Same destination, different pathway: Locality life - small beginnings and broad church approach

Groups setting up the Porirua and Ōtara-Papatoetoe localities want to transform community health in the broadest sense. They are just following very different paths.

When the nine prototypes were announced in July, the south Auckland team was already well down the track on collectivising.

Six Pacific practices, calling themselves the Pacific Consortium, had begun formally collaborating during the COVID-19 response in an effort to maximise their small workforce’s effectiveness and spread the workload.

When vaccination rates needed a boost, they went street by street to vaccinate opportunistically. Practices were also engaging more deeply with their communities, with direct and ongoing contact with churches, sports clubs and NGOs.

Vaccination events became as much about community identity as they were about being protected from infection, and those social connections solidified as time went on.

In contrast, the Porirua locality – led by Te Rūnanga a Toa Rangatira, the mandated iwi authority for Ngāti Toa Rangatira – is being built from scratch.

It’s all about relationship building, says pou ratonga Jennie Smeaton (Ngāti Toa), and connecting the key locality stakeholders: mana whenua, Ora Toa Health Services, Tū Ora Compass Health, local practices and community representatives.

“Once an agreement [between the partners] is locked in, we can put a formal approval process in place to advance other programmes of work,” Ms Smeaton says. “But I think it’s hard, from the outside, to appreciate the amount of work going on. We are setting up the foundations so people can participate in a safe way, and there is a whole bunch of work involved in standing up a locality that we need to complete before putting governance in place and having people operationalise programmes.”

Once done, a governance group of six people will be formed along with several subcommittees tasked with dealing with various health kaupapa. Ms Smeaton does not expect this process to be completed before April 2023.

“I know there is a rush to get a plan, but what we have been saying is that we need to slow things down, extend the frame to allow us to do true consultation.

“We are almost needing to create an environment where this process is a journey, so there is some storytelling needing to be done around this to bring people in, which is taking time. We have to build trust.”

Workforce issues “across all sectors” that were a constant challenge through the COVID-19 response must be addressed if the locality is to be effective, she says.

It isn’t just doctors and nurses: “During [the COVID peak], we didn’t have enough communications people to get the right messaging to our Māori and Pacific communities. If you want to make a change in hauora, you have to be able to communicate effectively with everybody, and that’s a skill in itself.”

There is also no clarity around how funding will work: “That’s another layer of complexity and a conversation that needs to be had, and it is not necessarily one we have had.”

But, says Ms Smeaton, if done properly, localities could reshape lives.

“From a Ngāti Toa point of view, we have to be hopeful of the process, especially in the area we operate in. It is high deprivation, so anything that can contribute to positive impacts for whānau and shifts the dial to better health and wellbeing outcomes we are supportive of.

“But now that we’re started, we need to be supported to maintain the momentum and trust we have gained and that is not necessarily only a health responsibility, other agencies need to have a bigger stake. [Ministry of Social Development], housing, the NGOs and social service organisations, they all have to contribute to achieve the outcomes we need.

“We want to see people living longer, with better education, better housing and, as a Māori provider, that is what we have been working towards ever since we were established. We’ve worked across all of the domains, and we know they are dependent on each other, but are not necessarily supported in a way that allows them to work collectively or collaboratively.

“It’s about taking health and widening it to wellbeing, and to support that we need contributions at central government level.”

While she has hope, Ms Smeaton knows she does not have much time. “Our system is not set up to create time, and we are caught in the election cycle. But we have to look beyond that, and the Crown needs to put in place an underlying policy structure to allow us to work forward. It is so important that we continue to be supported even if there is a change of government.”

If done properly, localities could reshape lives.

While Porirua is looking at big change from small beginnings, the Ōtara-Papatoetoe locality has taken a broad church approach.

Led by mana whenua, Ngāti Tamaoho and Ngāi Tai ki Tāmaki, and Ōtara provider South Seas Healthcare, the locality boasts more than 20 member organisations.

South Seas chief executive Silao Vaisola-Sefo says the most important message they have heard from their community is that physical health is not the biggest priority.

“Health [for the Pacific community] does not just mean physical health, it means being able to go to work for three days without needing a day off, accessing services that feel familiar, your kids are going to school, and being able to contribute to your local schools and churches; it’s about wellbeing, for yourself, your family, and your community.”

Here, the concept of locality is less about healthcare delivery and more about finding new connections with the community. “It is not just about fixing what is wrong, it is also about reinforcing the social cohesion of communities that have been really struggling, and the most encouraging part we have seen is how ready those communities are for it,” Mr Vaisola-Sefo says.

The locality partners first met on 6 May. They agreed to continue meeting fortnightly and established an informal “spine group” to catalogue how services with the locality were being provided.

By September, Mr Vaisola-Sefo was telling New Zealand Doctor Rata Aotearoa, “Give us the funding, we’re ready to go.”

The collective had an interim governance group with co-chairs from mana whenua and South Seas and all members had signed a draft charter.

A flexible approach is applied to the Ōtara-Papatoetoe boundary – two practices from outside the area, Southpoint Family Doctors and Greenstone Family Clinic, are formal members.

“Our model is not defined by geography,” says Mr Vaisola-Sefo, “it’s a relational model. We can’t be confined by boundaries.”

While it’s not known how funding will eventually be provided, he says South Seas GPs are trialling a new “one-stop shop under one roof” template where patients raising issues related to social determinants will be referred to on-site specialists.

“It’s only part of the solution,” he says, “but [the GP consult of] 15 minutes should focus on what GPs should be doing, leave the rest to the integrated team.”

And the integrated team will be accessible to people enrolled outside the locality: “[Outside] practices will keep their capitation, what we are interested in is the stuff not currently being delivered by primary care.”

This will partly resolve the problem that the locality still has a Tāmaki Health-sized hole in it, which is significant as that provider serves about 50 per cent of the area’s enrolled 117,000-strong population.

The localities concept

• Iwi and communities will be involved in deciding on the health priorities for their community.
• The care and support that is delivered will be joined up across different health and wellbeing providers.
• Those providers will be connected to community organisations that have a role in supporting people in areas such as housing, employment and finances.