Collective impact model – the Canterbury District Health Board

New Zealand’s Canterbury District Health Board achieved positive population health outcomes by uniting the health sector to better use limited resources.

In 2006, under a newly established CEO, the Canterbury District Health Board made a critical discovery. Through conducting an analysis, the board found that the current way of operating was unsustainable—the board was running a deficit and population growth and ageing was creating rising admission rates and wait times. It found that, if nothing changed, Canterbury would need another hospital by 2020 (with more than 500 beds), as well as 20 per cent more GPs and practice nurses as well as an additional 2,000 residential care beds for the older adult population. Not only was there insufficient funding to establish these additional services but there was also a lack of qualified staff.

Over the course of two to three years, the board undertook a collaborative process (which included a six‑week event with more than 2,000 participants from across the health system) to identify a set of strategic goals and principles. The process was underpinned by a focus on placing the patient at the centre of the service system.

In 2008 the board signed off on the set of principles that would shape the approach to redesigning services. One of these principles was that those in the health system—from primary care, to community‑based services, to hospitals, public and private—would work together to recognise that there was ‘one system, one budget’. Another principle was that ‘Canterbury had to get the best possible outcomes within the resources available, rather than individual organisations and practitioners simply arguing for more money’. Developing and agreeing this shared vision for change was a key enabler for reform.

As Mr David Meates, the CEO, said: ‘[w]e need the whole system to be working for the whole system to work’.
Another key enabler for change was establishing a pooled budget. The board shifted from contracting a whole range of external services (mental health, district nursing, allied health and so on) based on input‑defined, competitive and often fee‑for‑item‑of‑service contracts, to ‘alliance’ contracting. Alliance contracting, based on a model used in the construction industry, assumes that multiple organisations can achieve better outcomes by working together on agreed contracts.

It is a collective contract with pre‑agreed gains and losses dependent on the overall performance of all the parties, rather than with penalties solely for whoever fails within it.

While an element of competition remains because patients are still able to choose their provider and GPs choose providers to which they refer, the culture of the health system improved because different health services now have an incentive to work together to achieve better outcomes for consumers, rather than competing for funds.

Canterbury has, in effect, used its purchasing power and its moral influence to harness others into a joint endeavour aimed at effecting change beyond the board’s purely technical reach.

These steps, along with a number of other key initiatives and reforms, led to great progress towards improving the outcomes of the Canterbury community. Over the past decade, as Canterbury has undertaken this reform, acute admission rates have continued to decline, and when comparing acute medical length of stay and readmission rates across New Zealand, Canterbury comes third among the 20 health boards across the country.

The Canterbury example illustrates how shared responsibility and a better use of limited resources can have a great impact on the health outcomes of a population.