Since its conception more than 65 years ago, the health service has continued to work under broadly the same models and principles in its relationship with patients. Despite dramatic changes and developments in society, which has seen demand for healthcare reach record levels, it is still the case that the NHS – with its partners – absorbs almost all responsibility for keeping people well.
Through developments in technology and a broadening of the services and treatments on offer, public expectations about what the health service can deliver have, like demand, reached the highest levels – sometimes to the point of being unrealistic.
We currently have a health service with very few limits when it comes to determining treatment for an individual’s condition; no matter the cause. This way of working has undoubtedly been instrumental in the huge strides we have made in improving survival rates for a range of chronic and acute conditions. But there has been little debate about whether this approach, which sees the NHS taking significant responsibility for the management of health and illness, is always right for the individual or for society as a whole.
The NHS has a long history of clinical freedom to practice where the decision about who receives what type of care has rested almost exclusively with the treating clinician. This has resulted in significant variation in interventions – which drug is prescribed; who receives what type of surgery; what implant is used and even whether an individual receives treatment at all. This can create even greater variation in the cost of treatment and yet there is often no evidence to support an argument that increased cost improves quality or patient outcomes.
At one end of the spectrum prudent healthcare has been criticised as a mechanism for rationing access to healthcare and reducing clinical freedom to decide what is best for individual patients. At the other end of the spectrum it is positively seen as a way of systematically driving evidence-based clinical practice and reducing variation.
As health service professionals and leaders in Wales, we remain wholly committed to the founding principles of the NHS. We firmly believe in equity and that cost alone should never be a key determinant in decisions about patient care.
However, we also have a responsibility to live within the resources available to the NHS, which means spending money wisely and eliminating waste; ensuring everything we do is high quality and interventions are both clinically and cost effective.
We strongly believe prudent healthcare provides boards, clinicians, NHS staff and the public with a powerful set of principles to help us make decisions. The real leadership challenge is how we embed these principles in our governance and decision-making at all levels in the NHS and at the same time create a new relationship with people in Wales so they play an active part in their own personal prudent healthcare.
The challenges faced by NHS Wales are well known. We are experiencing record levels of demand on services which, due to an ageing population and soaring rates of chronic diseases, are only going to increase.
Service change will help us to deal with some of the long-standing issues but, at a time of austerity, it is important to go beyond this. We must fundamentally examine what we do, how we do it and the relationships between our health service and the public.
In times of austerity, the health service has traditionally looked to continue doing everything it currently does but at a lower cost. Reducing management costs; rationalising estate; more effective procurement and reviewing skill mix have all contributed to this approach. However, these opportunities are becoming exhausted, driving boards and clinicians to look more fundamentally at the shape of health services.
All NHS staff play an important role; chief executives and boards must lead the way in delivering this new approach. It involves changing the culture of the NHS. The responsibility for spending precious NHS resources must be something everyone, including patients, takes seriously.
Every decision NHS leaders make should be grounded in the principles of prudent healthcare together with every decision clinicians make about patient care.
However, this is only part of the story – the full potential of prudent healthcare will only be realised when the NHS supports the people of Wales to adopt a different set of responsibilities and behaviours in managing their own health and the way in which they access health services.
If we are to deliver the health service we want and need in the future we must find new ways of planning, delivering and prioritising services. Prudent healthcare must be embedded in the NHS in such a way that they are meaningful for patients, staff and health boards alike.
Arguably, what the system needs and what individuals need are the same. However, the language is important in this context so that engagement of everyone in the pursuit of better more prudent healthcare is meaningful and authentic.
It is vital we get into the mindset that the NHS is free from charge but not free from obligation. Prudent healthcare cannot work without prudent patients and the NHS must help people with this shift in thinking.
This means leading organisations to redress the balance by increasing the accountability of staff for their own actions and greater involvement of patients in their own healthcare. It is also about striking a new bargain where people have to take responsibility for their own actions and the subsequent impacts these have on their health and wellbeing.
The NHS can offer support to people to make changes to their lifestyles. In many cases, these kinds of initiatives can result in savings to the NHS because interventions are made earlier and services are more effective and efficient. It is this combined responsibility, which will lead to reduced costs and improved outcomes.
We know a shift in cultural change to make sure that every aspect of every organisation is working in this way will not – and cannot – happen overnight. But at the same time, we cannot afford to waste more time.
A change in culture has to involve the board and chief executives who must lead by example. This means improving patient flow, waiting times and follow-up processes. We will also have to break the cycle of allegiances to buildings and traditions. Transport and technology open the door to new systems of care. Access to definitive treatment will need to be the currency of success not how long it takes to travel to the hospital.
On an individual level, it is about using the health service wisely and not abusing what it can offer patients. It is about taking responsibility for the consequences of our lifestyle choices. It is also about knowing when to use the health service and where to go to seek medical treatment or advice. Self-help and prevention are key to driving this forward.