Jacinda Ardern won the New Zealand elections by a “historic landslide.” The result in part has been credited to the success of her management of coronavirus in the country. The world has marvelled at how well New Zealand has managed to keep coronavirus cases down. While it had its own peak in cases, by April 2020 it was reported that New Zealand was the first country to have eradicated the disease, and for a long time, no new cases were reported. Though infections have now returned in small numbers, the country has so far avoided a significant second wave of infections.
So what is their secret? Commentators have pointed to its relatively isolated geography, low population, and early lockdown. But does philosophy and approach play a part?
I was lucky enough to visit the Canterbury Health System in New Zealand in February of this year. Flying back through Singapore, which by then had had its first case, I tried and failed to get hold of a mask for my return trip. The pharmacies and hardware stores in New Zealand had already sold out. Temperatures were being checked in Changi airport, and I remember the strange sight of seeing a majority of people wearing masks for the first time. It was haunting.
And having seen the health system with my own eyes, I wonder whether other factors might have helped the country buck the international trend too. Visiting the District Health Board in Canterbury (CHB), Māori symbolism, culture and language is everywhere. The New Zealand health system is renowned across the world for its achievements with integrated care and quality improvement. The Māori people make up approximately 15% of the community. Maori are patients and carers. They are members of the public and they are staff. I was impressed by the inclusive ethos there, and how they worked hard to deliver a health service that worked for everyone.
But it soon became apparent that the health system is much more than that. Generosity is everywhere. As a visitor, I experienced it firsthand. There were the kind gestures—being bought lunch, and being driven around the community from visit to visit. Then there was the care and attention—terribly busy health leaders calmly giving me seemingly endless and unhurried time. And then there were the stories: Captivating tales of trauma (following the recent earthquakes and terror attacks), renewal and growth. “Welcomed” just doesn’t cover it. In my short trip, I was treated like family.
Whānau is the Māori word for family, or rather, extended family. In Māori society it has broader meanings, denoting local political networks of power, as well as concepts of being born or giving birth. The contrast to the Western idea of a nuclear family is stark, and has been responded to by the health service in New Zealand.
The concept of Whānau is everywhere. It’s in their health strategies. It’s in their service design. It’s even in the fabric of their buildings: One service I visited had a consultation room specifically to accommodate a large family group all visiting at the same time.
Whānau was reflected in the conversations that I had. I was struck that everywhere I went people spoke not only about patients, but also about the community. The population.
As a visiting doctor from the UK this was refreshing and inspiring. But where were the conversations about integration? I’d come to Canterbury to learn about integrated care, but nobody was talking about it. In the NHS, we are now moving towards Integrated Care Systems (ICSs), a concept that, following an era of competitive tendering for service provision, many have been trying to get their head around. NHS England explains “Integrated care systems are made up of three major pillars of work: Primary care networks, Personalised care and Population health management. Together, these three Ps form a core offer for local people which ensures care is tailored to their personal needs and delivered as close to home as possible.”
Meeting colleagues in New Zealand, it began to dawn on me that I’d been thinking about integration in totally the wrong way. I’d been trapped in the bell jar of my own experience, current NHS structures and organisations, trying to make sense of the future from within. Suddenly immersed in a new world, I began to see the potential of integrated care in new ways.
We have seen the problems of our old structures played out in the pandemic: The early energy in supporting hospitals saw attention focused there, with care homes being left behind. Over 6,800 covid-19 outbreaks have now been reported in care homes. In any local region in England we may have NHS trusts and Foundation Trusts—different organisations for acute hospitals, mental health, learning disability and community services. We have GP practices, some aligned together as GP federations, most now grouping as Primary Care Networks. We have Clinical Commissioning Groups commissioning most local services, with NHS England centrally commissioning specialist services. On top of this local authorities have responsibilities for public health and social care. Each have their own budgets and books to balance, and care is negotiated and provided between them.
Back in Canterbury, one District Health Board did all of that. Yes, they included different organisations, but all of them felt like they belonged to the health board. This was highlighted when I met the CEO of one small organisation in the health board, that helped people live with a learning disability. She impressed on me that when thinking of the services they provided, they would always think about what they could give back: to the health board, and to the community at large.
They were thinking Whānau. One big family. A whole community and health system, thinking about and looking out for, each other. Having a population health approach, where inequalities are reduced and everyone matters, is a mission we can all get behind. Let’s be inspired by our Whānau on the other side of the planet to make our response to the covid-19 pandemic and beyond work for everyone.
Billy Boland, consultant psychiatrist and deputy medical director, Hertfordshire Partnership University NHS Foundation Trust.
Competing interests: My trip to New Zealand was supported by the Health Foundation through a grant I received as part of the GenerationQ fellowship.