Forum 2019

29 – 30 October 2019, TSB Arena, Wellington.

Forum 2019 brought nearly 500 people together to reflect on successes, address challenges and shape efforts to deliver a strong and fair public health and disability system in Aotearoa New Zealand.

The Forum was opened by Minister of Health Hon David Clark. More than 40 presenters and facilitators from diverse health and social sector backgrounds then delivered two days of plenary and concurrent sessions.

Input and feedback will be used to help inform the future direction of our health and disability system. Planning is underway for a second Forum in 2021.

Below is a summary of each Forum 2019 session, including speaker presentations. Email forum2019@health.govt.nz if you have any issues accessing the videos or presentations.

In this section

  • Both in Aotearoa New Zealand and globally, our ability to address equity challenges in health has improved over the past decade. Read more
  • This session described the key functions of the Interim Mental Health and Wellbeing Commission, the increasing demand for mental health services and role of primary care, and the importance of a cohesive and resilient workforce. Read more
  • This session explores what the future might look like for our health system. Read more
  • The Health and Disability System Review Interim Report was released by Review Chair, Heather Simpson to the Minister of Health on 3 September 2019. An expert panel joined presenter Heather Simpson to discuss The Health and Disability System Review Interim Report.  Read more
  • In this closing session, members of the Ministry of Health’s Executive Leadership Team presented key themes from Forum 2019. Dr Ashley Bloomfield, Director-General of Health, provided the closing remarks. Read more
  • The aim of this session was to build a shared understanding of how we can work together to support the priorities outlined in the Wellbeing Budget 2019. Read more
  • This workshop considered the opportunities for person-directed support, associated challenges and ways to overcome them. [Dr Tristram Ingham's mihi] Thank you, Minister, for your opening words and to Mark for your introduction and to the Ministry of Health with the invitation to speak here today. We've heard a lot over the last day and a half about how the health and disability system is inequitable and unsustainable, that it's a system under strain and a system that needs to change. And we hear the people in this room over these two days actually really effectively represent the majority of that system. And so this is really an opportunity for us to reshape that system and for person directed care or person directed support to be a key vehicle to drive that change. I say ready or not, here it comes, because disabled people are finding our voices, and the level of advocacy impression in the community is rising, and the ministry central government is picking up on this, and legislative policy, regulatory changes are coming that will support this movement. So it's a time for organizations to get on board the walker, as the minister said, and really lead that change in parallel with us. We've all seen this diagram before. People watching a game, looking over a fence. And the point of the diagram makes the point that we need to distribute resources and supports to allow each person to fulfill their true potential. Equity over equality. But it can be easy to overlook a key aspect of this graphic. Who built the stadium? Who would build a stadium that only 1/3 of the people can see the game? And so really I think this is where it calls into question person directed support. It's really a vehicle for not only a human rights approach but actually just simply a quality framework. If we design the fence in partnership with the communities that we're serving, we can design a fence that doesn't require those supports, because those boxes-- we've built a whole industry around building boxes, moving them to the right place, lifting people on and off those boxes. And inevitably, the boxes aren't in the right place at the right time, we don't have enough boxes, and no one's really happy. If we had started from a premise of the people who use the system, we're integrally involved in the designing of that system. We would design a system that not only met their needs better in the first place but would save us a lot of work. And I think that's a really critical image. When we're talking about these fences, we're talking about quality. We're talking about processes. We're talking about the complexity that the system has. We've heard over the last two days, the system is very complex. That complexity is the fence. It's that complexity we have to remove. And I guess my question is, what actually drives quality and innovation in a system like ours? Take the metaphor of this communist architecture. In any monopoly or where a consumer or market economy doesn't drive that competitive change, a system inherently tends to become functional rather than inspired. So how do we get to a point where we subject our Uber drivers to more quality control and customer feedback than our health and disability service providers? How does that happen, and how do we bust out of that? Because I'm going to challenge us with the notion that the system is performing exactly as it was designed. But it's because it's a system that was created and evolved by providers primarily to support the focus of their needs and their efficiencies. So why would we expect a different outcome? And so this is where I think person directed support is not only just a means but an opportunity to change our organization. We need to identify levers. And finding levers in the system is a critical step and one that's been quite lacking at all levels. But with problems like this, there won't be a single solution. They require a concerted effort. We have to not only make the problem understood, and this forum, I think, represents the ministry during its part to try and engage with the sector in general to actually make some problem more understood and not bring a solution but to start the conversation and actually ask the sector for those solutions. So we're asking you to identify in your organization what are those levers? What can you do to break down those barriers? I want to give you an example, an opportunity, in fact, around the implementation of this practice. And this is something I've been involved in through the DPO Coalition, the Disabled Persons Organization Coalition. So this is an example of government working with disabled people in a partnership relationship to implement the UN CRPD. So the UN Convention on the Rights of Persons with Disabilities. This convention is in effect in New Zealand. It is legally binding an international law on all state parties. So government. And all government funded organizations. And its purpose is to ensure the full and equal enjoyment of human rights and fundamental freedoms by all persons with a disability. And in health, so specifically relevant to this sector, there is a whole article on the rights of disabled people. And that includes to the highest attainable standard of health with not only mainstream health services, but also disability specific health services and habilitation and rehabilitation programs. Programs that are close to home and that respect the inherent dignity of the individual. There are a number of other articles in the convention that are also specifically relevant to our sector. That our services must be accessible, that our staff must be trained in how to work with people with disability, that our materials, our information forms, et cetera, need to be accessible and forms, and that other technologies that are available to support those interactions. Legislatively, regulatory, this is already in place. There is nothing that stops each one of our organizations from taking this forward tomorrow. Article 4.3 of that same convention talks about the requirement and gives us a clue to the person-directed support element of this, that in the development and implementation of not only legislation and policies but in other decision making processes concerning issues relating to persons with a disability that the represented organizations or disabled people themselves must be closely consulted with and actively involved. So what does closely consult and actively involved mean for you, for your organization? So I want to just leave you with a glimpse at what a checklist might be, because I'm sure if I ask, most of you would say you're committed to working in a genuine partnership with consumers, disabled people, tangata whaka. So what does that mean? What in your organization's governance structure do you have to actually support that top down leadership? 24% of the population have a disability. How is your workforce in terms of its disability makeup? After all, if we can't make health and disability services such that they can meet the reasonable accommodations of disabled people, how do we expect any other employer to do so? In the commissioning of your services, how many of your services are actually co-designed, co-delivered, and co-evaluated with service users or disabled people? And just like the Uber driver, what do you have in the way of robust quality feedback mechanisms so that those consumers, those disabled people, can actually give you their feedback? We know that organizations need help to be able to move forward to this kind of way of thinking, and so we're really encouraging significant community stakeholder partnerships. How many of your organizations have relationships with disabled persons organizations or Kaupap Māori providers or other NGOs to kind of fill the expertise gaps that you're having? And just really finally, I think there's a number of key success attitudes that you've heard about from the previous speakers that are really going to underpin this. We need to recognize that consultation is no longer adequate. That we really need each organization to truly know its community and go beyond the usual suspects that you might have brought in on the promise of a petrol voucher or a morning tea for a consumer support group. We really need to recognize and remunerate the lived experience skill set of the communities that we're talking about and really be open not only to the input and critique that may come, but actually to recognize that we don't, as providers, need to have all the solutions ourselves. We need to bring the problem to the table and come to the table as equals so that we can work on the solution together. Kia ora koutou. [APPLAUSE] Read more
  • This workshop was designed to increase collective understanding of equity and develop ways to use this knowledge across the health and disability system. Read more
  • A strategic approach to planning and development of our workforce is key to ensuring Aotearoa New Zealand’s health and disability system can deliver safe, effective and accessible services now and into the future. [Dr Jo Baxter mihi] Well kia ora everyone. I really want to thank people for inviting me to speak here today, and I suppose I don't hide my passion for Maori health or Maori health workforce development very well, so I will always take up an opportunity. And actually, I don't hide my passion for the fact that I'm actually from the west coast. I happen to be [INAUDIBLE] and Otago, but I am west coaster born and bred. So issues of rural health and Maori health are also very, very close to my heart, and it's great to be part of a group that's hopefully going to help us tackle some of the issues that we have in terms of workforce and land in a place that means that the diverse communities that we have are well served by the health workforce that we have. I've also been really, I suppose, inspired already by many of the initiatives that are out there that I know many of you are already part of. And some of this is about joining those dots and bringing positive things together and working together to get to where we want to land. So I want to tell you a bit about my journey in supporting equity in terms of Maori health. And this has really been a 10-year journey with the University of Otago. So my background is in medicine. After leaving medical school, I trained in psychiatry and I worked in psychiatry for quite a long time. And then had an itch I wanted to scratch, which was around how can we make a difference at a really big picture level, and ended up coming back through public health medicine, and health workforce has been one of the areas where I think we can make a huge difference. So I want to talk about why we're focusing on equity at Uni of Otago, some of what we've learned to date about what are some of the critical success factors that have supported our outcomes, and our next steps because we are only partway through the journey that we are on. If you look at the international literature about the importance of having a diverse workforce, you'll see things that look like this. And this comes out of nursing research, which really highlights and focuses on diversity, but the important role that diversity has in supporting access. And access leads to reduced disparities, and reduced disparities contributes to health equity. Other models break that down in what are the mechanisms for why we have diversity contributing to health equity. And some of those come very much at the patient communication level, but it also talks about where people choose to work and the kind of roles they have. So increasing workforce that will support underserved communities. Growing trust between communities, patients, whānau, and health services. And then also having people in there that are advocates and champions. And I'd like to add another one here that we've certainly seen and observed within our health sector when we have seen the growth of Maori in the health workforce. And it's probably no surprise to people to start to see that we're getting pockets of growth in strategy, policy, commitment to things Maori happening in some really interesting places. Some of the colleges in medicine and some of the less well-known specialties. And often, when you look at what's behind that, it will be because there's been often been Maori staff or Maori communities or Maori people who've actually come in and started to push. So we've got a desire for enabling policy, and it's wonderful to see the prioritization and policy that's supporting things Maori, but also having the people in there to actually give life to that intent as part of this. And so research that we've done at our unit has really highlighted not just some of those formal roles and the recognized roles, when we've researched and looked at Maori graduates from our health professional programs, we've found people highlighted many, many things that they were doing behind the scenes, encouraging young Maori to think about careers in health, working with their own whānau in their communities, and very much that collegial providing support for their own colleagues and informal mentoring. And this was happening in all sorts of places and spaces. So the things that we don't often measure are out there, and so growing the workforce allows for those intangible and more organic impacts. And I think very much, when we think about the context that we have, then we can think about the advantages of having a full and flourishing health workforce that is Maori out there across all parts of our sector. And we have a long ways to go. And some of this data is taken from very recent. Some of it's a bit older, but we know that around between 6% and 9% of nurses and midwives are Maori, and for the programs we run at Otago, only between 2% and 5% of the registered health workforce for these professions and a number of others is Maori. So we look like that tiny little sliver. And so the question that I have is, so what have we missed out on, in terms of our capacity as a health workforce, to actually understand, to drive, to solve solutions, to actually meet the needs of Maori when we haven't been present in many places and in sufficient capacity to actually be contributing to that? And so often our focus on equity in terms of Maori as, we're here and we want to be there, and if we do, we'll get somewhere. But I also think we ought to reflect on the dynamics of not being there in the first place. And what is the implication of that? And some of the struggles that we have, like we want a program and we're going to try and make that program be responsive to Maori after it's been developed, for instance. Maybe we wouldn't be in that situation of always trying to adapt if actually Maori were central and part of the program development to begin with. So there's a whole range of impacts of this, and I'll just mention one of the ones that I think has come out very much. And I think that with underrepresentation of Maori, you have a small number of people who have multiple roles. So I also have a very personal vested interest in growing the Maori health workforce I counted up all the committees I'm on, and I was well into double figures and more. And I'd love to be able to share the love around, so another great reason to grow our workforce. And then qualitatively, I just want to acknowledge the experience of some of the young people in the emerging health workforce that we have. And so this came from a reasonably new young doctor as part of research. I'm usually the only Maori and the team. I'm always the only Maori doctor. Everyone expects so much, but I'm still training. So it'd be great to be a world one day where our young trainees weren't having to be all things to all people. So how many do we need? And we did a bit of modeling. This is back of the envelope modeling, but roughly if we were going to reach 20% of the workforce roughly, which is based on the proportion of Maori who are young people in our population, we'd need 13,000 more nurses, just over 2,000 more doctors, close to 400 dentists, and 300 and something midwives. If I had a magic wand, I might be able to do it. But otherwise, we've got to grow these. And you can do the sums about how long it's going to take and the commitment we're going to need to make a really meaningful dent on those numbers. So I call this a tale of two inequities because our health workforce inequity is a pathway that comes from education, and there are huge ethnic differences in educational attainment. And of course, for many of the programs we have, we require people to come into tertiary education often with a background that requires some science, and they have to compete and get into some very heavy duty programs that are often quite intense. So UE attainment, this is a decade of UE attainment. And what you can see for both Maori and Pacific as it's looking pretty grim, so around 25% And if we think that a small proportion of those are coming out with sciences as part of that mix, then you can see the challenge that we have. So our path in Otago was to partner with the Ministry of Health a decade ago, and the goal was to grow the numbers of Maori in the health workforce. And this lined up with our policy that we have as a merit on society so that our graduate poll would also reflect New Zealand society through a whole range of programs within the Division of Health Sciences, and then also in the wider university spanning a range of things. So prior to 2010, we had a fairly dismal track record as an educational provider for Maori in health sciences. So less than half of Maori students were getting through to second semester in our competitive health science first year. That's the pathway into the health professional programs. Many of those students came in with educational vulnerabilities, and although there was lots of support-- and there's always great pastoral support and some academic support-- we were dismally failing those students. So we set up in partnership with the Ministry of Health the Maori Health Workforce Development Unit in 2010 to do something about this. We aspirationally had a goal that 20% of students across the Division of Health Sciences would be Maori by 2020. It's 2019. I'll tell you where we got to later, but we started out with 4.2%. And these were very standard approaches to growing things, but in particular Maori-led and directed, and a strong social justice agenda and a very clear direction in terms of program development. Some very important policies underpinning our direction, both from the University, from tertiary education and health. And I just want to acknowledge here He Korowai Oranga. I think this is a great piece of policy that positions Maori participation and the health and disability sector right in the middle. And I see pathway 2 as a link to both pathway 1 and pathway 3. So I think if we can do something about the workforce, we will tackle some of the others as well. We have a range of health professional admissions, processes, and pathways at Otago. And just a new one we've got, there's a socioeconomic equity one as well starting this year, Maori, Pacific, rural. So our approach was, rather than to come in and say what's wrong with Maori, we took it the other way. We saw there is a whole lot of people in the society that seems privileged in order to get their young people, to have young people into health professional programs. What is that privilege? What does it look like? Where does it come from? How does it work? And then how do we unpack it and repack what we're doing for the Maori students that are coming our way? So over time, we've developed four programs underpinned by research and evaluation, and our tagline is "from inspiration to" graduation these are all evidence informed. They have strong student voice and co-creation, have theory of change, program logic, and Maori-centered in principles. So one of the programs as an outreach program where we work with years 9 and 10 on science engagement and years 12 and 13 on health science engagement and health professional pathway programs. We have our flagship program, which is Tū Kahika. These are young people desperate for careers in health, but who have had significant educational disadvantage. We provide a scholarship program for them. And then our health science first year, which we completely unpacked, repacked, and wrapped a whole lot of things around it. If this was an educational talk, I'd unpack all of it, but just to give you a bit of a thing, we work very much with peer tutors and supports. And we do a whole range of things with those students over the course of the year, which includes running all-weekend physics tutes on the weekend that the big Hyde Street Party's on. So we manage to cover hauora as well. And then we work with our students all the way through to graduation, and we're now starting to do a lot more to prepare those Maori students for what it's like to enter the health workforce. Range of research and evaluation projects, including one that I want to acknowledge working with the South Island DHB Health Workforce Hub, where we're looking at how do we support really successful transition from our Maori graduates into the DHBs and how the DHBs can support them through best practice and recruitment and support for Maori entering the workforce. So our outcomes have been exceptionally positive. We have a huge, high level of engagement for these young people. We have a high level of return from our outreach programs, and many of the students that we've seen in years 9, 10, 11, 12, 13 come back, and they're now out there in the workforce, many of them. Our foundation program has been hugely successful. Many of these students didn't have UE when they started the foundation program. Almost all of them do by time they finish. Most go on to health sciences, and many of them talk qualitatively about the huge difference this has made in their lives. These are just some of the graduates. We've had coming out of Tū Kahika, and some of you may recognize some of these. We've got dentists, surgeons, physiologists, physiotherapists, and a whole range of people here. So our numbers have skyrocketed, particularly more recently. And in terms of our health science first year, we had a 40% increase in just the last year, which has created logistics issues in terms of where do we get a room that will take 235 people. And that was on a average of between 50 and 65, 66 before we started the unit. High levels of engagement, and this is what our year looks like when you have to stick them on the floor because we don't have anywhere else to put them. And again, qualitatively, students are talking about this being transformational for them in terms of educational experience. In terms of health professionals, we now currently across all programs have 369 Maori students across our health professional programs. We have a whole pile more in health sciences and bachelor of health science. And this is the medical school. We have 264 Maori students currently in medical school across the years, averaging about 20% of the medical school class. So we've hit 20% in medicine and working-- they are in close in dentistry and on the way with physio. So watch this space. So we really have two overarching critical success factors, and one is the foundations and committed leadership, policy leadership, and a real commitment to this. And then the other one has been around evidence informed, data-informed, highly effective programs with lots of quality improvement as we've gone. And it really fits into these two things-- having the intention and commitment, and then paying attention to what we're doing. And both things have been required. Sometimes people think you do one or the other, but I think you have to do both. So our conclusion is that we can reflect society in our health professional programs. Success requires input and commitment at all levels, but that we get multiple benefits and both health and education. So it's like the bifecta, if there is such a thing. And really, if we want to tackle equity, if we take a our determinants, we work on health services and we get our health workforce right, I think we can really get to the goals that we want to. So just overall, we haven't got to 20%, but we have got to 15%. So I think that's pretty good, of our students overall being Maori. And we have some new projects, and part of it is actually preparing Maori students for the diverse roles they'll have in the workforce. So [MAORI]. [APPLAUSE] Read more
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