Prudent health care - the way forward for NHS Wales?

The National Health Service is 66 years old this year and there is much discussion around its future. We realise we need to design a better health service for people, and we need to find new ways to meet the challenges of today that simply did not exist in 1948.

Historically, it was enough for managers to provide the space and resources for health care: clinicians got on with the job. But there were two problems. The money ran out. Also, what was delivered didn’t always make sense. Unfortunately, the answer to the first problem (cut the spending) invariably left services making even less sense. These are global problems and Wales is not the first health system to ask if attention to quality and value would be a better starting point.

Quality improvement (QI) has long focussed on defects, wastage and variation in the system. However, few health systems have ever been able to give QI the traction or longevity to deliver real change. That is why the achievements of Jönköping, Nuka, Virginia Mason and Intermountain are so remarkable. They have aligned policy, method and delivery at a system level and their results are outstanding. Cynics may say that they are all small organisations with special circumstances but that misses the point about the learning which they have provided.

In Wales we have had some successes with QI but we have not yet delivered systemic change. Now, in an important development, the Health Minister, Mark Drakeford has given the strongest possible commitment to policy based on value. If health care is delivered prudently, won’t this be a better service and avoid unnecessary cost? As he describes it, prudent health care aims to deliver three objectives:

• Minimising avoidable harm.
• Delivering the best-evidenced treatment and services to the most appropriate level, based on individual need.
• Promoting ‘co-production’ of health and shared responsibility for delivering health care.

The Health Minister has asked for these principles to be tested by NHS Wales organisations. Over the course of four workshops, staff and service users considered the following questions:

• What happens now that does harm or little good?
• What happens now in an expensive way, which could be done in a more cost effective way?
• What would the pathway look like if organised around the minimum intervention principle?

Looking at the areas of orthopaedic surgery, chronic pain management, prescribing and hearing loss, the answer in the workshops was the same. Yes: the principles make sense and people could cite real examples of what could change.

These principles are examined further in a new report, Achieving prudent healthcare in NHS Wales, published by Public Health Wales with 1000 Lives Improvement.

Often, the key to unlocking prudent health care is in the people using the services. Taking their needs and wants into account changes the delivery mechanism in health care. Given detailed information and genuine choice, many people would prefer not to have expensive surgery or procedures that will deliver limited value. When the dangers of long-term medicines use are explained, people prefer to try to change their lifestyle with coaching.

This does require a change in the way those of us working in the health service present options and deliver services. Referrals to a specialist often put people on a ‘conveyor belt’ that ends with surgery or other interventions, because that is what we have to offer. We need to change the habit of matching people with the services we have, and start matching the services to the people we are trying to help.

The conclusion of the workshops is that NHS Wales can achieve a sustainable future as a high quality health service if we apply prudent health care principles to the work we do. This will result in better patient experience and outcomes while meeting the austerity challenge.

Is this the setting in which quality improvement can flourish and deliver sustainable change for a whole country?

For further information, read Achieving prudent healthcare in NHS Wales or visit the prudent health care section of the 1000 Lives Improvement website.

Dr Alan Willson is the director of 1000 Lives Improvement, www.twitter.com/dralanwillson.