Health secretary Jeremy Hunt has said he wants to develop “integrated care organisations” in the English NHS, with NHS hospital trusts taking a lead role in forming them. This has been challenged, quite naturally, because trusts are focused on hospitals, whereas integrated care demands a different orientation and a broader perspective on who should be providing care, for whom and where.
The worry is that if trusts are in charge, the end result of “integrated care” will be that hospitals dominate. If so, this would be counter-intuitive as for the most part the literature on integrated care emphasises the need for a pivotal role for primary care (day-to-day providers such as GPs) in care planning and delivery, and for involvement of the full range of health and social care providers. After all, an aim of integrated care is to keep people well and out of hospital through better care planning especially for those with chronic diseases.
Forming alliances
What then might New Zealand’s experiences have to offer the English NHS when it comes to integrated care? Well, New Zealand has a healthcare system not dissimilar to England’s, albeit with a bit less of the “national” focus. Like England, it has been striving in earnest for integration since at least the late-1990s, and, I believe, it has finally produced a governance arrangement worth a look. This is referred to as an “alliance”.
The alliance model derives from the world of construction where contractors on large projects work collaboratively and share resources as necessary to get the job done on time and in budget. It was piloted in New Zealand’s public health care system from 2010 in several different contexts with mixed results, at least in the short term. Importantly, however, it offered a mechanism for bringing the spectrum of healthcare providers together.
Since 2013, an alliance has been required in each of New Zealand’s 20 healthcare districts. Notably, each district has distinct institutional arrangements that have hindered efforts at integration: a primary health organisation or two which government-subsidised yet private GPs are loosely aligned with, and a district health board which plans local services and tends to be hospital-centric, as this is where most of its budget is allocated.
Each alliance is a mechanism for bringing together an appropriate range of providers from across a region. Members are leaders, preferably clinically-active, from different service areas such as GPs, nurses, aged care, ambulance services, public health, hospital specialities and so on. Importantly, an alliance also features those who command resources such as chief executives of the respective district health board and primary health organisations. This is so that decisions around how best to integrate the various services for a particular type of patient, service or condition can be clinically-driven and resourced by the respective providers conterminously.
Ideally, an alliance should also have independent chair and community representation in order to keep the various clinical and managerial members honest and focused on what patients would like to see in terms of how services are organised and where they are delivered.
Broaching difficult terrain
An alliance has considerable flexibility to plan for local healthcare needs and, within reason (and government policy parameters), can set its own priorities. What sets New Zealand’s alliances apart from present NHS discussions is the absence of concerns about the interests of particular groups (such as private corporations). This is because alliance members sign a charter binding them to work collaboratively in good faith with one another with a focus on the “whole of system” and put aside their own specific interests.
Obviously, this means there are potential losses for some such as hospital speciality services whose funding could suffer if an alliance agrees that GP-based services should be bolstered. This is difficult terrain. However, an alliance also has an unwavering focus on what is best for patients and the healthcare system per se meaning it would be inappropriate for one group to fight to retain resources rather than support better integration if this meant everyone – especially patients – would be better off in the longer term.
New Zealand’s nascent alliance model has yet to be fully tested. It does, however, offer a promising alternative for public health system and integrated care governance, which NHS policy makers could consider if they’re serious about finding a fair and workable system.
To see how UK and New Zealand health spending compares (along with five other OECD countries) in a neat infographic, click here.