HEI ORANGA
NGĀKAU
Report to the Chief Executive of Hauora Tairāwhiti
fol owing an investigation of a complaint dated 16
April,2018.
Mahuru/September 2018
Tiakina Ltd | Kaiti, Gisborne
Contents
Executive Summary
Background
Approach
Document Review
Inteviews
Findings
Recommendations
Appendicies
Executive Summary
Distinguised pyschiatrist, academic and Māori mental health thought leader Professor Sir
Mason Durie observed recently a significant shift in the way in which approaches to mental
health services are being developed and thought about.
In doing so he makes an important point that warrants exploration in the context of this
inquiry. He says that,
“mental distress is not the same as mental disorder that meets the Diagnostic
Statistical Manual (DSM) criteria. Even the most serious examples of diminished
mental health, such as suicide, do not automatical y indicate the presence of a
psychiatric il ness. Neither is distress always a precursor to disorder. The distinction
between distress and disorder is important because interventions to improve mental
health are not necessarily best delivered by a specialist mental health service. Nor
for that matter are they the sole province of health services. Instead, greater relief
may be obtained from changes to the environment that aggrevates the distress.
Quite apart from the provision of clincial services, the environmental approach leaves
room for different types of interventions aimed at altering a potential y harmful
environment.
Creating an environment that is user friendly can significantly alter the
mental health of any one with mental or physical disabilities.
(Durie in Te Kani et al, 2018, Māori Health Transformations, Huia Publishers, Wel ington)
In the letter of complaint written to the Chief Executive on April 16, 2018 a range of issues
and concerns are raised in a way that suggests that the thinking and intent that drove the
somewhat hasty establishment of a new pilot service for Māori may be wel understood by
Prof Durie, and the team who developed the RFP, and the evaluation team out of EIT, but
for the majority of those affected by this transformational change there appears to have
been little opportunity to real y engage in the thinking ahead of the change programme
bearing down on their own professional assumptions, livelihoods and careers.
The problem Te Kuwatawata, Te Kurahuna and their Mahi a Atua approach are trying to
solve is clear to some, but not to al . Despite the wel documented fact that Tairāwhiti has
one of the highest levels of Mental Health distress in the country and that Māori have
continued to have persistently inequitable health outcomes – the opportunity to engage in
solving this problem has not been presented to a broad range of stakeholders as part of a
cohesive change programme. What appears to have happened here is that a highly
motivated yet small group of health professionals have moved heaven and earth to do
something about this problem and encountered resistence to change and their hastily
developed pilot along the way.
Clarity, honesty and courage from the leadership of Hauora Tairāwhiti and the Ministry of
Health is required now to re-present both the problem and the opportunity to do something
about it to all stakeholders while acknowledging the impact of the transformational change
programme to date on those affected.
The transformational change programme requires a fresh approach to ensure that any gains
made can be built on and the workforce badly needed can be engaged respectful y in a
world leading service development opportunity right here in Tairāwhiti.
This reframing is important and wil require considered attention and culturally competent
leadership to enable the intended benefits of an indigenous approach and delievery to find
its place and deliver the kinds of mental health services that support wellness into the
future.
Background to this inquiry
Over the last three years mental health services at Hauora Tairāwhiti have been affected by
a range of different yet related issues. Prime among these are difficulties in recruiting to
key roles, the incidence of mental stress in the community and the acuity of people
requiring care within the services.
There have been particular cases which have resulted in additional strain on services and
increased staff turnover.
There has been an amalgamation of adult and child/youth services.
There have been service developments and improvements which have resulted in changes
in the way services are delivered, resulting in staff having to adjust to new ways of working.
Recently Hauora Tairāwhiti was successful in recieving funding through the Ministry of
Health for an innovation pilot – Te Kuwatawata – which is a single point of entry for al
services in Tairāwhiti (primary and secondary), delivered within a kaupapa Māori framework
utlising Mahi a Atua, and in a three way partnership with Te Kupenga Net Trust and Pinnicle
Midlands Health Network.
The pilot commenced in September of 2017 and the service changes, pattern of flow and
effects on individual staff have been significant. Al of this occured alongside the issues with
secondary services, as noted above.
Against this background the PSA has written to the Chief Executive setting out a number of
alleged deficiencies in management, policy and approach in Te Ara Maioha, the mental
health services of Hauora Tairāwhiti. These issues as documented require a response and
this report sets out to respond to them by identifying learnings, suggested improvements
and actions for the Chief Executive to consider. The Terms of Reference agreed are
attached at Appendix A.
Approach
Notwithstanding the issues, and the multiple chal enges facing the Chief Executive it
became clear after just two meetings that in the absence of trust being built staff were
unlikely to share their insights.
A kaupapa Māori principled approach was selected to offer the best opportunity to build
rapport and establish a safe space for open ended discussion.
The operating principles for the investigation of the issues were:
• Tika – doing what is right
• Pono – being true to ones word through ones deeds
• Aroha – paying attention to and being kind to people
In addition to this a wānanga context was created to enable participants in the interview to
participate as fully as possible. In kaupapa Māori research, wānanga helps to equalise any
percieved or actual power imbalance through a style of enquiry which places the
interviewee at the centre through open ended, broad questions. This is a common practice
which is highly respectful of participants and recognises their agency as holders of and
ultimately in control of their own knowledge.
Participants understood that their anonymity would be protected and that no identifying
language or terminology would be used in the report so as to inadvertantly identify them.
All participated and agreed for their transcripts to be submitted for inclusion in the report
on this basis.
Participants were invited to participate in interviews in either English or Māori languages
and the tikanga for commencing and ending each session was determined by participants.
Permission was sough to use an i-Pad to gather notes from the session, and where
participants indicated a preference for hand written notes this approach was adhered to.
Some participants sent additional information after an interview session which ranged from
academic articles to guidelines and plans. The ful range of documents reviewed is noted at
appendix B.
For the purposes of this inquiry participants were sent their transcripts within 48 hours of
interview for review. Permission to utlise their kōrero for the purposes of this report was
sought and obtained from 90% of those interviewed.
In line with the terms of reference and the principles outlined above participants in the
inquiry who appreared to be in distress were engaged in a further conversation after the
interview about pathways for support. With their blessing their names were also provided
to Human Resources and the Chief Executive for immediate support. Over the course of the
interviews undertaken 9% of those interviewed were identified as requiring additional
support.
Data col ection included document review and informal interviews with staff who chose to
take up an opportunity to share their views fol owing the submission of the 16 April letter to
the Chief Executive.
Document review
Key points from the 16 April letter
The main point of the letter was to indicate a vote of no confidence in two senior leaders in
the organisation, both named in the letter.
Other key points included:
• The lack of a Stratgic Plan for Mental Health Services: Te Ara Maioha
• A lack of action in respect of concerns raised since September 2017
• Concern about the rapid decline of staff numbers in secondary services
• Concern about bul ying
• Poor change managment practice in general and in particular around the Te
Kuwatawata pilot in the context of Te Ara Maioha: Mental Health Services as a
whole
• Concern about clinical safety at Te Kuwatawata
• Concern that Privacy and Human Rights have been breeched at Te Kuwatawata
• Failure by leaders to adhere to the WAKA values in their practice
A written response to the 16 April letter from the senior staff named
• Impact of change on Te Ara Maioha as a result of the Te Kuwatawata pilot was
acknowledged, in particular the speed of change as a result of MoH deadlines
• Notes Te Kuwatawata is a service stil in development therefore lots of work is
required to get it operating to its ful potential
• Notes that there are valid systems and process concerns to address and that this
work is underway
• Notes that there is a Strategic Plan and points to the ‘Te Ara Maioha Quality and
Service Plan 2018 – 2020’ (attached at appendix b)
• Believes fear of change and potential job loss due to disinvestment in secondary
services is creating distress for staff
• Reiterates the importance of health and safety for staff and desire to help remedy
distress
• Notes that the bul ying issue for Hauora Tairāwhiti and Te Ara Maioha is a
longstanding one, does not accept accusations of bullying noting very difficult
conversations have been had
• Do not agree that privacy and human rights have been breeched
• Would like to work with Te Ara Maioha as a while to implement the WAKA values
Clarifying the scope of the Te Kūwatawata Pilot as original y proposed
In line with the refreshed direction of the NZ Health Strategy a ‘Fit for the Future’ (FFTF)
programme was established. The key objective of the FFTF was to build a robust evidence
base for services for people with moderate mental health needs.
Funding was provided with a proviso that a robust evaluation process that clearly identifies
the outcomes for whānau would be undertaken. This service was provided by EIT, under
the leadership of Prof David Tipene-Leach.
At a high level these are the basic elements of the pilot according to the RFP (request for
proposal dated 7 February 2017).
The joint proposal was submitted by Hauora Tairāwhiti, Pinnicle Midlands Health Network &
Te Kupenga Net Trust.
The three key aspects of the initiative was described as:
1. Te Kuwatawata – a single point of access to all mental health support services in
Tairāwhiti (clinical and non-clinical) for al whaiora and their whānau experiencing
distress.
2. Deliberate reinstatement of Matauranga Maori into services through a col aboration
with Te Kurahuna and the embedment of Mahi a Atua.
3. Strengthening whanau and increasing community capacity across Tairāwhiti.
These three aspects were proposed to come together to ensure that any individual is
acknowledged as part of a whanau and community system and, wil receive appropriate
assessment and treatment tailored to their needs.
The service was proposed to span the continuum of care and life course from the first point
of contact and wil work towards providing care closer to home.
The initiative was founded on a discourse that deliberately reinstates matauranga Māori
into health services and recognises the importance of effective change management and
col aborative community wide governance.
The RFP goes on to describe the core elements of the proposed new service as fol ows:
Te Kuwatawata
Te Kuwatawata aims to transform mental health and addiction services. Essential to
this service wil be a fundamental philosophy that acknowledges indigenous people
of Aotearoa, their values and beliefs, their traditional psychology, and practice. Te
Kuwatawata wil uphold the kaupapa and principles of Mahi a Atua in al service
development and delivery, change management processes, and governance.
The service has been named Te Kuwatawata to better reflect our commitment to
Mahi a Atua which al ows us to explore deeper meanings from our history and ignite
innovative solutions.
Te Kuwatawata wil be working with whaiora of al ethnicities experiencing distress,
and their whanau, and wil align the most appropriate support services that wil
greatly improve the stabilisation, recovery and long term outcome for individuals and
reinforce supports to our wider community.
Te Kurahuna and Mahi a Atua
The Mahi a Atua wānanga are convened in a whare wananga (traditional Māori
learning forum), cal ed Te Kurahuna. Te Kurahuna aims to develop, grow and sustain
indigenous approaches, and to grow the capabilities and confidence within health
and non-health services in the Tairāwhiti. Over 20 community organisations have
been invaluable in shaping Te Kurahuna. The organisations involved are Te Kupenga
Net Trust; Hauora Tairāwhiti (Mental Health and Addictions, Women, Children and
Youth Department, Māori Health Advisory Population Health, Planning and Funding)
; Emerge Aotearoa; Turanga Health; Desmond Rd GP Practice; Te Rūnanga o Ngāti
Porou and CYFS Youth Justice; Te Aitanga a Hauiti, Ministry of Education, Tairāwhiti
Māori Artists, Te Whare Wananga o Aotearoa, GP Trainee Registrars, and Ka Pai
Kaiti.
The first of three critical principles for Te Kurahuna is to indigenise the space
occupied. Mahi a Atua has been the vehicle to do this as it is not solely focused on the
methods of ‘intervention’, but has broadened our clinical lens to consider a ‘way of
being’ for health services in Tairāwhiti, particularly mental health services. This
principle drives the continuous ambition to undo the institutional racism in our
society and guides the development of services that are intrinsically founded in
Matauranga Māori rather than applying “cultural y appropriate services”.
Ka mā te ariki, ka mā te tauira (Active learning) and Hongihongi Te Wheiwheiā
(Embracing feedback) are the second and third principles of Te Kurahuna which
guide practitioners to be immediately responsive to whaiora, whānau and the
community they are a part of.
Mahi a Atua as an intervention draws from Māori creation and custom stories,
known as pūrakau, to understand how Māori ancestors made sense of their realities.
The pūrakau act as mental frames; scaffolding that can help us understand ourselves,
our world, our place in it, and shape how we respond to distress, unearthing existing
resilience and resources within the whānau.
In summary Mahi a Atua deliberately reinstates Maori psychology into the Tairāwhiti
community. Through our pūrakau we are able to consider a range of new ways to
analyse, explore and act; motivating whole communities to respond differently and
col ectively to mental health and addictions service delivery. This analogy captures
the effect Mahi a Atua is having on whaiora, whanau and services.
‘When the waka is in the doldrums and the crew have lost faith in
their journey it only takes the sighting of one bird to reignite them and
give them hope.’
Hector Busby, Tohunga Waka
NZ Health Strategy: Future Direction
The Ministry of Health has expressed this vision for New Zealand in its latest strategy
document which discusses a human centred approach to doing things differently in the
future and signals a desired shift in approach and behaviour across the system.
The high level vision and implementation ideas are set out below:
All New Zealanders live wel , stay wel , get wel , in a system that is people-powered,
provides services closer to home, is designed for value and high performance, and
works as one team in a smart system.
To make this strategy work, our behaviours, actions and approaches consistent across the
system. We need to put people at the forefront of our thinking and actions.
Moving ahead wil involve some changes in behaviour, which we can use to identify success,
in particular when there is a shift from:
•
treatment to prevention and support for independence
•
a focus on the individual to a wider focus on the family and whānau
•
service-centred delivery to people-centred services
•
competition to trust, cohesion and col aboration
•
working in fragmented health sector silos to taking integrated social responses.
•
Refreshed guiding principles for the system
•
Acknowledging the special relationship between Māori and the Crown under the
Treaty of Waitangi
•
The best health and wel being possible for al New Zealanders throughout their lives
•
An improvement in health status of those currently disadvantaged
•
Col aborative health promotion, rehabilitation and disease and injury prevention by
all sectors
•
Timely and equitable access for al New Zealanders to a comprehensive range of
health and disability services, regardless of ability to pay
•
A high-performing system in which people have confidence
•
Active partnership with people and communities at al levels
•
Thinking beyond narrow definitions of health and col aborating with others to
achieve wel being
Hauora Tairāwhiti Annual Plan 2017-18
This plan picks up on the human centred themes of the Health Strategy setting out a range
of targets in the Mental Health area.
Mental Health: People powered
•
Analyse and identify existing client group subject to Section 29 to understand the
factors that contribute to use of the Mental Health Act
•
Utilising Te Kuwatawata model to implement service improvements.
•
Continue to work towards the elimination of seclusion within Tairāwhiti by 2020
•
Analysis complete and work plan established by end quarter 1
•
Quarterly reporting against work plan progress
•
Provider narrative update as required PP36: Reduce the rate of Māori on the mental
health Act: section 29 community treatment orders relative to other ethnicities.
•
Expand the understanding and application of Mahi a Atua across the care continuum
within the district. Mahi a Atua is at the core of mental health and addictions service
improvements in Tairāwhiti (e.g. Te Kuwatawata and Te Hiringa Matua). Reinstating
Mātauranga Māori both as a philosophy of each service and as a specific Māori
therapeutic intervention offered. Growing community capabilities and leadership in
Mahi a Atua is being fulfil ed through weekly wānanga.
•
Implement Te Kuwatawata - a “ Fit for the Future” initiative - an up-scaling of
existing services into an Integrated Single Point of Entry to al mental health support
services in Tairāwhiti (clinical and non-clinical), for al whaiora and their whānau
experiencing distress.
•
Implement Te Hiringa Matua (Parenting and Pregnancy Service)
•
Increased participation (whaiora, whānau and organisations) in Mahi a Atua
wānanga.
The Te Kuwatawata Evaluation – interim report
As this review kicked off the final touches on the interim evaluation report were being
completed. The report makes some helpful observations and useful conclusions which help
address some of the issues in the complaint and inform a range of learnings and potential
next steps for consideration.
Led by the team at EIT (Eastern Institute of Technology) under the guidance of Prof David
Tipene-Leach, the report sets out a far broader context for consideration than the terms of
reference for this report, which is worth noting as it goes to the heart of the drive for
change, which is an issue to be wrestled with for Hauora Tairāwhiti.
The report states:
New Zealand’s mental health services have been experiencing increasingly severe capacity
problems, with stressed mental health workers and a call for wider attention to the cultural
and social context of distress. Tairāwhiti has one of the highest levels of mental health
distress in the country (2018:Williment et al) and Māori have persistently had inequitable
outcomes, which appear to be at least in part due to a systematic ‘cultural competence’ gap
in services. (2017:MoH Report, Improving the Health status of people with severe mental
illness through improved access)
Te Kūwatawata is a ‘single point of entry’ (SPoE) service for al whānau in the Tairāwhiti
District Health Board (DHB, Hauora Tairāwhiti) region experiencing mental distress. It
involves both primary and secondary mental health services and uses a Te Ao Māori
framework. Te Kūwatawata is funded for sixteen months (1 June 2017 – 30 September 2018)
via the Ministry of Health’s Mental Health and Addictions Project, “Fit for the Future – a
Systems Approach”. The service is a col aboration of four quite different mental health care
providers in Gisborne; Hauora Tairāwhiti DHB’s Mental Health and Addiction services;
Pinnacle Midlands Health Network Primary Health Organisation (PHO); the community
based non Governmental organisation Te Kupenga Net Peer Support and Advocacy Trust;
and Te Kurahuna, a Māori whare wānanga whose training of mental health (and other)
workers in cultural competency skil s produces ‘graduates’ cal ed Mataora. Te Kūwatawata
opened on 1 September 2017. (2018:p7)
The primary evaluation question addressed by the team was this:
Wil the building of a primary mental health care service around a framework based on
Māori cultural values and knowledge successful y serve the Tairāwhiti community, both
Māori and non-Māori, who are experiencing mental distress?
The interim evaluation is attached at Appendix C
Interviews
Between July – August 2018 I engaged just over 45 people in a range of wānanga in groups,
pairs and as individuals. Of the total group engaged 90% provided written consent for me
to utlise their transcripts and/or whiteboard notes for the purposes of this report.
As I sat down and listened to what people had to say I noted that the majority of those I met
were disgruntled, but despite this they wished to convey their support for the idea of Te
Kuwatawata, they just didn’t like the way in which the change had been implemented in the
main. There were also some clear concerns about
not
being consistent with their own espoused values and those of Hauora Tairāwhiti (WAKA
values).
Of the total number of interviewees 0.6% expressed a view that Te Kuwatawata should not
continue.
Issues identified through the process of interview are captured at a high level below.
1. A lack of a (known) clear strategic direction
a. General confusion about the future state of Mental Health Service provision
in Tairāwhiti, especially around the place of primary and secondary services
in the future system in development.
b. A general view that Hauora Tairāwhiti has not adequately invested in Māori
cultural/clincal leadership at al levels of the organisation to assist the
changes needed to address community need.
c. Wide support for lifting the effectiveness of mental health service provision
for Māori, but a clack of clarity around what this means in practice for al
aspects of the system.
d. Concern about a shift in resources from secondary to primary services
without clarity about the strategic intent or a clear plan outlining how the
shift is to be implemented and managed.
e. Majority support for the kaupapa of Te Kūwatawata and Mahi a Atua.
2. Staff wel being & behaviours
a. Concern for the wel being of staff members affected by rapid and constant
change, a reduction in resourcing in their teams and workplace bul ying.
b. Concern about poor professional conduct by
c. Some concern that reputational damage had occured for Hauora Tairawhiti
as a result of poor professional conduct
3. Implementation challenges for Te Kuwatawata
a. Concern that ‘scope creep’ may have occurred around the pilot project
developed for Te Kūwatawata.
b. A general view that the ‘change’ aspect of the pilot project developed for Te
Kuwatawata had not been done wel and was/is under-resourced.
c. Concern that the ‘SPoE’ had moved to a pilot project which was/is stil in
development.
d. Lack of clarity about the way in which clinical and mahi atua approaches
propose to operate together.
e. Some concern about data integrity in the monitoring of the perfomance of
services delivered by Te Kuwatawata and Mental Health Services: Te Ara
Maioha.
f. Worry from some about the lack of clinical robustness in the Te Kuwatawata
aproach
Findings
1. The kaupapa of Te Kuwatawata is widely supported by those interviewed
Despite establishment and implementation issues there is widespread support for Te
Kuwatawata as an innovative new service.
The majority of staff affected by the impact of change or poor professional conduct
maintained their support for a need to do things differently and acknowledged that
the kaupapa of Te Kuwatawata offers an important kaupapa Māori service for the
region.
One person stated, “
Te Kuwatawata has been a wonderful opening for many, mostly
young and Māori people who would have never engaged a service before”. Others
said, “I think the idea of Te Kuwatawata is good”, “we total y support this new way
of working with whānau, its so much better than what we had before”.
2. Lack of clarity about the scope and focus of Te Kuwatawata
However, clarity of scope, the focus of the service and operating interface with
mental health services more broadly remains unclear for those interviewed working
within Hauora Tairāwhiti.
As one interviewee shared
“I was expecting to be inspired by the wonderful ideas
being woven into the Te Kuwatawata service but found a chaotic disconnected set of
services instead”.
There was also a lack of clarity for those interviewed about the SPoE functions of Te
Kuwatawata, with some fearing that the SpoE pilot had been ‘randomly added’ to
the Te Kuwatawata pilot with little consideration. It is clear from the RFP documents
that the SPoE was function was a part of the plan for Te Kuwatawata from the very
early stages of it’s development and is consistent with the Hauora Tairāwhiti Annual
Plan.
Further to this for some, Te Kuwatawata was understood to be a strictly Primary
mental health service, while the evaluation makes it clear that it is a ‘SPoE with
secondary and primary service col aboration’, and the RFP describes the service as
spanning the care contiuum. This may be due in part to the description of the Fit for
the Future fund which describes its funding focus as ‘for people with moderate
mental health needs’.
3. Clinical risk identified and under active management
I note at time of writing that sigificant progress has been made (evidenced by the
Operations Manual and findings in the Interim Evaluation) on addressing clinical risk
and clarifiying intake and other processes, although the extent to which these
service improvements have been successful y communicated outside of Te
Kuwatawata is unknown.
What is also not clear is the extent to which the operating guidelines across al
mental health services, primary, secondary and tertiary, are effectively aligned and
commonly understood. Some interviewees noted that while
“the focus has been on
Te Kuwatawata, the other services also need to pul their socks up”. Such comments
and observations point to an opportunity to provide greater clarity across Mental
Health Services general y and a chance to examine the interface between each of
them again in given the introduction of the new service Te Kuwatawata and its
kaupapa Māori approach.
4. Poor change management
Evidence of a committed change team, change leaders and change programme was
not found in any of the data reviewed or col ated.
As one interviewee rather candidly shared,
“I think those… who were wel versed
with the concept and philosophy of Te Kuwatawata, lost sight of the huge paradigm
shift for the rest of Te Ara Maioha staff who did not have intimate knowledge of it.
We implemented revolutionary change without adequately socializing it first”.
Given the background of complexity and unrest in Mental Health Services prior to
the implementation of the pilot and the significance of the chal enge that Te
Kuwatawata seeks to address, investment in change leadership and best practice
was warranted but appears to have been overlooked.
From the perspective of those interviewed for this review and the interim evaluation
provided by EIT, change in this instance has not been managed wel at al .
The interim evaluation also found evidence of the impact of poor change
management (p38) in the overly negative feedback encountered despite almost all
participants expressing that they wanted Te Kuwatawata to work.
Participants in this review and in the interim evaluation process described
“rapid
decision making and poor consultation”, “feeling not listened to”, and “not valued”.
People also discussed their concern that “secondary services resources are being
drained”, and “the way this has been done has left a really bad feeling with people”.
The rapid implementation of the service in response to Ministry of Health
timeframes, (Hauora Tairāwhiti was notified in April 2017 that they had been
successful in their bid and directed to commence the service in June 2017), placed
significant pressure on a smal group, who remained focused on building and
delivering the new service rather than managing the change according to best
practice principles.
The service opened its doors on 1 September 2017 after just four months
implementation time, which in hindsight resulted in a chaotic and stressful change
experience for the majority of people interviewed.
5. A problem with bullying and poor professional conduct
A significant number of those interviewed described incidences of bul ying and poor
professional conduct
. These descriptions and complaints
seem to be intertwined with the impact of rapid change
This was compounded by a lack of faith in the wider leadership to act appropriately
to address issues of bul ying and poor professional conduct, one interviewee stated,
“the issue here is that in the past I have escalated these issues...nothing gets done,
then the affected person (sic) just leaves”.
This behaviour was described by one interivewee as something that
“we have al
become so accustomed to...that we just tend to rol with it”. Another shared that
they had been
“sworn at, cursed at, talked over, told I don’t understand about
equity, told to shut up”.
Such behaviour as described by the interviewees is not consistent with the espoused
values of Te Kuwatawata nor the WAKA values of Hauora Tairāwhiti. As such, these
behaviours present a risk to the success of the programme and the reputation of
Hauora Tairāwhiti if not managed appropriately.
6. A lack of clarity around the vision for Mental Health in Tairāwhiti
The majority of people interviewed and the complainants who wrote to the CE in
April all complained about a lack of a clear vision or strategy for Mental Health in
Tairāwhiti.
What is clear is that the respondents to the April 16 complaint to the Chief Executive
are very clear about how their new service, Te Kuwatawata, fits with the NZ Health
Strategy, aligns with the Fit for the Future Programme and responds to deliverables
in the Hauora Tairāwhiti Annual Plan 2017/18.
This polarisation was also noted in the interim evaluation report and is consistent
with change implemented in haste where an insufficient level of resource has been
assigned to the important work of change management which includes
communication and engagement among other things.
It is also common in operational contexts where engagement with strategy and
vision occurs sporadical y if at al due to a high level of demand from the community
for service.
What is clear is that the people interviewed and voicing concern wish to be engaged
in this thinking and visioning and connected to the reasons why change to the way
we ‘have always’ done things might be warranted, desirable and lead to a significant
shift in wel being for the people of this region suffering from mental distress.
7. Working with Māori & using Mahi a Atua
For many of the people interviewed the shift represented by Mahi a Atua as a new
way to work with Māori is not only new, it is inaccessible.
For others one of the key issues faced is the smal numbers of cultural y competent
people available to work with whānau Māori in distress in a culturally appropriate
way. This is despite the fact that the majority of people requiring support are
Māori.
While the Kura Huna is understood to be working to address this issue, its training
programme and approach is arguably not wel understood, and given the people
running the Kura Huna are understood to be the same as the people running Te
Kuwatawata, where there have been issues or a lack of trust in Te Kuwatawata, the
same issues exist for Te Kura Huna.
The other issues with access are complex in and of themselves and appear to have
come about due to a range of intersecting issues and experiences. For some, the
exploration of Māori models of practice that operate in the Māori language is
challenging and sits outside of their levels of professional comfort. For others the
robustness of the approach, expecial y in respect of the expectation that negative
feedback wil be freely given, is too much of a stretch.
For others the stories they’ve heard about their col egues being ridiculed for their
poor Māori language pronounciation or lack of knowledge has exacerbated their
reluctance to explore Mahi a Atua.
For some people I spoke with the idea that Mahi a Atua sits outside of the known
practice approaches held by the kaumatua they have developed clinical support
relationships with was a cause for concern. For others the issue is that there are far
too few culturally completent Māori employed within the service to help guide and
influence best practice in working with Māori.
As far as the literature describes, there appears to be a lack of focus on lifting the
overal Māori cultural competency of leaders and influencers across the board.
When one person tried to ‘count’ the number of Māori senior leaders in Hauora
Tairāwhiti they said,
“I can count them on one hand”.
As is often the case with something new, shifting one’s professional practice takes
time, consideration and lots of coaching and support. I’ve had some interviewees
express a level of disconsternation with the Māori names for the processes utilised
within Mahi a Atua, but curiosity about the approach and a wil ingness to learn
within an environment safe from ridicule.
Recommendations
These recommendations are presented in a priority order and are reasonably high level.
They are designed to create an environment that supports transformational change in a
human centred way while building on the success and the promise of this new service in
development.
1. Urgently strengthen the Governance capabilities within Te Kuwatawata
The interim evaluation report notes this as an area for improvement and
stengthening. Work with the evaluation team to design a strengthened Governance
Group witout delay who are duly authorised and resourced to manage and mitigate
risk and optimise opportunity within the scope of the approved programme.
2. Urgently clarify the scope and focus of Te Kuwatawata for al stakeholders
Once the scope and focus is clear, successful engagment, communication and
planning can commence on that basis.
Central to this is clarification of the place of Te Kuwatawata within Mental Health
Services and the status of the service as a permanent service or an extended pilot
with a fixed term life.
3. Appoint an experienced change team
A team experienced in leading change needs to be appointed urgently, this includes
the identification of key influencers within the community, Mental Health Services
and Te Ara Maioha who can act as change champions and help shape the ongoing
development of service specifications, processes, communications approaches and
coach mental health professionals needing support through the change process.
There is an opportunity to establish a clear, shared vision for the future of Mental
Health Services in Tairāwhiti based on trusted data, known problems and existing
opportunties. The communication of this is best led out by an experienced change
team in partnership with Hauora Tairāwhiti leadership and the wider community.
A baseline must be established without delay that assesses the impact of change so
far on the workforce, communuity and whānau experiencing mental distress and an
urgent assessment of the gap between the current state and desired future state of
Mental Health Services in Tairāwhiti.
4. Establish a WAKA values taskforce
It is apparent that there is widespread support for the WAKA values and the kaupapa
of Hauora Tairāwhiti. However, the process for the implementation of these values
is unclear and does not appear to be wel resourced or supported beyond the
pamphlets and posters. Waka values are attached for reference at Appendix D.
There was also a reluctance to report behaviours inconsistent with the values based
on the experience of ‘nothing happening.’
Clarity is urgently needed around ‘what happens’ when someone is accused of
bullying and/or poor professional conduct. The process for investigation must be
clear and independant of current line management to win the early confidence of
staff.
A restorative approach works best when parties are wil ing to accept that their
behaviour is not welcome and wil not be tolerated. Behaviour change needs to be
supported by Coaching and/or Mentoring.
A WAKA values taskforce made up of Senior Leaders and Key influencers could
attend to these gaps and develop (with support and in consultation with staff and
other key stakeholders) a process for holding people to account and supporting each
other to act in accordance with the WAKA values.
5. Strengthen training and development to complement Te Kurahuna
If the overal workforce is to benefit from training in kaupapa Māori approaches to
service provision, a range of approaches to provide this may be required to assist Te
Kurahuna to achieve its goals.
Te Kurahuna aims to develop, grow and sustain indigenous approaches, and to grow
the capabilities and confidence within health and non-health services in the
Tairāwhiti.
These should be explored without delay and a training and development plan for
Hauora Tairāwhiti, Pinnicle Midland Health and Te Kupenga Net Trust scoped,
completed and implemented as part of the overal change plan. A critical mass of
trained professionals at al levels wil help drive the transformational change
programme forward in a more informed and robust way.
6. Aligning capability to our core demographic – achieveing a strategic shift
If Te Kuwatawata is to build on its success noted in the interim evaluation (see
appendix D) and suceed as a new model of service delivery it wil need champions at
every level of Hauora Tairāwhiti and across every corner of the community.
The (yet to be appointed) change team and the multi-level leadership of Hauora
Tairāwhiti wil need to be across the kaupapa to such an extent that they can speak
knowedgably about it in any context as the interest in transformational models of
health provision for Māori grows. Any gaps in understanding or questions wil need
addressing ahead of the emerging confluence of shifting policy settings, rising need
and a nation wide focus on improved outcomes for Māori.
As a kaupapa Māori model it wil require a level of cultural capability to be present
and able to influence at every decision point affecting the service. This is a
significant ask for two reasons. First, there is little evidence to suggest that a
stocktake of cultural capability has been planned or discussed, and second, the
current wānanga addressing this gap local y (Te Kura Huna) appears to be practice
focused in the main rather than addressing gaps in leadership, governance and
management. This wil need to be addressed and the broader training and
development needs sized and addressed.
Durie (in 2018:p 82-83) points to a period of change in Mental Health characterised
by two major shifts in policy and practice.
“The first was the move away from large
pyschiatric hospitals in favour of general hospital treatment and community care
between 1972 – 1996. He notes that deinstitutionalisation was a process that
earned ridicule, apprehension and fierce opposition despite the mounting evidence
that the old approach was not consistent with good health or timely recovery.
The second significant shift was in the indiginisation of the Mental Health system by
Māori health perspectives, cultural protocols for assessment, treatment and
rehabilitation and a growing Māori workforce. They al contributed to a recognition
of the importance of culture as an important component in assessment and recovery.
“transformation of Mental Health services occuring now that is characterised by
delivery systems that comprose a range of diciplines, sectors and agencies with goals
that reach beyond recovery to wel ness; environmental scanning to detect and
minimise risks to health and a workforce that is cultural y attuned and able to look
inwards, to meet the need of individuals, while looking outwards, to understand the
social, economic and physical environments”.
What is clear to everyone involved in Mental Health engaged for the purposes of this
inquiry is that Te Kuwatawata represents a significant shift in the right direction.
What is required now is a period of consolidation to stabilise gains made, clarity of
scope and resource, support to address issues that have emerged and plan for a
future where the way we work is as important as what we do.
Appendix A – Terms of Reference
Appendix B – Documents reviewed
• NZ Health Strategy
• Hauora Tairāwhiti Annual Plan 2017/18
• WAKA values document
• RFP Te Kuwatawata, Te Kura Huna and Mahi a Atua
• Complaint from PSA to Chief Executive April 16, 2018
• Letter from respondents to Chief Executiv, April 24, 2018
• Emails to CE March – July 2018
• Notes from meetings Sept 2017 – March 2018
• Te Kuwatawata Evaluation Interim Report, EIT
• Te Ara Maioha Service Quality Plan
• Terms of reference for Government Inquiry into Mental Health and Addiction
• Submission to the Government Inquiry into Mental Health and Addiction by NZ
Human Rights Commission
• Prevention and Responding to Workplace Bullying – February 2014
• Operations Manual Te Kuwatawata, February 2018
• Native Wisdom is Revolutionising Health Care – Shari Huhndorf (Stanford Social
Innovation Review/Summer 2017)
Appendix C: Interim evaluation report (June 2018)
Appendix D - Waka Values
Appendix E – Best practice change leadership (Kotters 8 steps)
https://hbr.org/product/hbr-s-10-must-reads-on-change-management-with-featured-article-leading-change-by-john-p-kotter/12599E-KND-ENG
1. Establish a sense of urgency – Examine the reality of the situation.
– Identify and discuss crises, potential crises or opportunities.
– Create the catalyst for change.
2. Form a powerful coalition
– Assemble a group with enough power & influence to lead the change effort.
– Develop strategies for achieving that vision.
3. Create a Vision
– Create a vision to help direct the change effort.
– Develop strategies for achieving that vision.
4. Communicating the Vision – Using every channel and vehicle of communication possible to communicate the new vision and strategies.
– The guiding coalition has a key role in teaching new behaviours and leading by example.
5. Empowering others to act on the vision – Removing obstacles to change.
– Changing systems or structures that seriously undermine the vision.
– Encouraging risk taking and non-traditional ideas, activities and actions.
6. Planning for and creating short term wins – Planning for visible performance improvement
Recognising and rewarding employees involved in these improvements.
7. Consolidating improvements and producing stil more change – Using increased credibility to change systems, structures and policies that don’t fit the vision.
– Hiring, promoting, and developing employees who can implement the vision.
– Reinvigorating the processes with new projects, themes and change agents.
8. Institutionalising new approaches
– Creating the connections between new behaviours and corporate successes.
– Developing channels to ensure Leadership development and succession.
