From the rubble of Christchurch’s earthquakes, its health service is emerging as a world-leading example of how to respond to a disaster.
Canterbury public health services should have imploded after the Christchurch earthquakes, the region's health supremo David Meates candidly admits.
Prior to the quakes services were already under massive strain - the Christchurch hospital was an antiquated creaking facility, no longer fit for purpose, and bursting at the seams.
Then the quakes came and Canterbury District Health Board was struck hard.
Most of its 200 buildings were damaged, 12,000 rooms needed repairs, 106 hospital beds were closed, 19 community pharmacies and five general practices were lost or damaged.
Six-hundred-and-thirty-five rest home beds were closed.
''What the earthquakes have done is remove any slight capacity that was going to enable us to get through the next few years and remove that from the equation,'' says Meates, the DHB chief executive.
''What it's meant is we had to move faster and quicker than we might have otherwise done.''
In other words, out of adversity comes opportunity. Canterbury DHB is now watched around the world, not just for the way it has coped with crisis, wrecked buildings and displaced staff, but because the earthquakes and the DHB's rapid response to them may be leading the way on how we think about the local hospital and the role it plays in our communities.
In New Zealand recently, King's Fund researchers Chris Ham and Nicholas Timmins agreed Canterbury could be on the cusp of transformational change.
The King's Fund is an independent charity focused on improving health and health care in Britain, researching and analysing systems around the world.
Its researchers came to New Zealand at the invitation of Canterbury DHB, which was concerned that the situation after the quakes was so extreme, and the pace of change so rapid, that it needed an independent pair of eyes to make sure it was on the right track.
Timmons says some of the programmes put in place since the earthquake are not just innovative - ''I've not seen anything that's done as well as that anywhere else''.
''If the idea is you're trying to transform the health system into a fully integrated one, has that been achieved? No. Is it transforming? Yes. Is what is being done transformational? Yes.''
At the heart of the changes is a drive to manage peoples' health conditions safely in the community.
The DHB states that people in Canterbury are less likely to end up in hospital acutely unwell; if they do, they stay for less time; and they are less likely to come back to hospital than anywhere else in New Zealand.
That result has been achieved through programmes like Crest - the community rehabilitation, enablement and support team - which provides services like nursing, occupational therapy and physio therapy, and other services in liaison with families, carers and GPs.
The DHB had been moving in that direction before the earthquakes.
But the sudden and massive lost of facilities on February 22, 2011, forced its hand.
The home-based service was up and running within three weeks of the earthquake to ease pressure on overloaded hospitals.
Other changes include devolving more procedures to GPs - a GP may get $140 from the DHB for treating a skin lesion, for example.
That has carved thousands of days off waiting lists. To Meates, that means less wastage, and putting the emphasis back on value of patient's time and quality of life.
''Probably about 30 per cent of what we do is wastage. Because what we do traditionally in health systems is design waiting into everything that happens ... we move people from one list to another and we call that care.''
The mixed blessing from the earthquakes is that Canterbury DHB will get to replace its 1950s era facilities with new fit for purpose facilities, with the Government pledging a $500 million rebuild.
The temptation might have been to build bigger and better - and to view services established in haste in the chaotic wakes following the earthquakes as temporary fixes only.
But Meates says all the earthquakes did was bring forward the timetable for change - while also appearing to accelerate some of the pre-earthquake pressures on capacity.
''I'll ask you a question? How many people do you think have left Canterbury?,'' he says.
''We 're back to pre-earthquake levels. What's really fascinating is that the part of our population that's grown is those aged 65 years and older. It's not because people have got older ... but actually more elderly have shifted into Canterbury from elsewhere than what we would have seen with normal population growth.
"Some of that's around grandparents and parents shifting back into the community to provide support for families. That may be part of the explanation but I don't think we fully understand that.
''So perversely, despite the earthquake, our biggest challenge is still the elderly population.''
The King's Fund's Chris Ham says health care infrastructure over the past 50 years has been centred around acute hospitals in an era when premature deaths from heart attacks, strokes and cancer were the main health problem.
''For the next 50 or 60 years that 's not going to be the case ... any more. We're talking about people in their 70s , 80s and 90s who have a combination of diabetes, arthritis, heart failure, dementia and so on, who do not need the life-saving specialist expensive care within the acute hospital environment.
They need the admission avoidance community support services that Canterbury and others have begun to put in place.''
In Canterbury's case that meant rejecting the model of building a ''bigger and better'' hospital when the Government opened its cheque book for the rebuild, Meates says.
''Because actually that 's the wrong thing to be doing ... if you look at the ageing population, much more of the ... increase in bed numbers we are putting in [the new hospital] is to do with short-term rehabilitation for the elderly and part of that is configured on the basis of less people going into aged residential care and supporting them to stay in their own home.
''It 's a very deliberate model of care that is about supporting people in their own home with very short term access to a very different rehabilitation model.''
It's that attitude, says Ham, which makes Canterbury one of the world's health systems to watch.
''When we do our work on the integrated care programme we often refer to a very small number of examples of successful attempts to integrated care from a round the world. And there are only a small number of examples for one very important reason ... integrated care is not the natural default system of any health care system I'm aware of.
''So people who achieve better integration are the exception rather than the rule. And what Canterbury has done in last few years is add another example of how it can be achieved almost against the odds.''
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