People, Places and Health – Change the Welsh Way: Reflections for Health Policy Futures by John Wyn Owen CB

Introduction by Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

This week’s blog, the sixth in our ‘20 blogs for 20 years’ series, is by John Wyn Owen CB, the Director of the NHS in Wales for the ten years between 1984 and 1994, and now a member of the Bevan Commission.  It was under John’s leadership that NHS Wales coined the term ‘health gain’ and led the UK as an integrated planning system.  In this blog, he reflects on what this experience now has to say in the era of ‘Prudent Healthcare’, the subject of Mansel Aylward’s blog last week.


People, Places and Health – Change the Welsh Way: Reflections for Health Policy Futures  

WIHSC’s establishment coincided with the reforms of the NHS in the 1990’s which fundamentally changed its management and organisation.  The hall marks of Change the Welsh Way[i] were strategic planning and operational management that integrated public health, quality of health care, people centred services and resource effective using protocols of investment for health gain to enable the people of Wales to enjoy a level of health amongst the best in Europe. Overall it was time of great innovation in service delivery and influenced developments internationally informing the WHO Ljubljana Charter on Reforming Health Care[ii].

“The future has no place to come from but the past, hence the past has predictive value.”[iii]

Globally governments are facing a number of major challenges which go beyond the health sector; aging populations, economic uncertainty, migration and the impact of climate on the fundamentals for health – clean air, safe and sufficient drinking water, a secure food supply and shelter. Business as usual is no longer an option and transformational change is essential.

So what are the lessons from Change the Welsh Way mid 80’s to mid 90s for today’s prudent health agenda?

  1. A clear Strategic Intent and Direction integrating health services and the public health agenda with benchmarks to assess progress – a clear and understandable bottom line –health gain: years to life and quality life years.
  2. Health services research and involvement of the academic community in policy advice in Wales as a priority after all bad policy hurts people.
  3. Smart governance businesses like – health gain the bottom line- but not a business.
  4. Futures focus – ensuring the future is better than the past – and thinking whole systems for health and wellbeing and health and social care as learning systems.

“There is little research on managing systems and relatively little taught about it in our universities.”[iv]

‘Smart’ governance requires high-level systems thinking and theories of complexity science are increasingly relevant to public policy and “rethinking a whole new systems approach to public service.”[v] Now is the time to adopt the Cynefin Framework[vi] – a place where we instinctively belong.

The Cynefin Framework explores the relationship between people, experience, and context and draws on research into complex adaptive systems theory, cognitive science, anthropology, and narrative patterns to describe problems, situations, and systems and has been used by governments internationally for analysis, policy making, organizational strategy, and cultural change.

The time has come to test the practical application of complexity science “Cynefin” to health governance of and for health in Wales and to “demonstrate the importance of knowledge as the foundation for sound policy making for the public good, for engaged educated citizens and wise responsive government”.[vii]

John Wyn Owen CB, Director NHS Cymru Wales 1984- 1994, Member Bevan Commission

[i] JW Owen. Change the Welsh Way: health and the NHS 1984-1994. Health and Society in Twentieth Century Wales. University of Wales Press, Cardiff 2006.

[ii] Ljubljana charter on reforming health care in Europe .WHO Europe 19 June 1996.

[iii] Neustadt and May. Thinking in time: the use of history for decision makers 1986. Free Press New York 1986.

[iv] Nigel Crisp 24 Hours to Save the NHS Oxford University Press 2011.

[v] J Wallace, M Matthias, J Brotchie. Weathering the Storm? A look at small public services in a time of austerity. Wales Public Service and Carnegie Trust UK 2013.

[vi] D Snowden , M Boone. A Leaders Framework for Decision Making. Harvard Business Review 69-76 2007.

[vii] 110th US Annual Congressional Debate 2007-2008. Washington DC.


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Wales Picks Up the Pace by Professor Sir Mansel Aylward, Chair of Public Health Wales and the Bevan Commission

Introduction by Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

This week’s blog, the fifth in our ‘20 blogs for 20 years’ series is written by Professor Sir Mansel Aylward, Chair of Public Health Wales and the Bevan Commission.  After a distinguished career in Whitehall, Mansel is now one of the architects of a new public health policy in Wales.  In this blog he points to a potential turning point in Wales’ public health – the golden opportunity offer by Prudent Healthcare and public sector cooperation to turn the corner from unsustainable to sustainable healthcare, and from widening to narrowing health inequality.  Wales could achieve so much in these areas – will we rise to the challenge?

Wales Picks Up the Pace

Advancing Prudent Healthcare and the Prevention Agenda are paramount priorities.  The prudent approach has captured the imagination as evidenced at the recent Summit Conference in Cardiff.  Nonetheless we are now faced with the almost unassailable challenge of transforming the rhetoric, aspiration and enthusiasm into reality.  We must learn from the sad history of failure of many promising bright ideas and new concepts which in the past could well have secured better provision of health and social care in Wales.  The reasons are legion but complacency, pedestrianism, inability to convert strategy into action and a general lack of confidence in our ability to achieve the desired goals must surely rank high among these frustrating impediments.  Unless we can rid ourselves of these weaknesses, Prudent Healthcare will be yet another most promising enterprise that ends up in the bucket of forlorn hopes.

Widespread recognition of the cardinal importance of prevention in tackling health inequities and social inequalities which underpin them contrasts yet again with the lack of meaningful progress in tackling them.  The recent initiative led by Public Health Wales and the Welsh Local Government Association is grasping the nettle. Though in its early days, it demonstrates already that there exists in Wales an innate commitment to achieve a better future.  Why am I optimistic that this initiative soundly promises a step change in the health of the people in Wales? It is driven by strong distributed leadership by all participants in this endeavour.  These range across Welsh government departments, third sector and community organisations, academia and public services in a concerted effort to tackle an agreed emphasis on the early years of life; sharing assets fully at local level; aligns with the goals in the Wellbeing of Future Generations Act and exploits the expertise and resources of all participants in a commitment to unrelenting concerted action.  There is brimming confidence that together we can achieve a significant beneficial impact on the health and wellbeing of the people in Wales; pace rather than pedestrianism is its hallmark.

In its 20th Anniversary year WIHSC can look back on the success it has achieved in bringing evidence, objectivity and rigour to the aid of all of us who are attempting to improve health and social care.  It bridges the divide between academia, policy and practice.  This is the time when we need more than ever before that expertise, knowledge and rigour.

Professor Sir Mansel Aylward, Chair of Public Health Wales and the Bevan Commission


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It’s not my fault by Dr John Bullivant

Introduction by Marcus Longley, Director of WHSC and Professor of Applied Health Policy

This week’s blog in our ’20 blogs for 20 years’ series is by Dr John Bullivant, one of the UK’s leading experts on governance in public services.  Drawing on both his professional and personal experience, he reminds us of some uncomfortable home truths about how the NHS is – and should be – run, and asks why problems take so long to be resolved.  We have worked with John since our foundation in 1995 (and some of us before that!), and he is a Senior Visiting Fellow on governance at the Institute.


It’s not my fault

Why do inquiries and reviews take so long? The Mid-Staffs problems were long standing, emerging in the press in 2009, but the final reports and flurry of activity across the country to avoid another Mid-Staffs took until 2013.

Dr Kirkup’s 2015 report investigating the Furness General Hospital maternity ward of University Hospitals of Morecambe Bay NHS Foundation Trust covered problems which started in 2004. By early 2009, there was ‘clearly knowledge of the dysfunctional nature of the FGH maternity unit at Trust level, but the response was flawed’, and the new Chief Executive is still saying sorry.

We have only recently seen the full report on Vale of Leven, where Clostridium difficile Infection problems started in 2007; an inquiry was launched in 2009 and only reported in November 2014.

The problems in Betsi Cadwaladr from the previous regime are still emerging with the Health Board being put in special measures for events that occurred in 2013 before the present top team were in post.

None of this is to say that the treatment of patients and the oversight by senior clinicians, management and boards was not appallingly lax, and similarly, there are some serious problems in the UK NHS, but shooting the new sheriff who is trying to clean up the town is not the answer.

Some simple points:

  1. Any enquiry still running two years after the events took place has lost the plot. The organisation will have fixed itself or will be in serious terminal decline if still awaiting the diagnosis and treatment.
  2. The regulators cannot possibly give assurance all is well, nor should we expect that to be their job. They should be able to assess if the board has a grip on what is going on.
  3. Boards should know when to undertake their own deep dives: they should be clear about when a non-executive director should intervene, what assurance they are looking for and equally importantly how to get out again, not staying micro-managing the business.
  4. Boards have to stop wallowing in the past and concentrate on the future; on setting ambitious goals and then focusing on the risks of not achieving their goals without fear of being criticised when they achieve less.

Since Sir Liam Donaldson told us in 2009 it was alright to say sorry, our clinicians, managers and chairmen have become more humble in accepting they have let patients down. What, often, they actually mean is that their predecessors got it wrong but they now own the problem of promptly putting things right. I know from my own personal loss that our main concern was that someone else did not have to go through the torturous process of trying to find out what went wrong, and also that we had confidence that in the future no one else would suffer the same problem.Back in 1995 when the Welsh Institute for Health and Social Care (WIHSC) was born, we were about to establish the eight new health authorities and I recall writing with Mike Ponton and David Pritchard about the critical success factors for the new authorities. One of the key ones was ‘easy to do business with’. Twenty years on, have we learnt how to do that?

Dr John Bullivant is a Senior Visiting Fellow on governance at WIHSC and Chairman of GGI, and author of the Good Governance Handbook (HQIP & GGI, 2015)


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Referred pain in the care system (or you do your job and I’ll do mine) by Professor Tony Beddow

Introduction by Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

The third in our 20:20 series of blogs for WIHSC’s 20th anniversary is written by Tony Beddow, Visiting Professor of the University, and long-term friend of the Welsh NHS.  In characteristically evocative style, Tony takes us to the heart of the current crisis facing health and social care, and urges us to address causes, not symptoms.


Referred pain in the care system (or you do your job and I’ll do mine)

The notion of referred pain, where the symptoms of a health problem manifest themselves in a part of the body that is not itself the cause of the suffering, is well known. The care system increasingly suffers the organisational equivalent but those managing it – unlike most doctors attending on patients – seem incapable of adequate diagnosis and effective treatment.

The author once worked with a “radical” surgeon of whom it was said that he never made a three inch incision if a two foot one was possible. One only sought his skills when all else had failed.

The care system has too much referred pain within it. Worse, politicians and managers continue to be distracted by where the pain appears, rather than attending to the root causes. A radical approach to treatment is called for.

A few examples will suffice.

The ambulance service regularly fails to meet its performance targets. (unmanaged) demands have risen. Front line vehicles, languishing outside A&E because that department is overflowing are pressed into service as overflow treatment bays. WAST performance targets do not reflect that assumed role. Neither are resources made good to ensure it still reaches the ill and injured in time.

A&E departments are overflowing partly because they never close and are the easy recipients of people who do not require its high powered skills and partly because they struggle to admit diagnosed patients to appropriate wards, or divert them elsewhere.

Wards are full, partly because of rising demand, but also because we have been slow to re-engineer the total care system. We do not provide a complementary 24 hour emergency social care system and primary care is not appropriately keyed into the total care system when care deemed urgent  by the public is sought.

What to do? We could follow the buccaneering approach of my surgeon friend and deliberately expose where the pain in the system is in order to fix it.

For example:

  • Ambulances arriving at A&E would handover and leave.
  • A&E departments would only treat those needing its skills and would move diagnosed patient onto wards if a stay was needed, or would divert them to a 24 hour community based care centre that would take over their care.
  • Wards would immediately move patients no longer needing their skills to settings and agencies better placed, or legally required, to meet their needs

The last change probably requires home adaptations and home care packages to be managed differently, and for residential/nursing home placements to be more available. In short, a round-the-clock social care service designed to “take the pain” could be one result of meeting care needs in a more timely and appropriate way.

Re-designing the care system as a whole to ensure that people rarely languish in the wrong bit of it would flow from knowing where the pain really is.

The sooner we reach a stage where the pain in the system is traced to its proper source – and then addressed – the better.

Professor Tony Beddow                    

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The Shoulders of Giants by Dame Deirdre Hine

Introduction by Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

The second in the ’20 blogs for 20 years’ series, celebrating WIHSC’s 20th anniversary, is by Dame Deirdre Hine, former Chief Medical Officer for Wales and President of the Royal Society of Medicine.  Deirdre reminds us of recent Welsh health ‘greats’ from Archie Cochrane to  Peter Elwood.  Her own contributions, too, are legion, including setting cancer care on a new path, and more recently – as President of Age Cymru – addressing the needs of an ageing population in Wales.


The Shoulders of Giants

In this 20th year of WIHSC we are celebrating the work done by the Institute and its expert and experienced staff in providing evidence and impetus to improve health and social care for the people of Wales.

Notable among their recent contributions have been those to the Prudent Healthcare initiative and the 1000 Lives + project. These two Wales Government initiatives are aimed at improving healthcare and its outcomes while involving and educating both staff and patients in how to prevent ill-health, which health care interventions are necessary and effective, and how professionals, patients and the public can collaborate to produce an effective and efficient service model.

In recognising the contribution made by the Institute I know that the staff would be the first to acknowledge that they “have seen further because they have stood on the shoulders of giants”. Moreover that those giants were Welsh or Wales-based!

Archie Cochrane wrote his seminal monograph on “Effectiveness and Efficiency” in Cardiff, arguably kick-starting a global movement. His work was picked up by Ian Chalmers who also worked in Cardiff and founded the world wide Cochrane Collaboration. Julian Tudor Hart, working in Glyncorrwg demonstrated how to achieve quality in primary care and formulated the “Inverse Care Law”. Peter Elwood, working in Cochrane’s footsteps has produced evidence on the risk factors and preventive measures for chronic diseases through his Caerphilly studies and John Wyn Owen in his time as Director of NHS Wales spearheaded initiatives such as the Strategic Direction of NHS Wales and the Evidence Based Medicine and Clinical Effectiveness project in Wales.

So the prudent healthcare journey did not start with the publication of the recent Wales Government proposals. Indeed one is tempted to note that “there is nothing new under the sun”! What is new however is the current climate of constrained resources accompanied by significant increases in demand as a result of an ageing population and the unhealthy lifestyles of a proportion of all of us. These make it imperative that these initiatives have a greater impact than was achieved by those of the past 20, 30 and 40 years.

In wishing the Institute every success in the future I express the hope an expectation that its work together with that of the Wales Government and the NHS and public will succeed as never before in improving the health and care of all of us who live in Wales.

Dame Deirdre Hine

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The Opportunity of a Generation by Sir Paul Williams

Introduction by Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

With that apposite title, Sir Paul Williams launches the first in our 20:20 Series – 20 Blogs for WIHSC’s 20th Anniversary. Apposite because a whole new generation of patients and staff has entered and exited health and social care during WIHSC’s 20 years, and future generations’ wellbeing is being shaped as we read this.

 Paul – who is a Visiting Professor of the University – talks challengingly about the purpose of public services in Wales today. As someone who worked his way up from the bottom to the very top of Wales’ public services, and then came back from retirement to chart a revolution in those same services, it is difficult to think of anyone better placed to bring us back to basics.

We will publish a new blog each week between now and our birthday in November. Please feel free to comment on what you read.


The Opportunity of a Generation

I have used words and phrases like sustainability and whole system in the context of the NHS on many occasions but now as a Board Member of Natural Resources Wales they have a far more significant meaning but are just as relevant to our health services. Indeed they have the potential to transform the health and wellbeing of our population in just as a fundamental way as the great public health measures of the past had on water, sanitation and air quality had on people’s lives.

The Well Being of Future Generations Act, Environment and Planning Bills will place sustainable development at the heart of strategic decision making in Wales.

Our air, land, water, wildlife, plants and soil are our natural resources and provide us with our basic needs including food, energy, health and wellbeing. Once fully enacted public bodies in Wales will be required to think long term and work more closely together and with their local communities to improve the social, economic and cultural well-being of Wales. This will have enormous benefits for the health of our population. The new Public Health Bill recognises this, sits alongside and compliments this overarching legislation.

There is a huge potential for the natural resources of Wales to contribute to improving the lifestyles, physical activity and wellbeing of our population. The concept of sustainable development is about using, maintaining and enhancing our natural resources now and for the future. Whole systems changes the way we think about natural resource management and how to improve our ecosystems and the richness of our bio diversity.

The Llynfi 20 Project involves the Abertawe Bro Morgannwg University Health Board, local community groups and Natural Resources Wales working together to create new woodland on reclaimed land above Maseteg. This Project will provide a range of outdoor activities and recreational opportunities which will be beneficial to both the physical and mental health of local people as well as improving air quality reduce flash flooding, increase bio diversity, increase amenities and boost the local economy. Indeed just about everything which will improve the quality and life expectancy of people in the vicinity.

A recent NRW survey on outdoor recreation shows that 93% of Welsh adults visited the outdoors in the last twelve months. The survey demonstrates the significant benefits outdoor recreation brings to our health and wellbeing and the economy.

Improving the health and wellbeing of our population through engagement in natural resource management is the opportunity of a generation. The role and importance of NWR on Public Service Boards may be of greater significance than the usual players might imagine?

Sir Paul Williams, Visiting Professor University of South Wales

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At last, a way of viewing politics with maturity

Last week’s Wales Report (BBC1 on 12.11.14) on the NHS turned out to be a real demonstration of how to support public scrutiny and democracy in a different, more modern way.

Health and Social Services Minister Mark Drakeford’s performance was a refreshing demonstration of a Minister prepared to explain, argue and promote policy and strategy on the basis of logic and evidence. Here was someone, clearly on top of his brief, prepared to trust the viewing public to listen and absorb the arguments, and at the same time be helped to understand some very complex issues in the comfort of their own home.

Of course, some may argue that Huw Edwards’ questioning was too benign to put the Minister under any pressure and he was given centre stage without fear of interruption by his opponents. But that really is the point. The subject matter and audience were both given the respect they deserve because the programme concentrated on a single issue – possibly the biggest single issue of the day – didn’t clutter it with alternative interventions, and gave breathing space for the issues to be explained properly. Marcus Longley’s short contribution was used sensibly and effectively to stimulate thinking and add value to the discussion.

All this was in stark contrast to the knockabout version of public debate we saw the following evening on ‘Question Time’ from Cardiff (BBC1 on 13.11.14). This time it was the traditional, or should I say outdated, sound bite and points scoring which dominated, with the contribution of the audience mainly relegated to a mix of superficial comments and personal anecdotes.

We have been brought up on adversarial politics, epitomised by the Parliamentary version of Question Time, where the personality, quickness of wit and even personal appearance are as important as the quality of the argument. If we could have more versions of the Huw Edwards style programme, enabling, over different weeks, different perspectives to be aired without interruption, we might even make the need for party political broadcasts redundant.

Messrs. Paxman and Humphreys may attract publicity and frequent boosts to their egos and, when at their best, can be both entertaining and appropriately provocative. But too often they have left the viewer and listener with a clearer memory of what they have had to say rather than the person they have been interviewing.  Politicians are on their worst behaviour when they are put in competitive environments. They are left with no choice but to fight their corner and beat their opponents within the rules of engagement.

Anyone who thinks that this is the style of politics still craved for by the electorate need only look at the declining voting figures to prove otherwise. I now look forward to the BBC giving time to the NHS spokespersons of the other parties to try to convince us that the Minister has got it all wrong.

Written by Tony Garthwaite, Senior Fellow


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Clinicians and managers must end their standoff

Unless doctors and managers are less tribal and listen to more patient voices, NHS services will struggle to improve, argue Phil Banfield and Marcus Longley

Relationships between medical and managerial tribes are rarely characterised by mutual understanding, harmony and common purpose. We may all be in it together, but we often wish we were not.

We can no longer deliver the “martini solution” for healthcare – anytime, anyplace, anywhere – but as the Welsh NHS is firmly committed to collaboration and cooperation, what gets in the way of our doctors and managers developing a shared view for the future?

Clinical information everyone trusts

Rational decision making depends upon knowing how well services are performing. There are huge gaps in available data, and quite often the data that do emerge leave clinical teams frustrated and suspicious. No one defends decision making in the dark, but this is precisely what follows.

Managers accuse doctors of not cooperating in the improvement of data; doctors accuse managers of failing to invest in data collection and credible feedback. Meanwhile, we sail on unaided into waters that are increasingly resource shallow.

Clinical managers need not cross the Rubicon

With such limited resources, those making clinical decisions ought to manage more than just the patient in front of them and clinical management should support this process directly. Yet a universally successful way of harnessing doctors to the management process proves elusive. Too many people report frustration with the complexity and slowness of the system, which is unsurprising when doctors are trained to make clinical decisions and choices rapidly.

‘Perpetuating the dysfunctional aspects of our healthcare system in a mutual standoff serves no one’

Many doctors believe the root of the problem to be the subordination of “clinical” to “managerial”. In Wales, clinical management initiatives have been inadequate because they’ve served largely to let doctors cross over to the managerial sphere, rather than linking clinical-managerial spheres together; and it’s one way traffic – there have been few effective ways to make managers more clinically savvy.

Consequently, a service manager without the confidence of clinical colleagues cannot effectively lead, nor will clinicians be effective followers.

You cannot plan a workforce when you don’t know what you are planning for

One of the greatest frustrations facing both groups is the apparent disconnect between service and workforce planning. This isn’t just getting the numbers wrong, it’s also about a reluctance to think through what services are really appropriate to patient needs in Wales.

“Doctors” say services will close because of a “shortage of doctors”; “managers” retaliate, highlighting more hospital doctors now than ever before. Politicians may appear Teflon-coated and above the fray, so is it surprising that the public are understandably and increasingly confused and frustrated, too?

Personal interest and parochialism paralyse

Doctors are often portrayed as putting their own financial and self interests first. Managers describe doctors’ “shroud waving” and refusal to acknowledge common problems. Doctors perceive here-today-gone-tomorrow managers enthusiastically implementing the latest vacuous political nostrum as they transit through.

Unlike doctors, managers rarely have to face the human consequences of their decisions. This tribal incompatibility arises due to differing time horizons – clinicians may be wedded to their service for 25 years or more, yet managers often move on after two or three. Such divergence makes cooperation and mutual understanding much harder.

It’s not just ‘them and us’

The closed nature of this doctor-manager dualism excludes the voice of patients. Doctors and managers both have their own partial understanding of what patients and the public want, but neither has much of an opportunity really to listen to these views, still less to have a meaningful dialogue with them.

Solutions urgently needed

Perpetuating these dysfunctional aspects of our healthcare system in a mutual standoff serves no one. It cannot continue. The answer lies in redoubling our efforts to address them together.

‘The clinical team is no longer only doctors, but a whole host of professions allied to medicine who support patients and provide care’

First, we need a proper strategy on clinical information, by agreeing what data should be collected and how they are used. Both managers and doctors readily understand the critical importance of good clinical data to both quality and efficiency, and we need to assure its place in the Welsh NHS – now.

Second, we need a grown up discussion on the pattern of services that Wales needs now and into the future. The clinical team is no longer only doctors, but a whole host of professions allied to medicine who support patients and provide the right care at the right time in the right place. It also – most challengingly of all – includes the patient. Wales has some defining features, such as rurality and significant deprivation, yet politicians of all hues tell the people of Wales that they have a right to expect world class care. Both doctors and managers must aspire to reconcile this conundrum.

We suggest that perhaps doctors and managers should be a little less tribal. They all need to find ways of listening to patient groups, the public, other clinical practitioners, and have a dialogue among equals, based around commonly agreed information. We can all be in this together, and the NHS needs us to be.

Writen by Dr Phil Banfield, Chair of the BMA Welsh Council and Marcus Longley Professor of Applied Health Policy and Director at the Welsh Institute for Health and Social Care

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Prudent healthcare: A ‘big idea’ that should disrupt business as usual

Prudent healthcare is a big idea, or it is nothing.

But big ideas are not always welcome in public policy – they tend to disrupt ‘business as usual’. While we are spending our precious, finite thinking time on what the big idea really means, we might just neglect all those other equally vital, but more pressing, objectives, like safer care and balancing the books… And anyway, big ideas come and go, don’t they?

Public services know how to deal with latest Ministerial big ideas. The time-honoured approach is to thank the Minister profusely for providing vital new direction and insight, talk about it a lot in conferences organised for that purpose, include the new catch-phrases in every possible document… then re-badge all the things you were doing already using the new label, and get back to the day job.

But before health boards and trusts kill off prudent healthcare in this way, let’s just recognise that its three key planks cannot just be swallowed up into business as usual.

First, a prudent healthcare system will really empower people to maximise their own wellbeing, often recognising that that there are no clinical fixes. Chronic conditions are often, by definition, incurable, and good healthcare is about helping people to minimise their impact on what matters most to them in their lives. So people with chronic conditions – most of our patients – should routinely be offered a wide menu of support, from information and skills training, to individual and peer group support, often provided by the third sector, so that they can find things which work for them. Choice and diversity here are vital – one size will not fit all.

Second, when it comes to clinical intervention, prudent healthcare depends on patients really choosing what’s best for them. That means finding new ways of supporting patients really to think through what would be best for them, and creating the expectation that they will often say “No”.  And if they say “No”, we have to have alternatives to offer them (see above).

Third, it means re-defining what good care means. Under prudent healthcare, the key issue is what patients think about their care, not as they leave the hospital, but months down the line. A perfect operation which the patient wishes they hadn’t had two years later, is a huge waste of time and effort, on so many counts.

So … All we need, then, is a whole new swathe of non-clinical service provision, supported but not provided by the NHS; a re-thinking of the clinical encounter, with new systems to support that; and a new way of measuring our performance, with patient-defined and reported outcome measures routinely collected and compared on thousands of clinical interventions.

That’s not ‘business as usual’.

We need to hear the managerial squealing of brakes across NHS Wales, as our leaders realise that this is big change, fit for a big idea, requiring a new direction.

For further information, read Achieving prudent healthcare in NHS Wales or visit the prudent healthcare section of the 1000 Lives Improvement  website.

Marcus Longley, Director of the Welsh Institute for Health and Social Care and Professor of Applied Health Policy

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Time to change the tune…

What do we mean by ‘Strengthening the Connections’?  Two examples show what this is really all about…

Richard is an 88 year old man living alone at home.  One Friday afternoon, his neighbour becomes worried about his condition, and calls the local surgery.  The GP visits before evening clinic and quickly realizes that Richard has an infection which needs immediate treatment.  It is perfectly feasible to treat him at home, but Richard is going to need nursing input, and some other care at home over the weekend to ensure that he is properly looked after.  If the GP can arrange this quickly, Richard can stay at home.  Is that package of care immediately available, or will Richard have to be admitted to hospital, with the very real risk that his capacity for independent living will never recover?

Eileen has a terminal condition, but since it is temporarily under control, she is about to be discharged from hospital.  Her daughter is phoned by the social worker to tell her that Eileen is about to come home to the daughter’s house, since that was where he was admitted from.  ‘But I can’t provide the level of support she now needs, I’m out at work all day’, she tells the social worker.  ‘Anyway, why wasn’t this thought about when she was first admitted?’ ‘Well, we are where we are.  We will have to declare your mum homeless, and then ask Housing to assess her needs.’ ‘But that’s going to take days… Can’t you sort something out directly with your Housing colleagues?’ ‘Oh no, not unless she’s actually homeless’.  Is Eileen going to spend precious days waiting on the ward for the system to work for her?

Care and support services are fundamentally about meeting the needs of individuals yet the government agencies which organise and deliver those services are big bureaucracies whose focus often seems to be on a mixture of politics, budgets, systems and strategies.  So, how can we ensure that the individual, who by definition is at a vulnerable point in life, remains the primary attention of commissioners and providers, with the bureaucracy becoming at most an invisible backcloth?

The “Strengthening the Connections” initiative has been designed to colleagues in the public, voluntary and independent sectors closer together in ensuring people receive services without feeling the lumps and bumps of being transferred from one to the other. Lessons learned elsewhere suggest leaders and managers must resist the temptation to concentrate their integration efforts on structures and organisational change and, instead, prioritise the care needed by service users, carers and patients at the individual level. Of course, changes in systems and processes will be critical to making the necessary changes but only if they are made on behalf of the individual.

WIHSC – the Welsh Institute for Health and Social Care – is pleased to be supporting ADSS Cymru and the Welsh NHS Confederation, and their partners, with their “Strengthening the Connections” project through the organisation of four major regional demonstration events across Wales. These will bring together a range of people from across health, social care and the voluntary and independent sectors to hear about successful initiatives in integrating services and to discuss how progress can be made on a regional and national basis.

WIHSC will also be working closely with key leaders and managers in the seven Welsh health and social care communities to assist in finding ways of moving the integration agenda forward. These ‘strategic conversations’ will help identify the enablers and barriers to progress and identify the key actions needed.

Integration has shot up the buzz word charts recently. If it’s to make a difference to the care and support people receive, the familiar tune of “To You, To Me” must change.

If you would like to know more about the Strengthening the Connections Project please contact Dr Mark Llewellyn.


Written by Professor Marcus Longley, Director, WIHSC and Tony Garthwaite, Senior Fellow, WIHSC



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