Nov 182014
Dr Alan Willson

Dr Alan Willson

I agree with the aims of prudent healthcare – I have yet to find anyone who doesn’t.

While the pre-election arms race between Westminster politicians is about promising extra money for the NHS, how much more useful to ask how we are spending what we have. When we ask that, like health systems all over the world, we find we could do much better AND that the result could be better care.

The more interesting question is “how?”. As Richard Bohmer says in his book Designing Care: “the work of care and the operating systems that support that work must be explicitly designed for that purpose and not just left to accrete by chance and happenstance”.

My recent experience of cardiac care at Morriston Hospital showed how a well defined pathway allows the many providers and individual receivers of care to play their part. Porters, cardiologists, A&E staff, nurses, technicians, GPs and physiotherapists were all confident and expert enough to support one another, take a pride in their contribution and to ensure that my experience was one of prudent healthcare.

As an improvement specialist, I couldn’t resist thinking about how I could help them make things even better and I am sure that they could find value in several approaches. Excellence is never about stagnation.

More important, what are the features of cardiology that can be imported to other areas? I think there are five and I will use the improvement terms for each.

1. Microsystems

We work best when we know who we are working with and what for. Cardiology is just such a microsystem. Much of healthcare can be delivered in this way and it is more efficient than centralising and anonymising. Fans of shared services and macroeconomics tend not to “get” this.

2. Agreed pathways and operating systems

How we work here (in our microsystem) must be set down and only changed for good reason and in a planned way. This is true even when the evidence base is weak or speculative. If there is no evidence to favour A or B, it is still better to stick with A (or B) and not vary it according to who happens to be on duty.

3. Process information

We need to continuously collect data and information about how we are doing. How well are we sticking to our agreed pathways and systems and what is everyone’s experience of that? This provides the stuff of management. Getting it right (getting it prudent) is about continuous quality management. Care needs to be taken to ensure that process information fits into the overall patient journey. For example, there is little value in a well-run pathology lab if it results in delays in patient care.

4. Leadership

The role of leaders is very different in this prudent world. It is less about command and control and much more about trust and facilitation, less about vision and more about information.

5. Co-production

If all of the above are in place, then there is space to develop better skills in understanding people and supporting them to meet their goals.

Watch Dr Alan Willson talk more about his patient experience, following a heart attack in September 2014.


My mystery shopper experience gave me practical proof that prudent principles lend purposefulness to those who deliver and receive care. I was lucky. After a life threatening event, I was in hospital for less than two days and discharged with two stents, medication, advice and entry to a rehab programme. I am sure the same prudence can be achieved in many other aspects of healthcare.

Dr Alan Willson is the former director of 1000 Lives Improvement, you can follow him on Twitter @DrAlanWillson.

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