The new bargain at the centre of Welsh healthcare

Health Minister Mark Drakeford argues that we need to be more prudent about the way we provide healthcare

In successive reports, the Auditor General for Wales has chronicled the tough financial climate for public services and particularly the NHS, in Wales. In this age of ongoing austerity in public services, it could be argued that the challenges today in Wales are as formidable as they have ever been since the emergence of the welfare state.

This week on Click on Wales


This week on Click on Wales we’ll be debating prudent healthcare in Wales.


Today: Health Minister Mark Drakeford argues that we need to be more prudent about the way we provide healthcare.


Tomorrow: Dr Charlotte Jones will explain to us how investment in GPs is critical to delivering prudent healthcare.


Thursday: Kate Macnamara will outline how prudent healthcare could be utilised in treating mental health conditions.


Friday: Dr Ruth Hussey OBE will describe some of the next steps for the Welsh NHS in delivering prudent healthcare in Wales.

However, that doesn’t mean that we should give up on a universal and equitable NHS, free at the point of delivery as Bevan envisaged it and file those challenges in the too difficult box.

But it does mean that we need to do something differently and change the way we provide services – we need to provide more care in the community; we need to lessen our dependence on hospitals and we need to make better use of the finite resources we already have.

I’ve spent most of this year talking about prudent healthcare and how this approach should underpin everything we do in the NHS in Wales. I cannot pretend to claim any credit for this – the principles of prudent healthcare are in use in a number of countries around the world. And they are now being adopted in Wales.

Prudent healthcare builds on work completed by the Bevan Commission in the latter part of 2013 and is concerned with a continuous improvement approach with a focus on the patient’s perspective. It is underpinned by the principles that any service, and any individual providing that service, should:
  • Do no harm;

  • Carry out the minimum effective intervention. Treatment should begin with the basic proven tests and interventions, calibrating intensity of testing and treatment with the seriousness of the illness and the patient’s own goals;

  • Promote equity of treatment across NHS Wales. It is the individual’s clinical need that matters when it comes to deciding treatment by the NHS.

The NHS is like an escalator on which we traditionally push people quickly up the levels of intervention – somehow the higher up you go; the more senior doctor you see; the more tests, surgery or medicines you receive, the more prestigious it becomes and the more you feel you’ve received something good from the health service.

Prudent healthcare is about reversing that escalator. It is about saying the more we can do at a primary care level; the more we can do at a population level and the more we can do at the citizen level, the better service we can provide to our patients.

The NHS is there to help us in our time of need, however that does not mean it is a licence for us to embrace health-harming behaviours with impunity in the knowledge the NHS will always pick up the bill. It is free at the point of need but not free from responsibility.

This is the new bargain – the bargain of co-production at an individual and population level.

At an individual level, the health professional and patient will work together instead of the patient putting their problem in the hand of the GP or consultant. The conversation we have with patients cannot always open with the question: “What can I do for you?” as though the encounter is one in which the health service takes the whole of the responsibility for that encounter onto its shoulders.

The first question we should ask, I believe, is that co-productive principle: “What can we do together to address the difficulties and the problems you’re experiencing?” and if we do that, the principle of minimum intervention becomes part of the conversation which relies on reinforcing people’s strengths and is always focused on maximising their own abilities.

It is a very natural human reaction when we see someone who is in distress or in difficulty to wrap our arms around them and say: “There, there, don’t you worry, we’ll do this for you”, when we know that it can lead to stripping that person of their abilities, to removing their capacities from them and in the short-term we end up doing long-term harm.

But we also know that when we are able to create the right conditions people respond. A recent paper by Al Mulley, a visiting fellow at the King’s Fund, shows that when patients are well informed, they make different choices about treatment and that what patients want often differs from what doctors think they need.

What does prudent healthcare mean on a population level?

Thirty years of public health education has succeeded in changing people’s attitudes. People understand the basic messages that smoking; drinking to excess and eating too many sugary and fatty foods aren’t good for your health. It has even succeeded in changing people’s intentions – people know what they should do and have intentions to do things differently.

What it hasn’t succeeded in doing is changing actions. It has not succeeded in changing behaviours. That’s a major conclusion of the Caerphilly Cohort study.

In a prudent healthcare world we have to change the way we think about public health and population-based health too. We have to move from education to motivation. We have to move our attention to those things we can do to change the environment people live their lives in and enable them to turn those good intentions into actions.

On a population level, the new bargain means that everyone accepts responsibility for their own health and a responsibility for managing demand on the NHS while the Welsh Government helps create an environment where it is easier to make healthier decisions while also safeguarding an NHS which remains firm to Bevan’s founding principles of universality, equity and free at the point of delivery.

I believe that the principles of prudent healthcare and co-production will help us to achieve the twin aims of better outcomes for patients in the here and now and the prospect of sustaining our most valued and loved public service for the future.

You can watch Mark Drakeford discussing Prudent Healthcare with IWA Director Lee Waters

Professor Mark Drakeford AM is the Minister for Health and Social Services.

6 thoughts on “The new bargain at the centre of Welsh healthcare

  1. I’m intrigued by this. The Welsh Government supported Betsi Cadwaladr’s centralisation strategy of two years ago, which got rid of many community beds. These are an integral part of any GP-led care strategy that focusses on community care rather than acute hospital care. Will Drakeford and his predecessor now accept that the BCUHB strategy was wrong?

  2. Looks like the right direction, but can we make the progress we want to fully develop a coproductive approach with this language – ‘ health professional and patient’ – is this an intrinsic inequality? Is it about changing society and working together – I still feel people can be too often stifled by an NHS culture, with heirarchy and control reducing the ability of people on the ground to work together and make a difference. So is the ‘we’ really ‘we’ together, as society, or is it ‘us’ the NHS?

  3. This is a great new way of thinking. People have to take responsibility for their lives at a number of levels particularly health. Mark Drakeford touched on the reversal of the system whereby you get more intervention at the grassroots level rather than being pushed up the chain to an ‘expert’ in your particular condition. I also agree with this. I wonder though will this lead to a number of new treatments being available like recommendations on food supplements and routine hormone testing as we age which I feel could prevent a lot of people slipping into more serious health conditions. I would also like to see hospital systems reorganised. I often wonder why people have to keep returning for appointments which take up a lot of time and resources in the NHS when a number of tests can be run at the same time. I am sure there can be savings made with a leaner, better co-ordinated appointment system. Lastly, can we ensure that nurses have the materials they need to treat patients. I understand that a lot of their time is taken up bartering with other wards for items that can be in their store cupboard. For ordinary people like us, we see only the huge salaries that managers earn and then the lack of a bandage at hospital level which reflects badly on everyone involved. I know that Mark Drakeford is the man for the job, he has a massive task ahead and he will get all my support.

  4. It sounds reasonable – people should take responsibility for their health, and so on – but if this is the crux of ‘prudent healthcare’ then the Welsh government will face quite a challenge upholding its side of the ‘bargain’. We don’t live in a society that fosters well-being and good health. There are plenty of healthy living messages, but our society is riddled with inequalities, and cultures that dispose us to malcontent, and poorer health. Whitewashing the interiors of our homes won’t make us healthier. Removing our access to a full GP service and hospital out-patient consultancy, and in-patient treatment, will disenfranchise us.

    Spend your efforts on improving living conditions. Make your community care a broader concept, so that communities are enabled to be good communities for the well and the unwell, take decisions on food access, quality, and freshness, in the home and in businesses. Discourage fast food lifestyles by enabling gardening, allotments, and market gardening, and local markets. Enable lots of local businesses…give them space in town centres, give them priority in out-of-town shopping parks. Insist that big business shares land with small local outlets.

    Draw a line around television advertising; announce that what follows a break in the programming is advertising. This announcing is always done with party political broadcasts.

  5. A very good theoretical position for Professor Drakeford to take,however economic reality is going to force welsh politicians to take some very unpopular decisions and some ‘sacred cows’ will go the slaughter house. The world of 1940’s when working class people in UK were unified in demanding a better and more equitable future is well and truly gone,and paradoxically its the welfare state that has played a part in creating the current mess. The gaps in wealth between the upper middle classes in public sector Wales,and ordinary people is now very wide and with tax ‘planning’ those sort of people are buying their way out of the NHS which is deteriorating before our very eyes. The demands on welsh NHS are bound to increase and outstrip public funds in future,so with the current open door policies there are going to be major a)reduction in hospital services,b)rationing to a great extent than at present or the WG will eventually run out of money.There are only only two ways to provide a service that is not funded properly and they are a)restriction by pricing for all services,b)restriction by manipulation of waiting lists.They are both to an extent already working in that well off people are increasingly paying to see Consultants within NHS Hospitals and, even having operations carried out but NHS staff within NHS Hospital’s. Its called rank hypocrisy by welsh politicians to ignore this practice,whilst poor people are FORCED to remain on seemingly ever longer waiting lists.

  6. Can someone please provide a clear one-sentence definition of ‘prudent healthcare,’ and what exactly distinguishes it from current and traditional practice in the NHS?

    Having read all the articles in this series, it seems to be no more than a combination of (a) the usual public sector jargon that sounds dynamic but can mean absolutely anything and nothing, (b) a few common sense ideas which one would have assumed had always been standard practice, and (c) ‘when in doubt, blame the patient.’

    One cannot but suspect that at least some of the people now advocating ‘prudent healthcare’ would be calling it ‘Tory cuts’ if the idea came from the Secretary of State in London.

    Of course the NHS should be prudent in allocating its limited resources. One would have hoped – perhaps naively – that has always been the case. The best idea would be to move towards a more client-centred approach. Yet this is where the Assembly has fallen down. To repeat a question from another thread no one has answered yet: what was the total cost of the unnecessary reorganisation and consequent necessary re-reorganisation of the NHS in Wales?

    Also, how many of those of us who can afford to pay prescription charges would rather do so than run the risk of being left on a trolley in a hospital corridor when in need of serious medical attention?

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