The answer is ‘prudence’. Let me explain…
Early in 2014 the NHS in Wales took a new direction when its then Minister, Professor Mark Drakeford AM, announced a new vision of ‘prudent healthcare’. The vision can be summarised into four principles:
- Achieve health and well-being with the public, patients and professionals as equal partners through co-production.
- Care for those with the greatest health need first, making the most effective use of all skills and resources.
- Do only what is needed, no more, no less; and do no harm.
- Reducing ‘inappropriate variation’ so evidence is used more consistently and transparently.
Who wouldn’t want to work in or be cared for by such an NHS?
The acid test was: can you transform a whole health care system to deliver it? Research conducted by the Health Foundation in Path to sustainability showed that, if it has the desired effect, prudent health care would be broadly cost-neutral. Our own research (supported by the Health Foundation) looks at what has happened over the subsequent three-and-a-half years from the perspective of health board members, health care professionals, managers and policy makers.
What has the new vision achieved?
In general, principle 2, caring for those with greatest need, and principle 4, reducing inappropriate variation have seen the most progress. Caring for those with the greatest health need first and making the most effective use of all skills and resources has been helped by emerging new roles, and has also benefitted from a link to cash-releasing savings. Reducing inappropriate variation has seen most progress, largely because this has been a long-established priority for the NHS so has professional acceptance and is gradually being fuelled by better evidence on outcomes and efficiency.
On the other hand, principles 1 and 3, co-production and doing only what is needed, have been much harder. Given that the latter probably have the most potential to revolutionise our health care system, this remains a challenge.
The need for a ‘prudent workforce’ has emerged as one of the key enablers, and some progress has been made, especially in the remodelling of the workforce. This is often greatest where staff see the benefit of change, where patients are involved, and where changes have already been explored for some time. Prudent Healthcare provides what many regard as a useful lens through which to examine the workforce, and the slogan ‘only do what only you can do’, and the desire to work ‘at the top of one’s licence’ has gained traction.
In some ways, prudent health care is more than a conventional policy: it was designed as a ‘social movement’ and has become a rallying call for change, a framework of analysis and a ’driver of change’. However, it’s also less than a conventional policy, because it has no clear destination or milestones, and its performance management would be unrecognisable to those used to waiting times targets and financial management.
So far though, the response of the Welsh NHS has been welcoming. There are many examples of the policy being used in ways which managers and practitioners feel is consistent with the principles, but it has also had greater practical value for them as a tool for change. It has been used to address relatively simple questions, such as ‘what is the most prudent configuration of the workforce in a particular service?’ as well as more complex questions such as ‘which approach to service delivery would add most value?’
What happens next?
Much to the delight of its many enthusiasts, prudence remains a cornerstone of Welsh health policy. The Welsh Government is reportedly considering a more detailed plan to tie together the early successes and address any constraints. Interest and enthusiasm from professionals for work to date adopting the principles across NHS Wales will help with this – as would a continuation of light touch accountability for progress.
However, several limiting factors will also need to be contended with: services have too many other priorities; current service patterns and behaviours are rigid and entrenched; and there is a lack of resources to deliver change.
Wales should be able to make a go of this though, if any system can. It’s both big and small enough. It has a simple and unified organisational structure, political buy-in, and like many small nations, it needs a triumph to call its own.
But the crucial question is, how much time have we got to make the change? Imprudent health care harms people, wastes money, and fails to provide the buoyancy tank that the NHS needs now to keep its head above the rising tide of demand.
Professor Marcus Longley is Professor of Applied Health Policy at the University of South Wales and Director of the Welsh Institute for Health and Social Care.