Written Statement - Delivering Prudent Healthcare in Wales

In an age of austerity, 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.

Informed by the work of the Bevan Commission and others around the world, the NHS in Wales is embracing the principles of prudent healthcare as it seeks to respond to these challenges.  Prudent healthcare puts NHS Wales at the forefront of a growing international movement to secure greater value from healthcare systems for patients.  

Some aspects of prudent healthcare are already evident in the working practices of every health board and NHS trust in Wales. However, the NHS must now work together to enshrine the value-based principles encouraged by prudent healthcare across its entire system.  

Through placing greater value on patient outcomes rather than the volume of activity and procedures delivered, as we currently do, prudent healthcare aims to rebalance the NHS and create a patient-centred system. An NHS based on prudent healthcare principles ensures patients receive the most appropriate treatments to achieve mutually-agreed goals, which reflect the contribution individuals can make to their own health and wellbeing.

Prudent healthcare is built around a set of principles, which state that any service or person providing care should:
 

• Do no harm. The principle that interventions which do harm or provide no clinical benefit are eliminated;
• Carry out the minimum appropriate intervention. The principle that treatment should begin with the basic proven tests and interventions. The intensity of testing and treatment is consistent with the seriousness of the illness and the patient’s goals;
• Organise the workforce around the “only do, what only you can do” principle.  The principle that all people working for the NHS in Wales should operate at the top of their clinical competence. Nobody should be seen routinely by a consultant, for example, when their needs could be appropriately dealt with by an advanced nurse practitioner.   
• Promote equity. The principle that it is the individual’s clinical need which matters when it comes to deciding NHS treatment;
• Remodel the relationship between user and provider on the basis of co-production.  

All these principles are underlined by a commitment to rebalance the healthcare system by strengthening primary and community-based care to support the establishment of a more equal relationship between patient and professionals and changing the relationship between healthcare services and the public, characterised by a shared responsibility for securing improved health outcomes.  

In addition to prudent professionals, prudent healthcare requires prudent patients. The NHS is there to help us in our time of need but with that comes a responsibility to use its resources wisely. The NHS is free from charge but not free from obligation. This is the new bargain in this ongoing age of austerity – it is the bargain of co-production at an individual and population level where patients and the NHS each make a contribution to improve health and wellbeing

The first half of this year has seen a period of engagement and debate to gather the views of people in the NHS, including clinical teams in four treatment areas – orthopaedics, pain management, prescribing, and ear, nose, and throat services - on the impact prudent healthcare could have, if applied to the NHS in Wales. Debates have started with the public too.   

Prudent healthcare has been widely welcomed. The engagement exercise found examples of imprudent practice but it also found many examples where organising services around the principles could deliver increased value.  

The way in which heart failure teams, led by advanced nurse practitioners, are already exemplifying the only-do-what-only-you-can-do principle and Cardiff and Vale University Health Board’s optimising outcomes policy, which demonstrates the co-productive approach, are just two examples

It was clear from the engagement work that prudent healthcare will not be delivered by the actions of NHS Wales alone.  Continuing to secure best value from our investments in healthcare requires a move away from only treating diseases, to an approach which also treats the related conditions, complications, and circumstances. This will only be achieved with meaningful partnerships between all sectors and industry. The Tredegar Deep Place Study and the Caerphilly Cohort Study demonstrate the strong relationships between poverty, place and public health and, by implication, the importance of effective partnerships to delivering prudent healthcare. Both provide further evidence to support one of the key conclusions from the Commission on Public Service Governance and Delivery that public services must take action to prevent the preventable.

The Caerphilly study in particular shows that substantial reductions in serious health conditions are linked to five healthy lifestyle behaviours - not smoking; a low body mass index; regular exercise; a plant-based diet and alcohol consumption within guidelines. By maintaining four or five of these the study showed there was a 73% reduction in type 2 diabetes; a 67% reduction in vascular disease; an 18% reduction in cancer and a 64% reduction in dementia. If these health improvements were realised across the population, they would make a significant contribution to a sustainable NHS in Wales.  

Prudent healthcare and the work of people in Wales to secure better health outcomes for the population of Wales will be captured in an e-book to be published this autumn. Contributors have been challenged to set out what more can be done to advance the movement at pace.

Alongside this e-book, Welsh Government, NHS Wales and key partners will take forward action by organising their work around prudent healthcare principles. Key aspects will include:

• Build on the recent strengthening of the NHS Wales planning system. The planning requirements and outcomes framework are being refreshed to embody the prudent healthcare principles to ensure they are embedded within health boards and NHS trusts;
• Draw on the Choosing Wisely work, which has been developed in the US and Canada. The Choosing Wisely campaigns help clinicians and patients make smart and effective choices about tests, treatments and procedures;
• National guidelines for interventions not normally undertaken and National Institute for Health and Care Excellence “do not do” guidance are being refreshed, alongside the introduction of enhanced compliance at health board and NHS trust level.  This will be complemented by the planned care work programme, which is developing prudent surgical and medical pathways;
• The re-vamped Bevan Commission will improve the evidence base for, and advice around, prudent healthcare as well as championing the agenda;
• Continuing to work with the Department of Economy, Science and Transport on initiatives which will drive healthcare improvement and economic development. This will develop a more systematic approach to product and process innovation, including for example applied research to address clinical needs and challenges, co-ordinated adoption of new technology into practice and more engagement with industry.

Prudent healthcare will not suddenly happen overnight. We are at the start of a journey which will ensure that public value is at the heart of our healthcare system; there is always a culture of putting people first and there is an expectation of constant measurable improvement in the delivery of health and better care for all.