The new bargain at the centre of Welsh healthcare

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.

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