In Canterbury, New Zealand, a new holistic approach to healthcare has been the goal for six years, with measurable success. A report written by The King's Fund - an independent charity working to improve health and health care in England - looks at the work undertaken by New Zealand’s Canterbury District Health Board (CDHB) to create a more integrated, patient-centric, efficient and high quality healthcare system. Authors Nicholas Timmins, Senior Fellow, Health Policy and Chris Ham, Chief Executive explore how an integrated system has improved health care in Canterbury, and consider the lessons which other countries can learn from the Canterbury model.
The driver of change in Canterbury was a health system which had come under pressure and which was not future-proof. The situation of the Christchurch CDHB hospital in 2007was a significant trigger: the 500+ bed organization regularly went into gridlock due to high demand in the emergency and other departments. As a result of this critical situation the hospital was frequently scrutinized in newspaper headlines. It appeared that the construction of an additional hospital of a similar size by 2020 was unavoidable, a 20 percent increase in the number of GPs and nursing staff would be required, as well as 2,000 additional beds for elderly care.
An analysis showed that this approach was not financially viable. For this reason, an expert group was established with the aim of identifying leaner processes, based on Six Sigma and other management and project methods. In the end, this expert group involved 2,000 of the 18,000 CDHB staff. The key conclusions which emerged was that a single health system and a single budget for providing care were a sine qua non - "one system, one budget". In the emerging "healthcare landscape", the patient is placed at the centre... and the hospital merely plays a peripheral role.
The approach to reform
Patients should take on more responsibility for their own health... this was another change which was required - the aim being to keep the patient at home in their neighbourhood for as long as possible. In cases where complex hospital care cannot be avoided, access to hospital care has to be quick and relevant. This new approach in Canterbury - a programme entitled "Xceler8" - consists of three pillars: top-quality primary care which keeps patients from being admitted to hospitals e.g. through outpatient services which used to be performed by the hospital; quick care for hospitalized patients; and provision of good health and social care within the community. The CDHB Board agreed this new distribution of services with all the key stakeholders.
This new "healthcare landscape" required a commitment to ongoing investment in the competences of the staff and contract partners - and it required new types of contracts of a collective character in which budgets became transparent and profit and loss pre-determined.
Technology plays a pivotal role
The adoption of enabling technologies was key to the reform. Some of the technologies deployed originate from New Zealand - e.g. HealthPathways, a tool which helps implement locally adjusted best practices, as well as an electronic referrals management system (ERMS) for planning collaboratively with the hospital. The patient-centred website HealthInfo realizes HealthPathways in lay language, and Electronic Shared Care Record View (eSCRV) - based on a platform provided by e-health solution provider Orion Health - offers care providers across the healthcare spectrum access to a platform of consolidated electronic patient records. eSCRV consolidates information from pharmacies, community care, GPs, as well as hospitals and specialists. In addition to these solutions, CDHB also acquired tools applied in health systems outside of New Zealand, including solutions for falls analysis in homecare and for medication management.
Integrated care requires close collaboration and widespread adoption across the entire healthcare value chain; technologies such as those used in Canterbury enable seamless interlinking between sectors, which is a prerequisite for success.
The current status
Today, CDHB managers measure the success of their reform based on three indicators: 1. figures of acute care admissions, 2. average length of stay, and 3. readmission rates which are all lower in comparison to other Health Boards in New Zealand
Waiting times for patients have also been significantly reduced whereby direct access to diagnostics tests for referring physicians has led to better preparation for specialist outpatient care. The reform has had a positive effect on budgets: in 2007, the deficit was NZ$ 17 million and turnover was close to NZ$ 1.2 billion. By contrast, in 2010/11 CDHB was in the process of generating a surplus of NZ$ 8 million. The earthquake which struck Christchurch on 22 February 2011 - taking the lives of 185 people and injuring over 6,600 people - disrupted this trend.
Today, the number of beds at CDHB's hospital may be slightly less than prior to the earthquake. Reducing that number has not been a goal of the reform however - avoiding an increase in the number of beds and large capital investments to meet future demand is a key objective for CDHB.
Convincing the stakeholders
Modifying an entire system requires the buy-in from a number of stakeholders. In Canterbury, leaders played a significant role. However the management of change was decentralized. Change required time, and Canterbury has been working on achieving one single comprehensive system and one single budget for over six years, and this process is ongoing.
A clear vision of an integrated healthcare value chain played a key role in motivating stakeholders to improve the future of care. The system was to be patient-centric and truly integrated, removing duplication and waste, saving patient time and - in addition - improve staff productivity and job satisfaction. Acceptance for change was achieved by focusing on reducing patient wait time. This provided relevant arguments to achieve leaner processes. And most importantly, CDHB displayed its willingness to support this change in values by making significant investments in enabling technologies.
Integrated care - conclusions for Europe
European health systems require innovative solutions to address public pressures to improve healthcare services while also addressing ballooning budgets. Canterbury is developing an integrated, patient-centred health system that is also focussed on delivering high quality care. Canterbury offers innovative and practical approaches that European policymakers and stakeholders may wish to adopt and tailor to meet their own health systems' needs.
For more information on New Zealand's health system and the providers involved in CDHB’s journey towards integrated care, please contact:
New Zealand Trade and Enterprise
Nicola Taylor
Business Development Manager - Germany
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https://www.nzte.govt.nz
About the Canterbury District Health Board
The Canterbury District Health Board (CDHB) organizes and funds - based on taxes with some out-of-pocket contributions from patients for services - the entire spectrum of health and social care for more than 500,000 citizens in a remote region of New Zealand’s South Island. Six years ago, the organization launched a reform programme aimed at ensuring effective, quality services and access to care across sectors. Technology plays a major role in this reform, in particular IT-based information management.
About the King's Fund
The King's Fund is an independent charity working to improve health and health care in England. They help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate.