HC22096

GUEST EDITORIAL https://doi.org/10.1071/HC22096

New dawn or false dawn? – what are the challenges in implementing Localities?

Tim TenbenselA,*

PhD

For full list of author affiliations and declarations see end of paper *Correspondence to: Tim Tenbensel School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand Email: t.tenbensel@auckland.ac.nz

When it comes to primary and community-based health care, the crucial component of the Pae Ora (Healthy Futures) reforms is the development of Localities. According to the government’s own health reforms website, the core principle of Localities is that ‘people and organisations with influence over community health and wellbeing will collaborate on what outcomes they want to see for their community.’1 To do this, Locality Plans will be developed to shape services in the Locality, and ‘well resourced, coordinated and integrated networks of providers will support the delivery of Locality Plans’. There are expected to be around 70 Localities by 2024, with the first nine ‘prototypes’ announced in April 2022.1 As well as being strongly shaped by Te Tiriti o Waitangi considerations, the Pae Ora reforms have been strongly influenced by recent trends in public policy and management that emphasise collaboration between organisations and between policy sectors (eg health and social services), and the importance of community ‘co-design’ of services in order to tackle wicked policy problems.2 The Localities concept has also been strongly shaped by international health services and policy research into integrated care and models for addressing the social determinants of health through health services.3,4 The aspirations that underpin the vision for Localities are laudable; however, some hardheaded realism is required to understand the scale of the challenge in manifesting these. In this Editorial, I set out four key challenges that need to be faced in the implementation of Localities.

(1) Funding flows and structures will need to support Locality collaboration

Received: 16 August 2022 Accepted: 17 August 2022 Published: 6 September 2022 Cite this: Tenbensel T Journal of Primary Health Care 2022; 14(3): 197–199. doi:10.1071/HC22096 © 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners.

This is an open access article distributed under the Creative Commons AttributionNonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

OPEN ACCESS

The funding arrangements under the previous system privileged traditional general practice over those providing a broader range of primary health services in the commu­ nity.5 The consequences of this funding system for Māori were outlined in vivid detail by the WAI 2575 claimants.5 More flexible and pooled funding across a wider range of service providers is a precondition for Localities to make progress. Locality funding pools need to be large enough to incentivise collaboration between health (and other sector) providers. This could occur in two ways. Either significantly more funding is allocated to primary and community services by Te Whatu Ora, or primary care funding that has been channelled through Primary Health Organisations (PHOs) to their member general practices is made accessible to a broader range of service providers. Decisions about how to fund primary and community services will be an early test of The Ministry of Health (MoH) and Te Whatu Ora’s commitment to making Localities work. These deci­ sions will not be made any easier at a time in which organised general practice is very unhappy about the recent rollover of the PHO Services Agreement Amendment Protocol, and years of delay in reviewing the capitation formula.6,7

(2) Partnership and collaboration in Localities will require significant resourcing, training and support Collaboration is not for the faint-hearted. International research in health services shows that most attempted collaborations in health care are patchy or fail to gain any

T. Tenbensel

traction at all.8 A recent systematic review of successful collaboration has emphasised the importance of achieving ‘small wins’ early on that help virtuous circles of trust develop between collaborative partners in order to support more extensive and impactful collaboration.9 Recent New Zealand (NZ) research has shown that even the most collaborative of health districts rarely include organisations and communities beyond District Health Boards (DHBs) and PHOs.10,11 Partnership between tangata whenua and health sector organisations is a cornerstone of Pae Ora generally, and Localities specifically, through iwi-Māori partnership boards. But, in addition, Locality partners will also need to learn how to involve a broad range of communities (Pasifika, rural, people with disabilities) in co-design of services and collaborate with social service organisations and local government. This will generate multiple, and often conflicting, imperatives for Localities.

Collaboration, done properly, is highly resource- and timeintensive,12 and requires skillsets of managers, clinicians and community representatives, which are unevenly distributed across the country.11 It is not yet clear what support and training will be available to participants in Localities to sup­ port the development of these skills where they do not cur­ rently exist.

(3) Public officials will need to think and act differently Most Te Whatu Ora managers will have worked previously in the MoH or DHBs. Health officials at national and local levels will need to unlearn many practices and attitudes. The most pervasive impact of NZ’s neoliberal revolution of the 1990s has been how MOH and DHB officials have related to nongovernment organisation (NGO) providers in primary and community care. New Public Management inculcated ‘habits of mistrust’ between government and non-government pro­ viders of health services. The prevalence of short-term con­ tracts with non-government providers (reducing real levels of funding over time) and the use of financial and reputational sticks and carrots across the whole range of service providers fostered a ‘them and us’ relationship between funders and providers in many, but not all, parts of the country.11 Although the reforms aspire to improved collaboration and improved accountability, on a day-to-day basis, these impera­ tives are often in direct conflict with each other. Collaboration takes time to bear fruit, but timeframes for accountability are notoriously short-term in the routines of the state sector.

(4) Primary care providers will need to think and act differently Relationships between primary and community providers are strongly shaped by the relative power of medicine and 198

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general practice, which is manifested through funding flows and control over scopes of practice.13 Taken at face value, the introduction of Localities could challenge general practitioner roles, business models and relationships with tangata whenua, local communities, other professionals and other service providers. Collaboration in primary and community care is often counterproductive when existing power rela­ tionships are left intact.8 The implementation failure of the parts of the 2001 Primary Health Care Strategy that were aimed at broadening and widening the governance and delivery of primary health care can be attributed to a wide­ spread (although not universal) unwillingness of general practice to share power.14 Although Localities are a national initiative, implementation is local, and we can expect to see multiple new dawns and false dawns across the country. What happens in the first 12–18 months is crucial. No-one involved should underesti­ mate the scale of the challenge.

References 1 New Zealand Government. Localities. 2022. Available at https:// www.futureofhealth.govt.nz/about-the-reforms/how-health-systemchanging/localities/ [Accessed 9 August 2022] 2 Head BW. Coping with wicked problems in policy design. In: Peters BG, Fontaine G, editors. Research Handbook of Policy Design.

Edward Elgar Publishing; 2022. pp. 155–575.

3 Gottlieb K. The Nuka System of Care: improving health through ownership and relationships. Int J Circumpolar Health 2013; 72(1): 21118. doi:10.3402/ijch.v72i0.21118 4 Hildebrandt H, Schulte T, Stunder B. Triple aim in Kinzigtal, Germany: improving population health, integrating health care and reducing costs of care – lessons for the UK? J Integr Care 2012; 20: 205–222. doi:10.1108/14769011211255249 5 Waitangi Tribunal. Hauora: report on stage one of the health services and outcomes kaupapa inquiry. Legislation Direct; 2019.

6 Cassie F, Johnston M. ‘Insulting’ sum threatens services. New Zealand Doctor, 2022. Available at https://www.nzdoctor.co.nz/ article/insulting‐sum‐threatens‐services‐0 7 Johnston M. Beyond wishing: No fees? Targeted fees? Get primary care funding sorted! New Zealand Doctor, 2020. Available at https://www.nzdoctor.co.nz/article/news/spotlight/beyond-wishingno-fees-targeted-fees-get-primary-care-funding-sorted 8 Ferlie E, Fitzgerald L, McGivern G, et al. Making wicked problems governable?: the case of managed networks in health care. Oxford, United Kingdom: Oxford University Press; 2013.

9 Aunger JA, Millar R, Greenhalgh J, et al. Why do some interorganisational collaborations in healthcare work when others do not? A realist review. Syst Rev 2021; 10(1): 82. doi:10.1186/ s13643-021-01630-8 10 Gauld R. The theory and practice of integrative health care govern­ ance: The case of New Zealand’s alliances. J Integr Care 2017; 25(1): 61–72. doi:10.1108/JICA-10-2016-0035 11 Tenbensel T, Silwal PR, Walton L, et al. New Zealand’s integrationbased policy for driving local health system improvement – which conditions underpin more successful implementation? Int J Integr Care 2021; 21(2): 8. doi:10.5334/ijic.5602 12 Keast R, Mandell M. The collaborative push: moving beyond rheto­ ric and gaining evidence. J Manage Governance 2014; 18(1): 9–28. doi:10.1007/s10997-012-9234-5 13 Tenbensel T, Miller F, Breton M, et al. How do policy and institu­ tional settings shape opportunities for community-based primary health care? A comparison of Ontario, Québec and New Zealand. Int J Integr Care 2017; 17(2): 13. doi:10.5334/ijic.2514 14 Neuwelt P. Community participation in primary care: what does it mean ‘in practice’? J Prim Health Care 2012; 4(1): 30–38. doi:10.1071/HC12030

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Conflicts of interest.

Journal of Primary Health Care

The author is a member of the Editorial Board of the Journal of Primary Health Care.

Author affiliation A School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

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