When faced with problems of bad press and the need to build (and staff) an additional hospital for your largely aging population, what’s the solution? And by the way, you don’t have any money. Sound familiar?
In 2006, the region of Canterbury in New Zealand was faced with this question. Their solution was integrated services, in which patient’s time was put first. To skip to the end, Canterbury developed and implemented a strategy which over the first four years, saved over 1.5million days of patient time, and within seven years had the proportion of people aged 65+ attending the emergency department dropping by over 4%.
How did this happen? It started from a recognition that the track record of chief executives and boards telling staff to change simply doesn’t work. Instead, the Canterbury District Health Board (CDHB) created ‘Vision 2020’, in which 80 members of staff (referred to as ‘the 80’, ranging from chief execs to cleaners) were pulled together into workshops to think radically about health and care in the future.
How did these processes contribute to such significant change? Four features were key.
Who knows nothing about health and care?
CDHB made a point of inviting industries to the workshop that had no relation to health but had valuable lessons, these included:
Bringing in other industries allowed the 80 to draw their own conclusions. They were then given a card, stating ‘you have permission to change the system’, signed by the CEO. This simple gesture was an act to empower the 80, and allow them to dream and discuss change rather than feeling hopeless about it.
Reframing the problem
The 80 were not asked to think about what services should be stopped, but rather how they can best spend $1. They did this by focusing on patient time and outcomes. This led them to putting patients at the centre, where patient time – not cost – should be the metric from the outset.
Scrapping what a meeting usually looks like
Canterbury realised that traditional 3-hour meetings were not going to help them think sufficiently differently. Instead, CBHD produced ‘Showcase’ – an interactive experience designed to break down siloed thinking and push the limits of health professionals to plan in new ways.
This involved setting up an old warehouse where small groups experienced a health care version of Dickens’ Christmas Carol: the ghost of health care past, with statements such as ‘that’s not my job’ displayed on large briefcases; and the ghost of health care in 2020, with 82 year olds Skyping their GPs.
Canterbury's 'Showcase' interactive exhibit
Participants from across Canterbury were asked how they would like to be treated, and what their personal role could be in transforming the system to achieve this.
All conversations were recorded in infographics on large paper for people to hang up in their hospitals. Showcase was highly popular for the six weeks it ran, with 2000 visitors, some of whom travelled from the other side of New Zealand to visit.
To implement change, participants were asked how you equip people with the skills needed to make change happen. The Board’s Chief Executive, David Meates, then set up ‘David’s Den’, a dragon’s den for groups to pitch their healthcare ideas to him.
One outcome was upskilling GPs, for example in removing skin legions, which reduced waiting times from 8 months in some cases all the way to 8 days. GPs have also been able to better address a patient’s issues through www.healthpathways.org.nz, a website that acts as a referrals directory and what cases can be treated in house.
Lessons for the NHS?
In England, we’re big fans of talking about radical change. Tony Blair stated in the NHS Plan of 2000 “at every level there will be radical change”. Lord Darzi’s review of 2008 proclaimed it “will improve services radically for patients.” The Forward View of 2014, emphasised “a number of radical new care delivery options.”
However, our ability to walk the radical change walk is not quite as impressive as our talk. One lesson from Canterbury is that if we want very different services, it helps to approach how we think in a very different way. The sustainability and transformation plan process might provide an opportunity, yet with a highly compressed timescale (described by a recently departed NHS England leader as “shameful”), it doesn’t appear to be one we’re grasping. A radical change for the NHS? Let’s plan to plan differently.
Further analysis of Canterbury’s transformation can be found in Chris Ham and Nick Timmins’ analysis for the King’s Fund, and in Judith Smith and Nick Mays’ article for the BMJ. Tanuj's blog draws on an event attended whilst working for the Health Foundation.