This is the third paper in the Exploiting the Welsh Health Legacy series, and describes how we can drive and embed prudent health and care in Wales by building upon existing initiatives, using established networks to engage wider views and collaborating further with others to use the knowledge, experience and expertise of people and organisations including universities, industry and agencies.

The Bevan Commission recognises the unsustainability of the current health and care system that predominantly treats ill health at the expense of promoting health and wellbeing. Future health and care services will also need to be more focused upon addressing people’s needs, not just on paper, but in reality.

A Prudent Social Model sets out a clear vision and way forward for future Health and Care in Wales. It reinforces the need for rapid transformational change, moving away from traditional thinking and a solely medical model of care towards one that empowers and engages the passion and ideas of people to deliver innovative approaches based upon their own experience, ideas and expertise.

There is an urgent need to translate the thinking behind the development and application of the Prudent Model, reinforced by the Parliamentary Review into Health and Social Care which called for revolution not evolution and the more recent Welsh Government’s Long Term Plan: A Healthier Wales: our plan for Health and Social Care.

Action is now required to engage the ideas and passion of people and communities to shape current and future health and care services. A combination of approaches are needed to drive and embed Prudent Health and Care in Wales, including opportunities for patients and the public to describe what matters to them. The Bevan Commission’s ‘Big Conversation’ is the start of an ongoing process to help make this happen.

The paper describes how this can be done by;

• Building upon existing ideas and initiatives through schemes such as the Expert Patient Programme, Making Every Contact Count, Social Prescribing, will help ensure we are making the most of our current knowledge and expertise.
• Using established networks to engage wider views, skills and expertise will also help. Existing networks such as the National Federation of Women?s Institutes (NFWI) the third sector, community connectors, health and care facilitators all offer access and insight to the needs and solutions held by others.
• Collaborating further with others to use the knowledge, experience and expertise of people and organisations including universities, industry and agencies such as the Life Sciences Hub Wales and the Bevan Commission.

Programmes which try out and test new ideas such as the successful Bevan Exemplars and Advocates provide a tried and tested infrastructure to assist people in developing their own innovative ideas and creating social movements for change, driven by people themselves.

We must also challenge ourselves and our ways of thinking and working our current practice, our individual behaviours and our organisational cultures, so that we are receptive and open to deliver the seamless new models of care required with a workforce that is fit for now and for the next 70 years.

This paper is the second in the series called ‘Exploiting the Welsh Health Legacy’ which calls for a joined up, prudent and social model of health and care – moving away from the more traditional medical model of care.

A New Way of Planning: Working Towards a Prudent Model of Health and Care” sets out the planning, thinking and approach required to implement this new, social more Prudent model of Health and Care in Wales. In our first paper, we set out the case for change and described the new model – a model which best suits the needs of people in Wales. A model which prevents ill health and preserves and supports all aspects of wellbeing, in which everyone has a responsibility.

We have looked at how this could be achieved by looking at health and care through a different lens – a prudent lens. This proposed new model is based on the Bevan Commission’s concept of Prudent Healthcare and the application of its principles in practice. It recognises the shared responsibility of society starting with the individual.

A Prudent Model of Health and Care will:

Actively encourage everyone to take collective action and responsibility to help us all live the healthiest lives for as long as possible;

Call upon all agencies to act together and assume joint responsibility in whatever way they can best do this to ensure we make the most of the resources we have to meet individual and population health needs;

Develop a strong, robust and prudent integrated health and care system to support both our health and care needs;

Make the most effective use of all skills and resources available including local people, patients and the third sector;

Ensure that those with the greatest needs are prioritised and the hard to reach groups are included.

A Prudent Health and Care System is one:

• In which we all share responsibility for maintaining our health and that of others and that we have high quality, effective and efficient services which meet the needs of people, as and when needed;
• Where the focus is on the joint ownership of the NHS by all in Wales, through the co-operative concept of ‘Our Welsh Health and Care Service’, ensuring that this is;
• A shared responsibility belonging to the people of Wales, who use it and pay for it;
• Focused on preserving and protecting health and wellbeing, not just treatment and ill health;
• High quality, integrated prudent health and care services, equally available for all, working with everyone to ensure the most prudent and right care is provided.

Moving forward and next steps

This paper represents the first stage in a process of essential and fundamental change and the rebalancing of the NHS in Wales. Further ongoing engagement and consultation are needed to expand upon and test out whether the ideas in this paper fully represents the feedback and views received to date and in determining the next steps.

This model is designed around the needs of people in Wales, not the systems the processes or the professionals. It embraces the principles set out by Aneurin Bevan for a National Health Service, namely; comprehensive, free at the point of delivery and accessible by all, alongside the fundamental 4 Prudent Healthcare Principles. It builds upon its origins whereby communities, people, professionals, patients and local employers all played a key part and responsibility in maintaining health and in caring for its communities and the people within it with great pride.

The Bevan Commission proposes to ensure that the people of Wales recognise both their rights and responsibilities and are able to respond by getting involved and finding solutions to the challenges that the NHS faces. It will seek to ensure that our NHS in Wales is co-owned by them, similar to members of a ‘unique NHS club’ in which we all have our individual club numbers and clear ‘rules’ by which it operates in response to services and support received.

The Bevan Commission worked with Swansea University, Gwent Association of Voluntary Organisations (GAVO) and 1000 Lives Improvement to analyse 1,400 patient responses to the Education for Patients Programme (EPP).

Executive Summary

The Bevan Commission has recognised the unsustainability of the current healthcare system in Wales which predominantly treats ill-health at the expense of promoting health and wellbeing. This has recently been reinforced through its Prudent Social Model of Health series. This sets out how health is everyone’s responsibility, not just the NHS. It cannot be based on fixing people when they become ill in the traditional way, but must be one which is sustainable and engages people and their ideas, making them jointly responsible to produce their own health and wellbeing.

Education Programmes for Patients (EPP) is a successful and widespread programme of patient empowerment and self-efficacy in Wales. It provides a prudent method consistent with the principles of value based healthcare. Its problem solving exercise provides a valuable way to access the views and experiences of patients and their carers. This report describes the outputs from 93 EPP courses with 797 participants setting out over 1400 issues and challenges that they face on a regular basis. The outcomes of this work provide a rich and unique source of the wide-ranging challenges that people with chronic disease in Wales can face. The solutions proposed by the participants were broadly grouped around either how to change the system or how patients could be better prepared to interact with it.

There also appeared to be an overestimation of the expectations, particularly regarding the role of GPs. While many patients would often be better suited to meeting with a specialist best placed to meet their needs, e.g. pharmacist, chronic condition nurse, Occupational Therapist, physiotherapist or social worker, it appears that many people are unaware of this and the avenues to access support. This would suggest that there is a clear need for greater understanding and awareness of how the system operates, and how patients might be empowered to help manage their care and their expectations.

This report sets out the following key recommendations:

• Emphasise the importance of the patient as co-creators of their own health and well-being with patients and professionals.
• Enable patients to become custodians of their own health information, through cloud-based patient records and other tools that can be amended by the patient.
• Increase health literacy and knowledge of how the system works to help make shared decisions and manage expectations.
• Undertake further research for future EPP courses, to look at driven by geography and deprivation.

This builds on the findings of the Bevan Commission’s 2016 report A Workforce fit for Prudent Healthcare, this paper examines the workforce of the future through a prudent lens, within the context of a social model of health and care.

It recommends that a workforce fit for the future will need to be different to the one we have now and be empowered to put prudent healthcare into practice. Health and care professionals will need to work together with (not to or for) patients and communities and to participate proactively in addressing their own health and care.

This is reinforced by the Welsh Government’s recently published long-term plan for Health and Social Care which puts Prudent Healthcare and its principles at its heart – a concept and philosophy developed and championed by the Bevan Commission.

The Bevan Commission identifies the need for a rapid transformation of traditional health and care roles to take this transformative process even further, proposing new combined multidisciplinary roles and teams across health and social care and other important disciplines such as; health data analysts, wellbeing coaches, health technologists and new ‘core health carers’. This role would put the holistic needs of the individual (environmental, physical, social and psychological) at the core of any role transformation.

There is also a clear need to continue to expand upon the diversification of existing roles focusing on future needs, in an ongoing, flexible and responsive way. The next generation of health and care professionals will need to develop core competencies in problem-solving, emerging technologies and communications.

The Bevan Commission calls for the inclusion of the wider workforce (members of the public, patients, carers and the third sector) within future workforce plans. Maximizing the skills and assets held within these groups through training and other support will be essential to achieve more sustainable health and care in the future.

Creative thinking and bold leadership are needed to trial these transformations in roles and services. It will also require professionals and their representative colleges to embrace the challenge and work together with others to find the best solutions.

Different approaches to training and professional development are required through schemes such as; joint bursaries within the commercial and life sciences sector (all major growth areas for Wales), continued collaboration between the life sciences hub, academia, the NHS. Health and care apprenticeships or bursaries etc. New approaches will also be needed to support the next generation of health and care leaders to drive transformation and develop the new skills and competencies to achieve this.

The Bevan Commission calls for Welsh Government and Health Boards to take urgent action to ensure that the financial resources currently invested in the workforce is prudent and that a fit and healthy NHS workforce is actively promoted. Absence rates are higher in the NHS workforce in Wales (5.5%) than in the wider Welsh workforce (2.6%) and the highest for any region in the UK and leaves Wales particularly vulnerable. Due to absence, sickness and recruitment challenges, agency staff are increasingly relied upon to fill the gaps – a costly and imprudent measure.

Recruitment and retention is an ongoing issue – new roles and more flexible, integrated career pathways to fit with people’s changing family and care needs will be needed, moving away from the more traditional fixed training and development pathways. This should be used to help make Wales attractive to recruit and retain the future health and care workforce in a globally competitive market.

Health Education and Improvement Wales (HEIW) should lead the way in implementing the recommendations of this publication, supported by Local Health Boards, NHS Trusts, Professional organisations and Regional Planning Boards in Wales.