1. Prudent healthcare Chris Jones
Deputy Chief Medical Officer / Medical Director, Welsh Government
Co-lead, Health Services Research, NHS Wales
Honorary Professor, Cardiff University

2. Prudent healthcare A challenging philosophy for NHS Wales
Ministerial leadership
Implies de-escalation, simplification, cost avoidance…
Improvement, not rationing

3. Prudent healthcare - where did it come from?
A synthesis of evidence
Avoidable harm, inconsistent EBM, overspecialisation, poor patient experience, poor decision making, power imbalances
But also….
Ministerial economic concern
Ministerial concern on clinical outcomes
Ministerial advice from think tank
Similar international movements

4. What is the point? Each year, NHS Wales:
Consumes 50% Welsh Government monies
19 million patient contacts
1 million seen in emergency units
1 million referred to out-patients
750,000 admitted to hospital
80 million blood tests (40% not seen or duplicates)
Nearly 1 billion spent on drugs

5. Problem is…. Despite all this activity:
6% exhibit 5 healthy behaviours
50% adults treated for an illness
Inequality worsening
Services struggling to cope
20% activity of no benefit
10% procedures cause harm
17% patients >85yrs in hospital are harmed
25% patients regret their knee replacement

6. So how to implement it? But minimal evidence that NHS more prudent
What we did
Prudent in every policy and programme
Coalition of leaders
Requirement in NHS Plans
A focussed national plan
Prudent programmes for primary, planned, and unscheduled care
Website for good practice
Choosing Wisely Wales
Thematic research call
But minimal evidence that NHS more prudent

7. Why is implementation difficult?
Lots of reasons:
Change is hard
Evidence based medicine makes us do more
Professionals like to do things
People believe more is better
High tech is excellent
Tribal boundaries
We make poor clinical decisions
Medico-legal fear
Misunderstand risk
Don’t know patient preference
Conflicts of interest

8. So what for research and policy?
Research coalescence drives strategic policy
Complex relation between research and policy
Researchers must see big picture
Policy makers need help with implementation
Cultural change
Professional behaviour
Use of evidence
Impact on equity