Developing accountable care systems: Lessons from Canterbury, New Zealand - The King's Fund August 2017 OR "Bending the demand curve"
is an encouraging document in many ways but does draw stark contrasts with what has been achieved in a relatively small health and social care system over a long time, compared with what STPs and vanguards are trying to do here on a vast scale and very short timescale. The Canterbury District Health Board serves some 544, 000 people and the main hospital in Christchurch has some 650 beds. The “quest” for integration of health and social care in New Zealand started in 2000 and the crisis in demand for acute care, poor performance, high bed occupancy and hospital funding shortfalls began to be addressed ten years ago. Other important differences include a very well-established integration of primary care services through a network called Pegasus Health involving more than 100 practices caring for around 350,000 patients and the fact that patient co-payments to GPs account for about half of primary care income. Furthermore, social care provision is relatively more generous than in the UK and so health and social care entitlement is far closer aligned than it is here. This report identifies three key factors in what success has followed: a unified message of “one system, one budget”, sustained investment in staff training and giving them permission to make changes and, crucially, new models of care and contracts to support and not to hinder them.
One interesting feature comes at the very start of the project was that the “Showcase” event, intended to help staff understand the vision of the future, which was intended to last two weeks and have 400 participants actually ran for six weeks with more 2000 attendances. Common themes in all of the subsequent interventions were the familiar integration across organisational boundaries, increasing investment in community-based services and strengthening primary care. Healthpathways was a programme to bring together GPs and consultants to agree referral and management plans for particular conditions and (rather like our 100 day projects) were welcomed as building trust and so encouraging participation. One GP felt that how such plans are agreed can be as important as the outcomes. These were, of course, subject to audit, review and adaptation and resulted, for example, in more diagnostic tests being ordered directly by GPs. All referrals became electronic allowing feedback between consultants and GPs. An internet website was set up for patients to use and was aligned with the HealthPathways criteria to ensure a consistent message. There are now some 900 pathways and the website was looked at 1.3 million times a year by a population of 544, 000. Acute demand management has been running since 2000 with urgent care available at home managed by GPs and supported by “rapid-response community nursing.” This has reduced hospital stays as patients can be discharged home earlier too, for instance, allowing intravenous therapy to be given at home. Paramedics and emergency department staff can refer into the scheme. Costs are about half that of hospital stays. Reviewing this one could not fail to reflect on all the brief-lived “assessment bed” projects and difficult relationships between GPs and community hospitals we have seen locally over the same period. There is a shared care record scheme using existing computer integration rather than attempting a new all-embracing information system. GPs can use prepopulated forms to order tests and make referrals and these were designed by the people using them.
The 2011 Christchurch earthquake, contrary to what one might expect, actually accelerated the acute demand management system with lasting impact. Incidentally, hospital admissions fell in the aftermath.
In conclusion, the experience from Canterbury is that demand for acute hospital care can be ameliorated but not reduced by investing in community-based care but that to work these need time, consistency (New Zealand’s health services have not undergone numerous reforms in recent decades) and commitment from all parties to work together for the greater good of a common purpose. Although more frail elderly patients are now being cared for outside hospital and acute admissions have “been moderated” there has been no reduction in bed numbers, no resources have been diverted to community-based care in real terms and the financial situation remains challenging. The King’s Fund suggest that the NHS should therefore aim at “bending the demand curve” rather than trying to reverse growth.
Dr Barry Moyse
Deputy Medical Director