Random Politics & Religion #20

As the British government grapples with its current round of reforms to the NHS, it could be useful to consider examples from elsewhere to help inform the change process and its underlying goals.

The distant shores of New Zealand, which has a broadly similar healthcare system to Britain’s, provides some lessons. New Zealand has a slightly longer history in working towards creating a national health system, having embarked just over 75 years ago on such a process via the landmark Social Security Act 1938.

The visionary principles laid down at the time were that healthcare access should be universal and free from financial and other barriers, that all New Zealanders should have equal access to the same standard of treatment, and that the health system should be integrated and preventive rather than curative in focus. Indeed, these principles are close to what many of the world’s policymakers aspire to today.

New Zealand, however, deviated from the 1938 principles through policy compromises in the implementation process. These compromises were mostly to ensure support at the time from the powerful medical lobby. They meant that New Zealand has since developed a dual health system with those able to pay, or those with insurance, guaranteed quicker access to specialist care provided in the private sector.

Such care is provided by the same specialists holding joint appointments in public hospitals where thresholds to get on comparatively long waiting lists are often much higher. Levels of unmet healthcare need are unclear, as patients either wait until their condition worsens to warrant public sector treatment or find the money to pay to see a private specialist.

New Zealand’s comparatively high GP part-charges (up to £25) also pose an access barrier, especially to the less well off (public hospitals are free). A public-private mix with GPs (mostly private) and hospitals (mostly public) has meant integration has largely been an aspirational goal, while hospitals and personal health services have continued to dominate at the expense of preventive services.

Over the years, New Zealand governments have experimented with health system designs aimed at promoting competition, national equity and democratic governance.

Virtually every organisational and funding model has been tried. The most recent model – alliancing – provides hope that the 1938 goals may be rejuvenated.

Derived from large construction projects, alliancing requires that all providers in a region work collaboratively within a whole system approach to ensure that services are designed with what is best for patients and the public in mind. Alliances tend to include public hospitals and associated services, primary healthcare services (including GPs), and other services an alliance agrees will be pivotal to service planning and provision in the region.

Alliance members, a mix of clinical leaders and senior management, sign a charter which binds them to building trust in one another, focusing on the whole system, not the specific interests of the sector they may work for, and agreeing to help one another to achieve alliance goals.

These goals include redesigning services considered to be an alliance priority, such as integrated services for older people with chronic care needs, or access to GP-referred specialist services (which an alliance may decide should be provided in primary care settings rather than hospitals). Underpinning all decision making is a first principle of what the system should look like from the patient perspective. Very importantly, equity, access, integration and prevention – core goals from 1938 – are the overarching goals as they make sense to patients and professionals.

Alliancing provides a different incentive set from the current clinical commissioning group (CCG) model in the English NHS, yet GPs are at the heart of New Zealand’s current arrangements. The model could be useful for visionary CCGs to embrace if basic NHS principles of equity and universal access are to be protected.