Forum 2019 - Next steps towards a fairer and more sustainable public health and disability system

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.


John Whaanga, Deputy Director-General Māori Health

Video: John Whaanga - Forum 2019 - Next steps towards a fairer, more sustainable health system

[John Whaanga presenting to an audience as part of the Next steps towards a fairer, more sustainable health system session of Forum 2019]

I think across all the presentations, If I was to summarize them, I'd summarize them this way. I think the first of those is that we need to have a clear vision and agenda for action. There was a clear theme from what people were saying, that we need to move on.

We need to address equity. And we need to have a clear vision and agenda for action. And that action needs to be framed in what's important in this country, in particular to Te Tiriti.

The second thing is that we need to respond to the evidence and change practice. We have a lot of evidence now which is showing us where inequity exists. We need to take that evidence and do something about it.

Thirdly, we need to embrace different ways of doing things, make them sustainable, and to forge relationships. It's really important that we are able to look and work on things there are different ways of doing things, that a lot of what we're doing in equity is about challenging the status quo, and finding different ways to respond better to the needs, and the diverse needs, and different needs of our community.

The last two, we need to recognize and address stigma, prejudice, bias, and racism. And we need to address those things honestly, and openly, and directly. And lastly, as a summary for all of those things, we need to learn and we need to change.

I think one of the things I heard come up a number of times was that it takes courage to address these things, because it requires getting a bit uncomfortable first, in order to address them. How do you think we're doing at getting comfortable with being uncomfortable? Because we have had some uncomfortable conversations during the conference.

Yes, I think we have. And I think there's a real willingness to have those uncomfortable conversations. They are not easy conversations. There is no easy way to have a discussion about prejudice. There's no easy way to have a discussion about racism, or bias, or stigma.

But what we all know, and certainly, as I saw people coming to sessions, we all agree we have to do something about that. And as leaders, we have a responsibility to not only talk about those things, but to be the champions of that change.

We are leaders in our professional lives. We are leaders in the community. We are people who others listen to. We have an obligation, because we know that inequity exists. We know what needs to be done. And we need to be the champions of that change.

You're right, we do know. And it came up in your sessions several times that we have known for some decades that this was an issue. Do you feel like there is more of an impetus for change now than there has been before?

Yes, I think so. I think there's a strong focus at the moment on well-being. There's a strong focus led by the prime minister, no less, to address-- to have a national level discussion and international discussion about racism and prejudice.

I think there's a real willingness to be re-looking and re-enthusing our partnerships, not only our partnerships with Marty, but our partnerships across the sector. So my view is that in the current environment, there is a lot of support for us to challenge, and to pick up, and to address these significant issues, and challenging issues.

Deborah Woodley, Deputy Director-General Population Health and Prevention

Video: Deborah Woodley - Forum 2019 - Next steps towards a fairer, more sustainable health system

[Deborah Woodley in front of an audience as part of the Next steps towards a fairer, more sustainable health system panel]

Thanks, Nadine. And first, can I just start out with a big shout-out and thanks to our presenters? We had three great keynote speakers.

But our presenters who did full presentations, big thanks to Claire, Greg, Tepuia, Rachel, and Innie. Great job. But also, personal thanks-- and this is off-script-- to Sharlaine Chee, who facilitated the well-being session. So thanks to that.

In terms of your question, I think one of the key things-- Audrey and I were talking before coming up that we've got quite a big intersect actually with some of the themes that came out of the person-directed care and also the well-being session.

And I think some of the themes that came out of the well-being session was very much around treating, whether it was a person or the community, holistically and that it's not just about, for example, quitting smoking or a particular service intervention. It was actually about the person, the fan or the family, and the community. And actually, it was an essential part of actually getting amazing outcomes to actually start at the community base.

I think some other clear themes-- there's a very clear theme and intersect between well-being and equity. And given the sort of uneven distribution of the social determinants of health at the moment, we're not going to be able to achieve health for all unless we tackle those determinants that sit outside of health.

There was also a really big theme around the permanence of nature that we need to create. So across all our three presentations, they achieved some amazing outcomes for the community and for individuals by working within a permissive environment. They weren't bound by service specs or contracts.

And they didn't head to a whole lot of widget counting. They were just given an outcome and a focus. And they could be nimble with the ability to shift resources around.

And another key thing we did hear is that well-being was very much about when people feel valued and included in the decisions about them.

Anna Clark, Deputy Director-General Health Workforce

Video: Anna Clark - Forum 2019 - Next steps towards a fairer and more sustainable public health and disability system

[Anna Clark presents to an audience as part of the Next steps towards a fairer and more sustainable public health and disability system session of Forum 2019]

Thanks, Nadine. I think the health workforce sessions were a great opportunity to introduce Judy and the new Health Workforce Board to the sector. I know that Judy was really excited by the opportunity to meet with people.

And it was also a great opportunity to share some successful workforce initiatives that are underway. And I think those initiatives have a real focus on equity. We heard from Jo Baxter talking about the work she's doing at the University of Otago to increase the number of Maori students studying health sciences.

And then we heard from Sue Pullon, who was talking about students learning in rural areas, where they learn to meet the needs of rural communities and in high needs areas. And that made me really thoughtful about the equity work that we do in the Health Workforce Directorate.

And I think we need to work really closely with the sector on this, with John and the Maori Health Directorate. We've got a chief advisor of workforce equity coming on board. And that person has got a really big challenge ahead of them, as do we in the directorate.

But I think a place that we can start and that we've identified is picking up on something Shane just said about data and equity around data. And one of the gaps in our data is around the unregulated workforce and, in particular, the Kaiawhina workforce, which is the largest Maori and Pacific segment of our workforce. So it's about thinking how we grow data in that area so we better understand that workforce and their needs and the opportunities for it.

Shayne Hunter, Deputy Director-General Data and Digital

Video: Shayne Hunter - Forum 2019 - Next steps towards a fairer, more sustainable health system

[Shayne Hunter in front of an audience as part of the Next steps towards a fairer, more sustainable health system panel]

Yes. So I think I'll start with data. I think one of the opportunities that we get through data is to see what is actually going on in the system, to understand-- through data-- the story of the people who have the lived experience the ta-- I mean, I went to two sessions today. I'm sorry, I've been to the person directed support session twice because I was very enamored with the presenters. Actually Andre, I thought it was fantastic to see them up here. And it did give me pause for thought around both data and digital technologies and what we can do to support people.

Some of the themes, some of the comments that were coming out were things like equity by design, and how do we actually remove barriers in the system. And there's no doubt that we've got some real complexity in our systems. I think those, in themselves, present barriers. I think the way that we design systems need to reflect the people that actually use those systems. As I say, I think that the data that we capture, did we capture the right data? But more importantly, when it tells us something, are we going to take action? Because there's no question through the data we will see inequities.

And the question is are we willing to actually act upon the data? They call it actionable insights. It's not something I think that we're necessarily particularly good at. So the opportunity to improve equity through data I think is incredible. The other thing I would say around digital is we've got to remember that there are those that have access to the technology and those that don't.

And so we can't forget the people that don't. And I know digital inclusion is a big focus for the government. And we have to find ways to make the technology accessible. But we also have to deal with people that can't necessarily use the technology but still need to access services. Otherwise by design, we make the system equitable.

That's an interesting point you make about not just using the data to identify the problem, but also the solution. In the equity session, Dr. Nina Scott talked about presenting data, clearly showing the issue but no one wanting to leap on it and address it. So I guess using it to identify the problem is only half the way there.

Oh, absolutely. And I think that that's about leadership and being prepared to and, I think I heard you mention, but I certainly heard being prepared and being open to different ideas. Because I mean, while the data shines a light on the issue, we then have to have the right conversations about what we're actually going to do about it. And it's about leadership, and the term that came out of the person directed thing, which I really liked, was community leadership because the answers actually lay in the community. It's not something that we can design from the top. And we shouldn't design from the top.

Adri Isbister, Deputy Director-General Disability

Video: Adri Isbister - Forum 2019 - Next steps towards a fairer, more sustainable health system

[Adri Isbister in front of an audience as part of the Next steps towards a fairer, more sustainable health system panel]

Thanks, Nadine. Look, firstly, you've mentioned this, and I would really, really like to thank our wonderful presenters and person-directed support. Like, you were so generous with your time and sharing your experiences and competencies with us, so thank you. One of the key things that I've heard is that disabled people want the right to the highest attainable standard of health care. And that's come through and I really appreciate that.

Another theme that came through today and yesterday is the complexity of the system. You know, particularly the assessment process, both for our equipment management, environmental support services, and the process for accessing disability support at home. It appears from conversations that the process is for the system rather than for the person. And words like "simplified" and "as necessary" have been used. I suppose another strong message that came through was that disabled people, family, whānau, they want to be at the table. We've been challenged in our willingness to share power, and codesign was often mentioned in that.

There's also been a challenge in the fundamental shift in culture and working with the community and developing solutions together. A culture of trust and building relationships, very similar to what John said. But not only in health, but right across the sector with other agencies. And I must say, it's really good to see other agencies here today. And this was highlighted and is most important.

We heard about pockets of innovation or postcode services that are happening in New Zealand. And our challenge is to scale this up to a national consistency. We also heard people challenge each other to be the change that you want to be. Lastly, disabled people are up for leadership, and I was really, really pleased to hear that because that's something that we all wish to see. But the other thing that we also heard was that we are all leaders, all of us, no matter what our roles are, so we need to role model that leadership and role model the behavior that's expected. So, sort of on an end node, and many people see that we can't forget that actually one of us is not as strong as all of us. And that really came through, that whole change of willingness to be part of the solutions. So yeah.

Dr Ashley Bloomfield, Director-General of Health

Video: Dr Ashley Bloomfield - Forum 2019 - Next steps towards a fairer and more sustainable public health and disability system

[Dr Ashley Bloomfield presenting to an audience as part of the Next steps towards a fairer and more sustainable public health and disability system session of Forum 2019]/p>

Kia ora whānau. We're nearly there at the finish line, or is at the start line? Thank you that you've stayed to the end here. Often, the room empties out as people have to leave. But I'll take it as a good sign that you're here and you want to be here for this final session.

Over the long weekend just gone, I took the opportunity to sort out a few boxes in my study at home. For those of you who have seen my office at the ministry, and you transfer that to home, you get an idea of what my office looks like. But some of these boxes contained things from my parents' home that we cleared out two years ago when my father died.

And I discovered, in the boxes, many mementos from several generations of my family. And amongst them were many gems and some things that really made me think, and particularly about my parents and the impact that had on me. One box that I pulled down off the top of my shelves contained a range of papers and reports from the 1990s that I had accumulated when I was a public health medicine registrar specializing in public health.

And it also contained some gems, one that was particularly striking and I've brought along to show you. It's called, "Healthy New Zealanders, Briefing Papers for the Minister of Health, 1996, Volume 1, The Key Policy Issues." Now at the time that that briefing for the incoming minister, or BIM, as we now call them, was written, Dr. Karen Poutasi was the Director-General of health.

She's been here for the forum these last two days. She's now the commissioner at Waikato District Health Board. And I have to say, I remain in great admiration of Karen, in particular the energy she brings that she had then when she was DG, and she still brings to the role. She's here, and I showed this to her this morning, and she recognized it immediately.

I thought I'd just read through some of the headings on the contents page. We could do better on health outcomes. We could do better on health and disability support services. Tackling some longstanding problems. And here, I'll come back to that, because the first one of these longstanding problems is called, somewhat cryptically, Aiming for more than middling. I'll come back to that.

On we go. Balancing the inevitable tensions. Would it help if the structures were changed? Realizing the potential of the sector. And the first subheading is Leadership-- focus and clarity. And here we go. Or I should say that earlier on, under We could do better for health and disability support services, the first subheading was, Doing better on Maori health.

Here's another heading. Is there enough money in the health and disability sector? And finally, under Next steps, An agenda for a healthier New Zealand, is, Intersecular collaboration for health.

Coming back to that somewhat cryptic heading, Aiming for more than middling, if you open up the report, it says, In general terms, the motives for reform include-- these were reflecting on the reforms in the early '90s-- included more effective and efficient use of resources to achieve the following health gains for the people of New Zealand.

Greater coordination of care, services more responsive to consumers, including Maori, clearer and stronger lines of accountability, cost containment and increased focus on public health, and the removal of conflicts of interest in the area of health board structures. That was the rationale for moving to a purchaser-provider split at the time.

I found that quite salutary. Does it sound familiar? Plus ça change, plus c'est la même chose. The more things change, the more they stay the same. I think there are three things we might take from this. First, the fact that the challenges and issues that we are dealing with, we are grappling with, and we are here to discuss now are not new does not mean we have failed, or got it wrong, or indeed, that we should be cynical or despondent.

Rather, to me, it emphasizes that the fundamental challenges in our health and disability system are longstanding and most of all, they are complex. This should come as no surprise to any of us, and I doubt it does. After all, the late management guru Peter Drucker describes just one part of our system, the hospital, as the most complex human organization ever devised.

Second, because they are complex challenges, they cannot be resolved by simple, unidimensional solutions, or by one particular idea, or one actor. The answer is not simply more money, or more coordination, or more leadership, or more of this particular professional group, or specialty, or technology. It requires all of these and more.

These complex issues require sophisticated thinking, multi-dimensional responses, and above all, a wide range of actors working towards a common outcome or vision. And as has been highlighted over the last two days, we have to collaborate. We need to work together to continue to make progress on these complex issues.

And the third point I think it's important to reflect on is that we need to pause periodically and reflect on progress achieved. Have we improved safety, quality of care, health outcomes, efficiency, Maori health, accessibility to services since 1996? Most definitely we have. Have we achieved everything we aspired to back then? Heck, no.

By way of example, there was another document I found in my treasure trove from the mid-'90s. It was the "New Zealand Public Health Report" from July 1998. A very topical heading of the lead article-- "Immunization Coverage and Risk Factors for Immunization Failure in Auckland and Northland." Believe me, I've given this a lot of thought over the last few months, as have many of you.

But just as you look in that article, there is a table that includes the vaccination coverage of our mokopuna, of our tamariki back in 1996, fully immunized at two years of age. Get this. Maori, 44.6%. Pacific, 53.1%. Other ethnicities, 72.3% Have we made progress? Amazing progress. Are we there yet? No. Is the challenge ongoing? Yes. But we do need to pause periodically and reflect on our successes.

The solutions to these challenges and complex problems that we deal daily lie with us. As I have often been heard to say to my team, no one is coming. No one is coming. It's up to us. However, fortunately, that was not the case with this forum. You did all come. Thank you for that.

In the first session, I explained why we convened this forum, and I just want to reflect back on that because some have been asking that question. Here's what I said. A key role for the Ministry, and the wider health and disability system, is to convene, to bring together the full range of stakeholders that are essential to ensuring New Zealanders receive the services they need for their health and well-being.

This forum provides the opportunity for us all to hear about, to discuss, and to better understand the future direction of the system, as well as helping us all refresh and generate the energy needed to renew our focus and commitment to improving health and well-being in Aotearoa New Zealand, and in particular, to achieve equity for Maori, and indeed, all New Zealanders, which I strongly believe is a common aspiration.

So that's what I said at the beginning of yesterday. I sincerely hope that in attending the forum, you have achieved some or all of these objectives yourself. I have been inspired. I have been re-energized. I have written a lot of notes and have a lot of great ideas to take from what I've heard.

Thank you all for coming. Thank you for contributing, for bringing your energy and ideas, and for your ongoing commitment to health and well-being in Aotearoa New Zealand. Thank you, Nadine, for being an outstanding MC for us. A huge thank you to all our speakers and presenters. You've been fantastic. You've gone out of your way. And for those of you who had to do it four times over, a special thanks to you.

I do want to call out the team in the ministry who have done a fabulous job of organizing this with a very short runway, and four or five people in particular. And I'm going to name them because they have been outstanding. Lisa, Megan, Alex, Mikey, and Sarah, who heads up my office of the director general. Can you just put your hands together for those people?


And finally, the challenge, the wero, which in a sense was laid out for us in the "Interim Report of the Health and Disability System Review," and Keriana asked this question of Heather directly about the lack of leadership in the sector. Now, you will all have your own ideas about what that means, and indeed, what we might do about it.

But that is a challenge for all of us. My strong sense is that we're up for it. For our part in the Ministry of Health, we're certainly up for it. We'll be doing our bit. And what I can say is that we have already started to develop up a proposal around a sector-wide leadership development and support program. I think this is something that we used to have a little bit of in the sector and we need to be really deliberate about supporting, training, and developing our leaders right across the sector, clinical and non-clinical.

And we're going to be developing up a program to do that. We look forward to involving you in both helping shape that up and, of course, in delivering it. So I look forward to continuing the work with you beyond the forum. When is the next one? Well, I'm told by Lisa, organizer extraordinaire that she is, that she's already booked the venue for April 2021. So we'll let you know more about that is it firms up.

Tēna koutou, tēna koutou, kia ora tatoa katou

I'm going to hand it over to John now for the mihi whakamutunga. John.


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