Episode 1 - The Canterbury Story

Welcome to How to Build an Integrated Health and Care System, a channel sponsored by Health Pathways, joining up care and clinicians across the world. Hello, I'm Dr David Hamilton. I'll be your host and guide in this the first of a series of podcasts that explores integrating systems. How to build an integrated health and care system seems to be something that many people in the NHS and actually right across the world are turning their attention to right now. But what do we mean by integration? And more importantly, what are the essential bindleding blocks that you need to put in place to actually make that change happen across the system? In the coming weeks, we're going to be exploring all sorts of different issues and challenges, including primary care and secondary care and how you get those two elements of the system joined up, focusing on mental health, recovering from disasters such as we're experiencing now in our pandemic, the role of the state and many other things. I'll be interviewing chief executives, system leaders and clinicians from New Zealand, Australia, Canada and throughout the UK. I hope that we will give you insight into firstly, why it is so difficult to get system players to come together and behave like they are truly in it together. And more importantly, how you go about engendering that philosophy in your own local system. I've spent more than 30 years working in the NHS in England as a frontline clinician, a consultant geriatrician actually, and then a range of director and then chief executive roles across what we currently call commissioner and provider organisations. I now work independently and split my time between helping to support systems with change management in the health sector and working with streamliners, the provider of health pathways and sponsors of this channel. I would also say upfront that when we talk about health systems, we use that term to embrace a wide range of activities and we specifically acknowledge the intimate links between social care, the third sector organisations and health generally. It's also worth saying that most of our patients and indeed the population as a whole take the granted the fact that people in our business don't behave like in other businesses. We all assume that basically doctors and nurses, specialists and GPs, social workers and physiotherapists are all pretty well connected and frankly play nicely together, particularly when we're talking about patient care. So let me start by describing some other things that really do not help those of us working in health and care systems to exhibit those types of behaviours. For about the last two decades we have spent a lot of our time trying to design our health systems to allow market forces and specifically competition to drive up standards and quality of care, as well as somehow also improve some of our health outcomes. We have seen the introduction of autonomous profit making hospital based organisations, foundation trusts operating in a supposed free market competing with each other to treat patients. Coupled with the payment by results tariff system, this was all meant to enable the best performing and highest quality organisations to increase their share of that market but also drive up standards in other less well performing organisations. However, there are a few people that would now dispute the fact that this philosophy has fundamentally failed. Financial problems still beset many NHS organisations and there remain wide and unacceptable variations in standards of care for patients. The national tariff payment system is almost certainly now about to be abolished, foundation trusts will be expected to collaborate with one another rather than compete and the new language is now all about system leadership rather than organisational success. When I became chief executive of the then newly established clinical commissioning group in South Tyneside it was abundantly clear to us that in a fairly small, intimately connected borough we needed to establish and build strong relationships with our partners and start to behave in a way which ran counter to the prevailing policy direction at that time. At this point we were lucky enough to meet a team from Canterbury District Health Board in New Zealand. They had already established an incredible track record and a reputation of being world leaders in integrating health and care. The independent think tank, the Kings Fund and others, wrote glowing reports of the success of their system working but it was not always this way in Canterbury and it definitely did not start life as one of the most integrated systems in the world. I talked to David Metz, the former chief executive of Canterbury District Health Board about what life was like in the early 2000s in Canterbury. David, thanks very much for sparing us your time here. It's really great for you to speak to us from the other side of the world. I'd like to start by just asking you a little bit about how the Canterbury system was in the beginning of your journey really and where you started from. So Canterbury was an exemplar of a fragmented, disjointed, broken system that was made up of lots of different people and organisations doing their best to working really hard but not in a joint up connected way. There were again lots of different organisations, primary care, organisations, general practice, community pharmacy, eight residential care, non-government organisations as well as all of the professional tribes that existed within the existing hospitals. So again, there wasn't a sense of a system. There was a sense of lots of different provider organisations competing against or competing for a finite pool of resources and that sense of working together in collaboration was just not part of the system and yet all of the people that were working within what was going to become the Canterbury health system really talented and gifted individuals, really talented and gifted departments and really talented and gifted siloed providers. And again in the context of Canterbury, it had been a region that had run deficits for at least the decade beforehand, had really poor history on safety and back in the early 2000s there had been a big external review titled 'The Patients are Dying' and again a system where management, clinicians, the board and the community were all at war with each other and a public media element that was totally negative. The District Health Board had failed to deliver on elective targets for again since its establishment and the hospitals were in gridlock pretty much every single day. That description of a disjointed, fragmented, fairly broken system can sound pretty familiar to us but things were about to get even worse in Canterbury as the local hospital exited or removed around 5,000 patients from its waiting list. Carolyn Gullwing now takes up the story. Carolyn currently works as a strategic advisor for Lightfoot Solutions here in England and Wales, advising a number of systems but she is also the general manager of planning, funding and analytics at Canterbury District Health Board. Yes actually David, at the time that those people were exited off the waiting list I was actually the chief executive of the primary health organisation. I was on the receiving end of number of people being exited and it wouldn't be an exaggeration to say that the general practice teams I was working with were almost in tears in despair about what they were going to do with these patients who had been waiting quite often quite a long time and were either waiting for outpatient or surgical events. So what we did and what we were able to do was actually we got the whole 5,000 people and we managed them back into the system. Either by delivering their care out of general practice, which in a New Zealand based system where general practice isn't free, we had to organise to actually arrange free visits for these patients. We found often that the care that they needed could be delivered in primary care but had been referred to a hospital based system because the hospital was free. The nice thing about the process as we managed each of those patients back into the system and made sure they got the care that they needed, is it helped us learn and it helped us understand why the system had broken in the first place. And the fundamental underpinning problem was of course communication. It was about the hospital based system and the primary care based system not knowing what each other did and therefore general practice didn't know who they should refer, they didn't know what the thresholds were, they didn't know what their alternatives were, what their other opportunities were. And neither did the hospital based system understand what general practice could do. So that started again what we see in Canterbury as being one of the core parts of building an integrated health system, which is actually conversation. You can't change people's behaviour, minds, you can't change how a system works without getting people in a room and having a conversation. So it seemed that in Canterbury, something needed to change and it was about to. David Meigs now describes something of a new beginning. The initial part of the journey started with 40, then about 80 of leaders within what was going to become the Canterbury health system. Not necessary people in terms of titles, but those that were able to or key influences both in primary care and in the hospital part of the sector, NGOs and the broader community. And again the part where we're starting to engage the community of saying if we're going to really create a different health system, we needed to have the input of a broader range of people than just the traditional health input. The beginning part of the journey started with these thought leaders that a series of two-day workshops that were done on weekends that were not paid were basically there in terms of people wanting to create or be part of creating something different. And in those conversations, beginning parts of the workshops, what was involved in that were a number of other organisations to prompt and challenge some of the thinking. So high-performance sports teams, like the New Zealand netball team, New Zealand, which had a long history of innovation, particularly in terms of customer service, environmental organisations, they were all part of a structured set of workshops that were about creating a conversation that wasn't anchored just in health in a site that was totally different and non-related to health. And one that prompted a set of dialogues and conversations of people starting to challenge those that worked in with health, what was important, and what started emerging from that was the concept of the citizen-centred health system that became such an important part of the foundation of the Canterbury health system. The beginning part of the concept of actually the patient at the centre of the system, not as traditional health systems would have as the hospital sitting in the centre of the health system. So the beginning parts of actually how do you start reorienting a health system that's built and designed around the patient, the citizen, actually the core stakeholder in every health system kind of in the world. And again, what started falling out of that was some of the key things that were really important in terms of a connected system, one that was centred around people and one that aimed not to waste their time. And time started becoming the default for dollars. Why time was important as a construct is that actually everyone can understand the wastage of their time, whether it be a patient going to see a GP, getting bounced around the system, having to go and get tests at lots of different places and no one quite coordinating that and then being referred to into the secondary or tertiary part of the health system and then going through these inordinate complex processes and systems that were all very much designed around how organisations wanted to work, not actually what was patient or citizen centric care. So that concept of wastage of time became the really core metric of the Canterbury health system. So it seems like getting people in the room is certainly important. But equally getting them to focus on doing things differently. Here's Carolyn Gullery again. So one of the interesting things about the Canterbury system is if you talk to us about how Canterbury works, they say we just get everybody in a room. And that's because we deliberately set out to build a system based on trust. Now you can't have a system based on trust if people don't know each other. You can't have a system based on trust if we aren't all seeing the same thing. So we deliberately got people in a room and we built a shared understanding of what we were trying to achieve as a health system and what good looked like. We built a shared understanding of what each of us were doing and what role we had to play in that system. And we unleashed a system to work on the basis of trust and a really simple set of principles. So we designed the system around three key principles, which was building a system that supported people to stay well and look after themselves wherever possible in a community-based setting. Building a system that supported people to stay in a community-based setting with the support of their general practice team and the community providers with that concept of a single point of continuity, which for most people would be general practice. So designing a system to support that and then freeing up our hospital and specialist-based system to be able to support people when they were acutely unwell and support primary and community providers to do what they did. So that was the kind of strategic goals that we agreed for a health system. But what was really more important than that was freeing up a system to say, "This is about putting the patient at center." And we really meant that. It wasn't a trite statement, which you hear repeated all over the world. This is about saying, "If it's better for the patient, do it." So we freed up an entire health system to say, "Is this going to reduce the amount of time that a patient wastes waiting to get to the next step on their journey?" Then get it done. And that empowered the clinical teams because the reason we use time was because that's really important to patients, but it's also something everybody can measure. We all know what time is and we all know when we're wasting it. So when you turn around and you say it's about not wasting the patient's time, it ensures that you put the patient at the center of your thinking. It also means that everyone can measure it. Everyone knows what good looks like. But on the other hand, it changes the paradigm in the conversation. Because if you're a group of specialists and you're a group of general practice team members and it's all about the patient's time, you can't make it about you and you can't make it about your system. It's actually about how do we make it better for and Canterbury's case, Agnes. So establishing this new order of things and new way of working sounds very laudable indeed. But things didn't always go completely according to plan. Here's David Matzigan. So right at the beginning part of the engagement, we almost made a fatal mistake. We got the hospital part of the system together with the first workshop without primary and community care in the room. And again, it reinforced that actually if we were talking about a different journey and we continue to then just engage the way that we had traditionally done, we were not going to get past step one. That first faux pas required a lot of relationship building and repair to get and to encourage primary care in the NGO sector to be back into this process. That it was going to be worthwhile for them to be part of that. Again, it was just one of those simple things that no ill intent. But again, continuing to think of the old ways that we used to approach things. And it is one of the challenges that we often look to the future with our backs to the future and kind of try and create solutions with all the tools and all of the baggage that we've had in the past. And then we dress that past up with a new set of clothes and we somehow call it a future. That was the journey that we had just about started on. In a funny sort of way, that was the first bit of actually what was going to be really important in terms of some of the values around trust in particular, I've actually been out to acknowledge we got that wrong. Learning from that experience was an important part of the Canterbury journey. They went from strength to strength and became world leaders in delivering really truly integrated health and care. We'll hear more about their story throughout this series. But we're finished by asking David some advice that he might have for those who might be starting out on their journey of integration in other health systems. I guess there are a couple of things. One is you can't expect things to change by just continuing to do what you've always done. And generally speaking, all of our learnings in the past we might call that experience are often anchored in yesterday's thinking and yesterday's systems. So, you know, kind of an important part is starting to orientate yourself to the future and starting to look at how do you solve the problems of the future and the context of the future, not the past. Another aspect of that is you can't jump a chasm one step at a time. So, doing lots of incremental change, you will invariably have a sense that you're doing a lot. But with almost absolute certainty, you will end up just be putting a new set of clothes onto the existing framework and you will have not have actually changed anything. It might look a wee bit more modern. It might look a wee bit more flash. But actually fundamentally, that's the same. Needing to look at where the incentives lie, because actually if you're held to an activity-based contract as your key metric, the one thing you'll continue to do is deliver brilliantly against that incentive, because that's what you're held accountable for. And so there is an element within a system of starting to change mechanisms that change the incentives that are aligned to integration. The other bit is when leaders talk about integration, it's often as I'll collaborate as long as you do it my way. And you end up with the stance of lots of different leaders that actually don't have the skills or necessarily the capabilities to actually collaborate. And so there's a danger of assuming that actually leaders know how to collaborate. So there you have it. In Canterbury, they have deliberately changed their focus. They concentrate on getting people in the room to have the right conversations. They focus on patient's time, not wasting it, and deliberately take money off the table, instead developing strong relationships and trust. In the coming weeks, we'll explore in much more detail what it takes to deliver this very significant change, this paradigm shift. In our next episode, we will be having a focus on achieving that culture change, how you focus on having deep conversations and changing culture and behaviours, rather than those structures in your system. So thank you once again to our sponsors, Health Pathways for this channel. Thanks to you for listening, and join us again next time as we explore how to build an integrated health and care system. Goodbye.