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Our CEO, Dr Chris Tooley was invited to talk about our COVID-19 response at the Waiariki Whānau Ora Summit.

Watch the video or read his transcript below:

Firstly, let me shout out to all the other Whānau Ora, Māori, Iwi providers out there, that just dropped everything and hit the frontline during the lockdown. Our lockdown wouldn’t have had the urgency or responsiveness across the country if it wasn’t for Māori providers. We were always the first onsite, always 24 hours ahead of the rest.

Second, let me acknowledge Merepeka and the Commissioning Agency for the support you’ve provided. When you’re isolated, responding to the situation on the ground, surrounded by all this mainstream noise, sometimes one can doubt oneself, but it was always comforting to jump on one of our regular zui’s and just hear everyone saying—lets go to war! As entertaining as it was, it was also quite reassuring.

Over the next few minutes, I’m going to try and map our COVID-19 environment and describe some of the modelling and scenarios we are working on, what actually happened in practice—and ongoing issues around equity—so hopefully it can contribute to how you may think about the next few months or so.  

COVID-19 Testing: The Early Days

First, let’s start with testing and surveillance. Our first lesson begins right at beginning—and that is, no-one really knew what to do or how to do it; everyone was writing the play book as we were doing it.

In a matter of hours, after the Prime Minister announced the Alert Levels system and placed the country straight into Level 2, we were asked to set up an off-site testing station within 24 hours. There was no manual. There is no modelling. Ministry officials would be on the other end of the phone screaming just get it done! Everything was done from scratch.

And you would be surprised how many times this scenario played out as we moved up and down the alert levels. In fact, when the country moved to Level 4 a few days later, various COVID-19 providers had to stand up a Community Based Assessment Center or CBAC that hadn’t even been heard of before either.

It was a high-pressured environment, and it didn’t matter how many cases you had, it was always a race against the clock. It was also a high-risk environment as well. Even though we deployed multiple teams 24/7 and mobilized resources from day one—we never saw a funding agreement or signed a contract until we were well out of lockdown.

Operational Challenges

It was also touch-and-go sometimes, there were a number of operational tipping points that almost made the whole thing fall over.

• First, was PPE. There was enough PPE in the country to cover our lockdown; the problem was that the supply-chain had been regionally structured, instead of nationally, and access became difficult in provincial and rural areas. Our savior ended up being the private sector and being able to order direct from China to cover the shortfall. If that hadn’t happened community transmission would have been a different story.

• Second, is what became known as the testing lag. The incubation time for the virus was anywhere from 2-12 days before symptoms appeared—and there’s nothing you can do about this. But once tested, the turnaround time for lab results in the beginning only took a couple of days. By the end of week three of the lockdown, this testing lag had been pushed out to a week to find out results—just because of the high demand placed on Pathlab. However, when you consider incubation time plus turn-around time for results—in some cases, the virus had a two-week head start on the contact-tracing teams which is fatal in a pandemic.

• The third tipping point could have been our kaumatua. At the end of lockdown research was released out of Italy showing kaumatua that had COVID-19 were actually presenting as asymptomatic. Given the clinical complexities kaumatua experience in their twilight years, usual COVID-19 symptoms were being masked by other indirect clinical conditions. The only way to test kaumatua, without any doubt, is through an oxygen-blood level test. Needless to say, knowledge gained through the tragedy of others is awfully humbling.

However, at the same time, perhaps for some of us—it was one of the best environments we’ve ever worked in.

Breaking Down Barriers

It’s unfortunate it took a pandemic to break-down all those institutional and bureaucratic barriers we’ve been fighting against for so long (and how quickly they have returned after we moved out of Level 2).

It allowed customized and responsive models to be designed and delivered on the ground in a matter of days. And when we had a flashpoint—especially around equity issues—we would huddle and just having it out with each other until a compromised was reached.  If only this could be replicated in our normal BAU.  

When you think about ‘form’ and ‘function’ of the health system, the latest Health & Disability Sector Review gives us lots to work with in relation to form, especially in the way of a new Maori Health Authority. But function remains. Our COVID experience needs to shape this discussion over next term of government.

Issues around Equity

• The first was case definitions for what we could or couldn’t test. Every morning at clinical briefings, the case definitions for the day would be confirmed. These would define what travel or movement history or what symptomatic conditions needed to be present, to warrant test.

Of course, when you apply a Whānau Ora or equity approach to this, your scope of assessment includes more variables and often our doctors and nurses would have a 9 out of 10 testing ratio compared to a 6 out of 10 mainstream ratio. Testing case definitions remains ongoing battleground Māori testing providers.  

• Another flashpoint was our mobile units. Within a couple of weeks of lockdown, we noticed our whānau simply were not coming in to get tested. The model of siloed fixed healthcare sites has always shown to fail our communities, and these were no different.

At the heart of this argument was traditional infection control procedures developed by the Ministry and DHBs that didn’t recognize that this could also be delivered via an integrated or mobile platform. Initially for them, infection control was fixed and linear, creating a very unfriendly sterile environment.

Our mobile units travelled around the region, from Matata, to Murupara to Waikaremoana and everywhere else in between. Within four-hour windows, in the most remote isolated townships, our teams would test more whānau than would go through the Tauranga CBAC in a whole day.

The numbers simply showed an integrated and mobile platform can deliver a pandemic response.

Surveillance

Now that we are in a Level 1 environment, we’ve moved to a surveillance model. This means we can randomly test asymptomatic people and require goodwill to make it work. We’ve been testing councils, kohanga’s, marae, papermills and spent quite a bit of time in pack-houses during the kiwifruit season.  

But let me describe the wider scenario. Imagine there is a cluster outbreak in either Rotorua, Tauranga or Whakatāne. How do the other two locations stop from being captured in a regional lockdown if one of the others has a cluster?

The answer is surveillance. The more surveillance data an area has that shows a critical mass of asymptomatic people in their population; the better the chance of not being captured in that lockdown. In this sense, surveillance testing can act as an insurance policy.

And if anyone these areas do not have mobile surveillance units operating, it is now not only an equity issue but should be seen as a breach of a clinical duty of care to its population.

And let me be clear, cluster modelling is no-longer considering hot-spotting, where we simply focus on townships or the immediate areas affected. The outbreak in Melbourne clearly showed us that hot-spotting doesn’t work; the virus moves too quickly for this approach. Regional containment is the minimum threshold that we are now organizing ourselves around.

And the clock is ticking. Our next domestic flashpoint is the upcoming Christmas/New Year’s break, with the mass gatherings and summer travel movements—that are different to people’s normal business movements—the risk will be obviously higher during this period.

Whānau Ora

Now let’s turn to Whānau Ora. If COVID-19 required us to create and lockdown in our bubbles, then Whānau Ora allowed communities to sustain their bubbles.

And it has been the Maori providers ability to help whānau sustain their bubbles that has been the real achievement of the country’s success so far.

To the obvious things providers did like kai packs, firewood, free prescriptions, helping with travel, and yes all those damn hygiene boxes—to the less obvious support like triaging addiction relapses over the phone or working with police with domestic call-outs as a result of COVID-19 pressures.

So what now?

I want to come to something that is at the heart of Whānau Ora. Remember the soundbite when Whānau Ora was first launched—instead of having seven cars up the driveway, Whānau Ora replaces them with one car so to speak?

Well, this hasn’t happened. We still have seven cars up the driveway. The only difference now is that all seven cars are coordinated by Whānau Ora.

Providers have been given the means to create plans but haven’t been given the means to implement them.

And if providers can provide an integrated approach, its only because of luck that they have additional contracts from other agencies or are able to partner with those that have them, which is not always possible—especially in rural environments.

And it’s not for a lack of trying. The most recent attempts come in the form of procurement policies—from both Labour and Maori Parties. These are sound policies to redirect government funding into models like Whānau Ora and what is required to go version 2.0.

In fact, this is how Whānau Ora started in the first place. It was itself a procurement policy, created against the backdrop of the Global Financial Crisis in 2009, and the original figure of 1.2 billion was calculated against 12.5% population index at the time. Of course, this didn’t take hold, and Whānau Ora is, what it is today.  

But the point I want to make is that this kind of policy is a medium to long term one. Procurement is one of the foundations of Treasury, a central agency no less, that is governed by the Public Finance Act. Even if there was political consensus, it will take a while to unbundle everything required to make this work and eventually flow to providers on the ground.

Putting these kinds of pou in the ground are important strategies, especially the Commissioning Agencies leadership in taking over the roles and responsibility of Oranga Tamariki—is another example, but the question remains what about the short-term?

Commissioning Agency may want to consider inter-agency appropriations in the immediate term. Looking across to MBIE for example, employment workstreams and programmes like He Poutama Rangatahi, Te Ara Mahi and Mana in Mahi have a similar blue-print.  

These programmes were mobilized during the recent term of government, but the irony is that these programmes are essentially intensive Whānau Ora programmes. Albeit with an employment focus, they allow providers the means to both create and implement Whānau Ora plans.

In other words, and in financial terms, under Whānau Ora, we can utilize the direct impact funding, about $1,000 per whānau, and have to rely on other contracts to deliver the intervention; whereas programmes like Te Ara Mahi allow interventions to be designed and calculated at around $10,000 per individual.

Imagine, what you could do with $10,000 per individual under Whānau Ora?

And this funding formula, is not unique to MBIE. It also exists in TEC and MSD—and all but confirms a systematic and institutional bias towards Māori entities—one that has existed across many governments.

Nevertheless, identifying and transferring a schedule of appropriations across to the Whānau Ora Commissioning Agency, ones that have already matured, could be a short-term strategy and one that offers a 1 July timeline next year.

In a COVID-19 environment, it also offers the ability to bridge the protection and recovery phases of the alert level system.

One final point on Whānau Ora: from a strategic standpoint, as a collective, we also need to understand what equity means for us. Equity is everywhere, everyone is talking about it, but there is no united front at the moment. Iwi and Maori providers are having to go to each agency separately making their respective cases to address equity.

And if we don’t act soon, we might miss our window. For the last year or so the Ministry of Health has been negotiating with the Homebase and ACC Sector on equity provisions. The current equity marker’s that have been agreed to so far are cultural, clinical, deprivation and rurality. What weightings or premiums are going to be applied to each of these markers is yet to be seen, but whatever is finally agreed, will ultimately be rolled out across the entire Health sector and possibly beyond.  

The Maori-Crown Office refocused by Minister Davis in 2018 offers one point of leverage. The Office covers a number of kaupapa, but what is important for us is that it has all-of-government approach and it has some State Service Commissioner central agency powers—it can act as internal actor so to speak to address issues such as equity across all agencies.

The Commissioning Agency may want to establish a Whānau Ora Equity Group to partner with the Maori-Crown Office to bring about an all-of-government equity framework.

And let’s clear, equity is not a ceiling for self-determination; it’s not something that we’re aiming for, it’s the ground-floor, it’s a starting point, and we need to keep reminding government and agencies of this.

Employment and the BOP Regional Skills Leadership Group

So, now let’s look at employment—and I’m just going to confine my comments as a member of the Bay of Plenty Regional Skills Leadership Group here, established in August this year—and let me acknowledge the Te Arawa members of the group Karen Vercoe and Olivia Dhanjee.

There are 15 groups across the country and the Bay of Plenty group covers Tauranga, Whakatāne, Rotorua, Taupō and surrounding areas.

This group has two tasks—to come up with an immediate post-lockdown employment recovery plan for their region; and then a long-term employment plan pushing out to the next 5 to 10 years.

I am not sure what the long-term plan will look like yet given that in reality it is almost impossible to forecast beyond 3 months at the moment—and given Treasury has recently forecasted that our borders will not open properly until mid-2022 at the earliest, our long-term plan may actually just look like a regional domestic one in the mid-term.

But we’ve certainly made a start on the immediate recovery plan.

To begin with, our plan will be based on a Level 2 BAU. It is likely with community transmission already here; Level 2 will become the normal working environment for the foreseeable future.

Our immediate plan is not to duplicate but unify all the activity across the region. This can only be achieved by mapping our employment pipeline—and the complete journey our whānau take from unemployment to gaining a sustainable job.

Our mapping includes four parts:

First, is ground zero, we have started working with MSD to begin mapping unemployment across the region; who is unemployed, where are they, who are they—are they NEETs, redundant or transitional and so forth.

The second part involves working with MBIE and MOE mapping who has the apprenticeship programmes, bridging courses and trade academies, where are they located, what’s the volumes of their intake—how are they tapping into the unemployment numbers provided by MSD, if at all?

This second part also includes mapping all the different Whānau Ora and hauora providers who provide wrap around support or pastoral care services to ensure independence is achieved at the same time.

The third part involves working with TEC, which institutions are offering which programmes, degree courses, qualifications, where are they located, scale of intake—and how are they lining up with all PGF projects and public/private investment across the region and supplying a qualified workforce for when projects mature?

And the last part involves mapping all the PGF projects, public/private industry investments and macro-economic modelling to understand forecasted numbers around job creation so we have some idea of what the end game looks like.

Of course, overlaying all these parts are fundamental macro-issues relating to the Treaty, equity and productivity that will have to be implemented as well.  

So, you can see that there are already a number of actors, institutions, agencies and providers all working away in different parts of the pipeline across our region—it’s just that on the whole they are not connected or linking up.

And this is the immediate aim of the Regional Skills Leadership Group — to provide a regional public interface so each user can see what’s happening across each part of the pipeline.

For example, if an Iwi was considering a primary industry project here across the Bay, they would be able to go online and see:

1. How many unemployed people there were in their immediate area – how many are NEETS and how many of them have transferable skills;

2. In their area, they would be able to identify if there are are bridging courses, apprenticeship courses, He Poutama Rangatahi programmes and so forth as well as Whānau Ora/hauora providers that can deliver all the integrated care;

3. Then they could see what qualifications are being offered, at which institutions in the area, to fill the roles required once their project went live—or instead realise a new programme or qual needs to be developed to meet their needs.

Of course, this seems common sense and a pragmatic way to map the environment, but given issues around privacy and commercial sensitivities, there is already a few challenges we are working through.

By the end of the year, we will have completed the exercise of mapping the pipeline. Even if we acquired all the data and information we require, there are still going to be gaps and risks throughout.

It is at this point the Group will undertake public and stakeholder consultation to prioritize what needs to be funded in the first instance to address these issues and accordingly make recommendations to the incoming Minister of Employment.

Overtime, it is the aim of the group to make itself redundant. The group currently consists of Iwi, Maori, all four economic development agencies, and industry stakeholders. This group is also supported by a parallel regional heads inter-agency government group.

At some point, we’ll begin a discussion about how we best want to organize ourselves in the Bay on a long-term basis, does the current regional economic and employment infrastructure work for example? Are mandates and funding adequate – and so forth. But this conversation won’t start until well into next year.

Summary

This brings my remarks to close. This is just a snapshot of some of the features of our environment today.

The task in front of us is to develop our economy and employment opportunities, while in an alert level system environment that is not going to go away, with closed or restricted borders, while responding to equity issues.

This is some challenge in front of us; but we are what we make of it. Time and time again we have proven our wares and this will be no different.

Dr Chris Tooley

Chris Tooley, Ngāti Kahungunu, CEO of Te Puna Ora o Mataatua.

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