The New Zealand System Level Measures Programme - a New Policy to Implement a Whole of System Performance Framework Using Health Alliances.

Introduction: In 2016, the New Zealand Ministry of Health (MoH) introduced a whole of system performance policy known as the System Level Measures (SLM) programme to deliver integrated care using health alliances. Alliances were trust-based collaborative networks introduced in 2013 to integrate the planning and delivery of health care between primary care and hospital settings. The SLM programme attempted to move away from narrow target-based and pay-for-performance approaches focused on single organisations to a shared responsibility and decision-making approach using alliances. Description: The SLM programme was co-designed by the MoH and health sector clinicians, analysts, and managers. It consisted of six system level measures, each supported by a suite of contributory measures. System level measures were outcome focused while contributory measures focused more on process and activity. Alliances were responsible for leading the implementation of the SLM programme in their districts. Implementation of the programme required alliances to share health information and resources, identify priorities for their district, agree an improvement plan, and commit to delivering it. The MoH assisted the implementation process, provided access to data, approved the plan, monitored progress against the plan, and administered incentive funding for Primary Health Organisations. At the end of each year, alliances were expected to review and reflect on their successes and failures to inform the following year's plan. Discussion: Success with implementation of the programme varied and was influenced by two key factors. First, there was a lack of sponsorship from the centre. This meant that although there was sector support for the programme, there was a lack of leadership and adequate resourcing from the centre to sustain the programme. Second, the MoH expected alliances to use the SLM programme to improve their local relationships, develop their capacity and capability for improvement and improve their maturity as a network. Reflection and evaluation of the SLM programme found that these were necessary pre-conditions for alliances to succeed with implementation of the programme. In the end, this improvement programme could not be reconciled with an accountability framework. Conclusion: New Zealand's SLM programme was a unique experiment with a new system performance framework to improve integration across the health system. Its implementation provides important lessons on the role of centre to create the right conditions for integrated care initiatives, such as the SLM programme, to succeed. We conclude that successful implementation of integrated care initiatives requires sponsorship and leadership from senior leaders, adequate and appropriate resourcing, right incentives, and most importantly a strong platform for a collaborative way of working which nurtures high-trust relationships among system leaders and continuous learning.