Online hui on the interim Government Policy Statement

Speakers:

Moderator Richard Foy

Health Minister Andrew Little

Ministry of Health Acting DG Robyn Shearer

Maori Health Authority CE Riana Manuel

Health NZ CE Margie Apa

Richard: Tena koutou katoa.

(SPEAKS TE REO MAORI) Hello.

Ni Hau, talofa lava, namaste, hola.

Greetings to us all.

in just a handful of the 160 language is spoken here in New Zealand.

And this is Samoan language week.

I am Richard FOI, Deputy Chief Executive, community and partnerships at the Ministry for ethnic communities.

It is my great pleasure to be here today to moderate this discussion.

As you can see, we are taking a more casual, informal, fireside chat mode today.

But I think it is more of a campfire chat given the nature of the chairs we are sitting on.

A warm welcome to all of those who have joined us online for this information session on the government policy statement and its direction-setting role in the health sector reforms, improving equity in the reform system.

Unfortunately, as some of you may be aware, Director-General of health Dr Ashley Bloomfield has COVID and is unable to join us today, but we hope he makes a speedy recovery, don't we?

Minister Siaq is also unfortunately unable to join us.

Stepping in for Dr Bloomfield, I would like to welcome acting Director-General Robin Sherro who will talk to us about equity in terms of the health sector, the role of the Ministry of Health, and developing the government policy statement.

Then we have minister Andrew Little who will speak about the Pae Ora bill.

We might refer to as the GPS, not to be confused with the global positioning system that you used to drive your car, but it is the government policy statement.

We will hear about his priorities, objectives and what he wants to see achieved.

Then we have got the Chief Executive's of the two entities, Margie from Health New Zealand and Riana from the Maori Health authority, who will speak specifically for those groups for whom equity will be of the most benefit and expand on how the entities are thinking about specific components such as the development of the New Zealand health plan, the Charter, and how the new locality system will help address equity.

This session is being live captioned, so you can access that by pressing the cc button at the bottom of your screen.

We are also pleased to be joined by New Zealand sign language interpreters.

A recording of this session and the transcript will be made available both on the Ministry of Health's website and also on the link that many of you will be watching on now.

I know you will have a lot of questions as each speaker goes through their topic, so I welcome you to submit those through the online chat.

We will try to get as many of your questions as possible today, but quite a few have already been sent in in the last couple of days.

For the questions we are unable to answer today, the team will group those together into themes and they will be posted onto the Ministry of Health website where you will also find the recording from the first session in this series on the GPS and the health and disability reforms.

a quick note, a plug for the future.

We have two more sessions planned in this series.

The next is in one week's time and the Ministry will open registration shortly.

Be ready for that.

That will cover strengthening population and public health.

The final session which will be held on June 23, that will cover improving primary and community care and improving hospital and specialist services.

These are pretty exciting topics, but we have a great topic here today.

From my perspective, the Ministry for ethnic communities has a really key priority which is about ensuring government services are provided equitably and are always accessible for ethnic community.

So today's conversation is quite personal to me within that context, because I recall quite vividly the struggles and frustrations my dear mother had when she was engaging with the health system.

Particularly because of her very poor grasp of English.

And she had to rely entirely on her New Zealand-born, English- speaking sons.

And that was to help navigate a system that wasn't really designed to meet her needs, that didn't really understand her understanding of health and well-being.

And I know that she is not alone in those struggles.

And I know not everyone is fortunate enough to have me as their son to help them navigate that system.

With that, I would now like to hand over to Robin.

To talk about health equity and fairness and how the public health agency will create healthy futures for all New Zealanders.

>> Kia ora, Richard.

Tena koutou katoa.

It's great to be here on behalf of Ashley Bloomfield and the Ministry of Health and alongside minister Andrew Little and my colleagues Rhianna and Margie.

This demonstrates us working together as we face the challenges around an inequitable health system.

Thank you for the opportunity to speak today.

Our system is being transformed and we are working through this day by day.

So everyone has access to better outcomes from health services and from disability services as well.

The vision for the reforms is a system that delivers Pae Ora - healthy futures for all of us.

Achieving Pae Ora means our people, our whanau live longer, healthier lives and have improved well-being as part of being healthy and inclusive and having resilient communities.

And living within environments that sustain well-being.

Our health system has strong foundations, and for most people it delivers really positive health outcomes that compare well to other countries around the world.

However, across different groups and populations, some groups are consistently underserved.

We know this.

They are left behind.

These include Maori communities, Pacific people, disabled people, and that is a challenge that we face in the reforms and within our current and future health system.

On average, these groups die younger and live more of their lives in poor health and with lesser outcomes than fellow New Zealanders.

So the reform of the system provides us an opportunity to progress outcomes for our communities.

So what is equity?

It means recognising not everyone starts in the same place with the same experience.

So whanau in different contexts and positions will need different levels of support.

And it means we don't just give everyone the same thing.

I know that Margie and Rhianna will talk about that.

We give people what they need to let everyone get to the same outcome and achieving equity.

In the case of the health sector, this is what we mean by Pae Ora - healthy futures for all of us.

We know there are communities who experience in equity because of chronic underlying health conditions, disability, culture, ethnicity, gender, sexual orientation, mental health challenges, where someone lives, and other factors.

So the reason for inequity is complex.

And it includes the impact of social, economic, cultural, commercial, environmental and behavioural determinants of health.

Racism and discrimination have a part to play in inequitable health services and delivery of those, and how funding has historically been allocated.

If you think about how we challenge in equity, it requires a whole of system approach to change these priorities, attitudes and underlying bias.

I encourage all of us working in the system, those involved in communities, and people who are at the front line, to be thinking about, how do we ensure that what we're doing in our work is turning this around and creating opportunities for equity?

In particular, our starting point for the work should be about what it means for access to, for experience of, and for outcomes from care and for the groups Habs most challenged by the inequity challenge.

If that is the starting point, we will all take equity into our approach at work.

Collaboration is a really key part of making equity real.

The concept of partnership is key in these reforms.

As I said at the beginning, it's about all of us in part of the health system, having our part to play and working together to make this successful.

The Ministry of Health has an important role in improving equity and in the reform system there is the role in stewardship, leadership, kaitiaki, and monitoring the system, being an active leader and participant in how we address in equity is really important and outlined in the GPS.

The Ministry will be picking up greater responsibility in research and innovation, and that will be a key enabler for considering health in equity particularly for Maori, Pacific, disabled people and other underserved populations.

Providing strategic leadership for health research across the system will ensure equity is at its heart how research is prioritised, planned, delivered and evaluated.

And ensuring that research actually helps support changes and approaches we need to make.

Being the government's lead policy advisor for health research will allow the ministry to lead high-quality research and evaluation that actively addresses drivers of inequity and health outcomes.

In doing this in partnership with the Maori Health authority, Health New Zealand and the agency that sits within the Ministry of Health, the Public Health Agency.

This is a separately branded unit within the Ministry of Health and supports the ministry in its obligations and responsibilities as a steward, and ensuring the health and disability sector fulfils its relationship between the Maori , Crown, and under Te Tiriti.

It's also focused on enabling equity in public health and population health outcomes, and we have seen over the course of the last couple of years how important the role of all of us is in addressing those challenges in the pandemic has been.

So that gives you a flavour of the Ministry of Health's role, and how we will support, address, and work to address inequity in the system.

And we look forward to fulfilling that role now and into the future, kia ora.

>> Thank you, Robin.

It is always good to be able to talk about the difference between equity and equality, and talking about how equity matters on the person and the individual.

Tailoring that and designing it, like my dear mother, with the needs she had which are very different.

It's really good to hear about Ministry of Health continue to have that kaitiakitanga do not just create a system but make sure it is looked after into the future.

We have the government policy statement which starts our journey towards pae ora.

One of the priorities outlined in the GPS is achieving equity and healthcare outcomes.

To explain more about that in the government's goals and priorities of the system, I'm delighted to now invite Mr Little to speak with us on that.

>> Just a little public series.

It has just come appear that unfortunately, the sign language interpreters are not able to be relayed simultaneously so as Richard has said, a transcript of this and the video of this presentation would be available later on the Ministry of Health website.

As Richard said, the government policy statement, which will be a requirement under the pae ora health legislation, which continues to be part of it today, is that document is arguably one of the most or the most important accountability document for the health system we would have.

It is the government's expression of what it wants an expense from the health system and it will be renewed periodically.

At the core of that and I think this government has made it clear, one of the big changes we need to see is an improvement in the equity performance of our health system.

I have just come from revealing the government's response to the independent review of (unknown term) and it is interesting.

A lot of good things that they do but one thing they have been struggling with and the decision-making is to make sure that their decisions meet some basic equity principles and to put that into context, we know that Maori for example, are twice as likely to die of cancer is and part of that is because when we think about the treatments that are available, we think about the treatments that are easier to secure but if the cancer is that Maori are dying from a more likely to be the lung cancers and those others and we don't have effective treatments for them, and our decision-making is looking in and in equity that doesn't have to be there.

If we think about equity in the health system and particularly at the decision-making level, it is about understanding that different communities, population groups may well have different needs.

We also, it was that principal that underpinned one of the budget initiatives and as a couple of weeks ago and that is extending or lowering the age of entry into the national bowel screening program for Maori and Pacific and why was that?

Because statistically, and it could -- epidemiologically, Marie and Pacific are more likely to acquire be diagnosed with bowel cancer is at an early age that other population groups.

It makes sense for the bowel screening program to allow Maori and Pacific to get access to it at an earlier age than is the case father population groups.

Again, it underscored Richard 's point about health services being available to meet health need and health needs will be different or may be different across different population groups.

That is a change we need to see in our health systems and I'm confident that with the changes that we are doing we will start to see that.

I think we will see in the government's recent budget, a number of initiatives very much directed at weaving equity.

I've talked about the additional funding to lower the age of entry to the bowel screening program but also continued investment in the Maori Health Authority as it now gets itself established.

It will take over some of the funding currently managed by the ministry in terms of commissioning Maori health services.

We need the Maori Health Authority to build its capability not only in commissioning but its analytical capability to understand what those health needs are and they will do that with partnership boards which we have recognised in legislation and in the process of establishing and they will get additional support as well so they are resourced to do their job.

All that together will create a very powerful source of knowledge of insights that can drive our health system and improve health treatments and health services available to Maori and improve those health outcomes.

We have also enlisted more in workforce development for both Maori and Pacific health workforces.

We have seen during COVID and particularly in the vaccination program for COVID, just incredible workforce we have that we were able to draw on and put into effect for that campaign and many of the people that have been involved in that you are not currently necessarily qualified or have the qualifications recognised are very keen to continue playing a role in our health system and we need them because those health workers give great confidence to their communities that actually it is a health system that is there to serve and to meet their needs so we will invest more in developing those workforces so we have stronger Maori and Pacific workforces and also, the broader well -- work health force as the whole force does better and understand and meet the needs of other populations, we need to invest in developing those skills and what have you as well.

So that will be that.

We have invested another $186 million into primary care, into GP practices were dealing with patients with high needs, with special needs and so they will be patients with comorbidities and we know that a lot of GP practices already struggle to provide the care and attention that they know these patients need under kinda -- current funding models.

We will find a way to provide better support in that respect.

And then we put nearly $9 million into just improving and enhancing the consumer voice for health as well.

Because for health organisations or institutions, those making decisions and making big policy decisions or making funding and commission decisions, we need to make sure they're making those decisions on the basis of the best array of information possible and that will include what is coming from health consumers as well and making sure all those voices get a chance to be heard.

I mentioned before about the pae ora healthy futures bill and that comes back to Parliament, a clause by clause debate on that bill and then there is one more stage after that but that bill, it has really had a fair amount of examination and attention when it went through the committee process and came back with strong recommendations.

There will be a few more tweaks but a number of things in that legislation includes the fact that we now have a set of health sector principles and those principles are very much about improving the equity performance of the health system.

All health entities who, under the legislation would be bound by the health sector principles and that is about engaging with and improving health services for Maori, for Pacific and other population groups that up until now have struggled.

If not to get access, than to certainly get the level of service that we would expect every New Zealander to have access to.

This is about having a health system that promotes and serves the best interests of all New Zealanders but that won't be everybody seeing the same because were people have a need for more, we need to know that we have a system that recognises that and seeks to deliver on that as well.

And as I said before, it is also about improving the voices and giving more opportunity for those to see and improved system.

The government policy statement makes it clear that equity and achieving greater equity as a vital objective that we have for the reforms and for the health system on an enduring basis.

We do that through the development we do with the workforce, we do that with the institutions who are responsible for our health system and making sure that they have the information to understand the kind of health profile of New Zealand and the health profile of different groups.

We have to improve what we do if we want to truly be able to say to all New Zealanders that we have a health system that generally treat you fairly and equitably.

That remains a principle of ours and so I look forward to being on this journey with the ministry and with the Maori Health Authority and health and said and we have people of the calibre of these people heading up the establishment and a national phase because what we do in the next two, three, four, five years will be critical to the long-term progress of our health system and what it is able to do in the end for healthy futures for all New Zealand.

>> Thank you minister.

I think you painted a wonderful story there around the important investments that are being made and actually where we want to get to in the future and that dream.

I would now like to welcome the two new chief executives of the new entities, Margie and Rhianna.

They're going to talk about equity and how these issues are being looked at by health New Zealand and the Maori Health Authority.

Maybe over to Margie first.

>> Are very happy week and I want to acknowledge the Minister and my penal colleagues here.

It is very exciting.

I think as the Minister has outlined, equity has enabled a new organisation because the legislation makes it the DNA of what health New Zealand needs to be about and we know that there are many good parts of our services and system that we do, we have pretty good healthcare most of the time but again, not everybody experiences that care at the same level and their health comes that come from that.

So we are really excited that health New Zealand, as a Crown agent, is a key implementer.

We operationalise those expectations from the government in partnership with the Maori Health Authority, who are our co-commissioners, as well as part of the Ministry of Health and that is me and my 82,000 colleagues out there and the other 140,000 who are part of the health workforce that every day do amazing things for our patients, our communities.

Richard I like to call out a couple of the features of the new environment that helps us embed equity into the way we work and and the has mentioned the health plan and in our current environment we might have had 20 potential district health plans, we have one.

The government policy statement for health is the key document that will give us direction and clarity around what government expects from us as an entity and the New Zealand health plan will capture how we will operationalise it and the health systems.

We will have lots of work and that will be coming out over the next few months.

In the health plan, we do want to take the opportunity to express one of the causes of equity in our system is variation.

There was much about achieving equity that we know the signs, we know what best practice looks like but there are many features about a system that perhaps makes it difficult for people to express or practice that consistently.

So one of the opportunities we see, and I say equity does hide and equity hides in the variation that we see across the country and we want to focus on how we identify the variation that leads to inequity and my colleagues and ministers mentioned cancer is one of those examples.

When we look at pathways and how people access healthcare across a continuum of care or diagnosis or treatment, we see lots of opportunities where people fall out of the system or it isn't easy for our services to join up that experience to access diagnostics, to access treatments as part of that.

So addressing variation is one of the important features that we will see in the New Zealand health plan.

Certainly as we have travelled around the country, we know that in some regions for example, there may be districts whose population are not able to access cataracts almost until they have to lose their license and in the same region, we see some districts who are able to offer early intervention to their population and so we think there are opportunities for regions to get together to share that inequity they see across the districts, to look at the available capacity and planned care is one of the early pieces of work that we will do that and how best we organise and privatise our services so we are achieving equity for a region.

That's a really important message especially for rural communities to hear from our system.

We aim to reduce the variation that we don't want, that is unfair and resulting in equity of access to services, that results in in equity from variation of clinical practices and the services available to a region.

That's one of the things we want to design into our organisation and our systems.

So equity is the easiest thing for you to do from the front line right through to the decision-making steps behind that.

Variation can also be driven by things we need to support our people to do.

Bias, we may not recognise or compensate for.

Physical or geographical access to care.

While we know we want to remove unwanted variation, we know that in unifying our system, things don't need to be delivered in a uniform way.

That every rural community is special.

When you are in Motueka, Ashburton, Wairarapa, where we were yesterday, how that might look differently for each community so we want to look at diversity of delivering models and rolling out the government's program for locality is recognising that we have to support diversity of delivery but we don't want variation in health outcomes across our populations.

New Zealand health plan will also guide and talk about how we are reorganising Health New Zealand to be able to support equity across our system.

And, Richard, important in that reorganising is that we do want to recognise the voices of many communities who don't feel they have a voice.

I know how frustrating it is because many populations or community groups will say to us, "We might have a great relationship with this district, but then we have to go and build that relationship with other regions or districts to get a consistency of voice and recognition.

" Certainly one of the opportunities of unifying a healthcare system is that we create a place for the voices of communities, not just Maori, not just Pacific, young people, old people, people living with disability, supporting the new ministry to be formed, so all our community can express their voice to one place and the system and we will listen.

The other important part that the new reformed environment helps us do is helps us really focus on workforce and drive actions in this area.

Again, lots of different ways we look across our system and we see lots of great effort but we need to connect that effort and look across the whole pipeline from encouraging young, talented people to enter training, but we think there are also opportunities where we can simplify the way we might support clinical placements, that we might support funding of scholarships, and areas that we know we will have concerns about coverage if we don't invest in those workforces earlier.

We hear the cry and the concerns from our rural providers, and we see opportunities to support growing our doctor-nursing and building on the gains from COVID to make them not just a feature of the pandemic but actually they become a core part of the way we deliver health care.

And we made lots of decisions about workforce deployment in the pandemic that we can continue to use in this reform.

We also recognise a lot of the behaviour of our system may make it difficult or uncomfortable for our populations and communities to access healthcare.

So we aim for the charter, the input from workforce groups to set the standard for leadership, for the mindsets that we want to bring into our health system to make sure we are all supporting our teams but also making sure our healthcare system is a comfortable place for all of our community to enter and for our workforce to be safe and well in their practice.

Those are a couple of features that I would like to mention, Richard, and again supporting that while we see opportunities to make equity a core part of how we work, we also want to support, and that is an equity- enabling feature, diversity of care, and tailoring that care for different localities.

>> Margie, thank you, I really love the connection between equity of access and service that recognises diversity.

The differences that are inherent in all of us and being able to tailor to people's needs.

Not treating everyone as if they are all the same.

What I am also impressed with by the lorero is how much -- korero is how much of a team you play together so if we can hear from the other part of the team, Riana.

Talofa lava, (SPEAKS TE REO MAORI) It is lovely to be back here again.

It feels like yesterday, and it wasn't just yesterday we were talking about Te Tiriti o Waitangi, but I want to lead by recognising that the Maori Health Authority in itself is one of the key indicators we are taking equity seriously in this reform.

It is an opportunity, a once in a generation, that I can remember where we are seeing an intent, very purposeful action, to stand up an organisation that will work in partnership with Health New Zealand and of course with our whanau at Te Manatu Hauora to address the inequities that exist.

They didn't happen overnight, it's been a long 200 years.

What you recognise is given it has taken that long, it's going to take time to make sure we get the settings right but this is a great way to use Te Tiriti as a ship model.

We want to reiterate for Maori Health Authority and Health New Zealand, we are both Crown entities but we will use the model that the treaty gives us as an example to make sure that Margie and I and all of our teams, because while we have the real privilege of being the CEOs of these organisations, I want to give a big shout out to everybody who is working hard.

It is important to recognise it now because we are just over four weeks away from day one.

And there have been many, many, many hands on the hoe, if we use the expression of our organisation, many people working hard.

And we also recognise all of our whanau in the communities every day working hard to provide the best healthcare.

We know that everybody goes to work with the intention of doing just that.

Making sure we focus on equity to give our whanau on the front lines a purposeful intent to say we are coming in to get some help to make sure the people we know you love serving everything today get the right kind of access to care.

That's a great starting point, whanau.

I am very happy to be able to lead with that and, again, I want to acknowledge the privilege we have of this once- in-a-generation opportunity.

One of the driving forces behind this reform to address inequity is about our iwi.

You will have to forgive me, I don't know the reform by heart but I will use my talking points to make sure I get it right.

If we think about our iwi- Maori boards, it includes engaging with our whanau, hapu, iwi , during those insights they have in the community.

As Margie pointed out, the diversity of every single rohe in the country has to be recognised.

We know we will not have every single service in those really hard to reach areas.

I am a rural girl myself so I have always recognised we have to travel a bit to get to where we need to go, but making sure when we get there that those services are fit for purpose and that they meet the needs of our community, all of our diverse communities, and of course for our Maori people.

What we don't want to see is inequities such as mortality rates that suggest we are going to be more than twice as likely to die of bowel cancer than anybody else.

That is not appropriate and it's not necessary.

Making sure we put a focus on those areas and getting our iwi-Maori partnership boards to lead on that as well.

Assessing and evaluating the current state of hauora Maori, our locality prototypes are out there now doing the beginning work of what we expect and hope to see.

We saw it during COVID, we know when communities gather together, locally, and come up with solutions and use their workforce, the people, the know-how, to get out there into those really hard to reach places and/or populations, that's when you see magic happen.

We saw that all over the country, not just during COVID but prior to that.

We see our kaupapa Maori providers throughout Aotearoa making sure they get there on the day, making sure they support the existing systems and making sure they support whanau to get access to care that they needed.

That's one of the things we will continue to build on.

Making sure that we agree on what those priorities are and getting really exercised about addressing those priorities.

Monitoring the performance of the health system.

As Margie already mentioned, we have a dual role to play which is we will be commissioned working in partnership with Margie but we will also be working with our Te Manatu Hauora whanau so that we monitor for equity.

It's about observing and identifying when those issues are and working collectively to solve the problem is moving forward.

So that we all get the outcome we want which is Pae Ora.

And of course, having the iwi- Maori partnership boards in place, sorry, I shouldn't be using acronyms, but you get into the system.

.

.

So these boards will be making sure not only we have the voice of mana whenua , our iwi, our hapu but also those experts that have been working tirelessly to form the foundations of what we want to see.

And I want to extend on the conversation we had before about workforce, designing and growing a workforce, we haven't got the numbers at the moment, but what we did recognise again, not just during COVID, kaimanaaki have been with us for a long time but we saw the value in a time where we had a very short fall of a workforce, that by uplifting our kaimanaaki , making sure they were supported by those clinical positions on the road, at the marae, what we saw was better access of services.

Now what else could we imagine in the future that that workforce would be able to do?

Of course, my experience has been watching, especially at home, when you design a service, when you localise that service, when you get local workforce in there, then you have a more sustainable workforce.

But we need to reach out and partner with all of our universities, polytechnics, all of our agencies who train those kaimanaaki, need to make sure our nurses and doctors have the availability to be able to support and work at the top of their scope whilst we build the pathway forward for a workforce, for a resilient, sustainable workforce that we have the people on the ground for now but we just need to make that opportunity happened.

So, at the end of the day, whanau, equity is always going to be a focus for our organisation.

It has to be because it won't be solved overnight, if I go back to my original point.

The main message I want to lead for everybody today is that the Maori Health Authority are here to work collaboratively not just with our partners here with me today, but also with the iwi-Maori partnership boards, with our locality ropu, with our whanau on the ground to make sure we hear the voices coming through every day.

We want to acknowledge we will pivot, we want to make sure when we get it wrong, and I say when, that we make sure we hear the voices of our people and we take everybody with us.

Those diverse groups.

We want to make sure for Maori, Pasifika, for our whanau with disabilities, for any ethnic group who have arrived in Aotearoa, the original intent was to find a place for us all to stand.

Aotearoa is the turangawaewae for us all.

Tena koutou katoa.

>> That's very important kaupapa we're talking about today.

The partnership under Te Tiriti is significant but also the partnership you speak between the two Crown entities, government, and actually across the public service.

There are others.

My ministry would also want to partner and work with you to help to solve these problems.

You mentioned before, solutions can be found in the community.

Thios is an aphorism our work as well.

We had a lot of questions come through on the chat, and we have had people submit questions ahead of today so we will try to get through to answer some of those questions with you today.

If we don't get all the we will respond through the website.

I'm going to open up with one question.

Can I have the questions move up a bit please?

This is properly aimed more at not all of them but anyone can answer this.

What steps do you think would be open that meets the needs of diverse communities, especially ethnic communities.

We have a huge amount of diverse needs and cultural perspectives.

Before you answer, again, our ministry absolutely wants to help in terms of raising cultural capability across the system.

If we can work with your entities and agencies, we are here, you just need to ask.

Would anyone like to answer that question?

>> I am happy to start and I know that Margie will want to talk about this as well.

I think this is a real challenge for all of us but when you hear feedback from people who use health services, consumers, what makes a difference is values, attitude, having someone who has compassion, listening and actually supporting our workforce to develop those skills, grow those skills because that makes for an understanding of how support and equitable outcome for people and actually makes a difference in how people are supported in their journey through health services and out the other side to achieve better outcomes.

We have some real challenges in workforce, of course many gaps, a workforce under pressure, workforce well-being is real challenge for us.

The role that the ministry will play in this space is looking at a long-term view for workforce strategy and policy.

Very much in partnership with our agencies.

We need to create the environment and good policy thinking the long-term approaches and ensuring we grow our capability and capacity, enable training, enable learning and actually some innovation in the work or space to allow different approaches for communities to access care.

I go back the approach that people get on a day-to-day basis and how they are supported and their health journey becomes an starts with those attitudes and compassion and I think it is something that we can all work on and role model the work that we do.

>> Thank you.

>> Multiple interventions, I would say Richard, we need more people entering into our training pipeline right from STEM education in schools and how we have tried to increase that with a joint venture from the Department of education.

We need more people and professional training pipelines and we need to work with colleges to open up places.

We need some very rapid, out- of-the-box thinking about how we grow specific workforces which will if we don't have numbers, will it was not being able to provide service coverage and so there is a lot of interventions, we need to make it easier and again, the opportunity of a unified organisation was in the past, we had to try and afford extra places to train GPs or as a unified system we can plan and coordinate the across the country and grow places where we need them to go.

Possibly even be a bit more directive about where people need to go to get training, so we are growing a rural workforce pipeline, where people are experienced in Maori services and there are lots of out-of-the-box thinking we need to do but we need our tertiary colleagues to work with us and find some of the training pipelines for some professions and we would like a lot more places to be funded, just calling it outs, so any actions across all those pipelines but there are some areas where we need some quite focused attention which is going to be a risk for us if we don't get people in.

>> Thank you.

Here is the question, actually across all the panel if you wish and please jump in, I think it is important because we speak of equity, we speak of fairness, how do you actually operationalise, monitor and measure it so that we are accountable to that?

Who wants to go first?

>> Such a great question, isn't it?

I'm happy to speak to at first off because the Marie Health Authority will have a role in monitoring and of course equity will be one of the things.

I think you have to first of all be really clear, really really clear as to what it is you expect to see and what is it you will be monitoring against and as I said, I think I said this at the end before, once you realise and you keep an eye on what you are monitoring for, it is the conversation, I think the conversation is most important as to how you get around.

If you don't identify that equity has been gained in this area you have an agreement on, you will have to go back and decide how we are going to work toward that as more education for our people who are working in a particular sector.

Is about the system itself?

How do we move those lives to make sure that people get into the system and it is having good conversations.

And a strong partnership is the opportunity we have is to be able to work collectively together between the organisations but I also want to notice -- note as well that what will move these outcomes and exist in the other sectors so when Margie calls out to T EC to join that show and I point out the Minister of social development, when we call out to all of our sectors, that is one of the things that we are trying to do is we are trying to group up to make sure that we not only improve the system nationwide for ourselves and health but that we actually lift up our people to be able to access those systems and monitor for that so that we can see it in real time.

>> Great answer for top anyone else?

>> I think there are multiple levels of monitoring and also making invisible how we are achieving equity.

The ministry and the Marie Health Authority will have system indicators from the health New Zealand perspective.

We collect screens of data but how much are we actually used to help us make different decisions and if I take long cancer as an example Minister, we know that along a pathway, you access to a ray when your GP refuses you can be one of the most critical factors and help you get into diagnosis and assessment.

We know not everybody will go to a GP to get their child vaccinated so we need to make available diversity of options for our community.

From a health New Zealand perspective we want to be assuring and testing ourselves that the voices of our communities are telling us, this is how I prefer to access my care and then we have got enabling through flexible funding models, consistent pathways to make sure people are getting consistent quality of care but we are enabling a diversity of delivery models that overall we are seeing access care.

There are multiple layers and we hope that is that out.

>> Again, diversity to create that equity, fantastical stop we have probably got time for one more question.

Oh, I'm just going to go here.

Just waiting for the questions to stop scrolling.

I will go for the one that is there, Mr if I could pick this one to you, where does the ageing sector fit into the new health system considering it is the fastest-growing population?

I feel like I'm about to join that soon.

>> We have an ageing population so they are in the system but we can do more I think to better serve the needs of the population.

Things like integrated primary care.

We are not just saying a GP with their clinic and other GPs with them is kind of the way of the future.

Actually, our older population need a whole range of different health services but they need to be easily accessible, so integrated primary care in the budget has some investments to make and as we develop that.

That $86 million for GPs for their patients with high needs, a lot of that is directed at GPs with elderly patients with multiple issues and multiple conditions in one of the biggest complaints I get from GPs is that the model at the moment that requires everybody to be seen within 15 minutes just doesn't fit a lot of older patients and GPs need a bit more time to deal with a range of needs.

Some of which will be medical, many of which will be social and other needs.

I expect to see, especially after the system as we better accommodate the needs of our older population and I think one of the objectives our system has set itself is keeping people at home as much as they can but with the appropriate support to do that.

We are therapeutically, it is better for people to be in an environment they feel is their environment, they had their things around them, their family can see them there so better supporting people in those environments is one of the challenges we have to continue to meet as well.

>> Thank you minister.

It is time to sort of wrapping things up.

Thank you to our panel, thank you everybody.

A quick reminder to all of you who are listening in today, the next session in the series will be held next Wednesday at the same time and will focus on strengthening public and population health.

You will be able to register the session on the same link and we will update that in the next day or so.

So with that said, I do want to thank you all out there for joining us, thank you to our panellists for your thoughts, your insights into whether future might be and the way in which we are going to work together.

What struck me today is that the current health and disability sector reforms, it really is a once in a generation opportunity not just to change but the idea of equity at the very core of our future public health system in New Zealand.

Maybe not in time for my dear mum but certainly in time for my children and maybe grandchildren, if my kids have kids.

So pursuing health equity, really I think means driving for the highest possible standard of health and we have talked today about ensuring multiple pathways, lots of diversity so we can deliver on the equity.

I would like to wrap up by sharing a Maori proverb.

I think it sums up our health reform is an approach for achieving equity really well.

(SPEAKS TE REO MAORI) which translates to burn off the undergrowth so that the new flakes, shoots may grow and this proverb really speaks to the idea that sometimes we need to leave always behind, we need to make space for new ideas for the innovation and future generations.

If we decide to do things fully we will achieve equity.

I would like to say farewell to you all, goodbye.

It is Samoan language week and I think actually, really relevant given today's discussion, the salutation of live long and prosper, which is all about equity rights and healthy futures.

And I will just finish with one masterpiece,.

(SPEAKS TE REO MAORI)

Speakers:

• Dr Ashley Bloomfield – Director General of Health
• Andrew Little – Minister of Health
• Riana Manuel – Chief Executive of the Interim Māori Health Authority
• John Whaanga – Deputy Director-General, Māori Health

>> (Speaks Māori language) Kia ora everybody and welcome, welcome to the first of our information sessions on the health and disability reforms. And particularly to the Te Tiriti o Waitangi and our system.

Just to let you know, I acknowledge from a generation ago, the people who have helped shape the Te Tiriti o Waitangi and acknowledging that if they were here today, the excitement I’m sure they would feel as we are about to engage and embark on our next journey and embracing and incorporating Te Tiriti o Waitangi into our system. I also acknowledge the work of the professor, and his seminal work in reviewing and encapsulating the key direction for all of us that led to work that came later on by the Waitangi Tribunal. The development of the health action plan, and most important, and the basis of our discussion today, the new legislation. I would like to welcome today The Hon. Andrew Little, Dr Ashley Bloomfield, and Riana Manuel, who come along today to share their insights and observations and aspirations as we move towards an exciting development in the development of Te Tiriti o Waitangi. For those of you who are online, you will be able to participate and provide questions into this process through Slido and I invite you to do so. Also if there are questions that we aren’t able to respond to today, we will gather those together and provide online responses after this was that further ado, I would like to head over to Dr Ashley Bloomfield.

>> Thank you very much John.

Great pleasure to be here alongside you.

Welcome to you Minister Little, and my colleague Riana Manuel was the Chief Executive of the interim Māori Health Authority. Is a pleasure to be here today.

 I know that many of you will be aware that whilst I’m finishing up as the Director-General, I still have three months in the role and the global pandemic, that can be a long time, and it means I’m very excited about continuing to be involved in the implementation of these reforms to the system and of course they are not starting now, nor in July 1, but they are already well underway. I have always been a strong proponent of New Zealand’s health and disability system. It is by no means perfect but it is one that delivers very good outcomes for many New Zealanders.

However, like many, if not all people working in that system, and indeed New Zealanders, we have aspirations to do even better. And these reforms offer an opportunity to do just that, to achieve healthy futures for all New Zealanders. A system that is responsive to people and their needs, whatever their circumstances. The reforms underpinning them have this special relationship between Māori and the Crown, which we know exists under Te Tiriti o Waitangi. Embedding this will help us achieve and I know this will be the subject of some of your questions and we will hear more on this so we look forward to receiving those. There is a clear responsibility and commitment to continuing the good work that John has outlined that has been done in the past and laid down by some of those great names in Māori health development in Aotearoa New Zealand. And more recently the development of the Māori health action plan. That lays out some of the key actions that are aiming to improve services, services for groups that currently don’t get the access they should, like Pacific people, disabled people. Where this reform provides an opportunity for us to not just reconnect to but to make substantial progress in those areas. We are not starting with nothing. There has been a lot of great work happening already within the healthcare system and in particular, over the last two years and our response to the pandemic, I believe we have seen some step changes in the way our system has responded to inequities and the idea of course is that we build on those gains that have been made. But it is an opportunity for us to revisit how our system can better ensure equitable access to experience of and outcomes from care. Our role as the Ministry of Health is the key strategic advisor to government, is a key Guardian for the system is to ensure that the system is delivering for New Zealanders in the future. One of our most important roles will be monitoring overall system outcomes and we are working actively on how that will look different in the future, as we move, on one July, to that new system. Believe me, we will make sure we remain steadfast in the government’s health priorities are being met and that the system delivers a for the longer term health needs for all New Zealanders. One of the key documents that underpins the Health Minister’s priorities for the future system is the interim government policy statement. And that lays out, really, the government’s priorities as we journey towards. I would like to hand over to Minister Little to explain about the government’s goals and priorities for the new system, and then after Minister Little, will be over to my colleague Riana Manuel, to offer some insights. Kia ora Minister.

>> Good afternoon. It’s a great pleasure to be here to talk about the process of bringing the policy statement and as we head towards 1 July, the introduction of the new operating model for our health system. When the government reviewed the report of the health and disability system review, it looked very closely at what that reporter told us. Is indeed many others have told us about the performance of our health system, which is done very well, but has also seen a growing share of our population continue to miss out on frontline healthcare, particularly primary health care and a system that has been built up over many years to do a number of very important things, but still not addressing some of the fundamental aspects of broader well-being that we would expect a country of our size in the 21st-century. One of the other things that became apparent was for a country that understanding its history, and coming to terms in the last 30 or 40 years with the Te Tiriti o Waitangi and the founding role that that document plays in this country and us as a nation state, is to make sure that the Crown is truly honouring its obligations under the Treaty. We set is one of the first priorities of the reforms is that we must ensure that the way our health system operates truly honours and embeds the obligations of the Crown under the Treaty. Of the range of recommendations that the government picked up, which was establishing the Māori Health Authority to reflect the set of priorities about that. Is the job we are giving the Māori Health Authority that I think gives us the opportunity for a much more powerful response to lift health and health services and access to health services for Māori. As Dr Bloomfield acknowledged too, we have population groups within Aotearoa New Zealand, for whom there needs to be read emphasis, more work, greater priority. To make sure the health system is delivering. Pacific peoples, ethnic minorities, and others. But for Māori, to whom we have an obligation under the treaty, it’s not just a question about providing more or better health services, it’s also about a voice in the system. A way to express and the way we have set up the system. This is one of the things that we want to ensure that the reforms do. Have an opportunity now to, I think with a strengthened health New Zealand, with a Māori authority to decisions about health to really address some of the long-standing inequities in health care and health outcomes that we have seen in this country. As Dr Bloomfield also acknowledged, we have a number of what we might call accountability documents, we have the government policy statement which we are in the process of putting together and we will talk about that in the weeks to come. But that is the document that sets out the government of the day’s objectives and aims for the health system. To the structure and the entities that we have in place. In addition to health New Zealand and the Māori Health Authority, of course one of the new dimensions of the operating model will be public health agency, supported by the ministry, and providing leadership in our public health endeavours through the consolidation of the public health units within health New Zealand. And all of that under the stewardship of the Ministry of Health whose role will become very much a leader of the system, providing a policy support, and advice to ministers, providing that system stewardship, and enabling the Māori Health Authority and health NZ to get on with their task and their mission of running excellent health services and improving health outcomes for all of Aotearoa New Zealand. Within that system, there must be clear decision-making roles in place for married which will be expressed not only through the Māori Health Authority but through Māori partnership boards and drawing on the wisdom and strength from Māori. All of the entities must work closely together. From my position as Minister, from what I was served in the establishment phase, what I see as the Māori Health Authority and Health NZ, working incredibly closely together, is indeed a must for both organisations to succeed in working closely with the Ministry of Health. Because as I said, almost work with shared objectives and common goals and work closely together, the strength of those relationships is going to be absolutely vital to changing what we do. We do the first two weeks when we head towards 5 July, subject to the passage of legislation to cut over to the operating model, there are hugely exciting opportunities for all of Aotearoa New Zealand, think about their health sell visitors, the needs, those omit and unmet, and how we address long-standing concerns in that regard stop I look forward to the ongoing discussions as to how we continue to achieve the best health system to achieve Pae Ora.

>> (Speaks Te Reo Māori) My name is Riana, and I will start by first acknowledging the amazing work that has been undertaken over these last four years by all of the sector, workforce, communities, and in general. We are absolutely aware that there is so much going on in the communities. We are excited, given rise to excellent models out in the community is. Which uphold Tate to read the . One of the challenging aspects, as a Crown partnership, we are not part of the treaty, but between the partnership with the Crown will be what myself and the College of health New Zealand will have, including partnerships that we have with the Ministry of Health as well. I’d like to acknowledge that (Unknown name) passes her apologies, she is on holiday, and said everyone her well- wishers as well. So, the thing that is important to me, when we acknowledge that we historically have a health system that has not met the obligations for Māori under the treaty, it’s important we see the reform as an action to take and moving forward. And creating system that honours the treaty, upholds the rights of Māori and gives effect to the treaty principles by the Waitangi tribunal. That means sharing resources, tackling, sharing power and resources, and tackling racism within the system to ensure that we remove bias, make sure there is adequate access to health services, particularly for Māori in the relationship, but other parts of the community, who also have experienced in equities, and exist to these services as well. We want to have effective treaty partnerships, and have Māori principles for the time ahead of us. To make sure, when we develop a system based on understanding the relationship, and the inequities, that it has a massive benefit for all of us here in Aotearoa, health system that acknowledges and serves everyone, by acknowledging the special relationship between both the Crown and here we -- Iwi that’s the main thing I want to embed in. We will work on documents, as the Minister outlined, we will work hard with organisations to ensure that we uphold our responsibilities as a good treaty partner as well. We will give for not just exist in the system, but looking at innovative examples from the last couple of years, that we reach into communities, that we get services more locally exposed, and making sure the good partnerships such as localities will be explored, invested in, and create opportunities to ensure people, no matter which immunity you live in, be rural, urban, whether it is a person with disability, whether it is Māori, Pasifika, these are people who have better access and consult with the collective result with the health system. (Speaks Te Reo Māori).

>> (Speaks Te Reo Māori). Thank you very much for sharing preliminary insights and aspirations. And thank you all for putting your questions on Slido. I will take a bit of latitude, because there are a number of questions which are doubling up amongst people. But I will ask, in reverse order, the three guests today a question starting with Riana and then Minister Little. How can help ministers help embed the principles of Te Tiriti o Waitangi in the health system.

>> I think that is something that I alluded to previously. The approach we need to take now is not just one for health, we need to actively embed Te Tiriti o Waitangi across the health system. And that is working collaboratively across the sector, not just the Public Service Act, but taking opportunities to work collectively with opportunities -- communities, community leaders. If we look at rural and isolated communities, that we work collectively and collaboratively with people making decisions, and those decisions with those people. So, I think it can be embedded across all parts of the sector. We must make a collective effort to do so, and of course, like a semaphore, the opportunities for all of us will improve the health system overall. It’s one way to affect the health system with the most might is to bring all of the sectors, housing, (Speaks Te Reo Māori) all of us together so that when we go on the voyage and we reach Hauora for all of us.

>> With the question of how to embed Te Tiriti o Waitangi. We need to have a deep understanding of what it is, and what the articles are. Of what they actually mean for and a personal leadership level, an organisation level, the system level. Is incumbent on us to not just understand that, but to translate that into specific actions. And also, what delivery on those articles and treaty means, and particularly in the health sector, what it means for what the health sector is structured. From mainstream services, and Hauora Māori services. For my part, I am constantly thinking about how to embed the treaty articles, and leadership and a personal, organisation and system level. Kia ora.

>> Minister, thank you. A couple of points that I would make, the treaty is we have seen models for Māori, and support, is not just about boys, it is about voice, but it’s also about decision-making and rights. For Māori to lead their people, as contemplated by the treaty. My expectation, with the operating model that we have got, that the Māori authority and with the engagement reflecting their voice, and with the government of the day makes. the other aspect is that we talk about co-government as recognising that. The treaty always was a shared objective for the Crown and for Māori, and that doesn’t change, doesn’t change in the public sector. But the way the government through the agency conducts itself, can properly reflect what the vision of the treaty was. Māori empowered to make decisions for Māori, and Riana talked about sharing power and resources, that’s what it’s about, and the progress of our nationstate, Aotearoa New Zealand, and how they sit comfortably together. Which is what the treaty was always about.

>> Kia ora Minister. I will ask a similar question in reverse order starting with you, minister. What are you looking for as your measure for success, with 2 to 3 years into the reforms. One of the things that you expect to see in the New Zealand health system? Over to you, first minister.

>> What I expect to see 2 to 3 years from now is a level of confidence, and other parts of the health sector, a confidence of understanding the needs of Māori, and fulfilling building services that help to fulfil the needs. Bearing mind that the Māori health services does not stand apart from health New Zealand and the Ministry of Health. As I said before, they are all integrally involved, and they have to be for the total system to work. But the Māori Health Authority brings a strength that we have long lacked in terms of lifting the performance of the system, and providing access to health services for Māori. I would expect to see data that shows more Māori getting greater access to services. And in order to do that, and therefore what I expect to see is different types of services, and frontline health models providing those services, compared to what we have today.

>> Kia ora, Minister. Ashley?

>> So, the key thing is in three years, and one year, it is already seeing an improvement across the system, the more equitable access to experience outcomes. And we are actively monitoring that. Is a constant approach to improvement. We are looking at new ways to deliver services, and been very responsive at what the constant desire to learn and improve. And we have seen this a lot over the last couple of years, with the response to COVID. The need to respond to Māori and other communities to improve outcomes and deliver vaccines to Māori and other communities, the systems can learn and respond quickly. That’s a strong feature of the system. Finally, this is important, for the Ministry of Health and its stewardship function, it is a strong future view, not just here now, we are securing the system for the future in terms of workforce. In terms of infrastructure. And in terms of the way that services are delivered so that they are more accessible to the community. Kia ora.

>> (Speaks Te Reo Māori) when we talk about better access, we want people to be encouraged to get involved in the development of the services, health and well-being services, and I think that is the transformational part that we want to invest ourselves in over a longer period of time. We want to accept that there is one part, what we do right here and now, and the reforms and transition to reform, and the work that we do to make sure we transform the system over a longer period of time. Making sure, at a local level, people are able to influence the way services will be set up, and this will encourage different funding models for Māori providers, so they are resilient, they do the work we know they can do, and collaborate with ministry health, and other ministries at the same time. It has really been an investment style model, because we see the whole community wraparound, we see a lot of good outcomes for the communities, and that’s what we would want to see over a longer period of time as well.

>> I have a question to ask you Ashley. How can it marry become better partners in the regularly and public space with opposite the new Ministry and public health agency?

>> This is a good question. The agency will be sitting within the Ministry of Health, and I think about it, because I’m in a public health position, but I think about it as being in the heart of the future ministry and some of its functions will be fundamental to us to be able to deliver on our stewardship role, our monitoring of outcomes, and the system performance. Those public health regulatory functions are determined in effect by the Ministry of Health, but they are delivered largely by our public health units and our public health units will be coming together into a single national public health service within Health New Zealand, and so there is an exciting opportunity here for that national approach to our public health service delivery, including the regulatory aspects, the health protection aspects of this, to be much more connected to the local communities, including Māori communities, and in fact we’ve seen some very good examples of this and I talked earlier on about the need for the COVID response to respond immediately to what community needs were. When we saw our public health units having to develop new ways, new relationships with (Speaks Māori language) communities and indeed other communities in the delivery of that health protection function. To have a really strong base to build off here and in a way, this is one of the most exciting developments just to see that while those regulatory functions are prescribed legislatively, they determined by the mistreatment, the way in which they are delivered can be managed by partners.

>> I have a question here, particularly the question has asked will the audit approach be used to assist in embedding the treaty into the new system?

>> I would say that there is always an opportunity to embed whānau ora and the approach it is taken, because again that speaks to that whole collaborative network of providers, community, groups that come together to make sure that they create solutions and establish networks if you like for all whānau to be able to access. The order is so that whānau have a voice and that is an important part of this reform and how we operate moving forward. Not only do we want to lean into the final order outcomes that have been very successful to date, we also want to make sure we can establish finite voice and build on what they are telling us so it is a system that is cognizant of all of those factors.

>> Minister, I have a question here around the future for PHOs and general practice but I also think there is an interesting locality planning and I’m aware that there has been announcements quite recently around that. I wondered if you want to comment a bit on how you see that moving ahead, particularly with Māori health in mind.

>> I think a really important question. When it comes to PHOs, they’re not a creation of statute, the government hasn’t created them to establish, they arose out of the system as it is at the moment, there were some benefits to offer support across general practices in a particular area or region. I think the offering from PHOs was to assist with back-office functions, supports and innovation. And there are some PHOs that have done a great job in doing just that. There are some other PHOs who I would say haven’t actually risen to the occasion what PHOs do is really going to be entirely up to them and the practices that they represent. For me and for the new system, I think the locality planning network process is going to be absolutely critical. The way that process operates is to bring together different health providers in an area as well as iwi, as well as community leaders, To talk about the health needs in a particular locality, look at the profile of the population, see whether there are things that are distinct to that population, and for that to form the basis of what then Health New Zealand and the Māori Health Authority will fund. From that process, I expect, and if we don’t see this, it means it won’t be working, but I do expect to see a lot more innovation, a lot more collaboration and coordination. I think one of the challenges for primary and community care, not for all of it before some parts of it, is to examine the business models that they are operating under at the moment and then to think about what might be better ways of ensuring the full range of primary care services that we expect to be in communities can be offered. Bearing in mind that outside the big metropolitan areas, and provincial urban areas, we’ve got a large rural population whose health needs had often frankly sort of been secondary to what practices might want to do in those more populated sorts of various. Through locality planning, we have a much greater opportunity to think carefully about how we provide services at a more consistent sort of way, and reach into communities that I think for a long time have missed out. If there are PHOs you want to provide the leadership to do that, then that is a good thing, and that opportunity is there for them. But what is critical, I think, is through the way that Health New Zealand and the Māori Health Authority ends up funding services, and activities, it drives services to be offered in a way that meets a population’s needs, not that meets the service provider’s needs.

>> I have a question here around where we see, in any change process, particularly one as significant as this, which I think would easily be the most significant health changes we’ve ever had. But there is a question there around where we see the bumps in the road in the next six to 12 months. Obviously as we channel and move towards a change, it is important we know the destination, but also where some of those bumps might be. So might start with Riana and then Ashley and then yourself Minister about where you think those bumps on the road might be.

>> Getting today one, ensuring we have the organisations established, and ready to go, it’s going to be not so much a bump on the road, but it is certainly one of the things that we are really focused on prioritising at the moment to stop making sure we get the right documents, dress those priorities, and making sure that we partner up well both with Health NZ and with the Ministry of Health to make sure that we are able to roll out those key functions post 1 July. Partnership is always about having those good, high trust relationships, working together collectively, and working wider with the rest of the sector, that will be part of our key priorities. I think the potential for bumps in the road in any of those spaces, but what I would say is we are really committed to making sure that these reforms are extremely well. It is a priority for all of us because at the end of the day, we really want to address pae ora, we want to see it regain for our people, and that means being really good treaty partners.

>> I am very conscious as we come to just over two years in a pandemic, we’ve been asking a lot of our health workforce, in its broadest sense, the public sector workforce as well. And so it is very important that we make sure we are engaging our people who work in this system and that they have a sense of excitement about the future system and its purpose in the direction and that they can see the opportunities there and that they can see the aspirations they have, I know they have, for the system able to be realised. And of course that goes in particular in terms of our discussion today about our shared aspirations for improving Māori health and for delivering on our treaty obligations. It’ll be very important that we create the space for people, even as they are busy and no doubt tired after an amazing effort and amazing work in responding to the pandemic. And also it’s important that we are able to articulate to communities, to whānau, and others exactly what reforms mean for them and we are able to demonstrate as we go along the way the benefits of it. But rest assured, of course there will be bumps in the road was that we’ve seen that in a pandemic response. The important thing is that we are constantly articulating that really clear vision and that people are given the opportunity to respond to that and to engage with the changes that are on the way.

>> Thanks again, I agree, I think for health, the critical element in delivering health services is our health workforce, and we have an absolutely tremendous health workforce that has really delivered in a way that I think it really struggle to see just over the last couple of years and really risen to the occasion. That means we have a health workforce too that is really feeling it, has felt the pressure, and is feeling tired as a result. And it’s a health workforce that was under pressure anyway. We are in a system that still carries a lot of vacancies. So we need to address those issues. They won’t be fixed in the next few weeks, but we need to do that. We also need to continue a measured response to the COVID pandemic as well as facing what this winter might present to us as well. In terms of when you are setting up the new structure and a new operating model, there is risk establishing new relationships, those reforming old relationships. Those things can happen unevenly. I think as others have acknowledged, there’s no such thing as the perfect process. No change happens in a straight line. Think what’s important as we understand the magnitude of the task, we understand the state that the system is in, that the workforces in, there are still some outstanding issues that I think many in the public and private health workforce would wish were fixed, fixed some time ago, but fixed sooner rather than later. And we are determined to do everything we can to do that. Think equally as I get in, thing people do see the opportunity of the changes and also want to get on with that. So I think as long as we understand that there are still challenges to rise to, some important tasks to get stuck into that we support each other to get there, and we accept that it won’t be perfect but it will be headed in the right direction, for all the right reasons.

>> Kia ora Minister. One question that I am going to ask, start with you and then Ashley and then Riana, is what happens if there’s a change in the policy in the future? In recent weeks in the newspaper that something that has been posited. Do you have any reviews on that before a hand on to others?

>> I think is the legislation, the pae ora healthy futures legislation goes department, I think the be more of a public debate then perhaps we have seen up until now. And we should embrace that debate, it’s an opportunity to really layout what we’re trying to do. I’m confident that for those particularly in the health sector who know that we can do differently and we can do differently well, and we can do better, that they are willing to seize the opportunity that the changes present and I also think there are plenty in the community who see that opportunity and want to make the changes well. So I wouldn’t get too fussed about what is said in the political arena. I’m not trying to criticise legitimate criticism and legitimate opposition, of course there is. And as we know it health, nothing is ever going to be perfect. Let’s let the debate unfold, but I think the organisations, Health NZ, and the Māori Health Authority, and the revamped Ministry of Health, they will stand for themselves, and I’m confident that even after a year, 18 months operation, we will start to see change and difference and improvement and that is what will strengthen the organisations in the new operating model. I detect there is a willingness to embrace the change and as long as that is there, we will make that change and that will sell itself.

>> The area of reforms that tend to get the most debate and our time is around the structures, the organisational elements of the new reforms. But at the end of the day, the thing that our whānau and our communities really need and want of that system remains quite concert. In the structural reforms, the organisational forms, they are designed to set up the system to be able to better deliver for whānau and communities. And that is the thing that certainly is the stewards will remain focused on is the Ministry of Health, that actually what we’re looking for is what are the outcomes we are trying to achieve in making sure the system is delivering those outcomes, and certainly my experience having spent my career in the health system, is that ultimately, structures are important but they are not everything, and Relationships people have that lead to those outcomes. So, the approach that we will take being focused on the outcomes that we all aspire to achieve. Kia ora.

>> Kia ora.

>> I couldn’t have said it better myself. Rather than focus on the structures, I know that structures are one part of the reform, remembering why we have come into these reforms, it has been really cognisant Lee aware as to what C in the first place. We know, for Māori, we are not accessing services in the same way. Are not getting the same outcomes. We have mortality rates that are so different to other New Zealanders, and this is about exploring and making sure that we start working on the solutions. And that is something we should all get interested in. We all want the right response around. To make sure we look after all the people of Aotearoa. And if we get to the bottom of the long-term chronic diseases, mortality rates, and other issues for Māori, it will be a benefit to the health system overall. A bit like Ashley in that case, a job is to make sure the relationships are sound, we are working collaboratively, reaching across sectors, and we make sure we go back to communities who most want to be able to stand up these systems to themselves, and recognise there are other ways that people get the best services. As they define them, and as they aspire to be able to access them. Kia ora.

>> Kia ora. There is a golden opportunity with the reforms, amongst other things, to increase visibility and awareness, respect for and utilisation of mātauranga Māori and te ao Māori. How might they engage, Minister?

>> It’s a good point, Minister. The reason the system is set up, the Māori Health Authority is not just confined to health services, to cross the system. The whole system needs to be able to respond effectively to Māori, and address the needs. One of the jobs that the Māori Health Authority have as part of the workforce development mandate is engaging with the training institutions that have courses. One of the jobs is that we examine closely the training, not just to all health workers, that they get qualifications, and providing basic knowledge and understanding for all those who enter the health force, with qualifications, to understand what the expectations are, what the needs are for Māori when they engage with the health system.

>> Kia ora, Minister. Ashley, there are a bit of questions with the big letter R word, racism. Do you have the best way to go about this, given that we need to keep the health sector in a purposeful direction?

>> Kia ora, John to stop this is a important public, and the Māori action plan is addressing racism across the system. Going back to earlier comments about leadership and the responsibility of leaders on a personal and organisation and assistant level, we need to be open to and looking at what other drivers of poorer outcomes for Māori for the system. It’s no doubt, it is well documented in New Zealand and other countries and health systems, racism, conscious or unconscious, plays a role. Therefore it needs to be actively called and addressed. I have been very encouraged over the last two or three years in particular, to see a much more mature, systemwide response to acknowledging racism and the impact it can have. I acknowledge, it can be a tricky subject, can be something that I feel quite strongly about, and I will have a mature response to it, making specific actions in tackling it is a deliberate action. Kia ora.

>> Kia ora, Ashley. Riana there has been questions about the health system and the Māori Health Authority, how do you see that partnership being expressed between the two organisations?

>> I would expect to see it expressed in so many different ways. We should always look at our priorities, develop plans that will see better access to services, remembering that Health NZ will bring together the district health boards and services that are within there, but there are also community services, and I see as having a productive relationship could partnership around how we hold ourselves accountable in the system. The Māori Health Authority, we will not be trumped, we will make sure that my people have their voices heard, that we rely the information to our partners, and that is not just Health NZ, but the partnership with the ministry as well as those stewards. The Māori Health Authority has a big job ahead of it, and of course, making sure that we behave in a way that has partnership full, enhancing, that shows respect to all parties and people, and will result in good outcomes. I want to add to my comment, to take initiative, John, last question before, I think it’s the exciting aspect of the reform, we are having these discussions. If you wanted to see, in real- time, what change looks like, it is the fact that we are having conversations about Indigenous models of care, introducing concepts, people understand their history, that it leads them to well-being in their own right. Good health is not just the absence of disease, it is making sure that we have good housing for our people, that we are conscious of those that are without, and that we make sure we join together to pull all the levers to get a healthy nation for all people in Aotearoa. Kia ora.

>> Kia ora. We are coming to the end of time, but I want to leave a final question for you before we close. And that is where we see our particular roles in leading the change. I’ll mix it up, have Ashley, Riana and then you, John.

>> One is being leader of Ministry of Health, it really has a strong stewardship role. Stewardship role is even stronger and enhanced, we have a clear obligation to monitor and ensure that the system is performing for all of New Zealanders. So, it’s a key part of the Minister’s role in the future, and the Director-General has got a system leadership role that goes beyond being the head of the Ministry of Health. And worse in the importance of the role, through the pandemic. Whilst I have been moving on from it, I’m just one Director-General, in a long line of Directors-General, and another person coming into the role will bring you vision and energy, and a sense of deep commitment as well to continuing the leadership role across the system. I’m also confident going back to my early comments about the maturity of the system in terms of treaty responsiveness, in terms of its focus on equity, and the partnership with Māori, and the Director-General will carry on that important work. Kia ora.

>> Kia ora, Ashley.

>> I see my role as being a really good partner. And working collaboratively with all parts of the sector to embed all of these Te Tiriti, that we create better plans and that we make sure photo voices is at the centre of everything we do. That the Māori Health Authority is the voice for Māori, because people just won’t have that. But making sure that Iwi all have the opportunity to have their voice, and that the messages for people are adhered to will be a big part of my role. The last thing that I will say is (Speaks Te Reo Māori), and simply put that means it is not by the might of one, it is the collective that will get us the result we look for. Kia ora.

>> Kia ora. Minister?

>> I could say that we have the easy job, I received the reports, make decisions. No, it’s not. The important role that I will continue to play in this role is what I have done so far, to look closely at the reports, evidence, and recommendations, and work with other ministry and colleagues to get good decisions up, that are practical, ambitious, and that actually seek to do justice, particularly to Te Tiriti . We will send the milestones for the decisions, and the other milestones as well. That is what we have been doing. And the other thing is, to make sure that we continue, we have enjoyed so long to get people in the right roles to provide that leadership. So, Ashley in your leadership in the timer Director-General, what you’ve done to advance and improve Māori health. John, the work you have done with the Māori action health plan, and Riana your work as a health leader, I cannot feel like the Māori Health Authority is more blessed by having your leadership, working with the ministry, and Māori partnership boards, and your people to drive the change in Māori that we know we need to see. And we feel like we are truly honouring the treaty. I will continue to drive towards those aspirations.

>> Kia ora, Minister. (Speaks Te Reo Māori) Just on your behalf, thanking again, our minister the Honourable Andrew Little, Dr Ashley Bloomfield, and Riana Manuel, for the expectations we have and continuing to improve the health system, get the best out of it. On your behalf, I want to mihi to them for their time today, and their kōrero, and the questions that you put to the session. I want to close on the point that Riana made that it takes many of us to have our goals come forth. And I will end with (Speaks Te Reo Māori)

Speakers

• Dr Ashley Bloomfield – Moderator
• Minister Andrew Little – Minister of Health
• Minister  Ayesha Verrall – Associate Minister of Health
• Margie Apa – Chief Executive Interim, Health NZ
• Riana Manuel – Chief Executive Interim, Maori Health Authority

Welcome, everybody to the session. Thank you for joining us online.

I'm Dr Ashley Bloomfield, director of health, and my pleasure to facilitate today's session, our third in the series that build on the government policy statement but with a theme and today's theme is on public health and population health.

I'm joined today as I welcome the Minister of health, Andrew Little and also Associate Minister of Health, Ayesha Verrall. I also have the chief executive of health New Zealand and the chief executive of the interim Maori Health Authority.

This is an opportunity for us to talk about the direction setting in the new health system.

You can watch the previous two sessions on the Ministry of Health website and it is important to note that today you are also able to put questions to our panel using Slido, which you would have had information about when you registered for the session. We will aim to get to as many as his questions as possible during the session later on. If you don't get to them all, the team will theme those questions up and make sure they are responded to available online with the transcript of the session.

The session is also being closed captioned and please just press the CC button to access those.

Now turning to today's theme on strengthening public and population health.

Many, if not all of you, will be away I will step down from my role as director general of health in July but am pleased to see that a key focus of the reforms put in place is a strength and focus on population health and Public health. I will talk briefly about what these mean shortly and then minister Little will talk about the government and its priorities for the particular focus on population and public health and update on the Bill and also his expectations being set out in the interim government policy statement.

Minister Verrall will talk further about specifically how the reforms will strengthen the areas of public health and population health with the establishment of a public health agency here in the Ministry of Health, the National Public health service within Health New Zealand and also an independent health advisory committee.

Then we will hear from Margie and Bernard about just what the two organisations, health New Zealand and the Maori Health Authority, will be doing to strengthen that focus on population health and also strengthen our public health services.

The vision for the reformed health system is a healthy future for all New Zealanders where people live longer and in good health, have improved quality of life and there is equity between all groups in the population. We know at the moment that many whanau don't enjoy the level of health they should and we have ongoing inequalities in health and that many of these are unfair and we aim to address these through the health reforms.

In addition, the reforms aim to not just acknowledge but give life to the special relationship between the Crown and the iwi under the Treaty of Waitangi.

Just a word then beforehand at the two minister Little about what we mean by population health. Population health is about a focus on communities and on groups within our population. It means looking at differences in health outcomes between populations and the drivers of those differences. It puts into practice that special relationship between the Crown and Maori. It looks to achieve equity for Maori and other groups or populations who are experiencing poorer health and it also addresses not just through the health system, but addresses the drivers of poor health, so this wider determinants of health and well-being, so population health is about a systematic look at the health status of different population groups, the differences between groups and how, importantly, we can intervene to address those differences. In terms of public health, the WHO defines public health as - and this is a well-known definition for those of us in public health circles - "The art and science of preventing disease, prolonging life and promoting health through the organised efforts of society." We have seen over the last two 2 to 2.5 years through the pandemic what a public health approach involves and that is not so much a focus on the individual and on treatment, but on those measures we can take, both individually and collectively, to protect our own health and the health of others. Public health includes a range of services, health promotion and health protection services as well as activities like disease surveillance and we will talk about the establishment of the public health service and how that will strengthen our public health services. Now I would like to welcome again minister capital and asking to speak about his priorities and expectations for the reformed system and an update on the legislation. Kia ora.

>> (SPEAKS TE REO MAORI) good morning. Nice to be back in. Ashley, nice to see you again. Ashley and I last met at the world health assembly in Geneva and good to hear that you have come back safe and well. I can by way of confirmation say the bill passed its third reading in Parliament yesterday evening, so that legislation is now passed. It will become law subject only now to the Governor-General's ascent which will happen in the next few days and that law will take effect from 1 July this year, so the legal framework for the health reforms is now well and truly approved and we are now (INAUDIBLE) ahead for 1 July. I will become more to the content of the legislation as it affects what it is we are talking about today. But as Ashley said, we know that, like every health system, New Zealand is no different, we have a health system that has seen different outcomes achieved across different population groups. And we have an understanding about the reasons for some of those differences. It is socio-economic factors, things like housing, the communities that people living, things like incomes and job opportunities and what have you, so if we think about, as the legislation requires us to do, not just about health services, but about health and well-being and keeping people well, then we cannot think about a health system without thinking about those factors that affect people's (inaudible) including whole communities ' health. New Zealand in terms of our special characteristics, we are a reasonably small population and a long, skinny country. We have some large, concentrated population centres and small ones, particularly in rural areas, and we are a country that has a strong ethos around social equity. That very much drives what we do and what we want to do for our health system. One of the objectives of the health reforms is not only continuing to strengthen our health services and the health system, including through population and preventive health measures, but actually achieving greater consistency across the country. A consistency in terms of access to and availability of health services and also the outcomes of health services and help treatment. So, all of those elements come together in the reforms that we do. As I have said, an important part, it is explicit in the legislation, is public health and having a discrete public health agency. That would be embedded in the ministry and would have the benefit of external advisory or external advice and also the national public health service, which is the consolidated public health units, so a single, national operation that would be operating out of Health NZ. One of the commitments that sits through the legislation is our obligation, the Crown's obligation, to meet the commitments made under the Treaty of Waitangi, so when we think about greater equity in the system, it is very much in pursuit of our obligations and that is a treaty obligation to the Maori. We have equity obligations to the Pasifika communities, to women, to other communities, rural communities among them, who typically miss out on, I think, the quality of health services that are available in either more populated areas or to the rest of the population. There are a number of ways the legislation sets out to enable us to better achieve those objectives, the population objectives, we have and the equity objectives. Foremost among them is the government policy statement. It is now a statutory requirement that the government period -- periodically sets out its expectations and what it wants to achieve from the health system. It specifically is required to refer to these population groups I have just mentioned who typically have seen worse outcomes or worse access to health services than other parts of the population. From the government policy statement, Health NZ and the Maori Health Authority are required to develop a New Zealand health plan. They have to agree on that plan and that is ensuring that where the Maori properly we have a Maori health authority that is properly resourced. That is an organisation now that will play a very strong voice will bring a very strong voice as we put together the health services and health treatments across our system. And last but by no means least making sure we support our workforce not just in the present but into the long-term future through good workforce planning and development. It has to underpin health services. Health services are very people dependent, highly qualified people dependent through our health workforce and we need to make sure we are regenerating our workforce on the basis of our long-term needs well into the future. Against that, against the government policy statement and the New Zealand health plan, there will be some specific or discrete strategies that will be developed for Maori, for Pasifika for disabled people and rural communities because those are areas we know we need to particularly lift our game in. Those will be the things that are not just a nice to have any more, they will be statutory obligations that the state funded health services will be required to develop and will be held to account to on. Obviously, through health and said and the Maori Health Authority, there is a significant commissioning of health providers who get funding and financial support to provide services even if they are... Those services are privately operated or owned. -- health NZ. Part of holding the new entities to account will be making sure that in the commissioning of funding decisions that they are achieving the objectives and expectations that we have set for them. I am going to conclude my remarks there. That sets out what the new legislation requires of the system leaders, including at the political level, and then a critical part of that will be what we do in the population and public health space. I'm sure my colleague will be well equipped to talk about that. Thank you.

>> Thank you, Director-General and Minister Little. And as you have outlined, public health is at the core of the legislation and the health reforms in general because it is an approach that presents such an important opportunity for improving the health and lifespan and quality of life of New Zealanders. I will talk about some of the mechanics of those changes. Firstly, we are creating, as Minister Little mentioned, a public health agency, located within the Ministry of health, but a distinct branded unit, much like Medsafe is, responsible for leading population and public health strategy, policy and monitoring. It will have a role as steward of the public health system, work in partnership with the Maori Health Authority. It will be an authority on public health knowledge as well as monitor threats to our health and ensure we are ready to deal with them. And we are kicking that work off starting with the COVID work we are currently doing, but that will evolve to be a much broader piece of work overtime. The correction... Creation of the public agency will lead the ministry to have renewed focus on population and public health to address inequity and enable all New Zealanders to lead longer and healthier lives, support the health sector to reorientate towards prevention and the needs of community and whanau which will be central to the success of the system. We will have a focus on the upstream determinants of health and some of these, as you will know, was it outside of the health sector as well as on risk and preventative factors. The underlying causes of illness or well-being such as nutrition and physical activity, how products like tobacco and alcohol and exposure to environmental hazards will be important focuses for the agency. The public health agency will be able to build on the ministry's skills and regulation and its technical expertise and surveillance. It will leverage all of the things that we have had to bolster during the pandemic and become... Really be a legacy of what we have learned through the pandemic to be able to sustain having a very strong public health system in the future. There will be more emphasis on the determinants of health such as employment and housing, which will mean the agency will work more closely with other relevant government agencies and community partners and use intelligence and monitoring to strengthen the system to enable New Zealanders to live longer and healthier lives. We have also learned through the pandemic it is really important when making public health change to have science- based and community focused independent advice to government, but that advice also has to be public facing. A new public health advisory committee is being established to provide the Minister and associate ministers with independent public facing, science-based, public health advice. The secretariat for the committee will sit within the newly formed public health agency. Members will be informed by and They employed creative solutions to create better health outcomes full stop and look into long-term, often neglected health challenges full stop their approach will focus on addressing the social, and behavioural determinants of health such as the criminal justice system, education and climate change and other factors full stop in the selection process is currently underway, it is expected to be completed at the end of July full stop also, to ensure that there is consistent expertise and campaign design, easily available across the system, the health promotion agency will move into Health New Zealand and become a shared service with the Maori Health Authority. Finally, to further support the focus on population and public health, up to $37 million is being invested in the new national public health service being set up within Health New Zealand. Bringing together the existing 12 public health units, and maintaining regional infrastructure and local expertise, while having nationwide scope. The national public health service will be responsible for call public health services and programs, with the health CEO, Margie Apa, will speak to this later in session. Supporting the whole health and disability system to realise its potential, as a learning health system, asking the right questions, gathering evidence and using it to inform policy and practice, and evaluating outcomes. Ministry of Health hosted innovation function will provide tuition for the wider health section. And to establish a wider implementation of the Maori Health Authority for governance. If I wrapup, I like to touch briefly on the importance of these reforms in public health, in relation to supporting communities and other populations. These reforms give us the opportunity to think more holistically about what is happening in the community, and to plan the response to the needs of the community, activities, awards and collaboration between various groups and various different providers. As we know, New Zealand's population is ageing, growing and changing, along with the many opportunities and springs, poses significant economic and social challenges for the health and disability services. Over the next decade, the size and diversity of our older population will increase significantly. Older New Zealanders are the fastest age-group. The number of New Zealanders aged 65 is projected to increase over 819,000 in June last year, to 1.6 million by the end of the 26. The growth among older Maori, Pacific communities is significant between 2013, 2036, the Maori population is expected to increase by hundred and 26%. Pacifica and Asian by 216%. People living longer are often faced by comorbidities and complex health needs, and public health is about preventing illness and promoting health and well-being, to support all people, no matter who they are aware they live, so that they can stay well. Any health system provides a significant opportunity to ensure our workforce are prepared, so they can keep up with the changing needs of our population. Previous reforms, we aim to create a strong and equitable disability system, which focuses on improving outcomes for New Zealanders, and people who are most disadvantaged, will be based on health conditions, culture, ethnicity, gender identity or sexual rotation, where they live and other factors. (Speaks Te Reo Maori)

>> Thank you to both our ministers, for that over the public the expectations are -- overview. And what the government's ambitions are, particularly around population and public health. I can see some questions coming in, which will come to shortly. I would like to hand over now to Margie Apa, to talk about more about the national public health service and how it will strengthen our health functions across everything, and about localities and the focus they will have in promoting population health. Largely.

>> (Speaks Te Reo Maori) look, I'm really excited and acknowledge the passing of the legislation, that puts us into an exciting phase. I'm going to highlight a couple of areas, the ministers had laid out, and how we will make this happen on the ground. In Health New Zealand, we do bring together, it's one of the important shifts, that the reform program aims to achieve, which is unifying our public health service and strengthening the delivery of population health services across the country. From 1 July, we will have a national business unit within Health New Zealand brings together all the functions that Minister Beryl have talked about. Also, screening and immunisation, health promotion, health protection. Together we will form a very strong public health service. I want to acknowledge, this isn't something that will happen on 1 July. We have had some months, our public health colleagues across the country, working with Joe Gibbs and others, to design and work out how we can best organise ourselves, to get the best of our existing talent. But also position ourselves to grow our public health workforce, because we call it that we have to do a lot of work to strengthen and grow our public health workforce. This is a very important, lots of learning is out of COVID, and how we use many of the skills and the health system. That's an objective of bringing our services together. Bringing this teams together at a national level, and that doesn't mean based in one city or one area, we know our talent spread across the country. Are creating some centres of expertise that we can rapidly trophies will share that expertise -- diffuse. Where there is understanding water quality, immunisation or screening, and through our regional directors for publics health, we support the work at a local level that will happen within locality. Population health is an important part of locality work, because what we have national programs like screening and immunisation for example, which are very important for us to achieve population coverage, we know that we need a diversity of delivery models to make sure that we reach into communities that might not normally come into the conventional ways that they get a screen or immunisation. That the general practice of care providers. Certainly through COVID, we had an amazing opportunity to test diverse models that gets care into rural, Maori and Pacific communities. Including people within our mental health system, living within transitional housing, we were able to reach those communities that are festive models. That is the heart of locality is worth, population health is a key part of. Would like to emphasise whether we work together as a Maori Health Authority, and Health New Zealand, is at all levels of the organisation. I know, there is a senior executive that will work as part of her executive team, and the Maori health authority. Partner with the national authority with the public health service, and together we will have executive leadership that ensures that we will have Marie responsiveness built right through the organisation, and the regional directors for public health. -- Maori. Importantly, within locality. How we work within Maori communities in the local area, and I think that is a good segue, talking about the part of the fabric, and how it is relevant to the appropriate in local communities.

>> (SPEAKS TE REO MAORI). First, apologies from Tiana. She is travelling from this point in time and unable to make it. -- Deana. I congratulate members with the passing of the third reading last night. There are a number of key components in the Bill that have relevance for the Maori Health Authority and if we start right at the key system shifts of what was undertaken, the first is to provide a health system that is to rete enabled and meets its obligations and that is important because it is something that the Maori have long called out for an embedded in the heart of the bill. And for the Maori Health Authority, we have a responsibility right through the system to ensure that that is so, so being able to make sure that we are providing (UNKNOWN TERM) advice and leadership for the sector, being able to be a part of the commissioning of services, both... Whether that be direct commissioning ourselves or go commissioning with our partners, Health New Zealand in that particular process and being able to monitor the performance of the system right across all of its areas including in the public and population health areas, is very important. Our relationship and our partnership with the Ministry of Health is honestly a key component of that, alongside a lot of the strategy and policy setting that will enable a lot of these things to be able to pass. I think it is really important to the other system shift that I think is really important from a Maori health Authority perspective is the one around how we support and nurture our workforce and build up, in particular, the Maori health workforce and we saw that in COVID - the number of Maori able to heed the call to arms to support at that very localised level, was a great example and opportunity for Maori to be able to put our hands up and say, actually we want to be an active part of the fight against COVID that has occurred over the previous couple of years. I think when we look at the opportunities there for the Maori, it is about being able to have that national presence and approach and partnership, but to be able to also make sure that that occurs on the ground and those localities in the areas where our people live and the role of the iwi, Maori partnership boards will be key. Iwi Maori partnership boards are being developed and set-up at the moment so that a lot of them will be ready for 1 July kick off of the new system and they will have a number of different roles in there. The first one is to really make sure that whanau voice and community voice is heard at that local level, that those local priorities and local health needs are rarely heard and factored into how systems and services are planned for and provided in those local areas. -- really. There is also an opportunity there once that is taken into consideration, is to work with, as I said, Health New Zealand at the local level to ensure the services are designed and delivered in a manner that really encompasses the whole of our population, is not just the Maori but also the local communities. And then there is that ability to be able to monitor the performance of the system at that local level to ensure it delivers exactly what it was set out to do. I think the other important part for the iwi Maori partnership boards as they have a responsibility to report back to whanau and communities about how it is their own performance has been in meeting those expectations at a local level from that very local assessment of service need, right through to the actual monitoring of the performance of the system, so those are really important components of iwi Maori partnership boards and they will work in partnership with localities to ensure the services are delivered in the way that they were expected to be. I think, finally from me, the partnership will be absolutely vital for the iwi Maori partnership boards and when you think about it from a public and population health perspective, that real ability to be able to help to design and set up those sort of prevention services that sit alongside of an Aotearoa Maori perspective of things, so ensuring our environment, waterways and general approaches are all aligned so that you have a real (UNKNOWN TERM) perspective on our health represented and serviced in local areas is important.

>> Thanks to all our panellists today for those introductory comments and it is great to see that the questions are rolling in. We will move now into the next part of the session and that is to start to address some of those questions and I am going to share the questions around a bit and perhaps try to draw out from our panellists some of the key points we want to make in response to this. There is a first question, a big one in a way. This person is pointing out that certainly for the last couple of years, there has been a strong focus on COVID and so public health and population health we have been doing very much as that communicable disease lends with that specific focus on COVID. The question is about how we move beyond COVID to the emphasis on and an aspiration for health promotion and improving well-being systemically, improving well- being across the system, and I think there are a couple of areas that would be good perhaps to touch on and Minister you might want to talk about from the legislation point of view and also the government's aspiration about broader well-being, which goes right across government and I wonder, Minister manner -- Minister Verrall, despite the focus on COVID, and the government hasn't been idle on very strong public health measures and there are several year pushed through and perhaps you want to touch on those, but, Minister Little, you might want to touch on those?

>> It is going to be absolutely critical, so that is why there are specific references in the legislation to that being the job not only of the Ministry as the steward of the system and making sure the whole system is operating and working but for Health NZ and the Maori Health Authority as they work at all levels with communities in regions and across the country as a whole. We know that there are some communities that because of where they are located and levels of investment, if you like, and job opportunities, are under different pressures than other parts of the population, so we need to make sure that we have support to whanau, families, communities that uplifts well-being, so less prone to disease and unwellness. Through the work that the Maori authority can lead and we will see a shift towards that beyond just who is the next service provider we should be thinking about to what are we doing to encourage good nutrition, to encourage lifestyle choices that promote and encourage good health for children, for older citizens, for the community as a whole, so that is very much infused throughout the legislation and very much at the forefront of the government's expectations.

>> Thanks. I think there is certainly a lot underway outside of communicable diseases. We have the fluoridation of drinking water, the mandatory fortification of non-organic breadmaking flour with folate, substantial investment in women's health screening, both cervical, to enable self screening eventually by human papilloma virus PCR testing and also pressed screening to improve the breast screening register there, so we are active across a full range of public health issues. -- breast. The question asked about Post COVID and the domination of infectious diseases approach to public health during the COVID era and I guess when I am thinking about my tobacco control were, I think that is an example of how we have to learn the lessons of COVID and translate these to a new public health setting, so yes, we have really strong regulatory proposals we will take through the House in the second half of this year for tobacco control, so smoke-pre-red -- generation and (UNKNOWN TERM) cigarettes. We also know from COVID that we can achieve so much in communities through community mobilisation and I think that is a really important person that we have to translate into the noncommunicable disease prevention space and if you read our action plan, there is a lot of resource and effort to make sure that that workforce that has been developed and community organisations through COVID has the ability to have new work to be deployed to if that is what local regions want to do in order to be able to make their communities smoke- free as well, so I don't see it as an either/all and we have to translate the lessons we learn.

>> Thanks, Ministers. Before we move on to the next question, I will perhaps put this question to Margie. One thing I observed and Minister Verrall touchdown is actually there was a lot that happened during COVID and for someone who has been around public health in Aotearoa for the last... Quite a long while, over two decades, there was some absolutely rapid and significant shifts in the way we imagine and then developed public health responses. -- imagine. You touched on this a little bit early on, in particular, getting those vulnerable communities who the virus went to and so we need to make sure we could look after these communities but also get vaccination out of them. I'm interested in any thoughts you have from your time when you were chief executive at counties Monaco at the time and any reflections you will take from that experience into how we might deliver public health services including health promotion, including that wider focus on well-being and the new system. -- Manakau.

>> Just to echo the comments about community mobilisation and if I reflect back, it is not all communicable diseases, it is one communicable disease we are focused on and if we go back over the ties we have had, big outbreaks in our communities like hepatitis, meningococcal B, long time ago for those of us around and we seem to draw on community mobilisation, we have these big campaigns or outbreaks and the challenge for us as a system is how do we make that part of our core way of doing business? It is not something we call on when we have a major outbreak, that community mobilisation can work in peace time as well is an important part of our health delivery system and we need to support the legacy of providers, of workforce, ways of reaching out into communities and preaching -- appreciating in areas like South Auckland we are not unique. Maori families were differently. When we talk to whanau you do not see themselves as one house, they see themselves as 405 households working together, Pasifika whanau, so how we flex and adapter model so many parts of our community behave differently and think about how they work and we have to tailor our approaches to that rather than assume there is one model that fits all and the closer you get to communities, the providers, the networks, the community-based workforce are the best place to know how best to reach them and our job as national public health service and then regional directors to enable that is to really create an enabling environment for them to do their best for their communities. The question about that overlap between Maori and public health science, but will talk about both public health and science. Clue -- clearly some of them come from Western paradigms and some not, and making sure that they support each other, and public health doesn't overshadow all control Maori. Do you have any thoughts?

>> Thanks, actually. I think these are a range of different responses to this particular question, it's a great question. I think the simple answer is look, there is this dynamic that we need to happen a health system. Which is, how is it that we place not just Maori but local knowledge and understanding, next to the art and science of public health. For Marie, we have seen a number of avenues. -- Maori. Not just to let us. If we think about the role of the (unknown term) in safe sleeping practices, that is something that took a traditional approach, contextualised it into today's safe sleeping practices. And theories. Is a real dynamic discussion that needs to occur. And part of the role of the Maori Health Authority, working with both yourself and the Ministry of Health, and with the Public health Association, with Health New Zealand, is to ensure that dynamism around those conversations is not just developed, that actually becomes a principle under which we operate. We look forward to the fact that Maori is seen as a really legitimate and constant in our health system, alongside the other health systems that we need to develop this way as well. $$TRANSMIT? Thanks, really useful comments where I think, how the melting of the two, Patricia knowledge with the science, actually amplifies the effectiveness. -- how the knowledge with the science. The question next, and Margie, you might want to lead on this, this is about workforce training. Not just about the public health workforce, but how do we ensure that our work for -- workforce is enabled for holistic care. We consider the factors important to public health, there is a gap in how we deliver some of the parties and a gap in the skill sets, particularly when it comes to marginalised community. I think the pandemic shirt is clearly both through these marginalised communities were, -- showed us, and the need for us to developer services in different ways. Just any comments that you what to make around this workforce training?Should thanks, Ashley. I will make a couple of comments. What Health New Zealand is an opportunity actually take a national or holistic future planning workforce training, and organising and coordinating it across a system. At the moment, with all goodwill and intention, it's challenging to organise the efforts of 20 entities who are trying to develop their own workforces. I think the opportunities to national coordinated, right along the pipeline, from how we encourage and promote health is a fantastic career and place to work for those not yet in the system, but have visibility of training coming through the pipeline and making sure that we are supporting placements and coordinating clinical training placements. Working with colleges, to make sure that we have skill sets and planning long-term for more people to come for the system. As well as allying -- aligning them with service areas where we need to work quickly, to make sure that we have people available to deliver services. Coordinating national is very important, and I think that's the opportunity we take as Health New Zealand. Especially for the national public health service, as one unified service, we can work together with our public health service colleagues stop doctors, nurses and extra people that we have into the workforce, through developing contact tracing and the models that we need to grow and support the skills and professional development of those teams as a whole.

>> Thanks, Margie. Any comments from ministers?

>> We were very conscious of that we thought about how workforce development. It's not just the clinical qualified workforce, it's the other part of the workforce, that enable patients with those needing healthcare, to get there, and B, feel at ease. The workforce became crucial in the vaccination campaign. It's recognising that there is a whole range of skills, that perhaps, have been somewhat overlooked up to now. That are critical to good delivery of healthcare services.

>> Thanks, Minister. Minister, I wonder if the next question, I can ask you to carry on here. This is about the locality approaches, and what role you see this playing in helping address the challenge that all health systems have? Which is around differential access to this services, the postcode difference to access. This is not unique to Australia -- New Zealand, and your aspirations and thoughts about localities and approaches and working with existing communities. Cannot just respond better to local needs, but how that may play a role in address that differential access?

>> The benefit of locality planning is help but identify needs. Is a much richer conversation enabled, as a consequence and a combination of health providers in the locality and community. And other representatives. My expectation is that we will get a better gauge of what is needed, and therefore what the. In the Second Part of the Conversation Is, How Do We Provide the Services. It May Not Be in a Traditional Way. It May Not Be a Practitioner and what I expect to see, is a greater collaboration by health practitioners, and a whole range of disciplines, about how services can be provided and where they can be provided. It may well be that we will see more specialists travelling to areas, as part of their routine. We see some of that now, we might see more of that. As we had a natural right, -- Drive, to make services in health care more accessible. And we might talk about the business model what the sustainable long-term? That means that we are having highly qualified practitioners into the places that we need them. And they might not be spending five days a week in a particular community, they may be moving through communities with the male -- with similar needs. In a variety of different providers, doing a similar thing, to make sure that all needs are covered in a different way. I think is an opportunity to rethink how services are provided, and for Health New Zealand and the Maori Health Authority to provide some leadership and how that might happen.

>> Thanks, Minister. On that same question, thinking about equitable access to population health services, you touched on cervical screening and prescreening as well. Obviously, we are still finishing the rollout of the bowel screening program. The government is also planning to reduce the age of entry into that program for Marion Pacific Art, because they have higher rates of death from correctional cancer at younger ages. How might the new system support equitable delivery of those population health programs?

>> I think such an important question. Firstly, alongside the reforms, has been a major focus by Minister Little on the data shall -- data and digital. My view is, unless you know who it is that you need to reach, you can't even pass go, in terms of engaging with the underserved communities. For example, in breast screening, we have an opt on register, which means that people that are traditionally underserved, are not on it. Until we develop that piece of information and infrastructure, we won't be able to reach people. But I think there is the whole system of plans, setting priorities, doing health needs assessments. That framework will essentially mean that these preventative health interventions will be prioritised, the way that we always know they should be, as opposed to... The focus of DH budgets being on the larger hospital services. I think the system, as a whole, will elevate those considerations in specific things underway, in each of those programs, to make sure we identify those in need. $$TRANSMIT

>> Excellent. I think that's an interesting comment. In one of the areas where there has been a significant shift in the last two years, we have made huge progress through the pandemic in our data and digital system. There's been some phenomenal work that has set the system well, for some of the transformation that is needed. Will be a huge enabler of population health approaches and improved public health service delivery. I think we have time to address this last area. I'm going to invite each of the panellists to comment. Importantly, it's raising the area of mental health and well- being. And mental health services in the Neath -- knee health reforms and ensuring there is an element of nocturnal -- mental health promotion as part of that. A specific question that will come to you, Margie, around mental health expertise. Will that be part of the National Health Service and how you see that interaction happening? Minister Little, in terms of national health and addiction services, any comments from you?

>> Yes. Mental health services and the need to rebuild them very much remains a party for the government. One of the areas that was revealed, covert, was the need to provide the means for people to develop their own resilience and mental health resilience. -- COVID. During the course of the pandemic we funded a number of online providers types Kelly Services, back online. -- upscale the services. To make them more available. And expansion of (unknown term), which is for school-age children, in dealing with traumas and personal traumas, often out of home. Get some additional support within schools. With an opportunity, that age, for young people to start building their own resilience and developing the rentals. Had a great conversation with Sir John, a great promoter of growing and developing individual strength and resilience, for a lot of young folks. Particularly in the teenage and adolescent years. And confront big challenges. They actually need the means of getting access to tools, in order for them to navigate their way through the challenging times, but all young people face as they are making big choices about their lives. That would be very much part of the future for us.

>> Thanks, Minister. Minister Beryl?? Just before Margie commented on the public health service, the public health agency is also responsible for surveillance. There's a role for public health surveillance in relation to mental health, because that's a very important enabler of service provision. We have been through a budget process, for example, in the area that I was working on, eating disorders. All of our data is on service usage and service demand, but not about need. There is a need to make sure that we are strengthening the public health agency in that area acknowledges well.

>> Thanks, Minister. Margie?

>> Will have a strengthened mental health team in the funding part of Health New Zealand. That will need to work closely with the national public health service. There's a huge opportunity there, and strong advocacy within the mental health system, to take a population health approach to mental health more intentionally. That's an opportunity will take up. Building on the advice from colleagues in the system. Trim thanks, Margie. Bernard, did you want to comment?

>> Kia ora. We are acutely aware of the Marie over a century -- overrepresentation in mental health and the need to access services. There are a few simple things, the ability to bring a more Marie centred approach to how it is that we do -- deal with mental health issues and services. That will be key. The Maori Health Authority will have a significant role in terms of direct commissioning and co-commissioning with Health New Zealand around how their services are provided and funded. And then finally, actually starting to look ahead, in terms of the programs that we have got out there. That look at the prevention side of mental health. And really focus on some of our key population segments, within our Maori communities.

>> Thank you, Bernard. A good reminder that mental health is not just the responsibility of the health system, and ensuring and maintaining mental health and well-being needs a wider approach and response, and Bernard, a good reminder, the public health approach is absolutely the way to think about how to deliver on that wider responsibility. So, that brings us to the end of the session. I want to take the opportunity to thank all the panels, particularly ministers that have made our way up your. Margie 'thank you for your contributions, and thank you for those that have sent in questions to engages in the discussion there. There is one further one of the sessions in the next week or two, will be sending information about that. Obviously, a highly important topic today. And a very exciting future of the new health system and of the reforms, as the Minister Little has said, that are embedded in the legislation that is now past through the house. That is an exciting development, we look forward to following up on the questions that we haven't been able to answer in the discussion today, and welcome you back to the final session in the next week or two. (Speaks Te Reo Maori) thanks again.