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Whole-system transformation needs whole-system engagement

Recently, the Fund hosted a visit by leaders of the health system in Canterbury, New Zealand.

In this blog, the first of three drawing on experiences shared during the visit, Chris Ham focuses on how Canterbury’s leaders began transforming care and the results they delivered.

David Meates, Chief Executive of Canterbury District Health Board, talks of creating a ‘social movement’ when he recalls how the health system undertook transformation. The social movement focused initially on the 19,000 staff working in the system either as direct employees or employed by organisations delivering care under contract to the board. Staff were closely involved in creating a vision for the future and leading work to translate it into practice.

In the early years of Canterbury’s transformation, which began in 2007, engaging hospital specialists and GPs in change processes was a particular priority. A practical example was the work that went into developing HealthPathways, guidelines for the diagnosis and treatment of common medical conditions. Pathways emerged from discussions between specialists and GPs on how care was provided at the time and how it could be improved.

David argues that the process of agreeing these pathways was more important than the product because it helped to improve communication and understanding between hospital specialists and GPs. The resulting guidelines drew on the best available evidence and enabled GPs to take on more responsibility for patient care where appropriate and streamlined referral processes. Pathways contributed – along with other innovations – to stemming rising demand for hospital care.

GP involvement in the development of HealthPathways and the wider transformation of the Canterbury health system was facilitated by Pegasus, a federation of general practices that is now celebrating its 25th anniversary. Vince Barry, Chief Executive of Pegasus, describes how the federation was formed to support practices to deliver out-of-hours care jointly, and later extended its role into budget holding and educational programmes. Most practices in Christchurch are part of Pegasus and it is one of the means by which the voice of GPs is heard within the system.

Vince and David use the phrase ‘clinically led and managerially supported’ in outlining how change was realised in Canterbury. Listening to them speak throughout the week, I would add ‘community engaged’ to that list with the growing involvement of citizens, patients and service users. An example is the development of advance care plans through the Canterbury Consumer Council which have enabled more people to die in the place of their choice.

The belief that Canterbury should act as if it were ‘one system with one budget’ served as a guiding light during the journey of change even if this was not, in reality, the case. A philosophy of ‘alliancing’ – including alliance contracts but encompassing a wider commitment to collaboration and working in partnership – was developed to support this belief. A tangible example is the Canterbury Clinical Network which has received external recognition for the role it plays in bringing clinicians together across the system to redesign care.

During the past decade the Canterbury health system has invested in services in the community to support people to take more responsibility for their own health and wellbeing and as far as possible to stay well in their own homes and communities. The results include moderating demand for hospital care and reducing use of residential and nursing home care for older people. Canterbury has also coped with the consequences of earthquakes through the investment made in working as a system.

Its achievements have been recognised by the Controller and Auditor General which has also noted a recent deterioration in the health board’s finances. David Meates argues that this deterioration reflects in part the rebuilding costs associated with the consequences of the earthquakes. He adds that Canterbury is also disadvantaged by the funding formula used by the Health Ministry which does not give sufficient recognition to its growing population and the health impact of the earthquakes.

The lessons from Canterbury for the NHS are clear. Whole-system transformation is possible but it takes time and genuine engagement with staff, patients, users and other stakeholders. Leadership of change must be collective and distributed and guided by a compelling vision and narrative. Fundamental to all of this is the development of trust between leaders at all levels.