A centre-right coalition Government; an unsustainable hospital sector needing reform; an ageing population living with more chronic disease; calls for more integrated care; and a belief in the power of local clinical leadership to bring about such change. Sounds familiar? Well, up to a point.
Here in New Zealand, where Carol Black and I have been taking part in the Royal New Zealand College of General Practitioners' Quality Symposium, you have to pinch yourself, such is the commonality of much of the debate about our respective (publicly-funded) health systems.
The proposed solutions also feel familiar, notably the creation of a new National Health Board alongside the Ministry of Health. Even the collectives of GPs and other local health practitioners that form the basis of their new integrated health networks seem in some ways to resemble what is hoped for from clinical commissioning groups (CCGs).
We are however 'down under' here, where much is inevitably topsy-turvy for the itinerant Brit (sunshine in February for one). Health reform is no exception to the upside down rule.
What the Kiwi experience of health reform in recent years shows is the importance of the 'how' of health reform. It's not (just) what you do, but the way that you do it.
In New Zealand, the Government is just starting its second three-year term. Their 2008 election pledge not to impose a top-down reform continues to hold. Instead, change here is shaped through the setting of over-arching system priorities (more integrated care for people with complex needs, improving the quality of patient experience, and higher productivity and sustainability overall).
The sense of clinicians and managers being trusted to shape their local health economies is striking, albeit within a tough fiscal environment where the quality and economic stakes are high and where there is a broad national framework of assurances to deliver.
Local district health boards (who both run hospitals and act as commissioner) and primary care organisations are charged with planning the clinical networks and services that make most sense for their particular region and district.
Legislation is refreshing by its relative absence (apart from an amendment to the main Health Act in 2010 to enable the establishment of a National Health Board and a new quality and safety commission), although one does hear calls from some quarters for more direction and guidance by the centre. Some of which is provided.
In 2009, under a banner of 'better sooner more convenient' (BSMC) the Government invited proposals for demonstrators of what we would term integrated primary and community health services.
Nine sites were selected, covering some 60 per cent of the New Zealand population. Varied in their focus and approach, the BSMC sites aim to develop care that is more strongly based in the community, ensure that services for patients and their families are more coordinated and demonstrates strong leadership by local clinicians and the managers who work alongside them.
In many cases, the BSMC schemes are being shaped and supported by independent practitioner associations (IPAs) – GP-led primary care organisations that have existed for over two decades, surviving different phases of health reform and remaining focused on the development of services within and across general practices.
The Nuffield Trust is publishing an analysis of this IPA experience in the early summer, exploring what this tale of long-term survival by GP-led organisations has to offer the new CCGs in the NHS and international experience of physician organisations more generally.
As the BSMC sites have tried to work out how to enable multiple providers to work together to share risk, plan new services and work in a jointly accountable manner, the Ministry of Health has encouraged local networks to try out 'alliance contracting' – a form of contracting drawn from the construction and utilities sector.
We will be hearing more about New Zealand's experience with alliance contracting for integrated care at the Nuffield Trust’s Health Policy Summit later this month.
What the Kiwi experience of health reform in recent years shows is the importance of the how of health reform. It's not (just) what you do, but the way that you do it.
The NHS, tied up in legislative knots, would do well to heed lessons from New Zealand. There is another way and it entails resisting the urge to reorganise the system, instead trusting local clinicians and managers to develop solutions, albeit within a carefully crafted framework of targets and incentives.
This article has also been published on GPonline.com.
Comments (2)
The kiwi way has resulted in high variability across the nation in functionality of the systems that support general practice. If the local Health Board and Primary Care organisation doesn't support general practice, then the only changes are those that result from national activity, such as IT and funding. Kiwis are innovative in our "number 8 fencing wire" way but we are poor implementers and this shows when you get away from the BSMC demonstration projects.
Jim
Thanks for your reflections. I agree that a more devolved approach to running a health system brings with it inevitable local variation in how policy is implemented. This is the perennial challenge of a national-local tension within health policy, and the choices faced by governments in deciding how to ensure some national consistency of service provision, whilst leaving space for local adaptation to meet the needs of small-area populations.
I guess the challenge for New Zealand (and indeed many countries including the UK) is how the political centre decides to set and monitor overall objectives for the performance of the health sector, and what balance it strikes between national outcome measures, and local variation in how these are achieved.
There isn’t a clear-cut answer to this conundrum, but I think we can learn a lot from international comparisons in the approach taken by different jurisdictions.
Judith
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