Dr Shane Reti's speech to Iwi-Maori Partnership Boards, Christchurch
Wednesday 6 March, Christchurch
Opening kōrero
Can I start by first acknowledging the Te Aka Whai Ora staff, the leadership and the board, and all those who were a part of its establishment. I acknowledge for some, Te Aka Whai Ora was a dream and a vision. I understand the grieving, and while this particular version of that dream is laid to rest, please allow me to paint a different dream, one that I hope we can share together.
A dream that will be outcomes driven, providing greater devolved decision-making to deliver care as close to the home and the hapū as possible. There is expertise in the Māori Health Authority, and I want to retain that in the health system. I say to Māori Health Authority staff to please join me, guide me, and together we can row a different waka towards better health outcomes.
Often, we all agree on the destination, it is just the different journeys that get us there. I want to describe that journey today. I also want to thank IMPB chairs for the two meetings we have had to date, last year and a few weeks ago, and also, thank you to those IMPBs who I met with while in opposition for their advice and counsel.
We have inherited a health system facing a significant number of challenges following major reform. Much of this is as a result of poor leadership and decision-making by the previous Government. This is no aspersion on the hard-working health providers. Decision making has mostly been centralised in Wellington, with whānau and communities not having as much input into services delivered as is desirable. We are changing this.
I want to paint a vision for Māori and all New Zealanders. My vision is that all New Zealanders will have timely access to quality healthcare. That is the mission statement. I agree with ED doctors that targets save lives. This is why I will be setting clear health targets. These will bring attention, resources, and the accountability that's needed to deliver quality care in a timely manner.
The direction of our waka will be reflected by the GPS, New Zealand Health Plan and the Letters of Expectation to Chief Executives and Boards. These will be reflected by our five health targets, five behaviour modifiers and five pathologies. And while our vision may differ, the objectives in Pae Tu and the Whakamaua Action Plan remain in place and already neatly sit within these priorities.
I believe we all have the same dream for the health system: we all want to address health challenges, we all want to shorten waiting lists, and we all want a workforce that isn't overstretched and that has the right skills to respond effectively to all our diverse populations.
As we start to look at how we can shift the health system to be more outcomes-driven, providing greater devolved decision-making to communities, there is scope for further changes to be made to support this shift.
Hauora Māori Advisory Committee
I have had discussions regarding the future of the Hauora Māori Advisory Committee. I am retaining and powering up the HMAC. I see the Committee as an important and independent Māori advisor to me, as the Minister of Health, both proactive, interactive and reactive at times, and I welcome this.
System performance will be at the forefront of this government’s approach to setting the future direction for health.
The committee will play a leading role in overseeing system-wide performance, providing insights to improve how the system improves Māori health outcomes.
I have asked for a Maori health monitoring framework and the committee have agreed to deliver a first draft in the next 30 days.
In the future, IMPBs will be facilitated to do more including playing an important role in monitoring how well health care and services are working at the local level in support of better outcomes for whānau and communities.
I see the functions of both IMPB’s and the Hauora Māori Advisory Committee working complementary to each other, to achieve significantly improved health outcomes for Māori.
Localities
The recent amendments to the locality provisions under the Pae Ora Act will extend the deadlines for localities by five years.
I have instructed Health New Zealand to pause current locality planning while I reconsider the best mechanisms to shift decision-making and resources closer to communities.
Role of IMPBs
Let me speak more to the specific opportunities we will create for IMPBs.
I want to share with you a Written Parliamentary Question I asked to the former Government.
Will Iwi Maori Partnership Boards be direct commissioners and contracting purchasers of health provider services in their own hands, and if so, when?
The government’s reply, as you will see on the screen:
No. Direct commissioning and contracting purchasing is not included in the list of legislated Iwi-Māori Partnership Boards functions as outlined in section 31 of the Pae Ora (Healthy Futures) Act 2022.
I want to speak to what you see before you.
I will change this: I want to see IMPBs with the ability to have commissioning authority. I will empower local health decisions and Māori health providers with more autonomy than they have had for some years.
The IMPB whakapapa has been 40 years in the making. Your foundations are built on collective experience, including the experience of the MDOs and MAPOs that have come before you. Collectively we know what has worked and what needs to be different to be lean, mean local commissioning machines. I want to see IMPBs powered up to support the health outcomes for your whānau and your communities. I don’t expect you do that that alone, while you are building your capability and capacity, I expect Health NZ to provide you with the support you need and act as a safety net and back stop across this range of functions.
As IMPBs, you will have a stronger voice in local decision making, powering up communities to lead and shape the health system to work for them - alongside the needs of the wider community.
You will have a role in planning and delivery of healthcare in your communities. Local input into health services, especially primary and community services, is good for everyone and a priority for this Government.
I want to see ways of working that identify and support local solutions to local health challenges. Obviously there needs to be more thought given to how that is done but we will be using data, measuring progress, and working with you as you bring the voices of whānau to the table, and others who know their communities best.
I have outlined my priorities for the health system, specifically that New Zealanders have timely access to quality health care. There will be 5 targets that I will describe shortly but I have already flagged immunisation as an important target. Specifically on immunisation, I am deeply concerned for how a measles outbreak will affect our babies.
I also want to see the health system increase its focus on addressing non-communicable diseases such as cancer, diabetes, respiratory disease, heart disease and poor mental health.
I want to see continuing reductions in smoking and alcohol consumption, poor nutrition, and a lack of exercise as well as adverse social and environmental factors that lead to poor health outcomes.
We already know that Māori are more likely to be impacted by these diseases and behaviours – and addressing these issues is where we can make a big difference.
Underpinning all of this will be the health targets I mentioned earlier so we can be sure that the health system is bringing urgency, accountability and delivering where it needs to.
This is a story of greater devolution of decision making to communities and hapū, as this is where I believe real change can be made.
As IMPBs you have an important role in making this vision a reality, you are the change agents.
Current IMPB role
Your current role has great potential to influence outcomes for whānau. IMPBs should be supported to work with whānau to measure how well the system is working now and for the future so that health care is delivered where and when it is needed.
You have all been provided with a tool to assess your readiness over the next month. Thank you for working alongside the Māori Health Authority and the Ministry of Health to take stock of where you are now and what is required to power up your IMPB.
Our readiness focus is on 6 areas – hauora foundations, whānau voice, establishing priorities, strategic commissioning, partnership with Crown agencies, and strategic monitoring.
I understand that you have already started conversations with officials to go through the details of that tool and gauge your readiness across those 6 areas.
This process will help us collectively identify what developmental support you will need to ensure you have the capability to give the most to your whānau, hapori, hapū, and iwi.
Please continue to work with officials as these discussions will also help me to have a clear sense of where we can start making changes now and in the future.
The path to get us here has been walked by many before us, and many of you for a long time. I acknowledge those who have gotten us to this point so far.
Commissioning
Commissioning is a spectrum that traverses from budget holding to decision making. I want IMPBs to be the local decision maker of funding that meets their local health needs. That said there are some pre-requisites for commissioning.
Outcomes based commissioning
I see commissioning being based on outcomes, not based on FTE. We should embrace this and the flexibility it gives you to achieve agreed outcomes.
Capacity
There are a range of different starting points and what level of capacity each IMPB is at, and wants to be at, and how much decision making and analysis they wish to have. This will include the capacity an IMPB has to commission, monitor, undertake Health Needs Analysis and reporting. The readiness assessment tool that you already have will help describe current capacity and identify any gaps.
Conflict of interest
There will be a range of conflicts to work through these could include the role of funders versus providers and roles of commissioners, decision makers and monitors. We will need to work through those decision makers and potential funders who are also providers.
I see IMPBs able to have roles in the monitoring of commissioned Māori health provision and I am not speaking about just Māori Health commissioning, I could envisage IMPBs role extending to assisting with the monitoring of the provision of health care services to Māori in the mainstream too, through collaboration with PHO’s and other community providers.
IMPBs should be able to provide a level of reporting for local insights into how the health system is providing in their communities, and in a format able to be uploaded for aggregated reported nationwide.
When I talk about IMPB involvement in commissioning, I am describing a range of activities, including:
- Determining the purpose for investment – understanding the need or opportunity, the outcomes wanted, what’s already known to work, and how ready providers and communities are for action. This begins with understanding what matters to service users and whānau – and IMPBs are uniquely positioned to represent these perspectives and shape them into priorities for investment, through the engagement you do. This is directly in line with your current legislative functions. Your naturally holistic hauora focus will help to shape and drive the system to design, plan and invest in more collaborative way that in time can reach across and into wider sectors.
- Designing and planning – designing innovative responses to improve outcomes, deciding priorities for investment, and creating a plan of action. This is an area that I envisage IMPBs playing a greater role over time, this is about aligning strategy with needs.
- Sourcing and investing – this stage is about finding the right providers to deliver the services or supports, and using contract requirements to ensure what is delivered works for whānau and is a good use of public funds. This is a significant operational undertaking, and not necessarily one that IMPBs need or want to take on, Health New Zealand will be the default back stop to assist with this.
- Delivering, monitoring and evaluating – this is about implementing services or supports, monitoring how well they are delivered, evaluating whether it generated the desired outcomes, and implementing improvements. This has both an operational/contract management focus, but there is also a broader evaluative role that IMPBs can play in assessing how well things are working for Māori, and how they can be improved or what needs to change – again, this is already part of your function.
Do not be daunted. I know that each IMPB will have its own aspirations and plan, and we would like to work with you to facilitate a process where you are resourced to test and develop ways of working, which would then provide good evidence to inform longer-term resourcing. I know there are models that have worked before that we can better support, like the COVID-19 Care in the Community model.
Planning and commissioning Māori health services is currently shared with the Māori Health Authority and Health New Zealand. Under new legislation, planning and commissioning functions currently within the Māori Health Authority will be consolidated within Health New Zealand.
The provisions requiring the health sector to engage with the boards and support them in their own engagement with Māori will remain, with the responsibility sitting with Health New Zealand.
Timing
Currently there are two sorts of Maori Health provider contracts. Most are legacy and a smaller number are budget 22 contracts.
To ensure continuity to the Hauora Māori provider network, I have needed to make a decision to roll over existing contracts for a 1-year period.
Both legacy and budget 22 contracts up for renewal this year will be extended for 1-year.
In the next financial year, I expect IMPBs to continue to prepare for readiness, toward the financial year 2025/26 when local decision making will be available, however, decisions for IMPB funded commissioning that starts on 1 July 2025 will need to be ready by January 2025, only 9 months from now.
There is much work to do between now and when those decisions start to be made.
In the meantime, I would like IMPBs to be getting ready to monitor and report against the rolled over contracts from 1 July this year.
I want to talk about local needs and health needs analysis.
Understanding local need will be crucial to the health system in the years moving forward, as we move toward health care closer to the home. Local needs will mostly be captured by broad objectives in targets and the GPS with specifics within these categories determined by you.
For example, cardiovascular disease will be a broad objective for me. Within that, an IMPBs local needs analysis may have a particular focus on rheumatic fever, another may have high blood pressure, and another IMPB may lift stroke management as its particular high need.
Working with Health New Zealand
It is natural for there to be uncertainty as the Crown’s responsibilities transfer from one agency to another, take comfort that the relationships mostly transfer with the people you have already been working with. I am expecting officials to ensure that this transfer happens with minimal disruption to kaimahi, contract holders and you as IMPBs and as I have stated many times, transfer in this new journey are to be done with dignity and respect for fellow health professionals.
This will be important for ensuring that the discussion we have today and over the next few months can be progressed, especially when thinking about the role you will have in strategic commissioning.
The key next step is to ascertain the best mechanisms to give effect to the role IMPBs have to combine whānau voice with data and insights, and reporting those through to inform improvements to service delivery.
While there is a longer-term plan to shift the direction of health to be closer to communities, I know that there is work that we can do now within the existing structures of the health system.
I want to talk now about further collaboration with other community providers.
I will be creating an overlay across community health providers that generally includes IMPBs, GPs, Pharmacy, Radiology, Allied Health, Housing, Employment, Social Services and others.
That overlay will be a social investment overlay where, with new money, providers will be asked to collaborate across the silos to bid proposals with new money, not BAU, towards priorities such as targets that I have identified. This is an exciting social investment layer with room for new unthought of innovation.
Working with govt agencies
I value the role you IMPBs have and see you supported to do more, closer to home and hapori. My expectation of government agencies is clear and will be documented in the GPS and letters of expectation. They will support you to engage with other sectors and improve the health system’s broader social investment approach.
Concluding remarks
To conclude, I am encouraged by the passion and dedication you all have to support Māori Health outcomes. I believe you, I believe in you and I will back you.
I too have been a health provider and a Māori health provider for 40 years now, and like many of you, I’ve got the scars to prove it.
This afternoon you are also meeting with representatives from Health New Zealand. My expectation is that the tautoko you have received from the Māori Health Authority continues with Health New Zealand. My expectations are that you will receive the support to realise your ambitions and continue to round out your capacity and capability building.
Fundamentally, I have changed Pae Ora to give IMPB’s and Māori more local decision making, and I’m up for this walk, and without fear but with great hope, I invite you to walk alongside me.
Kia ora mai tatou katoa