Iwi Māori leadership and partnership in localities
Elements we are building from
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What we need to achieve
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Iwi Māori should have the opportunity to determine their own localities as ‘communities of interest’. 11% of the population in the Southern region is Māori, which is below the national average of 16%. The highest number of Māori tend to be within the urban centres of Dunedin and Invercargill, with a large population in Bluff. Rurally, the areas of Western Southland, Tokanui, and Milton have a higher Māori population than other rural communities. The remainder of the Southern Region has a relatively low number of people who identify as Māori (less than 200 within a TLA). The map opposite displays the number of people who identify as Māori within each TLA in the Southern region. The darker the colour, the more people. |
Iwi Māori defined localities may differ from those of the general population in how they function and in how boundaries are defined.
For example, a 'community of interest' may include the whole Southern District, or wider, to reflect Ngāi Tahu connections and interests. They may also reflect rūnanga interests in greater focus on areas close-to-home. The make-up and functioning of localities for Māori is for Māori to decide.
For example, a 'community of interest' may include the whole Southern District, or wider, to reflect Ngāi Tahu connections and interests. They may also reflect rūnanga interests in greater focus on areas close-to-home. The make-up and functioning of localities for Māori is for Māori to decide.
At the same time, Iwi Māori will have an interest in the functioning of the general localities, as much of the community health service infrastructure will be coordinated via locality health networks. Localities will have a focus on the determinants of health and population health - Iwi Māori will want to lead the thinking in how population health measures can be applied in a way that achieves equity.
Localities should be established to ensure partnership with Māori as part of the leadership structure. There are seven rūnanga in the Southern District who will have communities of interest based on geography and history. Māori will need work through how their own relationships with communities and the land best align with the concepts of localities and Pae Ora – healthy individuals, healthy whanau, healthy environment. The map opposite presents Te Rūnanga o Ngāi Tahu. |
Establishing localities to deliver improved population health
Elements we are building from
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What we need to achieve
3. Localities should quickly establish population health leadership functions, that will include health system, local government, Māori and community representation, at a minimum. 4. Local health needs analysis should be undertaken to drive population health priorities and actions. 5. Public health expertise in the region should be engaged to support the establishment of effective population health structures and programmes in localities. There may need to be investment in public health resources – as these resources are currently stretched. |
Southern demographics
The Southern Region has an even gender split, with 50% of people in the region identifying as male, and 50% identifying as female (from the 2018 Census). The region’s population tends to be similar to the national average in terms of age, however it is slightly weighted towards the older population groups. Southern has a low proportion of both Māori and Pacific people living there (11% and 3% respectively), compared to the national average. These populations are not evenly distributed across the region, meaning that there are pockets of communities that have higher percentages of both Māori and Pacific people. The smoking rate amongst the population living in the Southern district is also similar to the national average, at 14% identifying themselves as current smokers. Overcrowding and housing dampness are factors that contribute significantly to the health of whānau. The percentage of people in Southern living in an overcrowded house is 5%, which is less than the national average of 10.8% at the time of the 2018 Census. |
The Government has identified that localities will be a core element of the future health system.
Localities reflect communities of interest. The health reforms aim to achieve improved national consistency around issues like equity, population health, service access and outcomes (the what), however, the locality role is to ensure that solutions reflect local challenges, strengths and priorities and are developed with and owned by Māori and local communities (the how).
The health reforms aim to ‘rebalance’ our health system towards population health. Localities should be established with the relationships and leadership required to drive action to improve population health. This means that we need an improved coalition of health services, local government, Māori, community organisations and community leaders focused on improving wellbeing.
Health NZ and the Māori Health Authority will be looking to establish localities across the Southern region. There is an immediate opportunity for the Southern DHB, in partnership with Māori, the health sector, and community organisations to proactively identify and explore options for how best to establish localities in this area.
The Department of Prime Minister and Cabinet Transition Unit (Transition Unit) has provided an outline of the priorities and scope of activity to be lead through localities.
Localities reflect communities of interest. The health reforms aim to achieve improved national consistency around issues like equity, population health, service access and outcomes (the what), however, the locality role is to ensure that solutions reflect local challenges, strengths and priorities and are developed with and owned by Māori and local communities (the how).
The health reforms aim to ‘rebalance’ our health system towards population health. Localities should be established with the relationships and leadership required to drive action to improve population health. This means that we need an improved coalition of health services, local government, Māori, community organisations and community leaders focused on improving wellbeing.
Health NZ and the Māori Health Authority will be looking to establish localities across the Southern region. There is an immediate opportunity for the Southern DHB, in partnership with Māori, the health sector, and community organisations to proactively identify and explore options for how best to establish localities in this area.
The Department of Prime Minister and Cabinet Transition Unit (Transition Unit) has provided an outline of the priorities and scope of activity to be lead through localities.
The population health approach is to encompass:
The identified priorities for localities are:
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To achieve the aims and priorities for localities, strongly connected networks will need to be established that include health and social service providers, Māori and organisations that influence population health. There will need to be systems of leadership and organisation that are able to align diverse organisations and professional groups to work towards common goals. |
Identifying localities
Enduring local networks cannot be developed through a top-down mandate. They need to be developed by local communities and health organisations themselves through engagement and dialogue to come up with local structures and solutions that can integrate with other localities and secondary and tertiary services. That engagement can start now and should begin with exploring the shape and make-up of the localities themselves.
Enduring local networks cannot be developed through a top-down mandate. They need to be developed by local communities and health organisations themselves through engagement and dialogue to come up with local structures and solutions that can integrate with other localities and secondary and tertiary services. That engagement can start now and should begin with exploring the shape and make-up of the localities themselves.
Communities of interest in the South outside of urban areas are generally based around a town centre and associated farming community, that is often separated by distance and geological features.
The map below highlights potential localities, which are based on natural communities of interest.
The map is indicative only – and is purposefully not drawn with definitive boundaries.
Local communities should work with the support of the Southern DHB to develop options and recommendations for Health NZ and the Māori Health Authority.
Some of the issues that each locality may need to discuss in more detail are outlined in the table below:
Local communities should work with the support of the Southern DHB to develop options and recommendations for Health NZ and the Māori Health Authority.
Some of the issues that each locality may need to discuss in more detail are outlined in the table below:
Potential Locality |
Characteristics |
Issues |
Waitaki |
Population: 22,308 |
The natural community of interest includes areas in both the Southern DHB and South Canterbury DHB. Many people in the locality are more aligned to Timaru than Dunedin. Dialogue about a future locality should reflect the self- defined communities of interest and not that which is currently divided by the DHB boundary. Large Pacific population (around 17%) and aligns with parts of NZ with large pacific populations. |
Central Lakes |
Population (combination of the Queenstown Lakes and Central Otago authority areas): 60,711 |
Queenstown and Wanaka are growth zones. They are a natural locality as health systems will need to be more integrated to respond to growth needs. There are distinct ‘health communities’ in the geographically separated towns that would need to have a unique voice in a locality. Note also includes Ranfurly, which is isolated. |
Dunedin |
Population: 126,255 |
Dunedin does not naturally fall into separate localities as communities of interest, but it may be that it could split into two (north/south localities), as this would be the appropriate size of a locality (20-80K). The question is what would a division into two localities be seeking to achieve, and where would the best split be? |
Clutha/Gore |
Population: 30,063 |
Clutha and Gore are towns separated by about an hour’s drive. Both service rural areas. Both have a rural hospital. But Balclutha refers to Dunedin Hospital and Gore Refers to Invercargill Hospital. The two areas share many common issues as farming communities. They may function well as a locality, with strong local ‘health neighbourhoods’ for each town. |
Southland |
Population: 85,068 |
Southland has a strong community of interest and alignment to Invercargill and so should be one locality. However, it may be useful to look at developing health neighbourhoods in Bluff and in Western Southland as each has particular communities and interest and unique local issues and challenges. |
Population health approach
The health of populations, and equity, are impacted on by multiple environmental, lifestyle, social and health system factors.
Improvements in population health require the organised efforts of society.
Localities will need to be established in such a way as to locally lead, motivate, co-ordinate and act across many areas. As such, locality establishment will need to draw from the strengths of many organisations and local leaders. Population health concepts and relationships to empower them need to be an integral part of how localities function from the start.
One of the main challenges for localities is to work out how organisations should come together to address population health issues. One approach that should be explored is ‘Collective Impact’, which a framework used internationally for agencies and organisations working together. Collective Impact is also one of the core methods used by the Whanau Ora Commissioning Agency and Safer Waitaki. As such, it has a track record and learnings for application in New Zealand and working for Māori organisations.
Improvements in population health require the organised efforts of society.
Localities will need to be established in such a way as to locally lead, motivate, co-ordinate and act across many areas. As such, locality establishment will need to draw from the strengths of many organisations and local leaders. Population health concepts and relationships to empower them need to be an integral part of how localities function from the start.
One of the main challenges for localities is to work out how organisations should come together to address population health issues. One approach that should be explored is ‘Collective Impact’, which a framework used internationally for agencies and organisations working together. Collective Impact is also one of the core methods used by the Whanau Ora Commissioning Agency and Safer Waitaki. As such, it has a track record and learnings for application in New Zealand and working for Māori organisations.
The Collective Impact approach was derived from identifying common factors in successful social sector collaborations. There are five necessary conditions for effective collective impact, which are identified in the diagram opposite and cover:
There is a large literature and international community associated with Collective Impact if localities wish to use this model to support their local relationships. A local successful example of a local organisation that operates broadly within the collective impact framing is Safer Waitaki. In this case it is the Territorial Local Authority that acts as the backbone organisation. |
The Safer Waitaki project is a ‘whole-of-community’ community development project with a focus on community safety and wellbeing. It provides a mechanism for the community to work together, thus maximising resources and expertise. There are a number of workstreams that reflect the needs of a locality including mental health and addictions, positive ageing, family harm, housing and economic development. The project is well regarded and appears to be generating positive outcomes. |
The South can use the collective impact model to organise how stakeholders may come together within localities. A Collective Impact model would draw on strengths that already exist in communities across the South:
There may be a tendency for people and organisations establishing localities to rush into developing structures too soon. The collective Impact model is useful, but should not lead to bureaucratic relationships that are not based on ‘doing’. Localities should initially focus on evolving connections and leadership that is based around delivering coordinated action.
- Resilient local communities
- One Iwi for the district, with distinct rūnanga
- Existing collaborations to build from, for example Safer Waitaki, the Hokonui Huanui (Highway) project in Gore, and Central Lakes Locality Network
- General practices that are deeply embedded in their local communities, supported by a PHO that provides many community outreach services
- Rural hospital trusts, which have an existing community ownership model and an ongoing interest in local health outcomes
- Many health and disability NGOs and service providers
- Territorial Local Authorities that broadly align with localities
There may be a tendency for people and organisations establishing localities to rush into developing structures too soon. The collective Impact model is useful, but should not lead to bureaucratic relationships that are not based on ‘doing’. Localities should initially focus on evolving connections and leadership that is based around delivering coordinated action.
The National Health Service in the UK has been developing place-based partnerships for many years and has developed some useful principles to work from.
Place-based partnerships should start from understanding people and communities and agreeing shared purpose before defining structures.
Place-based partnerships should start from understanding people and communities and agreeing shared purpose before defining structures.
- Effective partnerships are often built ‘by doing’ – acting together and building collaborative arrangements to support this action as it evolves.
- Governance arrangements must develop over time, with the potential to develop into more formal arrangements as working relationships and trust increase.
- Partnerships should be built on an ethos of equal partnership across sectors, organisations, professionals and communities.
It is proposed that the public health units within the DHB act as the catalyst for developing population health leadership within localities.
Health promoters have the skills and background to guide community action. They should work closely with local communities, Iwi Māori, local government, WellSouth PHO, rural hospital trusts, and community providers to identify the right starting point to work together to achieve collective impact.
Initial work can start now. The Transition Unit has identified priorities for localities and the DHB needs analysis can add local information. Localities should aim to be in a position to identify activities Health NZ and the MHA can commission for each locality.
In the medium term some of the issues that a population health approach will need to address include:
Health promoters have the skills and background to guide community action. They should work closely with local communities, Iwi Māori, local government, WellSouth PHO, rural hospital trusts, and community providers to identify the right starting point to work together to achieve collective impact.
Initial work can start now. The Transition Unit has identified priorities for localities and the DHB needs analysis can add local information. Localities should aim to be in a position to identify activities Health NZ and the MHA can commission for each locality.
In the medium term some of the issues that a population health approach will need to address include:
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Proposed leadership for actions:
WellSouth, rural hospital trusts, Iwi Māori, public health unit - facilitate a co-design process that engages across the health/disability and community stakeholders.
WellSouth, rural hospital trusts, Iwi Māori, public health unit - facilitate a co-design process that engages across the health/disability and community stakeholders.
BUilding connected primary and community care
Elements we are building from
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What we need to achieve
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Establishing provider networks
The vision for the new health system is that community health care operates as a coordinated system with common goals. Achieving a coordinated system will require improving connections across community health providers, such Māori health organisations, primary care teams, urgent or afterhours services, diagnostic services, pharmacy, allied health, NGOs, disability providers, maternity providers, and social agencies.
The transition time is an opportunity for health organisations to come together to build connections and reimagine how they can work together to deliver better coordinated care. The Health and Disability System Review identified that there should be core services within every locality that are available to all New Zealanders. The recommendations are highlighted in the table below (taken from the HDSR final report):
The transition time is an opportunity for health organisations to come together to build connections and reimagine how they can work together to deliver better coordinated care. The Health and Disability System Review identified that there should be core services within every locality that are available to all New Zealanders. The recommendations are highlighted in the table below (taken from the HDSR final report):
Health NZ and the Māori Health Authority will provide guidance and need to agree to how provider networks form.
However, the South will develop better solutions and get moving with change faster, if local organisations have done the groundwork and come up with viable options.
The government has identified that there will be substantive changes to the ways in which community-based services are organised and delivered. These include:
- Establishing locality-based commissioning – for both general services and Kaupapa services
- Being more explicit about the services that should be available to all New Zealanders in every locality
- Enabling more focused service provision and leadership for Māori
- Changes to the current funding arrangements for PHOs
- Establishment of locality provider networks and provider network managers
- Focusing on coordinated care across the health system and with the social sector
- Care integration supported by technology
The locality model aims to achieve best our comes through bringing together clear national/regional policies and priorities, with good local ideas and functional networks.
The Southern system has an opportunity to organise itself to be best placed to take advantage of the flexibility of locality commissioning to improve services and outcomes for the region. Provider networks are the core infrastructure to deliver coordinated care for communities. Developing these networks will take time. Constructive discussions on establishing provider networks should begin as soon as possible. The DHB has a role as a catalyst for this work, but it would be best undertaken in a process of co-design with the key players in the system. The Transition Unit has outlined various concepts for how provider networks may be established. These are outlined in the table opposite, along with an overview of the options in the Southern context. |
Solution mix and implications for leadership
The make-up of provider networks for the South is likely to require elements of all the service mix options outlined above. Detailed thinking is required to explore the structural solutions that work best for the South.
An ideal solution would be one in which there was clear and consistent overall approach to establishing and supporting provider networks across localities, and also one in which the specific characteristics of each locality is reflected in its network focus and make-up.
Given the challenge of developing provider networks for the South, it is proposed that three key organisations are asked to work together with the DHB to lead the development of solution options that can be shared with Health NZ and the Māori Health Authority:
Three lead community organisations:
- Ngāi Tahu – (and the Iwi Māori Partnership Board when it is established)
- WellSouth PHO
- Rural hospital trust network
The co-design process would be empowered and supported by the Southern DHB.
The development of provider networks should be informed by further detail from Health NZ and the Māori Health Authority. It will also need to be undertaken in a co-design process with other interested organisations that would include, for example, mental health NGOs, Kaupapa Māori providers, maternity providers and disability NGOs. It will also be important to include MSD, the Community Council and local communities. It will be important to engage with MSD early, as it will help inform the framework for improved coordination and referrals between the health and social sectors.
The rationale for proposing the leadership of the three entities is that each of them has a core capability which vital to the effective operations of community networks.
The co-design process for the role of community provider networks should also build from the body of strategic planning that has already been undertaken in recent years for various areas, including: The strategies in these plans remains relevant and the health reforms should be seen as an opportunity for a new commissioning approach to enable improved implementation. Under the health reforms model, there is the ability for Health NZ to provide network support functions. However, existing community-embedded organisations should be encouraged to perform these functions if they have the desire, capability and capacity to do so. This transition period is an opportunity for local organisations to work together and put their best ideas forward. |
If the locally led co-design process were followed, organisations would need to agree principles, goals and how they would work together to provide advice on the future provider networks and provider network support options.
One outcome of this work will be to create improved strategic connections as part of the design process. As described in the population health section of this strategic briefing, the Collective Impact model may provide a useful starting point for establishing relationships and thinking about how provider networks may function.
Primary care teams
Primary care teams are at the heart of service networks and improved connectivity as a person’s health care home and the key point of advice, diagnosis and referral. Primary care teams need to be supported and developed to be able to practically function in a more connected system.
Access to primary care in the South
It is important for as many people as can to have access to primary care. The Southern District comprises the largest geographic area in the country, and the population of this region faces the greatest distances to health care. Mapping the journeys of patients to health services across the region, there are significant geographical areas that face a journey of over one hour's drive to access a primary care provider. This is consistent with other national comparisons, which highlight the South as having longer average times and distances to health services than the rest of Aotearoa. The map shows that while majority of people both urban and rurally have access to primary care within 1 hours drive, there are parts of the Central Lakes region, the Waitaki area, and Western Southland facing longer journeys. |
The Primary and Community Strategy is guiding the development of the capacity of practice teams and community care systems across the region. This advice remains relevant and the Action Plan should continue to be implemented through the transition period.
In particular, elements such as the Health Care Home and supporting pro-active identification, management and support of patients with high needs should continue to be implemented across practices – and the improved linking and coordination of people with high needs to a range of community-delivered services.
The heath reforms provide an opportunity for further enhancement of primary care teams and the dialogue around primary and community networks should explore how the role of primary care teams may evolve in the South. Opportunities exist for:
- Increased range of roles: Expanding the capacity of primary care with improved access to a greater range of workforce skills in practice. For example, this may include improved connection and integration with current DHB allied health services (in practice or virtual) and improved use of new workforce, such as health care assistants.
- Increased access to diagnostics and care options: Enhancing the use of Primary Options for Acute Care (POAC) or Acute Demand, which has been very successful in other large DHBs (e.g. Christchurch, Auckland). The templates and processes used in these regions could be replicated in the South, and clinical aspects are consistent with Health Pathways. POAC is a funding mechanism which can be leveraged by any primary care provider to keep a patient out of the more expensive hospital alternative and generally has 85-90% success for the agreed upon conditions. The POAC structure, which has nurses and administrative staff processing patient information and navigating them to a care option, has also been utilised in COVID to coordinate some testing and process payments for providers. Having a centralised, team of “system” experts is useful for any region, and given the geography of the South could support healthcare professionals to leverage the available resources and also engage private providers, especially radiology.
- Better electronic connections: To provide a more seamless referral to community NGOs and eventually social service providers.
- Connecting to Kaupapa Māori services: Enabling an improved understanding of the role of Kaupapa Māori providers and whānau ora services and when to engage with these services to support Pae Ora.
- Continuous improvement: Using data to provide feedback, within the context of locality networks, to identify and learn from variation to drive improvement actions.
Locality hubs
Rural hospital trusts are well positioned to become locality hubs in rural towns.
The rural hospital trusts are already well-linked to the local community, with a community ownership model. Many already include primary care teams and other services as part of their service mix and their facilities are home to various community services. The trusts want to have a wider role as hubs that can support health and social service integration – and should be encouraged to do so. They are ideally positioned to quickly transition as they have an existing base of local connections and relationships. They need clarity and mandate as to their future role within a connected local health and social system. |
In urban areas, community locality hubs need to be established.
The Te Kāika is a successful Crown:Iwi partnership in Dunedin and provides a range of general practice, mental health and social services. It should be encouraged to keep evolving to become an urban community hub. A second hub should be established in Dunedin and may also have a role of providing an affordable and accessible after-hours urgent care service, to complement that already provided by Dunedin Urgent Doctors. For the population of Dunedin, there would typically be two community urgent care and afterhours providers, as well as the hospital. The entry of COVID-19 into New Zealand has shown the worth of having increased primary care capacity, especially afterhours, to prevent hospital attendances which are more risky due to outbreaks. Urgent Care providers can also support swabbing and immunisation and have strong relationships with the hospital and traditional primary care. WellSouth and the Invercargill rūnanga have recently announced a partnership to develop a integrated primary and community services hub in Invercargill. This initiative should be supported to provide affordable urgent care access as an alternative to the hospital ED. Central Otago Health Services Ltd is exploring how best to establish a locality hub in Wanaka – and should be encouraged to continue with this approach. |
Understanding patient flows across the region
The six Southern rural hospitals provide outpatient services for varying geographical distances, from 30 minutes to 2 hours drive.
Patients from Wanaka contribute the highest volume of outpatients to Dunstan hospital and have the longest travel time (approx. one hour, or 78km) to attend the hospital. A much smaller volume of patients attend outpatient appointments in Queenstown, which offers less specialties.
Travel to Invercargill for an outpatient appointment is even longer for a substantial number of patients based in Te Anau, with a 2 hour, and 150km journey.
Gore and Balclutha have smaller catchments, primarily from a few surrounding towns including their own, while Dunedin has the smallest geographical catchment but does have a significant volume from Mosgiel, and also provides outpatients for all the subspecialties for the whole district.
The maps below identify patient movements across outpatient facilities in the district. Thicker lines indicate a higher volume of patient movements.
Proposed leadership for actions:
WellSouth, rural hospital trusts, Iwi Māori, - facilitate a co-design process that engages across health/disability and social service providers and consumers.
WellSouth, rural hospital trusts, Iwi Māori, - facilitate a co-design process that engages across health/disability and social service providers and consumers.