Harriet Maltby is a Government and Economics Researcher at the Legatum Institute and a former Senior Parliamentary Assistant.
Were Britain to have a modern religion that could match the fervour of historic dedication to the Church, it would be our dogged belief in the exceptionalism of the NHS. Yet it is this dedication to our state health system that stands to be its undoing.
The problem with the belief in exceptionalism is that it discourages an international search for innovation and improvement. With common health and budgetary pressures threatening the survival of a ‘national’ health service, it is international experience that can help save us. And as shown in the recent NZ-UK Link Foundation lecture series from New Zealand Professor Robin Gauld, we need look no further than our Kiwi cousins.
It is New Zealand, not the UK, that boasts the world’s first ‘national health service’. Despite great experimentation – from markets to democratic governance – since its inception in 1938, it remains the system closest to the NHS, and one facing a very similar set of challenges. As in the UK, reducing A&E admissions and a focus on primary care are both policy priorities in New Zealand.
This commonality makes New Zealand’s health experimentation particularly relevant to the debate over the future shape of the NHS. Where we have talked but not yet dared to tread – using charging as a means to control high demand for GP services, for example – New Zealand has already implemented. Free from the burden of exceptionalism, it shows us what can be done.
In some instances, New Zealand has imported a UK model and innovated around it. Clinical governance – the system through which NHS organisations are responsible for continually improving service quality – is a good example. Invented in the UK, it is a relatively recent project in New Zealand. Implementation has been patchy across the country’s 20 administrative health districts, but some successful areas have shown real creativity in its adoption. One such region has adopted a senate style model, bringing 24 professionals from all sectors of the local health system together to work on system improvement. If the UK is to continue to be a world leader in this area, implementation abroad provides interesting ideas for improvement at home.
In other areas, New Zealand organisational innovation marches past the UK. Both governments have sought local/regional health structures that take a ‘whole of system’ approach. In the UK, this saw the Coalition concentrate power in the hands of GPs through Clinical Commissioning Groups (CCGs). Whilst GPs represent a single interest group, they see the demand in the communities they serve. The New Zealand Government did the opposite.
New Zealand’s far more comprehensive ‘Alliance’ model takes inspiration from the construction industry, where a number of different providers and specialisms must come together to deliver a single project. Alliancing signs up all key parties involved in service provision within a local area, from public hospitals and GPs to the ambulance service and nurses.
It includes key clinicians as well as managerial leadership, and requires its members to sign a charter to ensure they work collaboratively across the whole system, not just for the interests of their sector. They must deliver services designed with their patients in mind. Within Alliances are small teams, dominated by clinicians, that target specific challenges facing that particular region. This could be looking at how to deliver services in remote rural areas, or how to reduce readmission rates by looking at the way patients are handed to community-based services on discharge from hospital.
Professor Robin Gauld, himself the Chair of the Southern Alliance, which covers about 300,000 people, has said that the model remains relatively embryonic, but has the potential to be game-changing. There are already some indications of reductions in A&E admissions and of more hospital services being delivered in the community. Not only does this save money, but it also provides a better experience for the patient. How to deliver a better service for less is central to the future sustainability of the NHS.
There are impediments to the model’s simple import. The UK has a larger, much less homogeneous population and greater financial constraints. Yet this does not detract from its potential.
Perhaps the biggest lesson from New Zealand is the potential to transform patient outcomes when outcomes are truly the focus, rather than who precisely delivers them. Kiwis do not regard their health system as one single state ‘system’, but as a set of services. Furthermore, they more tolerant of diversity in funding and provision. The UK’s fixation on who delivers rather than what is delivered is one of the major obstacles to meaningful health reform. The lack of wholescale public outcry at the scandal of Mid-Staffs is testament to that.
It all comes back to the belief in the exceptionalism of the NHS. The fervour with which we dedicate ourselves to this institutional ideal is misplaced. It restricts rational discussion, limits our outlook, and blocks debate. Unless we can see past it and learn from others like New Zealand, the NHS will not survive.