Analysis

Prudent care puts the focus on evidence-based services

Nurse leaders will gather along with other health and social care professionals at Cardiff City Hall this month for an international summit to encourage better outcomes for patients using best-value health care.

Nurse leaders will gather along with other health and social care professionals at Cardiff City Hall this month for an international summit to encourage better outcomes for patients using best-value health care.

It is more than a year since health minister Mark Drakeford called on the NHS in Wales to ‘enshrine the value-based principles encouraged by prudent health care across its entire system’, in response to rising costs and increasing demand while still wanting to improve patient care.

Four main principles

Prudent health care, which has already been adopted in various guises worldwide, has four main principles in Wales, making the public, patients and professionals equal partners through: co-production, encouraging care of those with the greatest health need first, doing only what is needed and no harm, and a reduction in inappropriate variation in services through evidence-based practice.

Mr Drakeford, who will be speaking at the summit, will be setting the agenda for health care in Wales and focusing on how to ensure prudent health care becomes a part of the day-to-day working of everyone in the NHS. He will also discuss priorities he set out earlier this year around primary care, remodelling the workforce in accordance with prudent principles and tackling over-treatment and over-diagnosis, especially towards end of life.

RCN Wales director Tina Donnelly says one way to reduce cost according to prudent health care could be to ask whether GPs need to see as many patients as they do: ‘We have done a lot of work around the role of the practice nurse and we are working collectively with the General Practitioners Committee Wales, the British Medical Association and the Royal College of General Practitioners to look at how we can work within practice health care in a way that is not going to put health professionals or patients at risk, but produce effective outcomes.’

'On everybody's agenda'

Nurse directors are engaging with prudent health care, a subject that ‘is certainly on everybody’s agenda’, she says, but adds: ‘I do not think prudent health care has fully had time to bed in yet. This is a topic which has to be dealt with sensitively because it is not just about doing more with less, but also doing more in terms of outcomes.’

Meanwhile, RCN members have given the concept a mixed response, she says. ‘Some nurses are enthused by it, but members are concerned there is a particular emphasis on role substitution, nurses taking on more of a medical-practices role and healthcare support workers (HCSW) taking on tasks previously done by nurses.

‘It is important to get the balance right; an HCSW may be able to give patients a wash, but we have to remember that as nurses, when we wash a patient, that is sometimes when we are able to use the time effectively by also undertaking a full healthcare-needs assessment.

Foundations must remain

‘We need to make sure we embed prudent health care now so, no matter what happens in the future in terms of a change of government, the foundations will continue to remain the same and we know the concept will not be “personality-led”, dependent on which government is in charge.’

Director of nursing at Cwm Taf University Health Board Lynda Williams is a fan of prudent health care having seen the results first hand over several years and through innovative services designed and run by nurses.

An intravenous antibiotic service provided by advanced nurse practitioners and district nurses allows patients to receive antibiotics at home through cannulae and midlines for example, rather than their having to stay longer in hospital. The latest statistics, from March, show that 150 patients have been seen since the service started in 2011, freeing up 6,826 bed days.

Ms Williams says: ‘We also have nurse endoscopists who are training junior doctors, and our nurses are at the point where they see more patients than doctors.

Opportunity

‘My senior nurse managers would have heard of and understand the prudent healthcare principles, and we view this now as an opportunity to attribute all that we are doing to a distinct entity.’

But she adds: ‘If I answer honestly about whether my front line staff recognise prudent health care, they understand the need to know what to do to the right person at the right time, but they would not necessarily label it.’

Ms Williams also admits that an area of prudent health care on which the board needs to work more is the element of co-production with patients to find solutions to issues equitably.

Informed choice

‘It is about finding a way to talk to patients about their condition and treatment so they can make an informed choice, and discussing the care where appropriate with the families of, for example, cancer or dementia patients so decisions can be made early on. We have been looking at more effective ways of working over the past two years and will continue to do so based on the prudent healthcare principles.

‘Clearly we will apply the same principles to commissioning services as we do to providing services. We want to ensure that the services commissioned are appropriate to meet the patient’s needs, are timely, delivered by the most appropriate person with the skills and competencies to do so, and involve the patient as partners in their care decisions. This would ensure appropriate value of the services. This is, and should be, an evolving journey for us.’

Public perception

Another important element to prudent health care is what the public thinks about any resultant changes to how care is delivered. There are seven community health councils (CHCs) in Wales, each a statutory organisation that monitors the quality of NHS services provided in a health board area.

Peter Meredith-Smith, director of the Board of Community Health Councils, which advises and assists the CHCs, says: ‘Prudent health care is recognising the real challenges we have across the country with rising demands and rising costs, which, unless we do something about it, will have an impact on safety and quality of care. However, implementing the concept must be done in the right way.’

Mr Meredith-Smith, who has worked in many nursing roles, including as a Welsh Government nursing officer and executive director of nursing, explains that most complaints the CHCs receive concern the fundamentals of care, care at the bedside, how patients are treated and communication.

He adds: ‘The way CHCs work has been standardised. The public need to be aware of what CHCs do as in the coming months and years CHCs will be more important than ever to see things from the point of view of a lay person.

Major issue

‘Health boards know that, if there is a change which the public and CHCs believe is a major issue, CHCs could effectively put a halt to it while it is reviewed.’

Chief nursing officer for Wales Jean White says that some of the principles enshrined in the prudent health care concept are not new to nurses and midwives so they have been accepted and embraced as part of how they deliver care.

‘The concept includes reference to ensuring the most appropriate professional should deliver care. This reflects the important journey Wales has been on to break down traditional professional silo behaviours and support the development of advanced practice.

‘So while the concept of prudent health care will take time to fully embed as it does require a different relationship between health services and service users, there is evidence that the existing nursing and midwifery practices can be used as a solid platform for the change needed.’

Important touchstone

Professor White explains that the concept, with its ‘easy-to-grasp principles’ provides an important touchstone for healthcare professionals in reflecting on their daily interactions with patients.

‘The concept will drive a more equal relationship between the individual and the nurse’

‘When fully implemented, it will empower individuals to take a greater role in determining their care and importantly the personal choices they need to make to ensure they optimise their personal health and wellbeing.

Options

‘Nurses need to think about the options available to patients, particularly if they choose to reject the medical interventions offered. The concept will drive a more equal relationship between the individual and the nurse.

‘We all need to pause for thought about the decisions and actions we take personally and professionally, and the way we organise care; perhaps we should regularly be asking “Is this the prudent thing to do?”’

'Being careful, sensible and using a bit of wisdom'

National lymphoedema education and research specialist Karen Morgan with a patient

 

Variation in services is something that practitioners of prudent health care hope to banish, and lymphoedema services across Wales are a prime example of where this can happen.

Karen Morgan is Welsh Government national lymphoedema education and research specialist, and Macmillan lymphoedema clinical lead at Abertawe Bro Morgannwg University Health Board.

She has been working as a nurse for nearly 30 years, during which time she has seen some health boards start commissioning full lymphoedema services, while others have offered only cancer services and some have neglected to offer any services at all.

Standardised approach

Lymphoedema is a condition that requires ongoing management, and six years ago the Welsh Government published a lymphoedema strategy to give patients better access to the services they need. The government invested £1 million to implement the strategy in 2011 and an all-Wales lymphoedema network was set up to promote a standardised approach to care.

‘Being part of Lymphoedema Network Wales ensures that good practice is national across Wales,’ says Ms Morgan. ‘It is a true example of how a good network should work. We are in the process of completing a national audit where we are peer reviewing all the services to ensure standardisation. This means that a patient from Wrexham will receive the same assessment and treatment as if they lived in Cardiff or Cardigan.

‘For me, being prudent in nursing is about being careful, sensible and using a bit of wisdom. It is also about having minimum intervention when possible, but also achieving the desired outcomes.

Joint clinic

‘For example, I noticed that some patients with chronic oedema, leg ulcers and skin conditions were travelling to many appointments to see a variety of specialist nurses so I spoke to my nursing colleagues and we arranged to set up a joint complex leg clinic where we would all be available at the same time for the patient.

‘It is sometimes a case of networking with colleagues to ensure the patient is at the centre of care. It is also important to discuss openly with patients the options available to them to self-manage their chronic condition.’

Patients with lymphoedema now have standardised referral criteria, assessment forms using the same data sets and care-management plans across the seven Welsh health boards, says Ms Morgan.

The waiting time target for patients with newly diagnosed lymphoedema has been cut from 24 to 14 weeks and the lymphoedema network has ensured that patients with palliative care needs are seen within two weeks of referral and urgent-but-not-palliative patients within four weeks.

Petra Kendall-Raynor is a freelance journalist

 

 

 

 

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