Annual Review

One year on from Te Whatu Ora’s birth, Chief Executive Fepulea‘i Margie Apa speaks to The Specialist about how far she thinks they’ve come and what the biggest challenges have been.

It’s been almost 12 months since Te Whatu Ora began. How has this journey been for yourself?

The past 12 months have been challenging – I think that is an understatement. Even though I had worked in a district health board running a local hospital and held national health leadership roles, I think the degree of variation I became aware of across the country still surprised me. It made me think carefully about what pace of change is appropriate for us at a time when we were still undertaking detailed due diligence and discovery of how things were working.

We are doing our due diligence while merging and working out what we have inherited, changing to realise the opportunities of being one organisation while ensuring we have continuity of care in day-to-day delivery.

It’s been quite challenging but at the same time inspiring and encouraging. We can see the opportunity – the differences in experience and equity of access across the country – is more visible. I think that is the crux of what the reform is about. It is not fair, for example, that people in places like Tairāwhiti or the West Coast do not have access to the same kinds of specialist services and outcomes that those populations need, compared to others.

What are the milestones for the next 12 months? What do we want to see happen by July 2024?

By then I would like to have fully functioning national clinical networks to support equity of access to care. We will have localities rolled out across the country for local voice in health service planning. I would like to think we will have recruited and reduced a large proportion of our clinical vacancies. This is top of mind because that will give our people more confidence that we have the teams to deliver care. I know that one of the toughest things right now is people are working a lot of overtime to cover those gaps.

I would like to have invested and/or increased support into primary care and our community-based NGOs to leapfrog shifting of care. I would like to have commissioning in a place where we can collaborate and better partner with providers in the provision of that care.

You talk about recruitment. Do we have a gauge on how short we are in regard to our recruitment level?

We are about 5,000 clinical roles short. That is doctors, nursing, allied health, midwives and care support workers. Midwifery has the largest proportion of vacancies – about 25 per cent of roles unfilled. At that size and scale it is tough to get teams to cover those gaps.

NOTE: ASMS’ 2022 survey of Clinical Directors found a mean 24 per cent shortage of SMOs across Aotearoa NZ. Some specialties were seeing greater rates, such as Emergency Medicine and Intensive Care (both 27 per cent), and public health medicine (44 per cent). These figures equate to a national shortage of 1,850 SMOs, alongside 4-5,000 nurses identified by NZNO.

Unions are in bargaining this year. Do you think any industrial action or negotiations themselves are going to affect the transformation of Te Whatu Ora?

We are going into bargaining with openness to understanding others’ views and willing to put our best foot forward. We are in the second year of a two-year funding pathway, and we are bringing everything we can to the table that is affordable for us to offer. It is not just about pay. There are many things we can do better as a national service – for example, health and safety. We are very worried about aggression and workplace violence towards our kaimahi, for example, and we need to work together on those issues. In bargaining, we want to do the best we can from the perspective of pay and improving our places of work.

What about the competition between Australia and New Zealand for workforce? Do you feel we need to be more competitive to attract and retain health care workers?

I find it difficult to compare without understanding what is underneath the differences – for example, taxes, work hours, other terms and conditions, and cost of living and non-pay related conditions. These all add to the mix of how a person decides what country they live and want to work in. I think we can do more to make our workplaces a better place to work –for example, leadership, having the tools and the kit [equipment] to do the job, how we invest in innovation and research.

We want to do everything we can to make the full package of working here as a clinician a really good experience. We will always be competing with a bigger Australian economy. I think the test for us is being sure that we are bringing everything to the table that we can. That is both pay and non-pay related.

Is there going to be a reset of Te Whatu Ora data to make information sharing easier? ASMS has called for a census.

We don’t need to wait for a census to tell us we’ve got challenges. I think we should go further than a census. We want information systems that offer real-time and live data we can use. We would be happy to share it as long as we anonymise individual data. Information is an asset for the whole health system. It will take some investment and time, some of which we have to make a case for because we did not get a lot of transition funding that would fund those big information system investments. We know our payroll systems need fixing so we can be assured we are paying our people what they are entitled to and ensure people are being treated consistently across the country.

Do you feel the vision of bringing together all these DHBs has been a good one? What does success look like to you for yourself and patients?

The vision is a very good one – to have a national health system that operates as one to meet the needs of people and includes the relentless pursuit of health equity. Success will be bringing teams together and joining clinical services across regions. A simple example is in Southern where they struggled to recruit to specialist roles – like many districts – they were doing it on their own. So success will look like bringing a national network of cancer colleagues together to co-ordinate care, support covering rosters or to provide treatment. We need to fill vacancies – don’t get me wrong. But if working together as a national or regional network means people will get treatment and care sooner and we can support teams providing that care locally (even if we offer it in another area), that’s got to be good for everyone. That is the power of having clinical leaders working together and having a mandate to make decisions and make things happen. Our job is to strip away all the barriers that get in the way of that.

Is there anything you would have done differently?

I would have focused much sooner on supporting local leadership leading change. We missed an opportunity to give our leadership some more headspace to get involved in designing the change process and to manage that at pace – but this was difficult when the first 5 months was dealing with winter and working through the technical aspects of change (e.g. keeping decision making going without boards).

As a national team we do have the ability to pool funding to get on with some action – without needing to negotiate with 20 district health boards. An example was early actions on workforce. We pooled $14.4 million in July 2022 (our first month) to get action underway on vulnerable areas such as the primary care workforce (equalising GP trainee remuneration, increasing General Practice Education Programme trainees), expanding NZREX positions, establishing more radiology trainee positions, and expanding Nurse Practitioner trainees among other initiatives.

We did not need to ask for permission of others or go through lengthy consultation processes to do what was obviously required – we could just get on with it. Simplifying decision making and freeing ourselves up to get on with implementation is refreshing – I look forward to doing more.

What was the process before?

To do anything nationally or even regionally, we would have to get the support of every DHB. There would have been consultation and, if required, we would need to ask for funding or contributions from every DHB impacted. Anyone could opt out. Some DHBs didn’t have funding to spare. We would go through all that, often taking months to do so, and end up with less than what we needed to be impactful nationally or regionally.

What has been your biggest learning through leading Te Whatu Ora?

Focus on what is critical to support implementation and getting things done. I’ve had to learn to be quite focused on the essentials – there are so many challenges and opportunities. There are always day-to-day issues and events that can attract public interest and scrutiny. It’s a real challenge to respond to what is sometimes ‘noise’ while keeping an eye on the fundamentals of what matters to delivery of care – people, resources and supporting regional and local leaders to maintain continuity of care.

I sensed there was some inertia creeping in because people were waiting for Te Whatu Ora to come up with the answer. Actually, all of our workforce are Te Whatu Ora, and regional and local leaders already had the authority and delegation to get on and do things.

We have had other changes in the health sector with the change of Minister and the sacking of Te Whatu Ora Chair Rob Campbell. How did that affect the past 12 months?

Even with district health boards you would have Board Chairs and Ministers change from time to time. So this change was not too different from that experience. I think it reminds us, actually, that Te Whatu Ora exists for a purpose, and the kaupapa is bigger than any one person. So our programme of work did not change. Our Board expects performance for New Zealanders, and their job is to hold us to account on behalf of the Minister – on behalf of all New Zealanders. Minister Verrall sets direction as the responsible Minister for Vote Health – it has been very useful having a clinician who knows the sector well from the inside.

What message would you like to pass on to the clinicians?

My main message is to get engaged. We want to support all the ways clinicians can get engaged in leadership – we will establish national and regional clinical networks and we will be advertising for national clinical leadership roles this year. Networks won’t work unless colleagues get actively involved – many already are. Those networks will help us shape decision making on service or specialty priorities, work on ways to reduce unwanted variation in access and outcomes from care, and support workforce and service planning. Networks will give the Board and me advice and recommendations on how we improve care. I really encourage people to get engaged and continue to give us feedback so we can keep improving. We are all in this together.