Implementing new forms of collaboration and participation in primary health care: leveraging past learnings to inform future initiatives
Lesley Middleton
1 * , Claire O’Loughlin 2 , Tim Tenbensel 3 , Pushkar Silwal 3 , Marianna Churchward 2 , Lynne Russell 2 , Jacqueline Cumming 2
1
2
3
Abstract
Within primary health care policy, there is an increasing focus on enhancing involvement with secondary health care, social care services and communities. Yet, translating these expectations into tangible changes frequently encounters significant obstacles. As part of an investigation into the progress made in achieving primary health care reform in Aotearoa New Zealand, realist research was undertaken with those charged with responsibility for national and local policies. The specific analysis in this paper probes primary health care leaders’ assessments of progress towards more collaboration with other health and non-health agencies, and communities.
This study aimed to investigate how ideas for more integration and joinedup care have found their way into the practice of primary health care in Aotearoa New Zealand.
Applying a realist logic of inquiry, data from semi-structured interviews with primary health care leaders were analysed to identify key contextual characteristics and mechanisms. Explanations were developed of what influenced leaders to invest energy in joined-up and integrated care activities.
Our findings highlight three explanatory mechanisms and their associated contexts: a willingness to share power, build trusting relationships and manage task complexity. These underpin leaders’ accounts of the success (or otherwise) of collaborative arrangements.
Such insights have import in the context of the current health reforms for stakeholders charged with developing local approaches to the planning and delivery of health services.
Keywords: Aotearoa New Zealand, care coordination, collaboration, consumer engagement, general practice, integrated care, localities, primary health care.
| WHAT GAP THIS FILLS |
| What is already known: Primary health care is expected to be a part of a wide diversity of activity providing a more seamless and coordinated patient-centred experience. Shifting general practices to take on more care coordination roles can be problematic. Some providers have a starting philosophy as well as the resources and capacity to be very good at this, while others need substantial support to make those transitions. |
| What this study adds: Providing explanation for what has caused variable progress helps identify the type of support that has the most chance of success. Familiar themes of trust and power are examined in different contexts, alongside insights into what helps complex collaborative initiatives gain traction. |
Introduction
As Aotearoa New Zealand (A/NZ) seeks to overcome the funding and organisational silos that pervade all health systems, improved ‘joined-up care’ was one of the aims of the new place-based Localities initiative. Introduced as part of the health system reforms, a Localities approach has been implemented in fits and starts. Twelve local network prototypes1 were expected to dissolve traditional boundaries between general practices, other primary health care services and community and social care. The learnings from these prototypes were then expected to inform a further rollout of new local planning arrangements. A change in government, however, signalled a rethinking in ‘how best to support community involvement in service design and delivery.’ [p. 2]2
The desire for more coordinated and seamless health care is not new. Globally, positive health outcomes are linked to primary health care systems that address the vast majority of a user’s needs, are staffed by providers who know the user’s history and help integrate care with other services.3 Our research stemmed from an interest in how ideas for more integration and joinedup care have found their way into the practice of primary health care in A/NZ. Our research participants commented on a range of collaborative practices directed towards overcoming fragmentation for the benefit of patients. Throughout this paper we have avoided narrowing our field of interest to one form of integration. In line with Hughes and colleagues’4 contention that integrated care is best understood as a set of emergent practices, we have deliberately included a diversity of practices and terms in this paper.
This research occurred prior to the 2022 reforms. However, it is evident from international experience that understanding the legacy of existing relationships and structures influences the successful implementation of new integrated care approaches.5 Furthermore, within primary health care, despite Starfield’s primary health care typology emphasising care coordination as a significant ideal, it is often regarded as one of the most problematic areas to implement.6
Attempts in A/NZ to improve linkages between primary and secondary care, and between health and non-health services, have mostly resulted in change at the margins,7,8 including with regard to Māori approaches. Whānau Ora, the uniquely indigenous paradigm, was introduced in 2010. The approach centres on the ways in which the wellbeing of individuals is intricately connected to the wellbeing of the collective and is based on a pattern of delivery that considers economic, cultural and environment factors alongside health.9 Reviews of Whānau Ora affirm that this comprehensive, joined up approach has resulted in improvements across a range of wellbeing dimensions.10 However, these improvements have been limited by the ways in which kaupapa Māori providers have been positioned as an ‘attachment’ or ‘add-on’ to an unchanged dominant system accountable to narrow predetermined state priorities.9 Moreover, concerns have been expressed that these providers have not been funded at a similar level to Primary Health Organisations (PHOs).11 In addition, their existence may mean central government agencies are opting out of their own responsibilities. This has led to a recommendation that there should be better support for other agencies to engage with Whānau Ora and whānau-centred approaches.12
This research aimed to understand more recent attempts at integration, with a view to building on where we are now and learning what has worked and what has not worked in recent years.
Methods
Our overarching research question for this study was ‘Do primary health care leaders see it as in their interest to be part of more collaborative and joined-up environments?’ Following a realist research approach,13 which seeks to identify the conditions that explain why some interventions work in some contexts and not others, we embarked on over 50 semi-structured interviews. These interviews were conducted with primary health care leaders who were either a chair or chief executive of a PHO, a senior leader responsible for primary health care contracting or a national informant with an overview of primary care change. Our participants were policy insiders working as part of the wider leadership landscape of primary health care. Ethics approval was granted by the Victoria University of Wellington Human Ethics Committee (ethics application #27171) on 5 March 2019.
Our key starting theory was that primary health care policy over the last 10 years has given 10 different primary health care goals varying degrees of prominence (Fig. 1). Each of these goals had energised a particular subset of actors and interests. In the first part of our interviews, we wanted to understand which goals interviewees thought had seen the most and least progress over the past decade and why, and which were the most and least important to focus on over the upcoming decade. Elsewhere, as part of the wider programme of research, interviews were held with key Māori stakeholders, and this has been reported separately.9
A subset of results is presented here focused on the patterns of reasoning participants reported, linked to the policy goals of (1) better integration with secondary care, (2) collaboration with other community-based services, and (3) the participation of communities and service users in decision-making. Fig. 1 displays all the policy goals that were explored in our interviews with the subset this analysis is centred on circled.
In the second part of the interviews, participants were asked to pick two goals for discussion in more depth. For each goal they were asked to indicate their level of agreement with four ‘if, then’ propositions of how change might occur to meet the objectives of that goal. This produced data from 30 respondents that chose to explore one or more of these goals.
The specific research questions we were particularly interested in were:
Results
Part 1 findings
For the three goals grouped around the concept of wider collaboration and joined-up care, what was notable were opposing views. Some participants ranked these goals as being less important and as having made more progress while others felt the complete opposite.
In this article we tease out some explanations for the variation in this subset. For example, those that identified better integration of secondary care as an area of progress over the last 10 years, talked of the success of policy directions mandating alliances between District Health Boards (DHBs) and PHOs, and the consequent successful implementation of work programmes that shifted thinking out of silos. These work programmes were seen as ‘less emotional and less challenging’ (D08_1) than integration between health and non-health services. In contrast, for others, their experience of work directed toward better integration between secondary and primary care was of programmes that failed to turn talking into action. This was often explained with reference to a lack of skills to manage the power dynamics involved. Vivid descriptions were given of those who ‘have predominantly been brought up in the bowels of the hospital’ (P24_1) struggling to understand and trust primary health care.
Those that identified the ‘better integration with secondary care’ goal as one of the least important going ahead, gave a mixture of explanations. While some pointed to having now reached a state of ‘reasonable integration’ (P03_1), others reflected on the sheer lack of progress, despite all the time and attention – ‘it has just been rats and mice and there hasn’t been any real smooth crossover for the population’ (D02_1) – and were thus inclined to move their attention elsewhere.
When considering the goal of working towards collaboration with other community-based services (health and non-health), there was a similar mixed picture. Some participants had seen a shift from competitive behaviour to collaborative behaviour:
I think that there’s just been a kind of an increasing awareness that if you really want to do what’s best for people, operating in a way that’s competitive and siloed just is not a way of working that is going to ever achieve anything. (N10)
Against this more positive assessment was a body of commentary explaining why different PHOs made different decisions on how much time and attention to give to collaborating with non-health services. These decisions were influenced by whether collaboration had commercial benefits, trust in the ability of others to deliver and a PHO belief that this was ‘not really my responsibility’ (D08_1). As one explained:
… the collaboration with things outside the healthcare sector is very desirable and relevant to a kaupapa Māori service or a service specifically taking care of disadvantaged populations, but not the dealbreaker for a traditional clinic. (D12_1)
Familiar themes of trust and power were drawn on to explain why certain collaborations failed to thrive:
Our general practices generally wouldn’t think of referring to our Māori providers or even our community pharmacists because there’s a lack of trust in their ability to deliver. I think that that’s despite the best attempts by our PHO. (D07_1)
When participants considered how much progress had been made towards the participation of communities and service users in shaping primary health services, a similar strand linked to the preparedness of PHOs to see this as their responsibility emerged. For some, progress was seen in PHO steering groups involving community members and the influence of Iwi/Māori community members on PHO boards. For others, progress was slower when the makeup of the PHO was to essentially represent a ‘bunch of small businesses’ (N9) with the consequence being that they failed to see the point of community input.
The following narrative highlights the ways certain cultures are a barrier but can shift:
It’s sort of ‘it’s not really my responsibility thinking’. … which comes through when you talk to any medically trained clinician; if you bring in other clinicians with other perspectives, you do move away from the medical paradigm a little bit more. It’s fundamentally embedded in the medical paradigm. (D08_1)
The Pacific leaders interviewed in this research reflected that collaboration and joined-up care is already a foundation for the frontline delivery of care for Pacific providers. While responsibility for working in that way is assumed, policy needs to catch up to that reality. Moreover, as one interviewee stressed, single issue targeted initiatives should be avoided as they fail to capture the complexity of multiple disadvantage and wide diversity of Pacific community experience in A/NZ.
In the next section we present a selection of explanations for why progress was variable. These explanations focussed on issues of professional power, the importance of building trust and the challenges of managing task complexity. Our initial search for explanations was particularly informed by theories developed by Aunger and colleagues as to why some inter-organisational collaborations in health care work when others do not.14
Part 2 analysis
Initiatives involving joint planning between PHOs and DHBs (ie District Alliances), or the involvement of service users (ie Consumer Health Councils), have been a common approach to prompting more joined-up care. Interviewees explained how joint planning drew on ‘the power of just bringing people to the table’ (D09_1) with change occurring through the ‘power of leadership that says the medical model does not dominate this conversation’ (D03_1). When participants expounded further on how they saw collaborative activities operating when a range of people were around a table, participants also identified governance structures such as PHO Boards that created space for a diversity of voices, and confident non-medical people prepared to challenge narrow medical views, as facilitating the sharing of decision-making power. This positive assessment was countered by others who observed different collaborative activities failing because the core power base never shifts ‘despite all the people in the room having good intentions’ (PO_4). Prior beliefs about the dominance of business incentives in primary health care were identified as a reason for collaborative initiatives between primary and secondary care not making much progress. In what follows, we focus on the skills needed by non-medical people to be heard and power shared as a context that helped explain one of the conditions where people saw progress in sharing power.
As participants relayed experiences of collaborative structures such as Consumer Health Councils or Service Improvement Teams, the potential for a large power imbalance between the health professionals and those representing consumers was regularly raised. The narratives below illuminate how a willingness to share power required an ability by non-medical people to challenge and a readiness from health professionals to listen to lay perspectives:
I think to get it, a consumer voice that has the confidence to stand up to a doctor, for example, is quite difficult. (D20_1)
… if you put a consumer with a bunch of clinicians …. We had to work really hard with our chairs to think differently and to be really clear about how a consumer doesn’t represent all of New Zealand, a consumer just brings a lay perspective to the table that might be different or challenge your thinking. (D08_1)
These lay perspectives may not always represent a diversity of lived experience:
Consumer groups, and you get consumer reps as such, they’re a very elite group of people generally with really high levels of competence. That’s not the people with bad health outcomes. (D11_1)
Examples were given of processes that did bring a diversity of experience ‘to the table’:
We have a … group here who through a peer support organisation have started conversation cafes and things like that. They’ve organised themselves around being able to reach other consumers, as opposed to them being the experts and having to represent that directly from their own experience, and they see themselves as a conduit for experience coming in. (D20_1)
In addition to highlighting a willingness to share power, interviewees also pointed to the importance of trust for partnership functioning and effectiveness. A common thread identified in many interviewees’ reflections were experiences that built the link between ‘trust’ and ‘relationships.’ As one participant explained ‘… you can’t have a strong effective relationship without knowing who people are’ (PO4_1).
Processes of building trusting relationships across the new collaborative arrangements were found to be supported or stifled via a myriad of different conditions. These included the inhibiting influence of forced or mandated partnering on the trust-building process versus arrangements where partners came together voluntarily around a shared vision. Interviewees also reflected on the authenticity of partnerships, namely whether partnerships are genuine, and stakeholder-focussed, drawing on examples from the measurement of patient experience in primary care. In the excerpts that follow, we highlight interviewees’ insights about developing ways of keeping relationships intact.
One participant suggested that physically locating primary care practices alongside other community services encouraged trust-building between partners, by providing opportunities to cement relationships:
At all levels it’s about relationships, and it’s always easier to get those connections to work with someone you know. It’s also harder to dislike, hate or vilify someone that you know. I mean, we’re human beings. It’s like the evil funder concept, we’re evil funders only because you don’t know us. Once you actually get to know us it’s actually hard to say that we’re nasty people. So, getting people in the same space talking to each other is always useful. (D04_1)
Another interviewee explained that co-location of primary health care practices supported the goal of collaboration with community-based services by facilitating trust in the collaborative partner to take over management of resources:
We did a lot of work with [name of Māori Development Trust] around putting GP clinics onto some of the marae that [the Trust] look after in [name of region]. Ultimately, we’ve kind of turned that over to them so they now look after that rather than us looking after that. (P15_1)
Related commentary drew on the structures and processes some PHOs have put in place to enable their primary care practices to better connect their patients to non-health services. One interviewee suggested that developing linkages with organisations such as Iwi, urban Māori providers, and Pacific providers, as well as housing, welfare, justice, education and employment providers, offered a supportive platform for building and maintaining trusting relationships:
Eighty percent of what most people want to do in health and social settings is the same. There’s a 20 percent difference – different ways of getting there and everything else, but 80 percent is we’re all pretty aligned and kind of the overall shared sort of outcome that we’re wanting to achieve in partnership. It’s about the relationships and the partnerships. (P24_1)
The previous sections highlighted the dynamics of trust and power, but as one interviewee pointed out ‘trust is only one of the ingredients’ (P27_1) and relationships, while valuable, need to be backed by systematic support. Integrated care initiatives also involve considerable managerial complexity as they assume a shared goal of population heath improvement and community engagement from a primary care sector that can easily be swamped by acute demand. Participants’ experiences with the functional activities put in place to reduce the complexity of managing integrated care underscored several important contexts. Some highlighted the complexity of the work involved in incorporating consumers in decisions, for example where co-design experiences created service user expectations that were unmatched by resources. Others pointed to the value of good information systems where managing the complexity required was enhanced by effective information exchange directed at identifying practical problems to be solved. In this section we focus on the importance of reading the context for change.
The theme of ‘making it easier’ underscores how PHOs potentially add value by making it easier for general practices to implement changes because they understand the context for general practice and work to make change manageable. Participants’ narratives explained how PHO leaders implemented changes in ways that fitted into workflows and responded to a call for proof ‘that it’s good for their patients and safe’ (D04_1).
An example of ‘making it simple’ concerned mental health engagement. In this instance, the PHO forged personal relationships between one mental health non-government organisation (NGO) and one practice in an environment where there were many competing mental health NGOs. The result was that:
Through having that personal relationship, people were much more likely to refer into those services. Now, the services weren’t always the right service, but the NGOs had a better understanding about what each other did differently to move the people around [rather] than trying to teach all of the GPs what all of the NGOs do. (P17_1)
Not all PHOs saw it as their role to prioritise actions that reduced the complexity of implementing integrated care initiatives. While in some areas, alliances had clearly created a sense of momentum, particularly in Canterbury where a ‘one system one budget message’ had resulted in new referral pathways, shared technologies and better management of hospital demand.15 Others found freeing up resources to do more integrated care ‘easy to talk about, but harder to do’ (N3). As a result, it was not uncommon for wider engagement to be recalled as ‘projects’ involving many meetings that only fleetingly influenced day-to-day operations. Frustration was expressed by participants that despite energy and effort put into projects designed to better integrate primary and secondary care, most had yet to become business-as-usual. One interviewee’s description of the ‘light touch’ primary health care policy environment as ‘programmatic’ was given as an explanation for why the resulting series of ‘projects’ had not been a powerful force for change:
From my perspective, we have potentially done some enabler policy like patient portal; still programmatic. We’ve done some workforce policy; increased the number of GPs on placements but [that] doesn’t recognise the trans-disciplinary nature of where we want primary care to go. We haven’t invested in primary care beyond the national contract and national formulas. (N10)
Discussion
When they were established, PHOs were expected to develop stronger relationships with their communities, but after 20 years the results indicate a patchwork of collaborative practice.8 Our findings indicate that wider collaboration only happened in contexts where PHOs saw wider engagement as their responsibility. With the introduction of the new prototype Localities, some of the explicit power differentials may have shifted as PHOs were only one of many players charged with place-based planning. However, given the further search for new arrangements to promote local responsiveness to local health needs, what is going to prompt further energy to collaborate, particularly from those who did not put their hands up to be early prototypes? Expectations of a central role for Iwi-Māori Partnership Boards alongside other community providers2 offer an emergent window of opportunity for a different form of local planning. Our findings suggest that whoever takes on a lead role will need to embark on programmes of action that successfully manage power dynamics, build trust and develop the capabilities to engage with the complexity of the tasks involved.
The implementation literature regularly points to the importance of trusting relationships. Our findings support the contention that strategies for building trust involve both relational actions modelling empathy-driven exchanges as well the technical work of frequent interactions demonstrating quick wins.16 Collectively, these relational and technical approaches build capability, opportunity and motivation for the concrete behaviour change needed by primary care leaders if they are going to commit to collaborative activities.
The international evidence suggests that effective integrated care is heavily influenced by culture, trust and relationships between professionals from different teams, care settings and sectors.16,17 These are ingredients that the designers of the new Localities arrangements were also well aware of, stressing ‘you cannot build anything until you have trust and relationships’.18 For Māori, trust in the health system starts from a low base with the system’s failure to be trustworthy to Māori laid out in the report on primary health care by the Waitangi Tribunal11 and other analyses.19 While the COVID-19 pandemic has been characterised by a new high trust environment between Māori providers and government, the tendency for agencies to ‘snap back’ to business as usual once the worst was perceived to be over, has also been observed.20 Moreover, the fast-track disestablishment of Te Aka Whai Ora, the Māori Health Authority, before the Waitangi Tribunal had an opportunity to complete an urgent inquiry into its disestablishment21 may create a new legacy of mistrust.
Imperatives to take on more population health planning approaches can expose health sector organisations to situations where they are forced to manage a complexity of issues often without clear models of what to do.22 Many of the models available still focus on single specific diseases or a specific target population,23 an exception being Whānau Ora that takes a more holistic approach to supporting the health and wellbeing of a community. As the Māori primary care leaders interviewed for the wider research programme stressed, this model must be implemented widely for Māori health gains, not merely be considered an attachment or add on, but as central to the system of primary health care delivery.9
We know an intense managerial effort is needed to deliver more joined-up care.24 A/NZ has a history of small pilot collaborative programmes making progress locally but rarely transforming the whole system.8,10,25 The new structures and arrangements introduced by the Localities rested on the hope that more collaborative activity will naturally follow, although the staged and organic nature of their rollout made change hard to discern beyond regions already accustomed to working collaboratively. While the Localities networks included new ground rules on how local actors would interact with each other, the underlying business and professional structure of primary health care remained untouched. A new network structure did not magic away workforce challenges or the business incentives currently hard wired in funding structures. Some realism will continue to be needed around the challenges of implementation.26 Primary health care leaders’ decisions to direct energy towards joined-up and integrated care activities will be enhanced by identifying practical problems to be solved, and a bank of trust to manage the inevitable differences between all the agencies around the table. For those regions that don’t have a body of strong pre-existing relationships, our findings highlight the importance of progressing trust-building strategies16 encompassing both relational actions (the soft skills of sharing perspectives openly and honestly), alongside technical strategies grounded in processes that manage complexity.
Data availability
The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.
Conflicts of interest
Tim Tenbensel is a member of the Editorial Advisory Board of the Journal of Primary Health Care. To mitigate this potential conflict of interest he had no editor-level access to this manuscript during peer review. Authors declare no other conflicts of interest.
Declaration of funding
This study was funded by the Health Research Council New Zealand (#18/667). The funder did not have any role in the design, analysis, interpretation of data or writing of the manuscript.
Acknowledgements
Thank you to the primary care leaders who volunteered their time to be interviewed for this study. Thanks also to members of the wider ‘Enhancing primary health care services to improve health in Aotearoa/New Zealand’ programme grant team. Finally, thank you to the Health Research Council of New Zealand for funding this research.
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