A Change is Gonna Come - talking with boss of new Māori Health Authority

But it isn’t about getting by with a little, it’s doing a lot with a little. That’s the thing

For someone charged with satisfying the greatest of expectations, Riana Manuel laughs a lot when she speaks.

In late December, this self-described “little old girl from Manaia” in the Coromandel was named as interim chief executive of the Māori Health Authority, an entity seen as a once-in-a-lifetime opportunity for Māori to take charge of reversing decades of appalling health statistics.

When it is suggested many may have responded “who?”, Ms Manuel laughs and says being new to the national stage may have been a point in her favour.

They could have picked anyone, she says. “Sure, some will have said: ‘You know, will she be able to cope with it?’

“But I believe they were looking for something different and I think that’s the thing I have to rely on, my point of difference that I can bring to the conversation that perhaps hasn’t been there before.”

When the role came up, she says, she was reminded that reforms don’t happen often, “and they are opportunities to change things we don’t enjoy about a system”.

“I’ve been working in a kaupapa provider and every day, on the ground, we felt the pressure of a system that’s not addressing our people’s needs.”

Ms Manuel (Ngāti Pukenga, Ngāti Maru, Ngāti Kahungunu) adds: “I’m a ‘money where your mouth is’ kind of girl, so I figured I’d done enough in my career to warrant putting my hat in the ring. I want to create change and I’m a big collaborator, so I figured, we’ve done pretty good here, let’s give it a go at national level.”

The news was broken to her by board co-chairs Sharon Shea (Ngāti Ranginui, Ngāti Haua, Ngāti Hine, Ngāti Hako) and Tipa Mahuta (Ngāti Mahuta, Ngāti Manu, Waikato, Ngāpuhi), and there were tears.

“I cried a little bit, but they were tears of joy, not tears of ‘oh my God’. But yeah, it was a bit emotional because, for these two fantastic women to ring you up and tell you you’ve got the job you dreamed of for most of your health career, it’s a big deal. And I was so honoured to be given this opportunity, and I don’t say that tongue in cheek, it’s not a cliché thing, I am simply honoured and humbled.”

Although her name is new to some, Ms Manuel hasn’t dropped from the sky. She has been chief executive of both Te Korowai Hauora o Hauraki since 2015 and Hauraki PHO since last April. She is also owner of the Phoenix House Rest Home and Hospital her parents built in Coromandel, is a Treaty of Waitangi claimant in the health-related Wai 2575 claim and, as a registered nurse, has done plenty of time in vaccination centres during the pandemic response.

In fact, she spent her first day out of her old jobs back in full PPE and jabbing arms: “I did ask if I would be getting locum rates and got told I would be getting lunch. I’m no longer on payroll, ha.”

As for motivation, she need look no further than her seven children and 12 grandchildren (with more, she hopes, to come), and says she is fuelled by the same drive her father had to set his children up for good lives. “That’s all it takes,” she says. “If you can short-circuit one generation, get things back on track so they can make better choices, then they can take that forward as well. That’s [the Māori Health Authority’s] challenge, to short-circuit things, but we need the resources and systems in place.”

Speaking to New Zealand Doctor Rata Aotearoa via Zoom about a week before taking up her new role, Ms Manuel says finally having just the one job to focus on will also make a nice change.

As that job will no longer be interim from July, she will be moving from Thames to south Auckland, where both the authority and Health New Zealand will be based. While not her decision, it’s a location she prefers to Wellington.

“There’s no better example of where equity or reducing the inequities that exist for our people should start, so I think it sends all the right messages from that point of view. It also takes our work away from being that ivory tower stuff, because that’s often what we’re accused of, or what we accuse people of in that government sector.”

At the same time, she knows she is tethered to those towers and will be reporting to ministers – no pressure, “but we’ll have to prove a point fairly quickly, and at the same time, we need to present a narrative of what the investment in our future will look like”.

Officially, she took up the post on 14 February, Valentine’s Day, which fits the times as St Valentine is, among other things, the patron saint of plague.

Ms Manuel had already made her several staff appointments by then – sorry, no names yet – and was holding daily 7am virtual meetings with Health NZ chief executive Fepulea’i Margie Apa as they both got up to speed.

These first steps were vital, she says, as she likes to be “very particular” about her team. It will be small – “I find small teams get more work done” – and not necessarily located in the same place.

“My expectation is that we will go for the right people and, when you get the right people, they often want to live in the places they belong to. I support that, it actually makes you more accountable, because no one knows how to tune you up like your own. We’ll use technology to join us all together.”

Work continues on a new name for the authority with workshops and discussions producing options that have been forwarded to kaumatua for further input.

Otherwise, there are a few incidental matters – such as how much funding the authority will be given, passing the legislation that will underpin it, and working out how and where it will operate around the country.

Yes, these are big holes that make it difficult to put plans into action for the moment. “But I work with a high-trust model,” says Ms Manuel, “so I have trust that the Government is going to come good on its intentions and we will see that legislation passed.”

She is buoyed by the calibre of the authority’s board. “When you have a really good board, that’s half the battle won,” she says.

“With this board, we are gifted with some amazing people, who have the same kind of zero tolerance for any kind of mucking around, and they are very clear around what their objectives are.

“They are community people, and they are all driving towards the same aspiration, oranga for our people.

“We talk at our meetings about being good tupuna, because that is where you want to drive towards: ‘What can I do right now that’s going to lay down that pathway for future generations?’ You know, leave nothing but good footsteps, or at least some guidance as to where to go next.”

How those footsteps are to be laid down nationally remains murky, but Ms Manuel intends to make use of the innovation and collaboration that has been central to Māori providers’ pandemic response.

“I have always said COVID is an opportunity because, until then, no one had seen the true hallmark of what we were doing in our communities – and we’ve all been at it for about 30-plus years now.

“So, it’s been fantastic in that it has shone a light on spaces where we have said ‘hang about, there might be a different way to do this’, which is about working together, like our relationship with the DHBs, and we’ve had to work hard to make sure we all worked collectively: public health units and the ministry, all those layers. Yes, it took some time, but those layers finally came together, the funding came down quickly, and decisions and policy were implemented really, really fast. We were given the tools we needed on the ground and that’s it, make a decision, get it done.”

She points to a cooperative project in which Te Korowai set up next door to the Thames Hospital emergency department and triaged category 4 and 5 patients who had been facing wait times of up to six hours.

Where appropriate, they were redirected to primary care.

A four-week trial saved about $300,000, and the ongoing savings are now funding transition beds between secondary mental health services and the community, and new roles the provider previously didn’t have capacity for. And it was all achieved on the cheap.

“But it isn’t about getting by with a little,” says Ms Manuel, “it’s doing a lot with a little. That’s the thing.”

The most important connections remain the oldest – whānau, hapū, iwi, Māori – and Ms Manuel is looking forward to fostering direct community engagement with the authority via the revamped iwi partnership boards.

It will be essential to ensure everyone ultimately feels part of the loop – and that won’t be easy. “There will always be some unhappy people in those spaces, as we all know, and we might even get it wrong from time to time, but we can’t wait another 30 years to get it right and reform everything.

“Delta has taught us some really harsh lessons with vulnerable whānau. It’s hard. You can’t track it, you can’t trace it, there’s no locations of interest because nobody is talking. You’ve got intergenerational families, 24 people living in a household with three rooms and one bathroom.

“Prior to COVID, we talked about what highly vulnerable subsets look like, but post-COVID you can actually touch and feel it, and our response has to be driven by whānau.

“Then, if you think about iwi, they are central to this conversation, they have to give direction. They are making decisions and drawing up strategies that go far further than anything I see in the public service sector.”

Iwi, she says, are not concerned about the next three, five or 10 years, but about the next 50 to 500 years, “and that’s kind of where you want to land”. Being a good tūpuna is part of their DNA; in this, the iwi partnership boards will be essential.

The next step, says Ms Manuel, is to establish systems around research, innovation and data so the authority can quickly see what is and isn’t working.

“Then we can hold each other to account by sharing all that information and saying, ‘actually, I can see you haven’t hit the outcome of this many whānau having completed their milestones. What do you reckon? What’s the rub and do you need support and help?’”

It may come as a rude surprise to a few other government ministries, such as housing and education, that she intends to begin holding them to account too.

So, where does she get the gumption required to be the first boss of a potentially game-changing entity?

“I was the first child of my family and that’s been my line – first to get married, first to this, first to that. I’m used to that, and I feel reasonably comfortable.

“All I can do is be as authentic as I can be and work hard, but I’m not an island so I expect everyone else to have my back when we get this thing going.

“The good thing, though, is that I’m still a registered nurse and there’s a massive shortage of registered nurses so, whatever happens, I feel like I’ll still be able to get a job.”

There’s that laugh again.