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February 26, 2014

The need for something Nuka

A central dilemma for those who seek a new template for public services is whether that search is actually about finding ways ‘to do more with less’ or to try something else altogether. And if it’s the latter, how leftfield is that thinking allowed to be? A unique approach in Anchorage, Alaska has transformed healthcare standards at significantly less cost than before. A former health advisor to Obama described the system as extraordinary. It’s called Nuka – a system based on reconnecting people with the entire living systems of their community. Nuka seems to be gaining traction here.



Graham Leicester

There were celebrations this month in the UK for the 65th birthday of the National Health Service…  But equally a sense of foreboding about its future.  The Nuffield Trust published a collection of essays to mark the occasion.  Contributors used various words to describe the state of the service today, all of them unsettling:  “tender, fragile, fragmented, strained, vulnerable, in disarray, at a crossroads.”  They all expected challenges ahead.

It is a good moment therefore for Don Berwick to proclaim in public the virtues of a healthcare model offering great hope for the future – a model that is also beginning to attract real interest in Scotland.

Berwick is a former health adviser to President Obama, a founder of the highly respected Institute for Healthcare Improvement, and was recently appointed by Prime Minister David Cameron to head the taskforce improving quality of care in the NHS following Mid-Staffordshire and other lapses.  He knows what he is talking about.

Last month, in the unlikely setting of Anchorage, Alaska, he had this to say about the service he was visiting:  “This is probably the leading example of healthcare redesign in the world.  US healthcare suffers from high costs and low quality.  This system has reversed that:  the quality of care is the highest I have seen anywhere in the world, and the costs are highly sustainable.  It’s extraordinary.”

Berwick was speaking on local TV news.  He was in town for the annual conference celebrating the ‘Nuka’ system of care – developed by and for the native Alaskan population and now delivering remarkable results.

Judging from the clip of the interview the local news presenters could not quite believe what they were hearing.  Was the great Don Berwick really speaking in such terms about Southcentral Foundation (the local healthcare provider)?  Could it really be true that this innovative service, twenty-five years in the making, is now recognised as “leading healthcare to its new and proper destination” (Berwick again)?  

To be fair, even though Southcentral Foundation won the prestigious Baldridge Award for performance excellence in 2011, the model is not well known – certainly not to the extent that many people are actively putting the Alaskan principles into practice elsewhere.  There are pockets of interest in Canada and other parts of North America, but nothing further afield.

Except in Scotland – where a number of brave souls, with gentle support from the Scottish Government, are starting to experiment with the Nuka approach.  A thriving, if small scale, exchange programme is now under way.  If Alaska is the pioneer, Scotland has good claim to be recognised as the most dedicated early follower.

The real mystery is why so few others have taken up the challenge, especially given Berwick’s strong advocacy.  At a lecture to the King’s Fund health think tank in London earlier this year he shared some of the Alaskan data.  In ten years, with a rising population, emergency room use has fallen by 50%, hospital admissions are down by 53%, specialist medicine usage reduced by 63%, primary care usage down 20%, and patient and staff satisfaction has risen to over 90%.  

These are the kinds of numbers that Berwick’s own Institute for Healthcare Improvement (IHI) can only dream of. The IHI improvement model is based on close analysis of masses of data and (like the British Olympic cycling team) ‘the accumulation of marginal gains’.

This approach has become highly influential – almost to the point of ideological fervour – within the Scottish Government.  Indeed, the current Director General for health and social care and Chief Executive of NHS Scotland, Derek Feeley, will be leaving his post next month to take up a senior position with the Institute itself.

The problem is that the Nuka system of care does not offer ‘improvement’ in these terms.  It offers transformation.  So it struggles to gain serious attention in a crowded policy landscape which hears “transformation”, if it is ready to take the word seriously at all, only as a synonym for radical improvement of the status quo.

Donald Schon, an expert on policy learning, wrote about the power of “ideas in good currency”.  It is usually the case, he suggests, that policy discussion is dominated by a small number of ideas that are in fashion and carry credibility.  Nuka is certainly not – yet – such an idea.

In healthcare the consensus is particularly strong.  While the contributors to the Nuffield Report had varying views on the state of the NHS today, they nevertheless displayed – according to the editor – “a profound, almost unanimous, degree of certainty about what needs to be done”.  The list of ideas is familiar: specialist centres of excellence, outsourced routine operations, integrated health and social care, more care at home, more ’empowered’ patients, more transparent performance data, efficiency savings, competition, charging, rationing, investing in prevention and – of course – organisational restructuring.

These are all laudable and worthwhile strategies to extend the life of a venerable institution.  But none will lead us to Nuka.

Southcentral Foundation did not generate their extraordinary results by these means.  They started instead from a radical reconception of what a healthcare service, particularly primary care, should provide for its community.  

‘Nuka’ is a native Alaskan word for a vast living system.  Their healthcare philosophy is based on restoring people’s connection to the living systems that support our lives – bringing us back to life.  Their simple insight is that health is a product of quality relationships – and they start therefore by developing these relationships in the surgery, amongst their own staff and with and between patients and families. They centre the entire system around the community.  This is the hidden resource.  The people formerly known as ‘patients’ they call ‘customer owners’.  It’s an ugly phrase, but indicative of a wholesale shift in attitude.

They have kept very closely in touch with the Institute for Healthcare Improvement throughout the transition – consciously using the methodology to help their new system grow as effectively as possible, rather than to bring about marginal gains in a system they want to leave behind.  

They are assiduous collectors of data to provide feedback.  But they are not driven by the numbers.  Reality is what happens, they say.  Models are a shadow of reality.  Data are used to measure the model.  Data are therefore a shadow of the model, which is a shadow of reality.  They would rather keep their focus on the quality of experience.


The Nuka system of care has involved a major cultural shift, in particular for the medical staff.  It has not been easy.  So we should applaud NHS staff in Scotland who are ready to step outside the technocratic comfort zone of today’s reform agenda to recall the deeper human calling that brought them into medicine in the first place.  That too is a hidden resource.  

Donald Schon praised the ‘vanguard roles’ that are needed to develop new ideas in good currency.  The good news for healthcare in Scotland is the number of people already playing them.  There are signs too that the Scottish Government is ready to make space for them.  Let us hope this spirit can be maintained, and is not inadvertently crushed by our impatience for immediate results and relentless marginal improvement.