You can spend a lot of time and money designing health systems when often what is really needed is just funding for what is already there
Opinion: We had Associate Health Minister Barbara Edmonds at a From The Couch hui in Manukau last week. It was a good opportunity to show her how this community-driven wellness service works. To ask her to press officials to see past the end of their desks and understand what good and bad health is really like.
From the Couch (FTC) engages people living with obesity in a programme developed by Dave Letele and Buttabean Motivation (BBM), now fully supported by the primary health organisation Total Healthcare. It is a wraparound, free-to-the-user service that combines exercise, nutrition, life skills and medical support in a whanau/aiga community style. It has demonstrable, researched success.
Nearby, Te Whatu Ora is setting up (at a huge multiple of the cost) a liquid diet/medication/surgery service. No, I don’t know why either.
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People in the BBM programme spoke with pride about their journeys. Weight loss is only part of it, just as weight gain was only a part. Depression, drugs, education, housing, food costs and all the related issues were how they arrived at FTC. Working together with their “village” of the other participants, they will work their way out. The medical world sees “co-morbidities”, which there surely are. But solutions do not come from such a deficit base view. Only treatments, not solutions or even prevention.
With my tendency to over-intellectualise I could not help but relate the korero to the recent book by Arline Geronimus, Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society. She draws detailed attention to the physical toll (expressed in co-morbidities) from the constant stress of life in marginalised cultures as compared with life in a dominant culture. It is another way of expressing what our FTC people were telling the minister about their “lived experience”. From the community and sharing even a home village with one of our leaders it seemed to us that Edmonds got it. We hope she can translate it to the very different village in Molesworth Street. If not they could do worse than read Geronimus’ book.
The prototype work on “localities” has mainly highlighted the depth and breadth of the needed network service response to health issues – much of it beyond the funding or operational scope of Te Whatu Ora
It's been a bookish week for me. The work of FTC and the wider work of BBM is all about a community – or local or village – approach to social and healthcare change. You can see this in a wide range of kaupapa Māori and Pasifika services which are trying to create solutions consistent with their own cultures. The importance of this is globally recognised by most analysts and policy makers these days, but translating it into action is much harder. Probably impossible for national bureaucracies, even with the best of intentions. This week, while thinking about this, I read Hilary Cottam’s Radical Help: How We Can Remake the Relationships Between Us and Revolutionise the Welfare State, which I also recommend.
Hilary Cottam is at base a social activist who turned her mind to policy and service design because she had to. She (and of course many others) have been working for the past couple of decades in the UK to set up social service programmes that relate local communities to local needs and bypass the established structures. Those old structures no longer work for so many of those most in need.
Community activists here will recognise all of the situations and some of the responses. It is inspiring and insightful stuff. People of good intent working in the old structures should be asking themselves hard if those intentions are capable of being met from within the machine. Radical Help will be more use than the latest encyclical from the Public Service Commission.
I have also been following material from the UK think-tank New Local which is aiming to “transform public services” to devolve power and funding and delivery. It is supported by a group of the more progressive local councils. Their work is insightful and practical for the situations they face, and we have much to learn from it. I wish we had something similar but our local government seems often lost in terms of purpose and resources.
Here the Pae Ora reforms have a very significant focus on the localisation of primary health services. This has been rather obscured in public debate by the centralisation of DHBs but to achieve local delivery and funding allocation is essential to the reform objectives. There are huge problems with this aspect of the reforms.
Part is knowing what “local” is. (I will write separately on that in due course.) Part is also the way the reform is structured. At a very simple level the reform is trying to drive localisation from the centre (not quite oxymoronic but certainly a challenge). The prototype work on “localities” has mainly highlighted the depth and breadth of the needed network service response to health issues – much of it beyond the funding or operational scope of Te Whatu Ora. I have no doubt as the Iwi Māori Partnership Boards get established and operating they will identify the same issues.
Local versions of Weathering and Radical Help will be identified and there is a long distance to travel to meet that. Although the legislation requires local government involvement in the “locality” process, this has been very limited. There is really no structure to deliver response to the needs being identified. Whanau Ora, the Primary Health Organisations, service providers such as GPs, local and central government social agencies, voluntary services and iwi/hapū all have to be involved. We are finding this is much bigger than the legislation drafters really grasped. Those trying to implement this part of the reform have a more than daunting task, and there must be some resetting to support.
The reason for that failure is the distance the reform drafters have from real community lives. You can spend a lot of time and money designing systems when often what is really needed is just funding for what is already there.
