COVID-19 care in the community system learning opportunities | KŌWHEORI-19 he whai wāhi hei ako pūnaha manaaki i te...

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Executive summary | He kupu whakarāpopoto matua

A project was initiated with Manatū Hauora | Ministry of Health (MoH), COVID Care in the Community (CCitC) health providers and Te Tāhū Hauora Health Quality & Safety Commission (Te Tāhū Hauora) to understand the processes that the CCitC hubs had adopted. The scope of the review includes four care coordination hubs identified by the MoH (three in Auckland and one in Southland) and may not reflect the approaches adopted by other hubs. Through a collaborative system learning review methodology[1] and the use of focus groups to hear the lived reality, we were able to learn about the important models of care delivery and how these have underpinned and informed improved care.

The project was to purposefully emphasise the localised lived experience of CCitC care providers, therefore the work that occurred before 2022 by the MoH in establishing and shaping the design of CCitC was not within scope. This review has identified system improvement opportunities, derived from common themes from the four hubs we engaged with, that can further inform and strengthen existing national and regional health care system enablers to support those providing care. Our aim now that CCitC has moved from the MOH to Te Whatu Ora, that Te Whatu Ora and Te Aka Whai Ora work together to act on the system learning opportunities to help strengthen the health care system and support all those providing health care in the future.

This report is focused on the CCitC response from January 2022 through to the end of July 2022 and there are several key salient points that are important to highlight:

• differing contexts meant that there was no ‘one size fits all’ approach. There was a need to work relationally to understand the contexts and find solutions that met these diverse needs
• decentralised responses were needed to respond rapidly to the changing needs of communities yet these were dependent on centralised resourcing and strategic direction. This local-central interdependence created challenges to coordination
• the historical system structures, priorities and funding models conditioned and constrained the way the response unfolded. Issues of power and voice were central to challenging these and finding new ways of working
• the formal safety systems captured certain kinds of harm but were blind to many significant risks being managed by staff
• the response relied on reprioritisation of care and redeployment of staff. The capability to respond effectively to future waves cannot be assumed.

Understanding the system to inform improved care

The changing risks highlighted throughout this report, and the adaptations that were made to manage them, were generally invisible to our formal safety system in health care. Health care workers saw that responding to harm and adapting for and resolving issues was core to their daily work rather than identifying such harm and issues as risks to be reported. This is a common finding in complex adaptive systems, such as health care, where managing competing risks is a key task and is seen as an intrinsic part of professional identity.

Safety learning is dependent on making visible the changing risks within the health care system and highlighting ‘system surprises’. It is notable that the issues reported by participants in the focus groups were not captured by the MoH CCitC framework or other formal safety structures. The concern is that this finding may be replicated in other parts
of the health system, meaning other areas may also be potentially blind to how risks
are changing.

Additionally, given the dynamic work and stretched systems, local quality and safety governance has predominantly focused on resolving operational issues, with limited use of hospital reporting systems or formal feedback channels.

System safety improvement opportunities:

• enable models of governance that meet the needs of diverse whānau and communities and inform the funding of health care services to meet the needs of end users
• widen the health care risk reporting system to encompass community, primary and public health care services and focus on making visible how risk is changing across the whole health system.

The CCitC response highlighted the different realities and needs that exist within Aotearoa New Zealand. Rather than a single response, multiple responses were required to deliver safe care that met the differentiated needs of people. These responses were built on the existing relationships that the CCitC hubs had with their communities.

However, the responses were constrained by historical structures that were often poorly matched to the need for a whole-of-system approach. These include the boundaries between primary and secondary health care or in traditional demarcations between ‘health’ and ‘welfare’. It took extensive effort to bridge system boundaries and develop innovative new ways of working.

Information technology (IT) system improvement opportunities:

• provide a single IT health record across all health providers (for example, general practice, ambulance, hospital, maternity) that also supports whānau-based health care
• create governance tools (dashboards, reports, etc) to provide transparency of the overall health care system performance and to inform clinical governance decision making
• telehealth services to support rural emergency and primary health care response.

Understanding the impacts of how health care is commissioned and funded will be central to meeting the needs of differentiated communities. Pre-existing funding mechanisms had significant impacts on the provision of health care. While these mechanisms have worked well for funding general practice (GP) services, they were poorly suited to other primary and community health care providers, particularly Māori and Pacific providers.

Commissioning system improvement opportunities:

• ensure investment in ‘by Māori, for Māori’ and ‘by Pacific, for Pacific’ health services that will enable health services to be responsive to their communities
• fund for capacity rather than just activity, allowing health care providers the flexibility to meet the changing demands of health care in their communities
• provide ongoing funding for the CCitC hubs to support health care delivery across system boundaries and maintain the health capacity to respond to public health challenges.

Authentic and appropriate models of care are informed by those who best understand the cultural needs of their communities. This requires a workforce that shares the same cultural values as the communities they support.

Workforce system improvement opportunities:

• a long-term commitment to growing a diverse workforce that can meet differentiated needs, in particular, increasing the number of Māori and Pacific people in the health workforce
• develop the unregulated workforce, such as kaimanaaki and health navigators, to help deliver appropriate health care services. This would include a pathway of recognition for unregulated workers and mechanisms of oversight.

The success of the CCitC hubs was built on being able to work relationally with those needing CCitC, taking time to understand the experiences and specific needs of people engaging with the health services to guide service delivery appropriately.

Consumer- and whānau-centred system improvement opportunities:

• models of health care must not be built on assumptions but are culturally intelligent, valuing communities’ ‘soft intelligence’ and focused on reducing inaccessibility.

Footnotes

[1] Pupulidy I, Vesel C. 2017. The learning review: adding to the accident investigation toolbox. In: Proceedings of the 53rd ESReDA seminar, Ispra, Italy. European Commission Joint Research Centre.(pp 255–61). URL: www.safetydifferently.com/wp-content/uploads/2018/08/171024TheLearningReview.pdf.