New dawn or false dawn? – what are the challenges in implementing Localities?

When it comes to primary and community-based health care, the crucial component of the Pae Ora (Healthy Futures) reforms is the development of Localities. According to the government’s own health reforms website, the core principle of Localities is that ‘people and organisations with influence over community health and wellbeing will collaborate on what outcomes they want to see for their community.’¹ To do this, Locality Plans will be developed to shape services in the Locality, and ‘well resourced, coordinated and integrated networks of providers will support the delivery of Locality Plans’. There are expected to be around 70 Localities by 2024, with the first nine ‘prototypes’ announced in April 2022.¹

As well as being strongly shaped by Te Tiriti o Waitangi considerations, the Pae Ora reforms have been strongly influenced by recent trends in public policy and management that emphasise collaboration between organisations and between policy sectors (eg health and social services), and the importance of community ‘co-design’ of services in order to tackle wicked policy problems.² The Localities concept has also been strongly shaped by international health services and policy research into integrated care and models for addressing the social determinants of health through health services.^3,4

The aspirations that underpin the vision for Localities are laudable; however, some hard-headed realism is required to understand the scale of the challenge in manifesting these. In this Editorial, I set out four key challenges that need to be faced in the implementation of Localities.

The funding arrangements under the previous system privileged traditional general practice over those providing a broader range of primary health services in the community.⁵ The consequences of this funding system for Māori were outlined in vivid detail by the WAI 2575 claimants.⁵ More flexible and pooled funding across a wider range of service providers is a precondition for Localities to make progress. Locality funding pools need to be large enough to incentivise collaboration between health (and other sector) providers. This could occur in two ways. Either significantly more funding is allocated to primary and community services by Te Whatu Ora, or primary care funding that has been channelled through Primary Health Organisations (PHOs) to their member general practices is made accessible to a broader range of service providers. Decisions about how to fund primary and community services will be an early test of The Ministry of Health (MoH) and Te Whatu Ora’s commitment to making Localities work. These decisions will not be made any easier at a time in which organised general practice is very unhappy about the recent rollover of the PHO Services Agreement Amendment Protocol, and years of delay in reviewing the capitation formula.^6,7

Collaboration is not for the faint-hearted. International research in health services shows that most attempted collaborations in health care are patchy or fail to gain any traction at all.⁸ A recent systematic review of successful collaboration has emphasised the importance of achieving ‘small wins’ early on that help virtuous circles of trust develop between collaborative partners in order to support more extensive and impactful collaboration.⁹

Recent New Zealand (NZ) research has shown that even the most collaborative of health districts rarely include organisations and communities beyond District Health Boards (DHBs) and PHOs.^10,11 Partnership between tangata whenua and health sector organisations is a cornerstone of Pae Ora generally, and Localities specifically, through iwi-Māori partnership boards. But, in addition, Locality partners will also need to learn how to involve a broad range of communities (Pasifika, rural, people with disabilities) in co-design of services and collaborate with social service organisations and local government. This will generate multiple, and often conflicting, imperatives for Localities.

Collaboration, done properly, is highly resource- and time-intensive,¹² and requires skillsets of managers, clinicians and community representatives, which are unevenly distributed across the country.¹¹ It is not yet clear what support and training will be available to participants in Localities to support the development of these skills where they do not currently exist.

Most Te Whatu Ora managers will have worked previously in the MoH or DHBs. Health officials at national and local levels will need to unlearn many practices and attitudes. The most pervasive impact of NZ’s neoliberal revolution of the 1990s has been how MOH and DHB officials have related to non-government organisation (NGO) providers in primary and community care. New Public Management inculcated ‘habits of mistrust’ between government and non-government providers of health services. The prevalence of short-term contracts with non-government providers (reducing real levels of funding over time) and the use of financial and reputational sticks and carrots across the whole range of service providers fostered a ‘them and us’ relationship between funders and providers in many, but not all, parts of the country.¹¹ Although the reforms aspire to improved collaboration and improved accountability, on a day-to-day basis, these imperatives are often in direct conflict with each other. Collaboration takes time to bear fruit, but timeframes for accountability are notoriously short-term in the routines of the state sector.

Relationships between primary and community providers are strongly shaped by the relative power of medicine and general practice, which is manifested through funding flows and control over scopes of practice.¹³ Taken at face value, the introduction of Localities could challenge general practitioner roles, business models and relationships with tangata whenua, local communities, other professionals and other service providers. Collaboration in primary and community care is often counterproductive when existing power relationships are left intact.⁸ The implementation failure of the parts of the 2001 Primary Health Care Strategy that were aimed at broadening and widening the governance and delivery of primary health care can be attributed to a widespread (although not universal) unwillingness of general practice to share power.¹⁴

Although Localities are a national initiative, implementation is local, and we can expect to see multiple new dawns and false dawns across the country. What happens in the first 12–18 months is crucial. No-one involved should underestimate the scale of the challenge.

The author is a member of the Editorial Board of the Journal of Primary Health Care.