Prudent healthcare and NHS leadership

Allison Williams says prudent healthcare cannot work without prudent patients.

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.

Allison Williams is chief executive of Cwm Taf University Health Board. This is an edited version of an article on prudent healthcare and NHS leadership by Allison Williams, written on behalf of the chief executives of NHS Wales health boards and NHS trusts and published on the Making Prudent Healthcare Happen online resource

2 thoughts on “Prudent healthcare and NHS leadership

  1. As a volunteer driver for the RVS IN Ceredigion I am profoundly disappointed that people in Cardiff and Hywel Dda Health Board cannot grasp the impossibilty of patients getting to Glangwilli in Carmarthen if they have no transport of their own.
    You cannot expect frail and ill people to travel by bus as the time taken to get to their appointment, the unknown time they will have to spend in the hostpital and the journey home is exhausting. It costs a passenger with RVS .45p per mile to travel which gives a cost of around £40 from Aberystwyth. Most of these jouneys are for 10minute appointments, blood tests etc. which can be done closer to home and the results emailed to Glangwilli.

  2. In line with two of the other later articles posted, you can’t have a modern prudent healthcare system, without the patient being at the centre. The whole world is focussed on the drive towards patient centric approaches and the desire to move towards the aspirational goal of personalised medicine.

    As a non-exoert I would imagine that the focus should be (and probably is focussed) on developing the core of our healthcare system around thorough understanding of our patient population, which comes from feeders like informatics and diagnostics. The focus should be on improving our predictive capabilities, based on knowledge and understanding of patients, populations and all the respective population sub-sets. Trying to control the patient to conform to a designed healthcare system is an almost impossible task – the system has to have the flexibility to conform to the diversity that we have within the population. The healthcare system needs to have the best of intelligence and be intelligent, but most of all it has to be more flexible in the way it interacts with the end-user.

    The communication and means of interaction with the system have to be patient centric – again technology is already playing a role there in terms of remote monitoring and patients taking more control of their treatments and diagnostics etc, but remote interaction with healthcare professionals is certainly not the norm and having Skype calls with your GP or consultant would be unusual to say the least. I imagine that patients in remote locations, having to travel long distances for brief consultations would certainly prefer that, but obviously in most cases the verbal communication is a small part of the consultation process. Why can’t telecons be set-up in general practices – with professionals on hand and experts dialling in? We still need to keep all these types of options on the table, because if you start trying something which has flaws, then you can usually develop solutions and alternative ways of working, but you have to experiment a bit – how else will you get the evidence to do things differently.

    As for evidence based – fine, but you can’t always wait for a body of evidence to develop, before planning to make changes to things. You have to envision changes based on ideas in part which may sometimes be weak in terms of evidence and then identify ways to pilot ideas and experiment a bit to get the evidence, before firming things up. If every scientist waited for evidence before experimenting, then nothing new would ever be discovered.

    For new emerging treatments, then there may be a need for the system to go full circle and revert to consider things that might be reminiscent of historic practices – the modern equivalent of the pharmacist may have to adopt more advanced tools to develop and produce new formulations for biologics and stem cell therapies. Consultants and experts may need to more flexible and travel more, both to enhance their international networks and also to be closer to the prevailing patient base. It’s hard to predict, so perhaps we need significant flexibility within the system so that it is very capable of evolving and adapting to meet changing needs and new treatment options or styles of intervention?. Perhaps, overconcentration in fewer centres of excellence will ultimately backfire and result in silos that lose the ability to respond effectively to patient needs – leading to inefficiencies through an inability to effectively engage, adapt or evolve?

    I’m no expert and happy to be shot down in flames, but I beleive that this is a public consultation and I’m sure there are plenty of good ideas out there within our population..

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