How to fix the NHS: a Canterbury tale

David Meates overhauled New Zealand’s Canterbury District Health Board so that it became a world-leading exemplar of integration. He believes that a similar approach could prove transformational for the embattled NHS

The maxim “prevention is better than cure” is widely attributed to the philosopher Erasmus of Rotterdam, who died in 1536. Has this adage ever been more apposite for the NHS?

Analysis by the Health Foundation on 13 July found that up to 39,000 extra beds are likely to be required by 2030 in England alone if the service is to restore the level of care it was offering before the pandemic. Scaling up could cost the taxpayer as much as £29bn.

The day before, Public Health Scotland statistics revealed that only 65% of A&E patients had been seen in the week ending 3 July within the Scottish government’s four-hour target time, marking the worst performance since weekly records began in 2015. In the previous week, data from freedom-of-information requests to every NHS trust in England showed that almost 117,000 patients had died last year awaiting care – close to double the pre-pandemic figure. Meanwhile, a record 6.5 million people are awaiting non-emergency treatment.

So, when 42 integrated care boards (ICBs) were created across England on 1 July as part of an NHS shake-up, the fanfare was muted. New pathways, such as blood-pressure checks in betting shops, failed to quicken the pulse of some observers, while the drafting of children’s mental health specialists into GP surgeries underwhelmed others.

Yet these actions were designed to transform how healthcare is provided and prevent avoidable premature deaths in the coming years. But such seemingly mild doses of alternative approaches to medicine could, with injections of trust and collaboration, actually revive the fortunes of the NHS tomorrow. So says David Meates, a consultant on the ICB roll-out.

By developing these ICBs and empowering local teams, communities and people, the potential of “precision health” – an approach to care that’s integrated, efficient, highly personalised and designed to cut hospital stays and costs – can be realised, he argues. 

Meates is well placed to comment, having led the transformation of the Canterbury District Health Board (CDHB) in New Zealand. His organisation came to be seen as a world leading exemplar of integrated health pathways. (But even paragons aren’t immune from being restructured out of existence: at the end of June, the CDHB and 19 other district health boards were merged into a new body called Te Whatu Ora Health New Zealand, which oversees the day-to-day running of the system for the whole country. ‘Te whatu ora’ translates loosely from Māori as ‘the weaving of wellness’.)

As CEO of the CDHB in 2009-20, Meates was responsible for the health of about 600,000 people. He inherited an organisation in desperate need of reform. Indeed, when he arrived, there was “internecine warfare” between various stakeholders – hospitals, GPs, care homes and pharmacies – according to Meates. The divisions generated by these self-interested factions had led to a “complete breakdown of trust and confidence of the community. Frankly, the very broken system couldn’t keep doing what it was doing,” he recalls, pointing out that the CDHB had been unable to hit its targets and was “perpetually in deficit”. Sound familiar? 

Seeing so many functions pulling in different directions, he understood that there was “nothing binding them together and no shared sense of purpose – a common ‘why?’” Meates set about reasserting the core aim of the CDHB: to improve the integration between community and hospital care by rebuilding trust.

He resolved to use relatable language and build a social movement that engaged various cultures and created a simple, user-centred vision for a better health service. His work aimed to make healthcare preventive rather than reactive, giving patients and communities the tools and knowledge to take better care of themselves. First, he invited the factions to an open forum to try to understand their frustrations and rebuild trust.

“We involved people from outside the system to stimulate those conversations, because stakeholders in this sector often look at problems through an internal lens,” Meates says. “Using other organisations as a part of the engagement also makes for a safer forum for conversations that otherwise wouldn’t be held.” Through these discussions with medical and community leaders, and also interactive workshops that hinted at what could be possible, a clear vision of what stakeholders wanted Canterbury’s health system to look like appeared: one that is connected, centred on people and aims not to waste their time. Meates’ objective was to empower people motivated by having “co-designed the vision” to take the actions required to realise that vision. 

To illustrate and so simplify the vision, the team drew a one-page diagram showing Agnes, a fictitious 85-year-old in the middle, and the relevant health services around her. Using a persona helped to change the attitudes of those within the healthcare system and, crucially, the wider community. “We had a large, ageing population, so this helped us understand what that typical person might look and feel like. This was different from the cold, hard way of thinking of things as outcomes or outputs,” Meates explains. Having the core focus of serving Agnes better made decision-making easier, drastically improving cost-efficiency.

Using the persona of Agnes to articulate the new vision led to other “game-changing” benefits, he adds. “Coming from a person-centred view of the world enabled us to engage with our indigenous populations in quite different ways.” Almost 10% of the population that was covered by the CDHB is of Māori ethnicity, while just under 3% is of Pacific origin. “We stopped talking about them as hard-to-reach communities and, after putting the lens back on to us, realised that we were a hard-toreach health system,” Meates says. “We flipped things around and made the community part of the solutions and ownership.”

There was more engagement with churches – which are central to the Pasifika community – and hairdressers, who were encouraged to refer older customers if they were having trouble getting out of their chairs. “We wanted to stop elderly people falling and ending up in a hospital, so we empowered people to refer anyone who seemed to be struggling to a strength-based programme. This resulted in a massive decrease in the number of falls,” Meates says. “We’ve saved thousands of people from dying that way.”

Meates stepped down as CEO of CDHB in late 2020 but was soon persuaded to travel halfway around the world to offer guidance on the ICB roll-out. From September 2021 to July 2022, via Lightfoot Solutions, he worked with various health systems in Wales and England. Having recently returned to his homeland to contest the mayoralty of Christchurch, Meates offers some reflections on his time in the UK. “It is said that ‘change happens at the speed of trust’, yet so much of our health and social care system is built on distrust,” he argues. “We continue to see the impacts of fragmented care based on the organisation’s needs instead of the person being at the centre of service design and delivery. Funding and contracts dominate the discussions and are often the key performance metrics, with limited visibility regarding patient outcomes.”

Meates believes that NHS leaders and strategic decision-makers in other sectors should be looking to the future rather than getting stuck in “crisis management” mode. The temptation is to revert to what the system has always done to deal with crises. This means that the necessary system changes will keep getting “put into the ‘too hard’ basket”.

Without the will to focus on the future, the health and social care system will continue to be “overloaded and under siege”. He continues: “It’s a fundamental shift of mindset. Most of what we use today is of limited value to tomorrow, yet we’re still trying to use everything from yesterday to solve tomorrow’s problems.”

This article was first published in Raconteur’s Future of Healthcare report in July 2022