Like many organisations around the world, NHS Wales is looking at ways to tackle the twin challenges of rising costs and increasing demands while continuing to improve the quality of care.
To do this, health policy and practice is being shaped around the concept of “prudent healthcare”, which is a growing international movement to secure greater value from healthcare systems for patients. Simply put, we need to focus our efforts on working with patients to ensure the best outcome with the least intervention. It is estimated that resources are wasted on 20% of services that do not work or cause harm.
Prudent healthcare is built around a set of principles, which state that any service or person providing care should:
1. Do no harm. The principle is that interventions that cause harm or provide no clinical benefit are eliminated - something expounded by Florence Nightingale that still holds true today;
2. Carry out the minimum intervention. The principle is that treatment should begin with the basic proven tests and interventions. The intensity of testing and treatment is consistent with the seriousness of the illness and the patient’s goals;
3. Organise the workforce around the “only do what only you can do” principle. The principle is that all people working for the NHS in Wales should operate at the top of their clinical competence. For example, a consultant should see nobody routinely whose needs could be met by an advanced nurse practitioner;
4. Promote equity. The principle is that it is the individual’s clinical need that matters when it comes to deciding NHS treatment;
5. Remodel the relationship between service user and provider on the basis of co-production (working in partnership to achieve shared goals).
In real terms, this means taking a hard look at treatments, care pathways and service models and challenging preconceptions and practices. It means practitioners will need to change their relationships with patients and other service users to determine mutually agreed goals, and possibly giving up long-cherished ways of working or taking on new practices to ensure scarce resources are used wisely. This will mean more services and clinical decisions being led by nurses and midwives. Attention is increasing on developing advanced practitioner roles and upskilling staff to enable this to happen safely and effectively. Advanced practitioner development is blossoming in acute, community and primary care settings.
It is clear from early engagement work that the concept of prudent healthcare is warmly welcomed - but it will not be delivered by the actions of NHS Wales alone and change will not be quick. The first half of this year has seen a period of engagement and debate to gather the views of people in the NHS, including clinical teams in four treatment areas - orthopaedics, pain management, prescribing and ear, nose, and throat services - on the impact prudent healthcare could have if applied to the whole of NHS Wales. Debates have started with the public too, as their prudent health and lifestyle choices are as important as those of health providers.
Prudent healthcare and the work of people in Wales to secure better health outcomes will be captured in an e-book to be published this autumn. Contributors have been challenged to set out what more can be done to advance the movement at pace.
We all need to pause for thought about our personal and professional decisions, and the way we organise care - perhaps we should keep asking ourselves: “Is this the prudent thing to do?”
Jean White is chief nursing officer (Wales) and nurse director at NHS Wales