of choices, but my guess is that for most of us it will involve some combination of :

  • having a sense of attachment to something or someone;
  • having a sense of belonging;
  • having a sense of purpose and self-worth;
  • having the ability and wherewithal to do the things that you want to do.

It’s about your place; it’s about the people in your life that you care for and it’s about having a contribution to make that is valued by you and by others.

We know from research that loneliness is one of the scariest things for most people. There is now evidence that loneliness can be a significant contributor to premature death. If you recognise the importance of these findings then it follows that for some people, being treated in a GP surgery rather than a big hospital, while being a step forward, just isn’t enough. Neither is it enough just to conduct the clinical intervention and discharge back home. Home is a warm, evocative word but not everyone will experience this. Home cannot just be the bricks and mortar of your residence If we are building a prudent healthcare system, home has to be a richer experience involving interaction with others in a space you feel you have a stake in.

A strong, community-based social infrastructure, which makes it really difficult for people to experience chronic loneliness but easy for them to relate to something or someone, allows patients to become people again. So when we talk about a shift in the delivery patterns of healthcare, from secondary to primary care, what we really need to be thinking about is how we find the most local piece of service delivery infrastructure, with the greatest contact with our communities and get the healthcare service out to where the people that need it are.

Local and county councils like mine need to think harder. Financial realities are pretty tough, they are going to get tougher and they are going to stay tough. Politicians across Wales are having hard conversations about closing services down, particularly “discretionary” services. I would suggest the really hard conversations are not about closing things down, but about how to keep them open. Things that are shut seldom come back – do we really understand what we are putting at risk in the medium term?

From a prudent healthcare perspective, community halls, libraries, theatre groups and adult learning classes are all really important. They offer neutral and safe places many people use as cornerstones in their strategies to stay active and engaged with others. They provide a reason for many people to get out beyond their front doors every day. It isn’t necessarily the book or the learning opportunity they crave; it’s the human contact and friendship.

Next steps

  • Prudent healthcare extends into prudent public services. It cannot be contained and designed in one part of a public service infrastructure without including the services supporting the places that people live. Prudent healthcare at a locality level needs to be owned and understood by a local service board rather as well as a health board or NHS trust. The former levers-in whole place support, the latter risks a unilateral agenda.
  • Outstanding episodic treatment of a patient and good reablement services will keep patients alive but may not be enough to give a person a good life. There needs to be additional reach beyond reablement for someone to help them connect or reconnect with their place. So what does reablement-plus look like?
  • Some of the services that are most directly threatened, at this time of austerity in wider public service, are crucially important to a system of prudent healthcare – they contribute to enriched lives. These services make an essential indirect contribution to preventing illness, slowing down demand for acute services and helping to enable or re-enable people maintain health and find a meaningful place in society who would otherwise be vulnerable. Very clear medium-term thinking needs to take place and be seen to take place before depleting communities and individuals of places and facilities, which enable relationships to develop.
  • Prudent Healthcare is about quality staff right at the front end who have the time to understand individual stories and who have the time to understand the strengths and assets people have, not just the deficits. Bringing high-quality staff to the front end of our systems of care with deep knowledge of local areas and groups who focus on the strengths rather than deficits of people is likely to make a significant contribution to reducing the flow of demand for more intensive specialist expensive services.
  • Combining healthcare with an orchestrated approach to community-based social capital creation and use will give us a better chance of delivering prudent healthcare successfully than we have alone. Local and county councils have a significant role to play in delivering prudent healthcare: if you care about a place as we do, you also have to care about the people who live there. And we do.

Image copyright: © GeeHock

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Watch Paul Matthews talk more about his article, click on the video.

Making it happen

  1. Building a sustainable and reliable system of prudent healthcare is not a technical challenge; it's an adaptive leadership challenge.
  2. Councils are charged with caring for both the people who live in the local area and the place itself. This duty of care for people and place allows us to interpret what may be seen solely as a health challenge, more accurately as a public service challenge.
  3. Most healthcare is episodic; life, on the other hand is not episodic – it’s a continuum of experience: public services have an essential role in enhancing quality of life.
  4. A strong, community-based social infrastructure, which makes it really difficult for people to experience chronic loneliness but easy for them to relate to something or someone, helps patients to become people again. Facilities such as community halls, libraries, theatre groups, adult learning classes are all really important.
  5. Healthcare and local government working together will strengthen the delivery of prudent healthcare.