Burwood Hospital, Christchurch. (Photo: Health.govt.nz)

How we changed the way we do health: a view from the future

The overhaul of the NZ health system promises a reimagining of cancer services. Dr George Laking, medical oncologist, propels himself to 2025.

Ki te kāhore he whakakitenga ka ngaro te iwi
Without vision or foresight the people are lost
Kīngi Pōtatau Te Wherowhero Tāwhiao

Although I work at Te Pūriri o Te Ora Auckland Regional Cancer and Blood Service, this is a personal view. The stories are true though.

Here’s how a reformed health system will look, according to Wednesday’s white paper:

  • our health system reinforces Te Tiriti o Waitangi principles and obligations, with rangatiratanga shaping care design for Māori, so Māori models of care flourish;
  • everyone can access a wider range of support to stay well in the community, with more services designed around people’s needs and which better support self-care;
  • emergency and specialist care is accessible and consistently outstanding, with a national network ensuring excellent care doesn’t depend on where you live;
  • digital services are far more accessible, with care close to home far more common;
  • health and care workers are valued, supported and well-trained, supported by shared values, better long-term planning, and collaboration between health organisations.
    This future is within reach – but requires major changes in how our health system operates.
    – Health Reform White Paper Summary 21/04/2021

Tēnā koutou e te whānau, ko mātou ko te Ratonga Matepukupuku o te tau 2025 – we are the Cancer Service of 2025. We’re visiting your place – it could be your local health practice, marae clinic, or perhaps even your house. Remember how in 2021 you had to drive for an hour across town, then queue in front of the hospital, then find a carpark? I remember that time you had to borrow money to pay for petrol to drive to the ATM to get money to pay for petrol to drive to the Hospital. Now we come to see you. With a broadband connection, we can access all the health records. With closed-system devices, we can bring chemotherapy as well. Of course there’s still a hospital, but it’s no longer the focus of everything we do. We need it for things like scans, and some specialised treatments and operations of course. It’s become a lot easier to find a carpark.

It was good you contacted us on the telephone hotline when you first noticed symptoms, a couple of months back. We alerted your family doctor, who made sure you were checked out. We hoped it wouldn’t be cancer but when it turned out that was the case, the surgeon was ready. It’s possible you’re already cured from the operation, but we’re advising chemotherapy to maximise the chance of that. Treating cancer is what we do – but it’s no longer the only thing we do. We also have an eye on prevention, screening, and diagnosis. We used to see a lot of people whose cancer had gone beyond the chance of cure, because of delays in diagnosis. We said that was very sad, but nothing to do with us, as our job was only in the treatment. It felt unbearably lame to keep saying this year after year, so we decided to increase our presence at the start of the cancer journey.

Being out and about across the district has brought us more friends. The Cancer Society remains a big part of our community connection, but we’ve diversified. You can’t weave a social fabric from just one thread. So now we have links into Rūnanga, Pae Kaumātua, Whānau Ora collectives, community trusts, sports clubs, churches, and other organisations. As much as anything it’s a way of saying “we’re here, if you or someone close to you has a question about health (could it be cancer?), then contact us”.

We can see the effect of what we are doing because we have access to the data in real time. For many years the hospital kept a note of every time you visited us and everything we did. That’s how we got paid. But we seldom used the information to keep track of what we were doing, and improve it. We were failing on equity. Access into our service was uneven, especially so for Māori and Pacific people. Now we have taken our work out of the hospital, and we can see the effects as they happen. We can see the equity situation has improved – we are consistently seeing a lot more people from communities we previously under-served.

We’ve learnt a lot. That felt strange at first – we’ve always taken pride in studying and being knowledgeable. Then we realised that large parts of the education we received in Aotearoa New Zealand in the 20th Century and around the millennium were deficient. So we organised a remedial program at work, to cover topics including the history of Aotearoa, Te Tiriti o Waitangi, Te Reo Māori me ōna Tikanga, the meaning of racism, and skills in communication and cultural safety. We got to know our own culture as health professionals. We learnt to recognise the aspects of our culture at odds with our purpose of increasing the health of the people. And we changed those aspects of our culture for the better.

And finally, our jobs aren’t always what you might have expected as recently as 2021. We used to be strict about demarcation of professional roles. Much clinical decision-making was tightly held by doctors. In the end, for many of us the workload became crushing, with professional burnout. We realised that increasing our reach into the community and across the continuum of cancer required us to share the workload across professions. That’s why today you’ll likely be meeting with an experienced cancer nurse working at the top of their scope. They are skilled in communication, carry the specialist technical knowledge and briefing relevant to your condition, and can astutely recognise when the situation requires a change of approach. They can call for advice or support where needed from a larger pool of nursing, medical, and other health professional colleagues. And we made a point of employing Māori and Pacific people into expert clinical roles, so our workforce corresponds to the communities we serve.

On Wednesday April 21, 2021, there was a reform of health services. At one level, it was a re-assignment of responsibilities and financing. At a more basic level, it invited a re-imagining of how we would actually do our work. Was the reform fated to be just another reset of power structures at the top level? Or could it open a path to culturally safe, effective care, integrated into the community? In April 2021, we felt this reform would have its best chance of succeeding if it could help to get our services out of the hospital, to engage with the continuum of cancer not just its treatment, to integrate into communities, to keep track of what happens as it happens, to train for equitable and culturally safe practice, and to employ a workforce that mirrors the people it serves and works at the top of its scope. What would it take to realise the imagined future of 2025? Without vision or foresight the people are lost. In the end it was the return to a collective vision that helped us find our way.




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