Turuki Healthcare and the response to COVID-19 between February and May 2020

In a series of articles on Aotearoa New Zealand’s resilient health care during COVID-19, we hear about Turuki Healthcare and the response to COVID-19 between February and May 2020

Turuki Healthcare is a multilingual kaupapa Māori health provider providing local whānau-based primary health care, wellness, pharmacy, parenting, domestic violence, mental health and social services to more than 11,000 enrolled patients in south Auckland.

Changing and adapting, rapidly and effectively, for people, by people

‘When the country went into level four lockdown we had to change what we had been doing in general practice, for 20 years, overnight,’ said Renee Muru-Barnard, primary health care manager at Turuki.

While many primary care practices were forced to close doors, ‘We had a commitment to stay open for whānau,’ said chief executive Te Puea Winiata. That meant a difficult calculus – protecting and treating whānau but not at the expense of workers’ own whānau. This meant personal protective equipment (PPE) and stringent infection prevention and control procedures to protect the families of workers.

Immediately, Turuki faced challenges: there was insufficient PPE or hand sanitiser for staff, for example. Leadership improvised to protect staff, purchasing their own PPE, even using painters’ overalls when PPE gear was unavailable. In general, it was felt that Māori providers could not wait for funders, so they provided out of their own funds and budgets.

Adaptation to events meant adaptation by clinical staff and adaptation by the whānau they serve, towards the outcomes that matter. These outcomes were the guiding value and principle that shaped the response. Organisational and staff and workforce adaptation was generous, permissive and founded on trust.

The Turuki workforce is a community in itself, and it rallied around itself in a spirit of trust and mutual assistance. Staff who were parents were granted freedom to work from home as needed, and time off without leave. Any illness at all and staff were sent home to protect themselves, their whānau and their patients. All staff were provided a lump sum payment by management to ‘top up’ their cupboards just before lockdown. Meanwhile, older workforce in social services were rapidly upskilled in digital environments new to them, and casual work delivering food parcels to clients was offered to staff whānau in need. Showing dedication and aptitude led to the transition for some into the Turuki workforce.

At Turuki practices, sick people were assessed by phone, then swabbed in their cars by staff in full PPE, and brought into quarantined offices if required, which were then deep-cleaned after every patient. As an essential service, Turuki was able to call on friends in the construction industry to source more disposable overalls to fill the gap of PPE gear, and gazebos and the sandbags to hold them down so they could make a makeshift waiting area on the forecourt of the clinic in Canning Crescent, Mangere.

Turuki staff displayed a commitment to work constantly during the response, long into the night, processing constant flows of information coming from the Ministry of Health, adjusting and updating protocols, and reinterpreting a massively emergent situation and sets of recommendations for their practice.

Changed models of care

GPs with colleagues in Italy were watching and learning daily as the Italian system became overrun. By necessity, and in the new mode of permissiveness, new models of care were able to be developed that responded to existing need and preference.

‘We were not set up for a virtual environment,’ said Renee. So leadership made bulk purchases of phones and laptops for staff to conduct consultations as well as proactive welfare checks on whānau.

In the first two weeks more than 2,000 virtual consultations were conducted, checking in on whānau, conducting antenatal classes, communicating the impacts of COVID-19 and what people needed to know. The school-based health team pivoted to conducting welfare checks by phone call to check on whānau wellbeing. At Turuki, prior to COVID-19, whānau generally disliked making appointments, and preferred walk-ins, even if that meant a 2–3-hour wait. It transpired whānau loved virtual consultations (which had been an objective for future planning).

Another aspect of the project plan for the future was GPs and support staff working in teams to deliver care, rather than the traditional one GP–one patient model. Turuki was working towards a model of a multidisciplinary team of clinicians providing wraparound care to whānau: GP, nurse, scheduler, health care assistant and support workers. The plan was intended to reduce GP time, increase and improve coverage of patients, manage risk and improve experience for whānau, so they would not have to repeat (often traumatic) stories to, over time, perhaps many different GPs.

When any given whānau member came into the clinic, someone on the team would know what the issues were, especially underlying issues beneath or around the central issue consulted on. Referrals to external providers (anything from breastfeeding to early childhood education to justice) would therefore be more appropriate to the underlying need. Part of this process was the introduction of ‘talking rooms’ – comfortable, intimate rooms for kōrero, designed to avoid the typical situation of a patient talking to a GP who is looking away at a computer to complete elements of the patient management system. COVID-19 accelerated this innovation in tandem with virtual consultations.

During lockdown, doctors and their teams of nurses and support workers operated in bubbles, physically isolated from other teams in the building, but complete within their own bubble. Every Thursday those bubbles sat down to talk over their own issues and their own stories. GPs loved the new working environment and teamwork, versus working isolated in rooms with single patients.

Wānanga online resources mostly delivered via Facebook experienced massive growth, generating up to 365,000 views. These included karakia sessions conducted daily at 7pm, providing spiritual guidance and connection for people during prolonged periods of isolation. Spiritual support, guidance and connection were also continued through online Maramataka Wānanga, where facilitators share mātauranga Māori frameworks for understanding of the lunar cycle in te ao Māori and how people can use these cycles to manage and enhance their mental wellbeing. Mental health and addictions programmes, also those addressing other issues like relationships, involving self-directed work alongside weekly Zoom sessions provided a measure of stability and consistency to whānau during isolation. These programmes, via the convenience of Zoom and Facebook, were achievable at low cost and large scale, reaching into Māori homes not reached before.

Organisational flexibility

Turuki mobilised its relationships to assist its community. Drawing on existing relationships and partnerships in the Whānau Ora network – more than 70 across the North Island – Turuki partnered with others to provide an outreach service, distributing kai, heaters and supplies around the community to rapidly address the new and evolving needs of whānau/families in south Auckland. The whakamā (shame) of requiring food parcels soon gave way to necessity for many, and was alleviated by wraparound support of food and care packages delivered to whānau confined at home by lockdown.

‘Māori providers have a nimbleness and an agility to mobilise and to turn a ship round on a penny very quickly. There’s no other network like it,’ said Te Puea.

Turuki’s focus on older patients meant proactive calling-up of kaumātua to check on their wellbeing, accommodation, food and medication. Some of the response was founded on opportunistic alertness: anticipating and investigating likely need and responding to it. Turuki team members in the community noted clusters of pensioner flats. Were these people being cared for under the unprecedented conditions of lockdown amid the national COVID-19 response? The conditions of their accommodation meant these elderly people were seen by the system as individuals responsible for their own welfare. Turuki sought sanction from Kāinga Ora – Homes and Communities, and the Selwyn Foundation Haumaru complexes, and proactively approached the older people living in the units (while obeying social distancing protocols), established connection and assessed their needs. Turuki received a koha from Kāinga Ora in response and delivered food parcels, ‘winter warmer’ packs including blankets, beanies, hot chocolate, heaters and bedding packs, as well as providing valuable contact and intimacy to elderly people secluded over this period. Flu vaccinations were brought to individual homes and administered there.

The focus was also broad – Turuki helped develop baby packs for whānau with new babies. Baby capsules that were usually reused were not able to be so during COVID-19 restrictions, so with financial assistance and blankets provided by the Middlemore Foundation, Turuki provided capsules, nappies, cots, prams and bedding. As part of the broader Whānau Ora response Turuki helped facilitate the distribution of Whānau Ora supplies – like disinfectant, toilet paper, flour, other similar supplies depleted due to early panic buying, plus boxes and tape to package them – to organisations and social services such as kōhanga reo and local kura to distribute them through their whānau and networks.

Turuki’s Te Ira team (which supports whānau going through the justice system) were redeployed after the courts were shut down to manage a ‘pop-up’ warehouse with pallets of donated goods and bulk-purchased kai to pack and deliver to thousands of whānau.

Organisations rallied around one another. Auckland City Council, with excess food donated by the Auckland community, handed supplies to Turuki for distribution. WINZ gave access to two dedicated workers and provided flexibility to whānau in need with top-ups, funded phones and kai in emergency situations.

What was learned and should be retained

Staff now remain keenly aware of the challenges ahead amid the massive economic fallout, such as the effect on people’s mental health and other issues currently invisible to the system, such as domestic violence and abuse, and drug use.

For Turuki, there were a lot of positives to emerge from the experience, including:

• the emergence of new capabilities within the organisation and understanding of the organisation’s capacity to be as responsive to whānau as they were, unshackled by prior service specifications that did not work
• more permissive structural and regulatory environments can lead to great innovation and it is therefore a struggle to return to a previous way of working with funders
• the emergence of new relationships and networks means that those connections will and can be quickly re-ignited for emergency responses and mobilisation of resources should this be required in any resurgence of COVID-19.

For Turuki, the discussion needs to be how they can do more of what they did. This makes Turuki an ardent supporter of the establishment of a Māori Authority and local commissioning where they have greater say in where the money goes to create a shorter pipeline from money source to provider to whānau.

‘No one comes to our practice with just one issue,’ said Te Puea. ‘We need to be an octopus.’

The need for an early strategic move towards ‘warm handovers’ of people presenting to the practice to a network of preferred providers for ongoing care came into stark relief during the response.

‘We need a network that “holds people”,’ said Te Puea. ‘The model of two GPs and a receptionist has its place but primary health is moving towards needing scale, responsiveness and collaboration. It is impossible to write what we did in an emergency plan. We were never invited by the DHB [district health board] to emergency planning prior to this pandemic and a forum of shared learning and building trust between government agencies and community needs to be an ongoing focus.’

Te Puea pointed to the need for – and permissiveness during COVID-19 – Māori to be Māori, and have Māori solutions, a shared language and shared learning.

Turuki adapted, improvised, did ‘whatever it takes’. The commitment and dedication of staff to respond quickly and in line with best practice were what strikes Te Puea as the key story of the Turuki experience of COVID-19 in 2020. There were multiple moving parts, and some grated. Staff failed fast and learned quickly, and adapted, forming new relationships at speed and displaying incredible precision in an imprecise context.