Dr Shane Reti's speech to Iwi-Maori Partnership Boards, Rotorua

Health

Dr Shane Reti's speech to Iwi-Maori Partnership Boards, Thursday 4 July 2024

Mānawa maiea te putanga o Matariki

Mānawa maiea te ariki o te rangi

Mānawa maiea te Mātahi o te tau

Celebrate the rising of Matariki

Celebrate the rising of the lord of the skies

Celebrate the rising of the new year

Te Arawa iwi, Te Arawa tangata, nei rā ko taku mihi kia koutou. Koutou ngā kai pupuri i te mauri o o tupuna, tēnā rawa atu koutou katoa

I pay homage to Te Arawa iwi, Te Arawa people for holding fast to practices of your ancestors.

Ko tēnei te mihi, ko tēnei te mihi, ko tēnei te mihi ki a koutou,

Kia ora mai tatou.

Meeting with you as Matariki returns to our morning sky seems like a good time to reflect on the progress since we last met.

Last time I spoke with you, I presented my long-term vision for Māori health and the critical role of Iwi-Māori Partnership Boards in making that vision a reality. We spoke about the goals to improve the access, timeliness and quality of health services provided to our whānau and our communities.

Since then, I have been working with my officials to create a pathway that will enable Iwi-Māori Partnership Boards to deliver the breadth of their legislative functions and drive the health system to be more responsive to Māori health need.

Today, in my second IMPB speech, I want to talk further on capacity requirements to be ready for rollout and to speak in much greater detail around expectations of health outcomes.

Work has recently been completed gathering information to understand what capacity IMPBs will need to be ready for commissioning, and where each IMPB is on this journey. This information has been collated and gives me a view of each IMPB across the eight capacity domains, which are:

• Formal recognition
• Support contract
• Staff and systems
• Whānau voice and engagement
• Health insights and data
• Community health plan
• Strategic commissioning
• Monitoring

These are how we are assessing readiness and capacity.

As we knew from the beginning, IMPBs are at different levels of capacity.

The Readiness Assessment undertaken by yourselves and Health New Zealand shows roughly a third of IMPBs are probably ready to deliver today, a third maybe six months behind, and a third needing more significant resources and support.

Can I particularly encourage you to complete your community health plans. This is the core of decision making where you get to decide what services are most important to your rohe.

In this context, this is also an opportunity for me to be clear on localities which will not progress in my hands, however, I do recognise the effort that the locality prototypes imparted and would suggest that some of that work, in my view, would seem well suited to be absorbed or at least considered in your community health plans.

I want to talk now around expectations for IMPB based Maori health outcomes.

Within an outcomes-based commissioning framework there will be two groups of outcomes that IMPBs will be a part of. These are a "minimum viable package" which I will describe shortly, and the second is each IMPB's rohe specific strategic commissioning aligning with their needs analysis.

The "minimum viable package" or MVP, will be a very short list of minimum health and outcome requirements that every IMPB will need to deliver, indeed in most rohe are highly likely to be delivered already.

You will not be at all surprised, that one of the required outcomes in the MVP will be immunisations and possibly hgt, wgt and BP basic measurements, but over the following weeks, the MVP requirements will be spelled out more fully. They will be a few basic, simple medical care elements, that I would actually anticipate most providers to be doing already.

The second set of rohe specific Maori health outcomes is, at your strategic privilege, and responsibility, and will be described by you in your community health plans. The community health plan and the MVP describe the Māori health outcomes that together we will deliver.

Let's think more widely for a moment on Māori health outcomes.

Many of you may think that the superset or universe of Māori health outcomes are those described in Pae Tū and the Whakamaua Action Plan. This is not correct.

We also find Māori health outcomes in budget documents, annual plans, GPS, health plans, statements of performance expectations and multiple other documents. There are plans for plans.

I had my team bring together all the Māori health outcomes and this is the matrix across several pages! [HOLD UP THE MATRIX]

Too much! We need to focus on the few things that substantively advance Māori health.

This is a task that I placed with the Hauora Māori Advisory Committee, to advise on a manageable set of overarching health outcomes, and they have done an admirable job. They have identified nine domains that I will describe here.

1. Māori are protected from communicable diseases across the life course (eg, immunisation rates at 2 years)
2. Māmā and pēpi receive consistent quality care during pregnancy and into the early years (eg, enrolment with a primary care provider in the first trimester of pregnancy)
3. Early prevention of long-term illnesses for tamariki and rangatahi (eg, ambulatory sensitive hospitalisations for respiratory disease in 0-5)
4. Rangatahi experience stronger mental health and resilience (eg, timely access to mental health and addiction services)
5. Rangatahi are engaging in healthy behaviours and are surrounded by protective social factors (eg, smoking prevalence)
6. Identification and treatment pathways for cancer are faster, timely, comprehensive and effective (eg, patients receiving cancer management within 31 days of decision to treatment)
7. Pakeke are accessing primary and community healthcare early, with positive outcomes and experiences relating to diabetes and cardiovascular disease (eg, people with diabetes regularly receiving any hypoglycaemic medication in the relevant year)
8. Kaumātua are supported to live well through managing complex co-morbidities (eg, rate of polypharmacy in over 65s)
9. IMPBs are well supported to deliver on their roles and respond to hapori and whānau wellbeing needs (eg, resourcing and capability)

A list that is evidence based, concise, focused.

Looking at the outcomes in phases

These domains cover a comprehensive set of health outcomes and system measures. Each one is integral to improving Hauora Māori and each of them deserves our close attention.

To ensure that HMAC and the Ministry can give the domains the necessary focus, HMAC is going to look at them in phases.

In the first phase, they will focus on four of the nine outcomes: protection from communicable diseases, māmā and pēpi during pregnancy and early years, primary and community care for pakeke focusing on cardiovascular disease and diabetes and ensuring you are well supported to deliver on your roles.

HMAC will monitor how Māori health outcomes progress in these domains and consider where there are opportunities for improvement in the health system.

Over time, HMAC will extend their monitoring focus to the other outcomes, however we are starting with these select few critical health areas to better ensure we can make the greatest change for Māori.

HMAC will provide me with tangible and actionable advice on how I can steer the health system to better support hapori Māori in these areas.

Government Policy Statement 2024-2027

These outcomes interface well with the Government Policy Statement, which I announced recently.

The GPS is the direction of travel for health that sets out the Government's expectations and objectives for what the health system needs to deliver for New Zealanders over the next three years.

The New Zealand Health Plan falls out of the GPS as the costed response to the GPS to be delivered by Health New Zealand.

High needs groups such as Māori will see themselves and their story in the GPS. In fact, Māori are mentioned 77 times and IMPBs at least nine times.

The first tier of the GPS states the purpose - we will improve life expectancy and quality of life. I will say that again, our purpose is to improve life expectancy and quality of life.

The second tier describes how we will do that - with timely access to quality healthcare involving workforce and infrastructure as enablers. In Tier 2 then, the five high level priorities are: timeliness, access, quality, workforce and infrastructure.

The third and final tier sets the roadmap in a 5+5+5 targets framework that aligns with the United Nations Sustainability Development Goals (SDGs) and the World Health Organization Non-communicable diseases (NCDs):

• 5 health outcome targets - reduced waiting times for a first specialist assessment (FSA), surgery, ED, faster cancer treatment and improved immunisation rates
• 5 modifiable behaviours - smoking, alcohol, diet, exercise and social cohesion
• 5 pathologies - cardiovascular disease (CVD), respiratory, cancer, diabetes, mental health

Three tiers: the Purpose, the Priorities, and the Roadmap to get there. This is a very clear direction for health over the next three years and a robust framework that will stand up to scrutiny in any international environment.

Now let's take the nine HMAC domains and the three-tiered GPS and weave it all together for Māori health outcomes.

Preliminary results, from the Global Burden of Disease - Māori 2021. IHME, 2024, tell us the following:

Remember, I said Tier 1 was the purpose to improve life expectancy and quality of life. Māori die around 7 years before non-Maori - so what do they die of and what does that tell us about where can we have real impact on a life lived:

• Nearly 30% of Māori years of life lost -that's 2 and ½ years, are lost from all cancers - do you see cancer in the HMAC domains and GPS - Yes.
• More than 20% of Māori years of life lost, that's 1.4 years, are from cardiovascular diseases - do you see CVD in the HMAC domains and GPS - Yes.
• More than 7% of Māori years of life lost, that's ½ a year, is from diabetes and associated chronic kidney disease - do you see diabetes in the HMAC domains and GPS - Yes.
• Around another 7% of Māori years of life lost, that's a further ½ a year, is lost from self-harm - do you see mental health in the HMAC domains and GPS - Yes.
• Around 6% of Māori years of life lost, that's 5 months, is lost from chronic respiratory disease - do you see respiratory conditions in the HMAC domains and the GPS - Yes.

By targeting these five areas, we aim to address more than 70% of Māori years of life lost, that is, 5 years regathered, and 3 ½ just in cancer and cardiovascular diseases.

All of the tier 3 pathologies in the GPS talk directly to those specific conditions that improve life expectancy for Māori, and the 5 Tier 2, modifiable behaviours, are key factors for how we will prevent them.

As a high needs group, I speak directly to Māori in my GPS.

The GPS also provides guidance for health entities to "work in partnership with IMPBs to ensure primary and community care services are increasingly tailored to better respond to the needs of Māori, and ensure they are well supported and resourced."

The GPS also highlights the role of IMPBs in monitoring the performance of the health sector in their communities.

You represent local Māori perspectives on the needs and aspirations of Māori, how the health system is performing in relation to those needs and aspirations, and the design and delivery of services at a local level.

Your key functions include engaging with whānau and hapū about local health needs, evaluating the current state of Māori health, identifying priorities, and monitoring local performance. I back you to do this.

Direction of travel for IMPBs

In some ways, setting system accountability is the easy part; it is another thing to how we make it happen.

I know there are many questions about the path ahead, and I appreciate the open and direct feedback that you have been sharing with me and my officials in recent months. I know there are challenges that we will willingly address head on. Strong relationships, where we can have those direct conversations, gives me confidence that we will be able to do that together.

I encourage you to keep talking with John and his officials in the Ministry's Māori Health Directorate, and with Margie and Riana and their Health NZ officials, asking questions and providing feedback.

I am pleased that you will have an opportunity to do that all together today and tomorrow, kanohi ki te kanohi.

The role of IMPBs

Regardless of the structures put in place, strong Māori leadership and involvement in monitoring the performance of the health system is important at both local and national levels to be effective.

I intend to grow Māori capability and capacity to take on greater responsibilities and accountability, to plan, guide, design and deliver health services that meet community needs.

This is where you, Iwi-Māori Partnership Boards with local and regional influence, have critical roles to play in holding the system to account.

A key part of meeting the expectations of the GPS is recognising and enabling you as Iwi-Māori Partnership Boards to do more, including your role in monitoring how well health services are working at a local level, to support better outcomes for whānau.

Last time I spoke to you all, in March, I introduced the concept of strategic commissioning, and my ambition to see IMPBs have a more direct influence over the planning, design and monitoring of health services in your communities.

Since then, there have been lots of productive discussions about what this means in real terms, whether it includes budget holding, etc. So first I want to make some clarifying comments.

Strategic Commissioning is about influencing the way health services are planned, designed, and monitored to meet need now and in the future.

It is consistent with all of your existing legislative functions which represent critical steps in an end-to-end commissioning cycle. It starts with understanding what Māori need and want within their local context, with continuous engagement and monitoring.

I have made it very clear that I expect Health NZ to involve IMPBs in their service commissioning processes from early 2025, including business planning, service design and monitoring processes.

Strategic Commissioning, at this point, does not include the operational responsibility for procurement of services, contract management or budget holding. These functions will all remain with Health NZ.

I want to stress this is just a starting point, which will help to build the evidence and case for a more direct role in future, if that's where an IMPB wants to go and IMPBs have a track record, and feel confident they have the capacity to stretch further.

Delivering community health plans by the end of September

I need something from you. I need a community health plan by the end of September. All good ambitions start with a plan. I know that many of you have already done a lot of great work.

I'm aware that Te Taumata Hauora o Te Kahu o Taonui has already released their strategic positioning paper, that outlines how they want to move forward, and that Te Tauraki has already published a lot of information that can be collated into a community health plan.

These are just two examples of the work that has been going on around the country.

The community health plan outlines how you will deliver legislative functions over the next 3-5 years. It should include a prioritised local needs assessment to determine health priorities in your respective Māori communities, as well as accountability and monitoring arrangements.

Having the community health plans by the end of September 2024 means there is a further 3-month window to bring together everything you know about your community into a single plan.

And let me note that, while planning for Localities has stopped, there may be plenty of intel you can take from that work and apply it to your community health plans.

I understand that not all of you will have set plans yet, so I have asked officials to work with you on those plans over the next three months, which will show (a) what the individual and shared priorities are for all IMPBs, and (b) what support each IMPB will need to deliver on their functions.

These plans are a key part of investing locally in our people and, in turn, they start to provide me with reporting and measurement towards our goals - giving visibility and accountability to progress we should all be proud of.

Health NZ is considering how best to support and resource your capability and capacity needs from their baseline funding, based on the results of your readiness assessments.

Gearing up for 1 July 2025

By the end of this year, we will be confirming an initial tranche of IMPBs to participate in strategic commissioning. This means officials will be working with those that are ready and best placed to test the settings for MVP.

This won't come as a surprise to those of you who have been in health for a long time, but I expect there to be teething issues while the first tranche of testing is underway.

This will help us to understand the conditions needed to succeed. Testing this approach will be completed in areas where:

• an IMPB has undertaken a prioritised local needs assessment and identified their most vulnerable population groups and health priorities;
• there are shared health priorities between IMPBs and the Government, for example, health targets such as immunisations;
• there are upcoming planning, design and investment decisions for Health NZ related to those priorities within the next 6-12 months;
• there are strong relationships at a regional and local level between Health NZ, IMPBs, and other community voice representative groups including, but not limited to, Māori health providers, primary health organisations and Whānau Ora providers, so that the wider community's needs are also addressed.

I want to stress that participation in the initial tranche will not advantage one IMPB over another.

The goal is to have all IMPBs integrated in Health NZ's business planning, service design and service monitoring processes from January 2025, and able to influence the planning, design and monitoring of health services in line with their priorities from 1 July 2025.

Working with health officials

This is what I expect to see happening in practice from as early as January next year, and from 1 July 2025 for all IMPBs.

I know that this requires significant changes in ways of working for Health NZ, and I hope you will continue to share your views about what is needed to make this work, both with Health NZ directly and with the Ministry of Health as my agent and system steward.

In particular, I expect you will need more resource to strengthen capacity and capability and appreciate further advice from you on this. I have instructed my team to facilitate this.

This is especially so for access to data summaries that assist your decision-making.

I have asked officials at the Ministry of Health and Health NZ to lead the day-to-day relationships with you on my behalf and update me regularly on progress. They have the teams behind them to support your needs as you grow your capability and capacity.

I expect health entities to support and work with you to take up opportunities to build on the gains you have made to date, including from early locality initiatives and past responses to immunisations.

Take the opportunity to work with them to test different approaches to the planning and design of health services within existing policy settings.

Testing will be focused on primary and community health care services, as this provides the biggest opportunity to redesign and deliver services to improve outcomes in communities.

Hauora Māori Advisory Committee

I have already presented some of the work of the Hauora Māori Advisory Committee. We are more likely to collectively achieve Māori health aspirations if decision-makers make it a priority to address Māori health inequities and develop initiatives that work effectively for Māori.

I deliberately retained the Committee in the recent legislative change process and refocused its terms of reference. Shortly I will be confirming the membership of the committee.

Previously, the Committee was specifically focused on the performance of the Māori Health Authority, which we have now formally disestablished.

HMAC will now provide me with independent, tangible and actionable advice and guidance around Māori health priorities at a national level and assist with monitoring of Māori health outcomes and system performance.

I know that you are already engaged in discussions with Committee members to align priorities and I encourage you to continue these conversations.

It will be important that you - as key influencers and monitors for Māori health -work together to ensure outcomes can be reached and targets can be met.

Concluding remarks

In conclusion, media tell me I am the first NZ graduate Māori to be the Minister of Health - for those of you who are thinking this through, Maui Pomare graduated from Chicago. What a privilege.

Long before I received my warrant, I was discussing with Maori leaders what Māori health could look like as an alternative to the Maori Health Authority, and what role IMPBs could play. I had discussions with iwi covering half the land mass of New Zealand, including Te Kahu o Taonui, Sir Tumu Te Heuheu and Tuwharetoa, Ngai Tahu, Ngāti Toa, Te Āti Awa to name but a few, and I valued and was muchly encouraged by their counsel. I thank them for their effort to what brings us to where we are today.

I look forward to progress over the next six months and being able to celebrate the success of your work through your collective contribution to making a real and tangible difference in the lives of your whānau and communities. Your community health plans are an important enabler.

You have an important role in the achievement of health targets, priority areas in the GPS and realising the aspiration of Pae Ora - healthy futures for whānau today and in generations to come. As Matariki rises, so should our expectations to deliver for Māori health.

No reira, Ko te pae tawhiti whāia kia tata, ko te pae tata whakamaua kia tina! Haumi e! Hui e, Taiki e!