Light touch, heavy touch? Dilemma for officials shepherding local health services

Primary healthcare leaders have long argued the only real system improvements are those that take root locally and are championed locally

All health systems are local.

In New Zealand, we have a version of a national health system in which funding models for health services are determined by central government, and the steering of the system is the responsibility of government.

However, what actually happens – the services that people experience, what they can get access to and what they can’t – is heavily shaped by local factors.

These factors include the composition of the health workforce, the location and spread of secondary care facilities, and the degree to which specialists split their work between public and private sectors.

Given such diversity between locations, the key policy dilemma for governments is whether to “stipulate” or “stimulate”. (This pithy distinction was coined recently by Canadian health policy academic Sara Kreindler.)

“Stipulation” involves setting service standards, benchmarks and targets, so that all citizens are able to experience the same health service wherever they are. “Stimulation” involves encouraging and facilitating improvements that people in the sector develop locally.

Primary healthcare leaders have long argued the only real system improvements are those that take root locally, and are championed by local healthcare leaders. Stimulation, not stipulation, is needed, in order to progress towards worthy goals such as quality improvement in primary care, better integration between primary and secondary care, or greater patient involvement in service design.

Stimulation requires only a light governmental touch – gently encouraging, perhaps providing the odd incentive. The National Party’s primary care policy from 2009 to 2017 encapsulated this approach to fostering integration and quality improvement.

Sure, the national health targets – a classic case of stipulation – may have been more visible throughout this period, but the stimulative approach has been gathering momentum since 2005, predating National’s time in government. Clinical networks, integrated family health centres, district alliancing and System Level Measures all follow the stimulation playbook.

We have seen examples where this bottom-up, stimulative approach to improving health systems has developed deep roots at the local level. The emergence of the Canterbury Clinical Network is a case in point. The jury may still be out on whether this improves health outcomes, but it certainly has been a shining example of how to build a collaborative, integrated, local health system that has developed the capacity to tackle bigger concerns, and this is a significant achievement.

Another example is the way in which the MidCentral DHB and Central PHO have quietly developed more integrated approaches since the late 2000s. However, these local-led developments are still the exception rather than the norm.

For every district that has made progress, there are two or three other districts that have tried and failed, or not really tried at all. This pattern is not unique to New Zealand.

A few years ago, with some Canadian colleagues, I was involved in research into an Ontario government initiative to foster better integration and coordination at the local level; first, by identifying those patients with multiple chronic conditions who frequently ended up in hospital EDs and wards, and then by developing coordinated care plans for these patients. Beyond these broad parameters, this was a highly permissive policy allowing for significant local experimentation.

Many local health organisations were delighted with the opportunity to develop some new approaches in this area and revelled in the autonomy, and used the scraps of new funding available to build better local models of care. However, evaluators also reported that many health sector respondents were perplexed as to what they should actually do, and wanted more direction and leadership from the health ministry. The mantle of autonomy was too daunting, and these participants could only see the obstacles that restricted their capacity to develop better models.

Government agencies typically are the target of criticism when they stipulate how things should be done in the health sector. But when governments adopt a more low-key, stimulative approach, the results are often disappointing. This is because leadership at the local level might be preoccupied with immediate priorities, or there is no local leadership to speak of, or the organisations at the local level have been butting heads with each other for so long they cannot trust each other in order to work together effectively.

Another potential downside of relying on local leadership to pick up the baton of health system improvement is the geographic inequity between districts that could result from it. The citizens of districts without effective, collaborative leadership are doubly disadvantaged, as only the citizens lucky enough to live in districts with better leadership reap the benefits. This only reinforces the instinct of governments to standardise and stipulate.

Stimulation approaches to health system improvement go with the grain of health sector professionals and leaders, whereas stipulation strategies typically provoke angst and resistance. Going with the grain of stimulation makes for a friendlier atmosphere in the health sector. But unless we work out how to improve the success rate of stimulative approaches locally, the policy fashion will turn back to more prescription and stipulation. In hoping for a thousand flowers to bloom, let’s hope that we end up with more than a handful of orchids in a field of weeds.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland