Wales in prudent health


Reflections on the past and future of the Welsh NHS.

The Welsh NHS suffers very real stresses and strains as a result of cuts imposed by the UK government but is holding up well. This is despite the sustained campaign of vilification of the Welsh health service, led by the prime minister and despite rising demand, the result of serving a population which, in the conclusion of a recent OECD report, is “older, sicker and poorer” than any of the other UK nations.

The OECD was unequivocal in its assessment that every part of the UK produces leading services in some areas; all have things to learn from services provided elsewhere. Wales provides an NHS every bit as good as any other UK nation. Central to our approach is the idea of prudent healthcare – a set of four principles developed in Wales but which draw on a wider international movement.

Prudent healthcare begins from the premise that up to a quarter of activity in any modern, advanced healthcare system is of low or no clinical value. Much of that rests in the well-tested phenomenon of over-treatment – the ordering of tests of no predictive value; the reordering of tests already carried out; the prescription of medicines which do no good and, as a consequence, expose people to the risk of harm. Prudent healthcare shines a light on these practices and focuses on their reduction and eradication.

The second principle is de-escalation. The healthcare system operates according to a particular internal dynamic in which people are always being passed up the hierarchy of professional importance and therapeutic intensity. Once they are in the healthcare system, patients quickly find themselves on an escalator towards ever-greater intervention. The de-escalation principle offers a necessary corrective to this way of working, emphasising the simplest and least intrusive forms of treatment.

A third core principle of a prudent healthcare system focuses on the workforce. Far too often the activities carried out by the most highly-skilled, and scarcest, members of the NHS workforce simply do not require that level of expertise. A prudent healthcare system insists that no NHS worker should routinely spend their time doing things that do not require the level of skill and expertise they possess.

Finally, for all its astonishing strengths, in the almost 70 years since its inception the NHS has rested on a relationship in which patients were the passive objects of the benign attention of healthcare professionals. The fourth prudent healthcare principle recasts that relationship and strikes a new bargain between user and provider. Instead of entering the consulting room and being asked, “what can I do you for today?”, the new bargain asks the question “what can we do together today?”

These ideas lie at the heart of the new co-productive prudent healthcare system we are creating in Wales.

Mark Drakeford AM, was Welsh Minister for Health and Social Services, March 2013-May 2016.