Why Canterbury's health system is doubling down on its drive for change
Source: https://www.stuff.co.nz/news/110805413/-

2019-03-08 15:18:54

Canterbury District Health Board (CDHB) chief executive David Meates is in no doubt. His health system is doing world-leading things.

Even if at times, he grins – blame the confusion and politics of having also to run an earthquake recovery these past eight years – that fact has felt a little unappreciated up in Wellington.

Since Meates arrived in 2009, CDHB has been embarked on its Vision 2020 health reforms, a revolutionary "wellness-centred" approach to public health delivery.

The aim is nothing less than a complete organisational transformation.

Through the seamless integration of hospital and community services, an increasing focus on preventative interventions, and letting staff lead the redesign of the system, CDHB has managed to slash runaway health spending in the region.

Just one example, Meates says, is Canterbury gets by with 30 per cent fewer hospital admissions than the rest of the country because its GPs are encouraged to do minor surgeries and community nursing teams manage patients in their own homes.

"We really have a story to tell here," Meates says proudly. And internationally, this is recognised.

Visitors arrive weekly to learn. Australia and the United Kingdom have been nicking CDHB's methods wholesale. Studies say Canterbury is the place to come to see where a modern health service ought to be headed.

And Meates says thank goodness the health board had begun its reforms when the February 2011 earthquake hit. Otherwise, the system could have imploded.

"Remember, we lost 44 buildings."

Rather than shelve its Vision 2020 changes following the quakes – which you might think would be the natural response in such an emergency – CDHB instead made the decision to double down on them, even as the dust was settling in the first few weeks.

The efficiencies the transformation plan promised were going to be needed even more in a crisis, Meates reasoned.

"It sounds counter-intuitive, but after the earthquake, we needed to accelerate what we had already started doing to enable us to survive."

And so – extraordinary perhaps – Meates felt CDHB could soldier on, at least until the hospital rebuildings began in earnest, on its existing business as usual (BAU) budget.

Then came the politics and confusion. Wonky modelling by the Ministry of Health (MoH) over-estimated the likely post-quake depopulation of the region.

Meates points out that even those who fled Christchurch mostly stayed within Canterbury's borders. They were on his budget. Not to mention there was soon a flood of arriving construction workers.

But the MoH said, by its calculation, CDHB could run a recovery on about $60 million a year less than it was getting even under its old "peacetime" population funding model.

A crazy situation. Did CDHB shoot itself in the foot by coping too well straight after the quakes, Meates muses?

"Because we kept on delivering, we kind of reinforced the view that it can't have actually been that bad."

Friction grew as it did start asking for its full budget. Meates kept knocking stubbornly at the Ministry's door with his spreadsheets and bar charts as evidence.

In response, the MoH hit the health board with one financial investigation after another. Consultant PWC became a frequent caller.

The nadir was mid-2017 when Treasury published a report accusing CDHB of poor financial performance and using "manipulative strategies" to push its case with the Crown.

The bitterness by that stage was visceral. Official Information Act (OIA) documents confirm Wellington bureaucrats were lobbying for the heads of the CDHB's leadership.

But now – well, it's not all over. However two of the key MoH players, director-general Chai Chuah and critical building projects director Michael Hundleby, have departed. The Government has also changed.

And over the past year, a "truth and reconciliation process" between CDHB and Crown has been under way – a name that makes it sound almost like a war crimes tribunal.

So it seems a good time to ask Meates what road CDHB is tracking on now.

Has the funding cloud lifted? Is attention finally going to turn to CDHB's other story of being a world-beating health authority, beavering away at the bottom of the Pacific?

And how much have the earthquakes derailed the scope of those changes? After eight years, has exhaustion set in and are things likely to go quiet for CDHB for a while?

Meates' eyebrows shoot up at the thought of that.

A CHEQUERED PAST

In his black office block overlooking Oxford Tce and the Avon River, 57-year-old Meates seems perkier, more energised, than expected.

He must be a tough nut to have come through his battles with the MoH intact. His dad, Bill Meates, and uncle, Kevin Meates, were both Canterbury-representative All Blacks. His own first ambition, armed with an agricultural degree, was to be a farmer.

Meates' path to being boss of one of the country's largest employers was roundabout. After being a government farm advisor, then national marketing manager for a UK chain store on his OE, he was lured back by an invite to run Greymouth Hospital.

Hospitals in Hawke's Bay and Whangarei followed. Next, chief executive of Wairarapa DHB.

Meates says when he got to Canterbury, the need for big change was already clear because the region had been through a black time in the 1990s and 2000s.

In the winter of 1996, seven people needlessly died in Christchurch Hospital. A report by commissioner Robyn Stent labelled the service as "dysfunctional and grief-stricken".

Meates says the problems had continued with budget deficits, gridlocked wards and missed surgery targets. "There were 7000 people dumped off the surgical waiting lists, back into primary care, in 2007."

So there were reasons CDHB stood ready to embrace a programme of radical reform. And senior clinicians had begun brainstorming the roots of a new "integrated care" philosophy. Meates says his task as chief executive was to crystallise the plan and get it moving.

He jumps out of his chair to point to a poster produced at the time. A simple thought was at the heart of Vision 2020, says Meates.

Put the patient – the customer – back at the centre of the health system. Accept there was one common budget behind it all. Then step back to let staff figure out the best design of the pathways for care and treatment.

"We said the changes would be clinically-led and management-enabled. Usually in health, it's the other way around."

Traditionally, medicine is divided into hospitals and GPs. Different worlds. Consultants run their own empires. If anyone has to wait, it is the patient, as it is the doctor's time that is considered valuable.

Meates says CDHB asked people about their experiences. The sense of being bounced about an unpredictable maze was the big complaint.

That led to a new approach called HealthPathways. Staff teams sat down to consider what ideally should happen from a patient's point of view, all the way from first appointment to final cure.

Meates says the aim was to capture a standard diagnosis and treatment routine for every kind of condition. Gall stones, skin cancer, broken bones, whatever.

"When I arrived, there were nine HealthPathways that were live. I think today we've got about 700."

The pathways approach made it obvious GPs – the frontline – needed to be empowered to make more decisions. In the existing hierarchy, hospital consultants expected to run the show.

So GPs took over minor procedures, like steroid injections and skin lesion removals, that previously required a hospital appointment. Using pathways, they were also authorised to manage the flow of patients into the hospital system.

"HealthPathways mean GPs will manage your condition exactly the same way. And if you're going to need an X-ray, they can organise that." Patients began arriving at specialists with all their tests in hand, cutting out multiple visits.

Meates says plenty of other health authorities around the world were talking about streamlining their procedures this way. But few were doing much, and then often only as isolated projects for some particular department.

CDHB was different in deciding to rebuild its whole organisation in this fashion. And also, in not imposing the changes by management fiat.

"That's part of the magic," he says. Adopting the pathways is voluntary.

"It is not contractually required that people use them. But then everyone does use them. Because it makes it easier to do their job."

HealthPathways meant CDHB had to make major new investments in IT. A key project – one of those that got accelerated despite being in the midst of the earthquakes – was HealthOne, a patient record system that allows medical files to be shared across all levels of the health system.

"If you pick up a prescription, and then later turn up at the Emergency Department, we've now got all the information about you."

That database has now been extended so everyone in the South Island is on it, says Meates. Likewise, the HealthPathways approach has become rapidly adopted by others.

"It's now across 40 health systems around the world. Every state of Australia and a number of parts of the UK."

Another post-quake step was the launch of the Community Rehabilitation Enablement and Support Team (Crest) – a move to free up hospital beds through a programme of early discharges and six weeks of home nursing rehabilitation.

NO BOUNDARIES

The pathways philosophy is working, says Meates. "We now have 10 years of evidence of that." But the scope of CDHB's ambitions are probably larger than many have realised.

Meates says it is the intention to keep extending the pathways – going even beyond the health board's own institutional boundaries – which really makes the Canterbury experiment unique.

This is why he now talks about a wellness focus, he says. CDHB sees its job as building a health lens across life in general for its region.

So it sits in on the policy-making of local and regional councils, making sure community well-being has a high priority in decisions. And it has started co-designing programmes with the region's schools and social services.

One of the first such projects was with Christchurch Police, when it placed a mental health nurse in the central station watch-house.

Meates says the idea is to be present, 24/7, to offer psychiatric and medical assessments. "When police are called out, often there are mental health, or drug and alcohol, issues. Sometimes  physical health issues too."

CDHB aims to head off problems before they escalate, creating pathways starting at the frontline that give police other options.

Another such cross-boundary initiative is the new school service, Mana Ake, or Stronger for Tomorrow, which is a direct response to Canterbury's quake-related mental health crisis.

Meates says by 2016, it was clear the psychological impacts of the earthquakes were much greater than predicted.

Three groups stood out, says Meates, all of whom had been at a vulnerable transition age back in 2011. Newborns and toddlers, teens just moving into secondary school, and women starting middle age.

CDHB is seeing delayed effects. "The kids transitioning from primary to secondary are now your 19-24-year-olds, where self-harm, drugs and alcohol, depression and anxiety, have become very evident."

Likewise, says Meates, there is now an unexpected lump of troubled 9-11-year-olds moving through the schools – the quake babies many thought would be too young to feel the stresses.

Mana Ake is a $28m project to create a team of 80 school support health workers. Meates says the Government agreed the special funding early in 2018. Then following its pathways philosophy, CDHB invited all the agencies involved to take part in designing the service.

"April last year, we had about 90 people – school principals, police, MSD, primary care, specialist mental health services – in our DesignLab in Addington. The framework developed from that."

Meates says by Christmas, Mana Ake teams served 100 schools. It will be 216 by this April. Teachers will have options – a recognised health pathway – if they spot children with difficulties in their classrooms.

Like every organisation, CDHB does make mistakes, says Meates. Often there are times he hangs his head. It isn't great at everything.

But it can boast something very different is under way in Canterbury, something you won't find so advanced in its implementation anywhere else in health care, he says.

NEXT STEPS

There are some who have remarked it is not surprising CDHB managed to get offside with the Ministry during its recovery budget battles. Sometimes the health board can sound a little big for its boots.

Meates admits he had a bit of that impression himself when running Wairarapa DHB.

"Canterbury could be frustrating from a North Island perspective. They liked doing things differently – and so often, they were right."

But what is happening next for CDHB? Is it finally time to sit back and relax, digest all the tumultuous changes? Hardly, Meates replies.

He says everyone knows how difficult it has been for CDHB staff, particularly at Christchurch Hospital, who have been both operating in a quake-broken environment, and also having to reinvent their systems at the same time.

Meates says the hospital has had to continue functioning through huge disruption. "You have the country's second-largest tertiary facility where 50 per cent of all clinical services have shifted on average four times."

Christchurch Hospital finally opened its new outpatients building and Manawa nurse training centre in January. The replacement Acute Services Building (ASB), although a couple of years over schedule, should be finished in July, ready for moving in by the end of the year.

Yet Meates says the unhappy fact is plenty of other repairs and rebuilds are still to come. The hospital campus will be a construction site for the next seven or eight years as well.

He worries about the unsustainable pressure on staff. Red flags, like sick leave, have ticked up.

But again CDHB is in the position where it must continue to press on with its HealthPathways reforms just to afford the costs of its own recovery.

"We're in this really interesting place in terms of the stuff we're doing that is right at the cutting edge, but there's the other element of how we can keep moving at the speed we are," Meates says, with understatement.

The good news of course is a change in both government and MoH management has brought a clean slate for CDHB.

Meates says last year's truth and reconciliation discussions won acknowledgement CDHB had been right about its population figures and the extent of the mental health need.

"It's agreed we aren't in a BAU situation and won't be in a BAU situation for a long time. There's now a much more consistent and shared view of what we are facing."

It is yet to be seen what this means in terms of funding.

And the fine print of the report back from the independent chair of those meetings, Garry Wilson, last November, suggests CDHB hasn't completely carried the day. Meates might be being optimistic.

CDHB has already been told its projected budget deficit for this financial year is way too high at $94.5m.

Putting CDHB's case, chair Dr John Wood has blamed the over-run largely on the ASB delays. Christchurch Hospital is having to outsource its surgery to local private hospitals at the moment.

On any day, it might be hiring eight operating theatres. That accounts for $50m of the budget blowout, Wood says.

Then the faulty way MoH has been calculating CDHB's post-quake deprivation index allowance – part of the population model wrangle – is another $21m hole in its funding, he says.

However the MoH has yet to sign off on the deficit and told CDHB to try harder.

Nationally, there is a squeeze on every DHB as all of them are running in the red this year. CDHB is caught up in that.

The population modelling argument may be harder to win as well as MoH has said it will have to stick with the 2013 census figures because of problems using the 2018 census data.

Then, in response to CDHB's general claim of being short-changed to the tune of $60m a year, MoH's position remains it "cannot reconcile these figures and does not support this argument".

So the signs are the new goodwill is not going to translate into instant dollars.

However Meates says he prefers to focus on the positives that came out of the reconciliation talks. And one big prize is MoH is backing a business case to consider all the remaining work that needs to be done at Christchurch Hospital. The Ministry had been stalling for some years on that.

Meates says the new ASB, whose two towers will house the emergency department, radiology, operating theatres and surgical wards, will already be at capacity when delivered.

It was designed for pre-quake need. And population growth in Canterbury – remembering the hospital also serves three of New Zealand's fastest-growing districts in Selwyn, Waimakariri and Ashburton – is closing in on what was originally forecast for 2024 or 2025.

So the hope is the business case will authorise two more towers next to the new ones. Word is expected by June.

It is an optimistic moment for Canterbury's earthquake recovery, Meates says. There are better relations with Wellington. And maybe attention will begin to turn towards the innovations CDHB has been achieving.

Meates says once the ASB does open its doors later this year, people will see what happens when you apply pathway thinking to let staff even design their own workplaces.

There will be hybrid theatres that combine medical imaging and surgery. Cleaners, nurses and patients had their input into how it should look too.

"It's going to be different. People will walk in and go wow," Meates says.

The photographer has arrived. Time for the interview to end. But Meates leaps up because he has one more impressive bit of kit he wants to show – something that would be the envy of many health services.

A wall-mounted touch screen application – Seeing our System – is displaying real-time data on every patient going through the region's hospitals. Meates flicks through rapidly.

"There's Burwood Hospital. Mental Health. Ashburton. Christchurch Maternity – you can see we're 107 per cent occupancy in Neo-Natal. And our theatres are chocka. At the moment, 70 people have gone to theatre, 31 are in recovery, 39 have departed theatre."

Instant information ensuring staff can tune patient flows, he says. Bottlenecks can be anticipated.

And it reminds CDHB deals in big numbers. Meates says Canterbury is a large health authority even by world standards, catering for 560,000 people.

This makes it still more impressive that for the past eight years it has been juggling organisational reinvention alongside disaster recovery.

Meates gives the display a pleased pat. From his expression, it looks plain he is keen to be around for the continuation of this story for a good few more years yet.

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