ASMS

Working for better health care in New Zealand

The Association of Salaried Medical Specialists (ASMS) is the professional association and union uniting doctors and dentists in New Zealand.

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Canty DHB’s collaboration throws shade on Auckland leadership’s market model

11 October 2017 Ian Powell for New Zealand Doctor

Does your DHB transact with other organisations, or does it form relationships? Ian Powell of ASMS believes the relational approach helps Canterbury DHB succeed, and avoid the sorts of disputes now surrounding after-hours provision in Auckland

In broad terms, DHBs can function in two ways – relationally or contractually.

The relational approach is evidenced by Canterbury DHB, and is most obvious in its community–hospital health pathways, sometimes known as the Canterbury Initiative.

The other is contractualism, a legacy of the 1990s’ market-driven health system ideology.

The most immediate example of contractualism can be seen in the leadership of the three Auckland DHBs. Now under one chair, Lester Levy, they find themselves in a virtual state of war with primary care, due to the high transaction cost and contractual nature of their relationship and the DHBs’ leadership culture that shapes it.

This has got to the ridiculous point of the three DHBs using the height of contractualism, a Request for Proposal, seeking commercial tenders to provide after-hours primary care.

Canterbury has noticeable advantages over Auckland beyond the latter’s control. It is one rather than three DHBs. More significant is that, in contrast with Auckland, Canterbury has one GP collective voice with which to engage – the innovative Pegasus Health. However, the sharp difference between Canterbury and Auckland is their respective leadership cultures.

Canterbury’s relational experience focuses at many levels on the collaborative working relationship between relevant stakeholders. This has attracted the interest of the London-based King’s Fund, which in 2013 published a report, The quest for integrated health and social care: a case study in Canterbury, New Zealand, by Nick Timmins and Chris Ham.

Last month, King’s Fund research fellow Anna Charles provided a further assessment, Developing accountable care systems: lessons from Canterbury, New Zealand. (“Accountable care systems” is the latest jargon from England’s NHS for the integrated health structures it is seeking.)

Canterbury’s vision

Canterbury’s vision, as Dr Charles says, is a “one system, one budget” process. She describes an aggregation of many simultaneous changes to the way care is organised and delivered:

  • integrating care across organisational and service boundaries
  • increasing investment in community-based services, and
  • strengthening primary care.

Critical to achieving this is networking rather than contractualism, particularly in engaging with and within general practice.

The biggest transformations have been supporting more people in their homes and communities, and moderating demand for hospital care (especially among the elderly). Compared with other DHBs, Canterbury has:

  • lower acute medical admission rates
  • lower acute readmission rates
  • shorter average lengths of stay
  • lower emergency department attendance (at least prior to the recent winter)
  • higher spending on community-based services, and
  • lower spending on emergency hospital care.
Bending the curve

This relational approach has not reduced, but has moderated, the acute care rate. It is “bending the curve” – ie, slowing rather than reversing growth.

Dr Charles points out that behind this turnaround has been the development of around 900 health pathways through a clinically led, collaborative, iterative process, in which hospital specialists, GPs and other health professionals discuss problems and identify solutions.

The process of reaching this consensus both determines, and is as important as, the outcome.

Some pathways have changed the way services are provided, for example, certain diagnostic and other procedures now being undertaken in primary care. The electronic request management system has significantly enhanced patient-related interactions between hospital doctors and GPs.

The King’s Fund research fellow also highlights the acute-demand management system that has been in place for several years. This enables patients with acute health needs to receive urgent care in their homes or communities, avoiding hospital admission or enabling early discharge from the emergency department or medical or surgical assessment unit.

Patients are managed by GPs supported by rapid response community nursing, community observation beds, hospital-based specialist advice and rapid diagnostic tests.

Cost of managing patients

Dr Charles further reports that, among GP practices that refer more people to the acute-demand management system, fewer people present at the ED. The average cost of managing a patient within this system is $140 per episode of care, compared with an average cost of $340 for each person presenting at the ED and $1180 per day per person admitted to an acute medical bed.

In my opinion, the success of this approach meant the previously identified need to build a new hospital in Christchurch and significantly increase resthome capacity by 2011 was avoided.

In what is described as an “unexpected twist in the road”, Dr Charles refers to the devastation of 22 February 2011. In my view, the increasingly embedded relational approach placed Canterbury in a better position than any other DHB to cope with the devastating earthquake that struck on that date.

Dr Charles goes further, describing it as a catalyst that enhanced existing initiatives and led to new ones, such as the acute-demand management system, a community rehabilitation enablement and support team, a falls management programme, and rapid introduction of the electronic shared-care record.

At a fledgling level, the Cantabrian health pathways are being picked up by the other South Island DHBs. There are two key aspects: the “tool” document and the process of implementation, the latter being far more important.

As discussed above, it involves health professionals in both hospital and community care developing the pathway in a way that makes good clinical sense in the local circumstances.

If this relational approach had existed in metropolitan Auckland, the three DHBs’ relationship with the GP bodies would not have become as corrosive and legalistic as it has. ?