‘You need a whole system to work for the whole system to work’

Recently, the Fund hosted a visit by leaders of the health system in Canterbury, New Zealand. In this guest blog – the second of three drawing on experiences shared during the visit – David Meates, Chief Executive of the Canterbury District Health Board, explains how organisations within the Canterbury health system have moved from playing the ‘blame game’ to working together to provide the best possible care for the local population.

In a system facing consistent hospital gridlock, persistent under-delivery of elective surgery, fragmented health services, management aimed at meeting targets, years of fiscal deficits and a future that looked increasingly unsustainable it was clear that a different approach was required. Continuing to work in the same way was no longer tenable and was failing a community that had a right to expect better. So, the transformation of the Canterbury health system began.

The vision that drove the transformation of the Canterbury health system and that has continued to be its focus is one orientated around care that is people centred, that is connected and that aims not to waste patients’ time: in other words, care that is provided at the right time, by the right person, in the right place.
 
Increasingly care provision is less about the individual organisations involved in the system and more about where care is best provided and organised.
 
Today in Canterbury an individual is 30 per cent less likely to be admitted to hospital medically unwell compared with the average for the rest of New Zealand. This is not because people are less unwell in Canterbury but rather it reflects the benefits of a health system that is working to ensure that the limited resource in health is used as effectively and appropriately as possible.
 
In the past 12 months more than 33,000 packages of care have been generated by general practice with a focus on ensuring that the right support packages of care are in place to safely and appropriately manage a patient in their own home instead of in hospital.
 
This is possible because those working in general practice are able to initiate the right care in the right place with the support and backing of hospital-based clinicians. If a care package needs to be put in place immediately it is activated by general practice without needing to seek approvals. Agreed guidelines are in place to do this and the packages of care activated are reviewed regularly to ensure that care is being appropriately managed.
 
All messaging to health service-users across the Canterbury health system continues to reinforce that their general practice team is their core health team. If someone is unwell then they can call their general practice team, no matter what time of the day.
 
The results of this whole-system working have been reflected in the experiences of the very heavy and pressurised winter that the Canterbury health system is now emerging from. While 96,000 people were seen and treated at the Christchurch Hospital emergency department, 84,000 people were treated at the 24-hour surgery – an urgent general practice facility, about 3 kilometres from the hospital.
 
Attendance at the emergency department is free, but a presentation to the 24-hour surgery (or one of the other two extended-hour seven-day a week practices) costs approximately NZ$80 for adults (with under 13s free). Despite the charge involved, the consistency of messaging across the Canterbury Health system means the community self-triages very accurately. In the past 12 months there have been only 4,400 triage level-5 presentations to the emergency department, or less than 3.5 per cent of emergency department attendances.
 
There has been much debate over the years as to whether the 24-hour surgery and the emergency department should be co-located. As a system we have arrived at the very clear view that if you co-locate or combine both, the message to communities becomes complicated and reinforces the view that if you are sick then you go to hospital. This is at odds with a health system that values the role of general practice and can often lead to emergency departments becoming clogged with patients.
 
With the whole system – general practice, hospitals, home-based care providers and ambulance services – working together, the focus on supporting people to be cared for in the most appropriate place meant that this past winter elective surgery cancellations almost completely disappeared. Increasingly it is now being seen as a failure of the system if planned care is cancelled because every cancellation involves wasting a patient’s time and means that they do not receive optimal care.
 
The ‘blame game’ is no longer played within the Canterbury health system but rather we focus on what, as a system, we can do collectively to make sure that our community is getting the care that it needs.
 
Truly, you need a whole system to work for the whole system to work.