Health reforms paper anniversary: Thoughts from a nurse practitioner in the city

I pondered these questions while watching episode 3 from season 20 of Grand Designs.

This epic episode follows two grand designs over sevn and 10 years till completion. The usual predictable storyline unfolds, where the owners are seduced by a sexy, high-concept architectural design and then caught out as the months then years roll by, and the invoices inevitably stack up.

The big drama of a major build is told as the viewer winces and the owners fire the architect and then their main contractor; watertight, corrosion and consent issues stack up; and building stalls then halts due to finance, COVID and a marriage teetering on demise.

The two approaches and the final outcome are juxtaposed. When the camera pans out on the finished product, “Is all forgiven of the pain endured in the birthing of this building?” the presenter enquires of the owner of a jaw-dropping, contemporary art deco lighthouse built on the corroding edge of rugged cliff of the North Sea.

I think there may be some metaphorical comparisons for a viewer of the biggest health reforms ever undertaken in Aotearoa.

Similarly conceptual aspirations of Pae Ora are seductive to those who believe in obliterating inequity from our healthcare system and society as demolition commenced without consented drawing plans in place. The best example of this lies in primary care and in localities and iwi Māori partnership boards, as well as the lack of detailed design of the meso-structures that will replace PHOs and sustainably run the primary care sector.

The uncertainty is certainly undermining the build. The workers are unhappy due to ongoing pay disparities and burnout from workload, COVID and unprecedented weather events. The business owners are angry at the lack of engagement around sustainability and viability, whilst grappling with capacity and planned care is out the window again this winter with increasingly closed books in GP land – no change really from 1 July 2022.

Where things are perhaps working well is that we have cemented population-level thinking and this is evident in the approach of Te Aka Whai Ora to commissioning. There also seems to be a slight shift systematically in culture and the conversation with funders now being felt in community provider land. However, sustainability is still a concern.

Another success is that Te Whatu Ora and Te Aka Whai Ora collaborated on the Immunisation Taskforce report and the prioritisation of the 54 recommendations to achieve the 95 per cent target for childhood immunisations. The communication direct to whānau and community is engaging, leveraging on what we learned from COVID; by Māori and Pacific for Māori and Pacific being the slogan to brand what these providers were able to do during the different phases of the pandemic response – elimination, vaccination and management, when “big G” gassed them up and mostly got out the way.

This was also true of primary care. We saw agility, collaboration, resilience and innovation. We saw real-time data and had a collective lived experience on how inequity can be best addressed using data tactically.

Yet, structurally we are still grappling with the construction of our “steel”. Do we have enough metal to continue to put equity at the front of a whanau-centred system? We have sociologist Peter Davis stating ethnicity is a subjective measure and advising we should look to fix all that’s wrong with the world rather than implementing real-time tactics – such as a prioritisation matrix (which he opposed in 2020) that will actually turn the dial on inequity.

We also have surgeons, arguably among the most privileged cohorts in the system and society, questioning aloud, “What is a Māori anyway?” on the 6pm television news. Addressing equity is a live and sadly divisive issue that is being driven by an election year.

Regardless of which political party leads us through this next phase, we all will wake to the same issues and reality that unaddressed inequity produces. The poor health outcomes, the worsening social concerns, increasing antisocial behaviour and the growing appeal to our young people of gang membership and ram raiding.

My hope for our grand design is a high-quality build and sustainable home that we can still afford to live in, that the marriage remains in partnership and provides the children and future generations a place where they can thrive. As keen as we all are to see change, upon reflecting on this past year and the runs on the board, I think that time may be the acceptable price to pay to ensure our design and build is fit for place.

Communication: I would give them a 5 for primary care and 7 for community care (Māori health provider).

Tamah Clapham is a NP and owner at The Doctors Middlemore and clinical director of Te Puna Manawa HealthWEST

Note: A shorter version of this response is published in the 5 July issue of New Zealand Doctor Rata Aotearoa