The King's Fund is an independent thinktank focussing on the health system in the United Kingdom. Founded in 1897 it is a non-government organisation and charity that actively publishes research and analyses as well as organising conferences and other events.
It has a strong focus on the benefits of integrated care – between community (including primary care) and hospital. This interest developed over the years and is now having a noteworthy influence in the direction of travel of the National Health Service (NHS) in England.
Those behind the decision to abolish district health boards (DHBs) in New Zealand next year argue that abolition would be consistent with the current structure of the NHS in England. But the English NHS is presently moving closer to our DHB integrated care structure; like ships passing each other in opposite directions.
Canterbury’s integrated care journey
A considerable influence in the King’s Fund’s thinking and advocacy was innovative work on an integrated care initiative based on distributed clinical leadership that started to get traction in 2007 in one of New Zealand’s largest DHBs – Canterbury (CDHB).
The King’s Fund dispatched to Canterbury Nicholas Timmins (Senior Policy Fellow) with an interesting earlier journalist experience as public policy commentator for the Financial Times. The outcome was a paper co-authored by him and its then chief executive Professor Chris Ham (12 September 2013):
Their paper explored the drivers for change, the leadership values, and the lessons that could be learned from CDHB’s experience of seeking to provide integrated care for all of its defined geographic population.
Its key findings were that the stimulus for change was a local health system that was under pressure and beginning to look unsustainable. Canterbury’s initiative added to the “small stock” of examples of organisations and systems that have made the “transition from fragmented care towards integrated care with a degree of measurable success.” The authors noted that such a new system takes time. What they assessed in Canterbury was a journey of least six years but was still far from complete.
It concluded that it takes many people to transform a system. A small number of leaders were at the heart of Canterbury’s transformation, but this leadership rapidly became collective, shared and distributed. By 2013 Canterbury had a system in which good-quality general practice was increasingly keeping patients who didn’t need to be in hospital out of it; was treating them swiftly once there; and discharging them safely to good community support.
Subsequent to this research Canterbury achieved the remarkable milestone of bending the curve of increasing acute demand – great for patients and cost-savings.
Canterbury’s success was the consequence of a developing genuine engagement culture where leadership was distributed throughout the affected clinical workforce (including hospital specialists, general practitioners and nurses) and actively encouraged by senior management.
There were internal contradictions and it was an incomplete journey. There was also good innovation in other DHBs by contrast it was patchy; CDHB was the leader of the pack in system-wide engagement.
Cardiff & Vale learns from Canterbury
This distributed leadership engagement culture wasn’t confined to the community-hospital continuum. It also was incorporated into improving internal hospital systems. Hospital specialists, nurses and other health professionals understand best both system problems and improvement.
The opportunity for them to lead through distributed clinical leadership was significantly increased under this developing Canterbury engagement culture. Further, this was noticed overseas including by the King’s Fund and in Cardiff & Vale.
The NHS in Wales has similarities with DHBs in New Zealand which our government now plans to abolish. Wales has seven Health and Wellbeing Boards (generally referred to as health boards) serving a population of over 3.1 million. Rather like DHBs, their role is to improve the health and wellbeing of their population and reduce health inequalities for their geographically defined populations. Cardiff & Vale University Health Board covers the Cardiff and Vale of Glamorgan area with a population of around 445,000 (Canterbury’s population of around 578,000).
Early in the Covid-19 pandemic, clinical staff at Cardiff & Vale realised that they would have to make rapid changes to prevent the widespread cancellation of elective surgery. This experience – process and outcome – are discussed in an interesting recent blog (27 May) by Ben Collins, a project director (including policy and new care models) in the King’s Fund: https://www.kingsfund.org.uk/blog/2021/05/leadership-innovation-covid-19-cardiff-vale
This collective realisation quickly led to reorganisation of surgery within the health board’s hospital network by creating Covid-free ‘green zones’ and making substantial changes to how services planned and delivered elective operations (including pre-assessment and establishing dedicated and self-contained clinical teams to deliver surgery pathways rather than sharing staff with other services). The result was significantly better patient outcomes including much greater access to treatment than would have otherwise been the case.
Collins notes that this involved abandoning a traditional model of senior oversight of major projects. Instead health staff leading the projects took much greater direct responsibility for decision-making, within a teamworking model, which provided a different form of oversight and challenge. In other words, in my view, leadership was distributed.
What is even more interesting is where the innovators at Cardiff & Vale got their inspiration from:
"In Cardiff and Vale, leaders have been investing in system-wide approaches to improvement, building on the model from Canterbury, New Zealand, for the last five years."
And yet the Canterbury senior management team who supported this model were savaged by our Health Ministry, the Health Minister’s crown monitor, and commissioned business consultants (who are also now leading the implementation of the Government’s health restructuring).
This savaging is fully discussed in my two background articles published by the Democracy Project: https://democracyproject.nz/2021/04/15/ian-powell-a-very-bureaucratic-coup-part-one/ and https://democracyproject.nz/2021/05/19/ian-powell-a-very-bureaucratic-coup-part-two/. It culminated in external business consultants Ernst & Young being engaged to do what amounted to a hatchet job on CDHB’s supportive senior management team: https://democracyproject.nz/2021/02/09/ian-powell-when-business-consultants-are-commissioned-for-hatchet-jobs/.
Thank goodness for their health professionals and population that Cardiff & Vale wasn’t subjected to such hostility from a managerialist leadership culture like that experienced by its inspirational innovators in Canterbury.
Now, rather than the rest of our health system learning from Canterbury, perhaps the whole of the system should learn from Cardiff & Vale.