This week at IH, we have been thinking about integrated care on a global scale; how other parts of the world may be facing similar challenges and what they are doing to facilitate positive change.
New Zealand’s ‘International Journal of Integrated Care’ published a paper which charts Aotearoa’s integrated care journey from 2008-2020. In this article, we will examine the key findings of the paper, what they did to drive integration, and how this will influence their future approaches.
Re-evaluating healthcare
The journal begins by stating that “Aotearoa/New Zealand (A/NZ) is generally regarded as having a high performing health care system” which, for the most part, “generates good health outcomes at reasonable levels of expenditure.”
However, it faces many challenges which we, in the UK, can whole-heartedly recognise: health inequalities, an ageing population, increases in long-term health conditions and a rising expectation to meet these pressures quickly and with less expenditure.
In her paper on integrated care in A/NZ, Jacqueline Cummings notes that “integrated care has been taken to mean the outcome of integration (processes) from a service user perspective, involving more co-ordinated care or a ‘seamless’ journey through the health system.”
Cummings recognises that the process of achieving integrated care would involve a “coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between sectors.”
The ‘Rainbow Model of Integrated Care‘
Another paper published in the National Library of Medicine references Valetijin’s Rainbow Model of Integrated Care, which combines “the functions of primary care with dimensions of integrated care. The model distinguishes four dimensions that play inter-connected roles on the micro- (clinical integration), meso- (professional and organisational integration) and macro-level (system integration) of a health care system.”
The rainbow model is made up of three overarching ‘triple aim’ outcomes: cost and utilisation, population health, and experience of care, with the various integrated care mechanisms split into two categories: functional integration and normative integration.
The paper identifies the key means of integration “considered particularly relevant in A/NZ” as information sharing, service co-location, case management or care co-ordination, multi-disciplinary teamwork, shared planning and/or budgeting (including developing a shared vision, agreed care pathways, and agreed resource allocations); through to full organisational integration.
‘Developing more person-centred care‘
The necessary actions Cummings describes, began to evolve and come to fruition between 2008 and 2017, when a new policy driven by a 2007 National Party election manifesto, ‘Better, Sooner, More Convenient Health Care’ (BSMC) was released.
This placed emphasis on “developing more person-centred care, to be delivered closer to home and to become more integrated, through greater collaboration within health and between health and social development services.” This also facilitated the establishment of Integrated Family Health Centres, which would “co-locate and deliver services through multi-disciplinary teams of gps, nurses, pharmacists, midwives, and allied health workers.”
Towards the end of 2009, the BSMC and the Ministerial Review Group policies became operationalised, which involved district health boards and primary health organisations working together more closely in planning and funding services. The successful business cases were able to pool primary health organisation funding streams into a flexible funding pool which was then rolled out nationally. These nine business cases became known as ‘alliances’.
This ‘alliancing’ concept was further enhanced by the government, who mandated that every district health board establish a district alliance to include primary health organisations and other health care providers. Alliances have since engaged in a number of activities, “including developing service-level alliance teams to support service-level improvement initiatives and resource re-allocations.”
From 2016 onwards, the Alliances have worked together to improve system level measures within each district, culminating in the System `Level Measures Framework (SLMF). The purpose of this is to stimulate “local integrated care initiatives aimed at improving health outcomes and equity.”
In 2016, the 15-year-old NZ Health Strategy was refreshed with a new ‘Future Directions’ strategy, which identified five key themes: “that the system is people- powered; delivering care closer to home; offering value and high-performance; delivering through a ‘one team’ approach; and intelligent – placing the “best interests of New Zealanders” at the forefront.
‘A Patchwork of Local Practices’
Moving on, the paper describes “a patchwork of local practices” in play; it points out that there is a “lack of uniformity between initiatives” evidenced by the business cases’ integration processes. This underlines an important challenge for evaluators “over what counts as an integration intervention, and what populations have then been exposed to make judgements over the extent of change that has occurred.”
The paper states: “The results highlight the staying power of initiatives which have adapted and evolved over time. One of the key lessons that emerges from this tracking is that multiple strategies for integrated care rise and fall within initiatives as change leaders seek to overcome organisational boundaries and professional scepticism.”
The paper notes that when short-term results did not reap the expected results, the system’s efforts evolved towards “implementing new models of service provision” in response to growing pressures and demands.
For example, the new Health Care Home model of care has gained prominence across its initial localities and has spread to other parts of A/NZ. Evaluations of these initiatives found that the implementation of these methods -for the most part – resulted in improved communication between providers and can be viewed “as differently tailored responses to different community needs” with suggestions that integrated care is “inseparable from context.”
Reflections
A wider research programme has taken place across A/NZ to better understand “which changes have been able to be successfully implemented and sustained, and how governance, strategy and planning processes have supported such success.” In 2019 and 2020, around 55 leaders across district health boards and primary health organisations were interviewed and asked to share their views on the progress, or lack thereof, that had taken place over the last decade.
Research found that one of they key themes was “the importance of change being driven from those working at the front-line, rather than being top-down” and recognising that conflict amongst different organisational health interests would be unavoidable. Canterbury’s experience in particular conveyed a high level of momentum, which was a result of the following factors:
- Implementing processes around a “one system one budget message”
- Investing in staff and improving their skills
- New forms of contracting
- Embedding new referral pathways
- Shared technologies
- Introducing case management programmes
Final thoughts
The paper acknowledges that “there is an increasing realisation internationally that integration is a highly complex, multi-faceted concept, with multiple goals at many levels making overall evaluation of progress difficult.”
In light of this paper, it seems a fair assertion that health systems are universally “complex adaptive systems” which rely on a combination of specific actions and initiatives, to achieve individual successes in the delivery of health and care.
For more information on the themes discussed in this article, please click here.
Citations within the paper:
Cumming J. Integrated care in New Zealand. International Journal of Integrated Care. 2011; 11 [Special 10th Anniversary edition]. dOI: https://doi.org/10.5334/ijic.678
Valentijn PP, schepman sm, opheij w, bruijnzeels
ma. understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care. 2013; 13. dOI: https://doi.org/10.5334/ijic.886
