Aug 292017

Can you remember when you visited the theatre? What was memorable and enjoyable? Are you looking forward to visiting again?

If it was an operating theatre, would you feel differently? Imagine if:

  • You couldn’t understand what was happening, or why;
  • You were made to wear someone else’s clothes (a hospital gown);
  • On your way to the theatre the people stared/ looked away;
  • The theatre smelled and the lights were very bright;
  • In the theatre noisy machines had flashing lights;
  • You didn’t know any of the people who all wore the same clothes;
  • You kept saying you were confused and scared, but no one noticed;
  • You wanted to leave, but they stopped you. The people appeared to be annoyed?

It would be memorable, but would you want to visit again?

Can we comprehend how a person with a learning disability experiences a hospital? Do we understand how previous experiences influence future behaviour? It may be a typical day for healthcare workers but a very different day for hospital users. It is essential we demonstrate empathy, compassion and understand how the environment and processes within a hospital may be very difficult for others. Whether, we are aware through the learning disability hospital passport, our knowledge or because we have listened to the person and their carers, it is essential we meet those essential reasonable adjustments for treatment.

Our team developed the Soothing Patients Anxiety “SPA” Experience to deliver a less distressing day and a positive experience within the theatre in a hospital. We achieved this by using iterative Plan Do Study Act cycles and other techniques taught by the Silver IQT course to ensure constant refinement of our processes. Patients and/or their carers are equal partners in planning their care. Reflection on every interaction and constant feedback provide new learning for continuous service improvement. An enjoyable memorable day is achieved through patient choice distraction techniques during induction of the general anaesthetic that we call “stealth or themed anaesthesia” which minimises/avoids sedation/and or positive behavioural management (restraint). All techniques are practiced within the theatre with the patient and carers prior to the day of operation, “a dress rehearsal”.

  • Stealth anaesthesia – covert administration of the anaesthetic whilst the individual involved in their favourite activity and chosen distraction technique.
  • Themed anaesthesia- the journey is built around a favourite thing. A gentleman with a learning disability during our dedicated pre anaesthetic assessment clinic remarked that the anaesthetic facemask reminded him of what fighter pilots used in his favourite film Top Gun. The morning of the operation he watched the movie. Walking to theatre he listened to the theme music. In theatre he was involved in a pre flight/anaesthetic checklist. He drifted off to sleep holding his facemask he watched an aerial flight scene via an i-pod in front of his eyes. On waking he received a Top Gun flight certificate.

Awards embody the opportunity to share learning and influence care external to your organisation. Last year the team won the NHS Wales Citizens at the Centre of Service Redesign Award and this year BMJ Anaesthesia Team of the Year. We are honoured to work with people with learning disabilities and the intrinsic opportunity to challenge the norms of healthcare. Our diverse and unique service users ensures constant learning and quality improvement as they each inspire new possibilities/options for future users.

Question: What would you need for a memorable and enjoyable visit to theatre?

For more information email:

YouTube: NHS Wales Awards The Spa experience

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.

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Oct 282014

Where do I start? Experiential learning seems a good place to begin, and being a part of theAngela Williams Improving Quality Together (IQT) Silver workshop sessions for educators in improvement organised by 1000 Lives Improvement earlier this year made me realise how good it is to undertake an improvement project myself. For all attendees choosing an ‘improvement’ project, it wasn’t as simple as first envisaged. A familiar situation for many students!

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Oct 102014

Peter Bradley

Professor Peter Bradley

Making prudent healthcare happen is a new website that was launched this week at the Welsh Public Health conference. It is an important online resource for everyone who works in NHS Wales, and everyone who relies on NHS Wales services, because it gets under the skin of ‘prudent healthcare’ and explores ways we can deliver better care and better outcomes.

Prudent healthcare has a central emphasis on outcomes – the results of what we do. We need to have a hard look at everything we offer as healthcare professionals and across all our support functions in NHS Wales. The question we need to ask is ‘Do we deliver high quality, good value services?’ And if we don’t know the answer, we must try and find out.

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Jul 012014

PeteStraw Image1A beautiful, sunny Llandudno greeted us on our arrival at the highly-anticipated 1000 Lives Improvement National Learning Event, a fantastic opportunity for healthcare practitioners and students to meet and discuss the notion of prudent healthcare and quality improvement within the NHS in Wales.

Welcome coffee and pastries lined the stomach for the launch session delivered by Professor Matthew Makin (Medical Director, BCUHB) and Dr Alan Wilson (Director, 1000 Lives Improvement), who introduced the concept of prudent healthcare – built on the three pillars of reducing avoidable harm, appropriately minimising intervention, and promoting co-production of health between service users and providers.

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Jun 192014

SallyLewis2Dr Sally Lewis shares her thoughts on ‘prudent prescribing’ after chairing a workshop examining how the principles of prudent healthcare might apply to prescribing and medicines management.

None of us need reminding that as a society we face a growing burden of chronic disease. Increasingly we cohabit with chronic pain, diabetes, respiratory disease, and cancer and neuro-degenerative disorders. The evidence based medicine revolution continues to develop guidelines for us to follow and there is a steady stream of new innovations in healthcare, not least in prescribing. This therefore will lead to rapid growth in the amount and diversity of medicines we will prescribe for our patients.

Is this bad? Not necessarily, but only if we have assured ourselves that every time we prescribe a drug it is a valuable addition to an individual’s management and has done no harm. This is the basis for prudent prescribing and makes it imperative that we determine the true value of the medicines we prescribe to each of our patients. Continue reading »

Jun 092014
Marcus Longley

Marcus Longley

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 is Director of the Welsh Institute for Health and Social Care and Professor of Applied Health Policy

Jun 092014


Professor Peter Bradley

Professor Peter Bradley

Achieving prudent healthcare in NHS Wales is a new paper published by Public Health Wales which outlines the findings of four workshops set up to test ‘prudent healthcare’ in the real world. 

What is prudent healthcare? The Minister has defined it as, “Healthcare that fits the needs and circumstances of patients and actively avoids wasteful care that is not to the patient’s benefit.” In practice this looks like safe, effective care delivered without delays. I think we’d all agree we would like to be guaranteed healthcare like that.

In the paper, we have summarised the principles of prudent healthcare as:

  • Minimise avoidable harm.
  • Carry out the minimum appropriate intervention.
  • Promote equity between the people who provide and use services.

The workshops raised several points of interest, but there was general agreement form the staff and service users present that the current system’s faults and occasional failings could be fixed by applying these principles.

The third one is key to successfully applying these principles. We know that when people are involved in their healthcare, and are given complete information and genuine choice, they often choose the less risky options, which usually are the least expensive. For example, if we advise people about pharmaceutical side-effects, they are more likely to want to try changing their lifestyle rather than being prescribed medicines.

The workshops also looked at some specific questions:

  1. What happens now that does harm or little good?
  2. What happens now in an expensive way, which could be done in a more cost effective way?
  3. What would the pathway look like if organised around the minimum intervention principle?

There are huge gains to be made in quality, improved patient outcomes and cost-effectiveness from reducing delays in the system. We sometimes automatically put people through the system because we are set up to deliver certain treatments or interventions rather than offering people a lower level of intervention that would be of equal benefit to them, and possibly more!

The perspective of the people who use our services is vital. They can alert us to delays and wastage in the system and have an equal role to play in ensuring they receive the treatment that is right for them. We have to learn to listen and involve them more. The future of our health service depends on it.

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

Dr Peter Bradley is the director of Public Health Development in Public Health Wales. Follow Peter on Twitter @pbradley1965