Constructing prevention programmes with a Māori health service provider view

ABSTRACT

Mainstream approaches to chronic condition management and prevention inadequately address the needs of Māori, the Indigenous people of New Zealand. Māori health service providers (MHSPs) are uniquely placed to address the critical gap in the prevention of chronic conditions. In this paper, we report qualitative research findings investigating how prevention was being modelled, practiced and measured in selected MHSP settings. Results indicate barriers to achieving wellbeing through health service delivery. The dominant individualistic, medical conditions-focused discourse, along with responding to acute need, is a driver of service delivery norms.There are examples of shifts in organisational structure and delivery configurations that demonstrate that these norms are being challenged and reframed, in some form, by MHSPs. Consolidation of these approaches requires significant work and increased resources as well as a broader systems-level response that prioritises prevention.

KEYWORDS:

• Chronic conditions
• prevention
• Māori health services
• Indigenous

Introduction

The National Advisory Committee on Health and Disability (2007) defines a long-term condition as any ongoing, long-term or recurring condition that can have a significant impact on people’s lives. Long-term conditions include diabetes, cardiovascular disease, cancer, asthma, chronic obstructive pulmonary disease, arthritis and musculoskeletal disease, dementia and mental health problems and disorders. Globally increasing rates of chronic illness are having a devastating impact on Indigenous peoples and are the major contributor to health disparities (Anderson et al. 2016). In 2014, chronic conditions resulted in 68% of all global deaths both Indigenous and non-Indigenous (WHO 2014). In New Zealand, the burdens associated with chronic illness are responsible for 88% of health loss (MoH 2016). The urgency with which we need to address this major health problem cannot be understated.

Māori have poorer health outcomes than non-Māori and disparities related to chronic condition outcomes are stark. For example, in 2010 the mortality rate for Māori with Type 2 Diabetes was 4.5 times higher than that for non-Māori (MoH 2013). The situation is exacerbated as most people with chronic conditions have more than one and experience multi-morbid chronic illness (MMCI) (Stokes et al. 2017). People with MMCI tend to exhibit numerous health risk factors (e.g. obesity, limited health literacy) and experience additional psychosocial challenges (e.g. unemployment, unstable family life).

Much of the burden of illness attributable to chronic conditions among Māori could be alleviated with effective prevention and management strategies (Ring and Brown 2003). The World Health Organisation’s Action Plan calls for urgent responses by communities and governments identifying objectives centred on preventing and controlling chronic conditions through, for example, cross-sector action; further research and service development; and strengthening partnerships (2008). The National Advisory Committee on Health and Disability (NACHD) has recognised these pressing needs, calling for a health sector-wide and intersectoral approach to the management of chronic conditions to address inequalities related to socio-economic and cultural determinants of health (NACHD 2007).

Extensive health sector work is underway to ‘manage’ chronic conditions, including specific funding provision for treatment, control and prevention; health promotion; surveillance; monitoring and evaluation (MoH 2009); service redesign (Wellingham et al. 2003); workforce redesign (MoH 2009) and development of clinical guidelines (MoH 2011). Key features of service design for managing chronic conditions include quality management, primary and secondary care integration, care and case coordination, and multidisciplinary teamwork. Two key service approaches underpin chronic condition management; self-management and patient-centred care (Wagner et al. 2005; Hudon et al. 2012). These approaches pose significant challenges for Māori, failing to take account of the broader cultural and socio-economic complexities associated with chronic illness (Geneau et al. 2010; MoH 2015; Marmot 2016) and placing an increased burden on patients with care being largely focused at an individual level (Sopina et al. 2008). The emphasis on the individual ignores the multidimensional role of whānau, or family, in the prevention and management of chronic conditions within Māori communities (Cram 2014) and fails to acknowledge the benefits demonstrated by relationship-focused family interventions (Hartman et al. 2010).

There are many challenges facing Māori health service providers (MHSPs) as they respond to the significant need within their populations to reduce chronic conditions. However, MHSPs occupy a unique position in New Zealand’s health and social sector (Boulton et al. 2013), with respect to their ability to design and deliver culturally relevant services. This ensures that they are well placed to undertake prevention work with Māori. Boulton et al. (2013) identify public policy shifts since the 1980s, in response to demands that Māori must have far greater control over health care decision-making, which have supported the development of MHSPs. Embedded within the Māori communities they serve, they have a primary focus on the design and delivery of services consistent with the cultural values and imperatives of service users.

Recent research conducted by the authors (Gifford et al. 2013a, 2013b; Boulton et al. 2014) highlights that there are MHSPs responding in innovative and strategic ways to the challenges of preventing chronic conditions among Māori. Most importantly, these providers are working to develop whānau-centred models of care that recognise the broader determinants of health including housing, education and employment as well as considering the impacts of these determinants on health and health care.

The research team, in partnership with three MHSPs, is examining models of care being implemented to prevent chronic conditions. This paper reports initial findings from the first phase of a three-year study, which commenced in late 2014. We explore how chronic condition prevention is being developed in three diverse MHPS settings.

Methods

Our overall research aims are to (a) examine how the primary and secondary prevention (National Public Health Partnership 2006) of chronic conditions is being modelled, practiced and measured in three case study sites; (b) define what short-term outcomes are being achieved; and (c) ensure findings from case studies inform wider health service development.

The research is underpinned by Kaupapa Māori theory meaning that the study is driven by Māori and focuses on issues of concern to Māori; employs methods and practices that take full cognisance of tikanga, Māori knowledge and contemporary realities; incorporates Māori research aspirations; and that the team is committed to building Māori research capacity. Kaupapa Māori affirms wellness as a collective aspiration and enterprise achieved through a Māori way of being (Cram 2010) with community-level health interventions, underpinned by Kaupapa Māori approaches to design and delivery, having the potential to improve health outcomes for Māori (Tipene-Leach et al. 2013). The research uses a case study design drawing on qualitative and evaluation-based research methods (Patton 2015) to examine the case studies.

The cases under consideration are the chronic condition prevention models being developed by Te Oranganui Iwi Health Authority (Whanganui), Tui Ora (Taranaki) and Poutini Waiora (West Coast). Case study sites were selected according to four criteria; each is implementing innovative strategies to address ongoing Māori health disparities; each has an existing relationship with the researchers, facilitating site access; together they provide a mix of rural and urban locales; and they represent diversity of prevention approaches.

Phase One of the research was completed at the close of 2015. It included identifying and defining each prevention case along with addressing prevention modelling and prevention prioritising research questions. Discrete tasks carried out included securing ethics approval from the Health and Disabilities Ethics Committee (#14CEN159). A literature search was completed and an annotated bibliography prepared, along with a summary literature review, to further inform the study. The first wave of data collection was also carried out.

A purposive approach was used to recruit key informants with the criteria for participation being an ability to answer questions about chronic condition prevention and prioritisation processes. Semi-structured interviews were conducted with a total of 25 key informants; 9 on each of 2 of the MHSP sites and 7 on the third. Informants included senior managers, governance members, policy-makers, programme coordinators and frontline staff. Table 1 identifies key informant numbers by site and role designation. Most informants were women and identified as Māori.

Table 1. Key informants (KI) by MHSP, role and number.

MHSP	KI primary role	KI number
MHSP A	Governance board member	2
	Senior manager	1
	Coordinator/team leader	2
	Frontline staff	2
	Policy-maker	2
		Subtotal: 9
MHSP B	Governance board member	1
	Senior manager	1
	Coordinator/team leader	2
	Frontline staff	0
	Policy-maker	3
		Subtotal: 7
MHSP C	Governance board member	2
	Senior manager	1
	Coordinator/team leader	2
	Frontline staff	4
	Policy-maker	0
		Subtotal: 9
		Total: 25

All interviews were individual and were conducted face to face by the lead researcher assigned to each case study site. Interviews focused on the collection of rich, descriptive data and ranged in length from 30 to 90 minutes. Most were conducted on the MHSP site. Open-ended questions and prompts were used to explore how practice knowledge is constructed within case study settings. The use of local knowledge and experience, including whānau or community input, to prioritise and plan approaches was also explored along with policy-level levers for initiating prevention initiatives. Critical to data collection was increasing our understanding of MHSP prevention initiatives being developed.

Key informant interview and researcher field note data were interrogated, using a qualitative thematic approach, with the aim of identifying patterns in meaning to make sense of seemingly unrelated material (Braun and Clarke 2006). Data were analysed across three interrelated nested environment levels (Berkeley and Springett 2006); policy (government), practice (provider) and wh ā nau (community). This multilevel analysis explored the diversity in perspectives, priority setting, intervention practices and experiences among informants. Additionally, it provided an opportunity to explore tensions as well as challenges in the development and implementation of prevention initiatives.

Results

Results are discussed under three key themes: (A) emerging prevention approaches; (B) the context for prevention, changes in the MHSP environment; and (C) pathway from national policy to local MHSP.

Emerging prevention approaches

MHSPs were focused on delivery of health and social services at a primary health-care level. Services were provided to all age groups and included medical, mental health, health promotion, social support and Whānau Ora. Broadly translated, the term Whānau Ora means the well-being of the extended family. Whānau Ora is an Aotearoa New Zealand public policy approach to service delivery aimed at improving the responsiveness of the wider social services to Māori (New Zealand Productivity Commission 2015). Initiatives arising from this approach include the funding of Whānau Ora services delivered by some MHSPs. A key common MHSP characteristic was the current redesign of services to focus on wider whānau with greater responsiveness to their self-identified needs. All shared a common goal of supporting whānau health and well-being. Services were focused on serving populations in regions with a clear strategic focus on preventing chronic conditions through promoting wellness.

Achieving community long-term well-being through health service delivery presents significant challenges for MHSPs. They are concerned with building organisations that can better meet the needs of the communities they serve. Simultaneously they must accommodate the immediate requirements of a population with disproportionately high and complex needs within the context of a wider health services operational environment centred around the individual, episodic care and distinct, separate health specialties. In the face of these constraints development of a chronic conditions prevention approach is beginning to emerge. As one informant acknowledged in the main, ‘we’re still the ambulance at the bottom of the cliff’ (MHSP A KI06) focusing resources on caring for those living with chronic conditions.

In clinical settings, it was particularly challenging for MHSPs to move beyond chronic condition management to primary prevention. Having a young and inexperienced clinical staff with little experience around primary or even secondary prevention posed a particular issue for one provider with an informant observing ‘I don’t think they’ve had that experience or someone to lead them [to work with a prevention focus]. To the point that I think it scares them a bit’ (MHSP A KI04).

Some informants, when asked about their chronic conditions prevention work, responded by describing chronic conditions management activities or tertiary prevention aimed at reducing any escalation of patient ill-health. That management focus was clearly apparent among clinical staff as the following example highlights:

[We want to address] how we manage respiratory illnesses … put some things in place so that we can prevent avoidable admissions. We can make sure that these patients are having spirometries so we know what their lung function is like and that they’re on the right medication. (MHSP A KI04)

Many informants acknowledged the influence of the Whānau Ora public policy approach, introduced in 2010, on their MHSP’s approach to prevention and subsequent service redesign. Whānau Ora funding had supported the flexibility to move from prescriptive contracting to a more holistic approach to service delivery. That approach facilitated whānau-level needs assessment and planning to achieve and/or maintain optimum health and well-being. An informant described the development:

We reshaped the way that we deliver. So Family Start … delivers with a Whānau Ora approach now. So we’ve been in a position where we’ve been able to beef up the [former] Family Start team and reduce their volume and they can work more holistically. (MHSP A KI06)

Finding ways to continue the transformational work instigated under Whānau Ora meant, for the above provider, ensuring an ongoing focus on long-term change driven by whānau aspirations for their futures. A prevention orientation was understood, at least at senior management level, to sit within this broader Whānau Ora well-being kaupapa.

Development of practice models which support working to improve Māori health outcomes for chronic conditions was reported. One informant described how the impetus for that development was driven from senior management level within her MHSP which:

always paints a big picture for the whole organisation, you know, this is what you need to do. It’s about our whānau getting well, improving their circumstances and ensuring that … we have the capability, the resources to do that. (MHSP A KI05)

Practice changes being introduced by one provider included adopting ‘a recovery model’ of care in its mental health services with the goal being ‘independent living’ (MHSP B KI18). The provider was ‘really working towards placing themselves as that early intervention … prevention [agent] as much as they possibly can’ (MHSP B KI18). Another informant, describing the work of the same provider, asserted:

They’re doing things differently … [in] our mental health residential facilities … all of those clients have chronic conditions, one or the other, so it’s about … healthy eating and the early intervention stuff that [the kaimahi are] trying to support … there’s a whole lot of stuff that they’re doing, more recovery focused and community based. (MHSP B KI23)

In the case of another MHSP, translating the prevention ideal into practice was supported by the recent launch of a new initiative (Healthy Families) that was ‘all about that preventative stuff … [and has] huge buy in from the community already’ (MHSP A KI06). A further informant shared the view that the same new initiative would support a prevention focus by providing:

a framework for settings based health promotion – and that framework will complement and support and enhance stuff that’s already happening. (MHSP A KI21)

The organisation was using the new initiative as a catalyst for aligning all its public health-oriented contracts seeking to better integrate activities:

Rather than wait … we’re starting to try and shift that practice now. So they’re moving away from the one on one delivery [to] clients … to more of a population scale approach … it’s around, I guess minimising those risk factors that lead to chronic preventable disease … . But it’s also bigger than that too I think. It’s quality of life stuff as well so … that brings in to play things like cultural connection … removing or reducing social isolation and all that other stuff that’s preventive or supportive. (MHSP A KI21)

Promoting a collaborative way of working both within the health sector, and more broadly across sectors, was identified as being a key element of the approach described above with the provider acknowledging that ‘we’re thinking big’ (MHSP A KI21). The same informant went on to note that ‘primarily though [we are] making sure we deliver to the … contracts’ (MHSP A KI21) signalling that despite the emphasis on working in an integrated, whānau-centred way it remained critical to simultaneously satisfy the demands of the silo-focused contracting environment.

The context for prevention

Prevention initiatives were occurring within a context of broader organisational change. This change appeared to be focused on organising services with whānau at the centre, attempting a more integrated approach to services, improving access and promoting health and well-being. Responsiveness to the needs of whānau was illustrated by an informant in relation to her provider’s development of a new service model. She described how additional whānau input to the new service design had occurred:

Some of the kaimahi [were] actually already working with mums and babies and families, that they had conversations with around, you know, ‘we’re doing this’ and, you know, ‘what do you think would be some good ideas’? – especially those that might not have been comfortable in a forum scenario. (MHSP B KI23)

The flexibility for providers to be responsive to the needs of their communities was highlighted by the data. An informant, for example, explained how the priorities of whānau may override the prescriptive nature of contract service specifications:

We deliver the services we want to while trying to just remember, once we’ve done it, flick it to where it needs to go in terms of the contracting. And it may or may not fit in to the contract but you do it because you actually base the service on the whānau as opposed to basing it on what we ‘should’ be giving the whānau according to the contract. (MHSP C KI08)

Constant organisational flux was the norm across the MHSPs. ‘Huge changes [aimed] at aligning our services more with … our whole overhead direction’ (MHSP B KI18) were noted by one informant with respect to her provider’s reorientation to better address the health and well-being needs of whānau. The ongoing nature of organisational change was highlighted by another informant who pointed out that her MHSP had ‘gone through … a huge change management process over the last three years, which they’re still going through’ (MHSP B KI22)

For all three MHSPs, it was clearly challenging keeping ‘all the balls in the air’; trying to build organisational structures more responsive to the needs of whānau whilst simultaneously ushering in shifts in process and practice. An informant highlighted the reality that, for her provider at least, not everything could be done at once. She explained that, though some requisite developments had been identified, these were still to be progressed:

with the restructuring – there is talk around having one point of entry and all the services coming together to discuss the whānau and see who is best suited for the needs … but it’s around getting … all the services to come together … to determine [how it would work] – you know, it might be a long process. (MHSP A KI05)

Another informant concurred observing the impact of the pace of organisational change on practice:

Meetings would be good … multi-disciplinary type meetings but … with the amount of change that’s happened we haven’t been able to develop that at this stage. But definitely it would be something that would be good if we’re implementing a long-term conditions type approach to how we manage things in the organisation. (MHSP A KI04)

Constant organisational change was sometimes problematic with one informant observing staff becoming ‘quite insecure about their own roles’ (MHSP C KI03). Keeping staff abreast of organisational change was therefore necessary but not always easy in the context of simultaneously conducting ‘business as usual’.

The pace of change contributed to staff from across all three providers being unfamiliar with some aspects of the work that their respective organisations were doing in their communities. It was apparent too that, in some instances, providers of in-house services tended to work in isolation from each other. In the case of one provider which offered a general practitioner service, that service appeared to be an ‘add on’ to the rest of the organisation with no common thread linking it with broader social support services. An informant highlighted that this service disjuncture had been recognised by the organisation and was consequently being addressed:

Our challenge has been to make sure that people recognise that general practice is part of [this provider] and vice versa … that it is an integral part of it and to try and make the services integrate completely. (MHSP B KI20)

In another instance, an informant noted that her provider’s general practice too could be linked more effectively with other service areas with limited capacity:

We can’t be everywhere so we have got to think of a way of doing this, you know? Having better alignment with our medical centres … this is some of the work that’s being done at the moment. Like how do we improve access? (MHSP A KI21)

The need to make sure that service user whānau were not disadvantaged in an environment of change was identified by an informant who observed:

… it’s quite a critical time for us at the moment. Just to make sure that people don’t fall through the gaps while we’re kind of getting ourselves together … and getting organised … it’s been a bit of a juggling act. (MHSP A KI06)

Responsiveness to evolving community need and accommodating a prevention focus demands a mix of staff and skill that may not necessarily be readily available. An informant reported that, in the case of her MHSP, ‘the reality of actually getting, attracting … [staff] unless they’re from here [the region], is really, really difficult’ (MHSP C KI08). An example of changing staff skill and knowledge requirements, to better support a preventative approach to service delivery, was provided by an informant in relation to increasing the health literacy levels of non-clinical staff such as community health workers:

I’ve had to retrain people to do this job [of interfacing directly, as Whānau Ora workers, with whānau living with chronic conditions]. In terms of this stuff we’re going to have to get some specialist training in to support us with that. The nurses have put their hands up and said they’ll give us some support around this in terms of focus forums and stuff … we’ll have to go through and tick off each area just to make sure that they’ve got enough training just so that if they could see that things weren’t okay … they would know what to do. (MHSP A KI06)

A further example of capacity challenge was provided by a key informant with respect to clinical practice experience:

We’ve got some nurses that have been out [graduated] for about two or three years. They’ve worked mainly in the clinic seeing acute patients so they’re seeing patients, treating them and then out. So there hasn’t really been … a way of dealing with patients’ long term conditions … . It’s actually [about] getting our nurses up to speed [with a prevention focus]. We have got a young sort of workforce in regards to their knowledge base. (MHSP A KI04)

The above examples highlight gaps in staff capability to adequately work with chronic conditions management and secondary prevention. However, of equal concern is the limited awareness of capability gaps with respect to primary prevention. In the case of one provider, recognition of the primary prevention capability gap was clearly apparent. The other two providers had yet to explicitly engage with what advancing the primary prevention agenda might require in terms of a changing mix of staff competencies. In the face of constant flux these staff capacity issues were brought in to sharp relief.

Pathway from national policy to local MHSP

The gap between the health policy prevention discourse, on the one hand, and the reality of negotiating the public funding and contracting environment, on the other, was noted by some informants. One of these informants talked about the perceived lack of continuity between what the government was saying about achieving well-being and the concrete mechanisms which could accommodate service delivery with a well-being focus:

The government’s got this new catchphrase ‘health in all policy’ and the Minister of Health is pretty hot on preventing long term conditions … . [but] when you go to the forums you don’t hear it; you don’t see it. (MHSP A KI01)

Another provider informant observed that government contracts still focus on high need or acute conditions:

Only just over two percent [of resourcing] sits at that mild to moderate [severity] space … we have very little that’s actually targeted at … early intervention/prevention. And so that’s one of the challenges … just to try and shift where those resources are actually delivering services so that it … stops as much of that kind of acute [service delivery focus]. (MHSP B KI22)

Though there are programmes with a preventative component being funded, at central government level, that funding is commonly short term in the experience of MHSPs. The short-term contracting cycle contributes to a pattern described by an informant as resulting in ‘whānau lurching from one programme to another’, perhaps resulting in changes in awareness and even some temporary changes in behaviour, but without developing the ability to positively impact their wider environment to support ongoing whānau well-being. She observed:

We do some great work but the sustainability of that practice after the programme, it just fades into the distance. And I think that’s the problem that we have … we’ve been really programme focused and so they just want another programme and you’ll often hear participants who have done programmes – [they] just want another one of those and another one. (MHSP A KI01)

At a national level, the fragmented policy approach of the Ministry of Health was identified with the same informant asserting:

They need a change … they’ve still got the domains of public health and primary medical and … they’re still working in their domains and they’re not talking to each other … . The policy writers who are delivering the mechanisms to guide our work aren’t talking to each other. (MHSP A KI01)

Despite these national-level constraints there were examples of local solutions being forged and of providers working with others, particularly their district health boards, to achieve longer-term well-being through health services delivery. An informant observed ‘when you get down to a local level there’s quite a lot of commitment [to reducing health inequality]’ (MHSP A KI01) through the development of approaches better suited to community needs. That view was shared by others, one of whom commented:

We’ve got the ability, I guess, because we are a bit smaller and I think relationships are a big, plus here too – because of the size of our community you’re able to develop relationships with providers and you all sort of know each other or … you all understand the needs. (MHSP A KI15)

Despite these positive views on collaboration within the health sector in the region another informant believed that it was only early days asserting:

There’s still some way to go locally so we don’t plan, the PHO and the DHB don’t do their planning together, so it’s still done in isolation. Nor do they share where their investment [goes] – they don’t make those decisions jointly. I still think that could improve the way we move money to focus a bit more on … prevention. (MHSP A KI01)

Discussion and conclusions

We identified a number of preventative principles and emerging practices at MHSP level. These include health services focusing on the needs of whānau, influencing community settings, a shift in thinking to upstream determinants, an understanding of the broader determinants of health, a focus on quality of life and well-being and a desire for more holistic integrated services with the ability to act across sectors. Early indications are that promising whānau-focused integrated models of care, incorporating a preventative focus, are being developed by providers. There is potential in Whānau Ora-type approaches to move away from siloed provision and consider prevention across whole services as well as address the socio-economic and cultural determinants that are factors in chronic condition prevention.

Providers know their communities in-depth (Boulton 2007) and have some degree of flexibility to be able to reorient themselves to better meet the needs of whānau and their own organisational aspirations (Boulton et al. 2013). That provider responsiveness, however, demands a mix of staff and skills that may not necessarily be readily available. Negotiating constant flux, exacerbated by ongoing changes in organisational funding and contracting, can undermine staff awareness of organisational vision, roles and responsibilities. Ongoing organisational change therefore has impacts that can undermine the momentum to keep moving forward.

While chronic conditions prevention is identified as a priority in the three case study sites, the ability to clearly articulate prevention approaches is not yet evident. This may be largely due to the emerging nature of the approaches, and the preoccupation with transformation to whānau-centred services, but most importantly it is about the need to deliver acute treatment and support services to the majority of their clients who are already manifesting the signs and symptoms of chronic conditions. The high level of need that the providers are having to deal with on a daily basis cannot be underestimated with rates of diabetes and cardiovascular disease two to three times more common in Māori and accounting for significant disparities in mortality outcomes (MoH 2015). To step aside from this, acting at a population level to address broader health determinants such as housing and employment, while simultaneously influencing health policy that impacts on tobacco smoking and alcohol and food consumption, is significantly challenging. Providers are potentially attempting to do something that as a nation we are struggling to achieve; a focus on prevention.

In 2011, the MoH briefing to the incoming Minister spoke to the need to prioritise proven ‘upstream’ preventative and early interventions to invest in better models of care and integrated services particularly recognising the importance of the health system’s responsiveness to Māori (Goodyear-Smith et al. 2014). In the 2014 briefing to the Minister of Health, the emphasis on changing health-care systems to improve the focus on prevention continued with the advice stating; ‘the focus on wellness, prevention and building individual and community resilience means that a health and disability system needs to change how, where, when and what services are provided and with whom it partners and collaborates’ (MoH 2014, p. 10).

Though the policy discourse may therefore showcase a pivotal role for prevention, there is less evidence that that discourse translates into the development of prevention policy supportive of chronic conditions prevention practice at the flax roots level. Mays (2013, p. 1), for example, observes that in Aotearoa New Zealand ‘most policy focus … relates to access to treatment’ rather than to prevention.

This emphasis on treatment may not be adequately preparing health professionals for a future role in preventing chronic conditions. The results from our study indicate staff skill and knowledge gaps when confronted with the complex task of changing environments and changing behaviours to ensure whānau well-being. Along with staff skill and knowledge gaps ‘there are no explicit financial incentives for general practices to prioritise secondary prevention’ (Mays 2013, p. 1) creating an additional challenge to advancing secondary prevention practice for the two MHSPs involved in our study that offer GP services.

Concomitant with an emphasis on treatment is the delivery of services to individuals. While MHSPs are working to develop the organisational structures to support whānau-centred approaches, implying a broader community approach, they experience the wider national policy environment as continuing to support a focus on delivery of service to individuals with presenting issues being identified and accommodated in isolation. By way of contrast, funding and contracting arrangements which facilitate whānau-centred approaches to service delivery are difficult to identify. The responsibility for change is clearly placed at the door of the individual. Theodore et al. (2015) highlight the issue for obesity prevention among Māori arguing that the current health policy aim is to increase access to better health-care information so that New Zealanders can take care of their own health through improved lifestyle choices. Less emphasis is placed on creating and maintaining the broader social-economic conditions likely to facilitate healthy behaviours. The epidemic increase in obesity and diabetes around the world suggests that factors far beyond individual behaviours are influencing the chronic conditions tsunami (Candib 2007).

The intersectoral and cross-sectoral collaboration that the government has signalled is integral to the delivery of services which promote wellness across priority populations is similarly hampered by much of the existing wider policy context which remains attuned to delivery ‘in silos’ with short-term funding promoting what our informants call ‘a programme approach’; one-off interventions delivered to individuals.

There are a range of impediments to achieving well-being through health service delivery. The dominant individualistic, medical conditions focused discourse discussed above is a driver of service delivery norms. There are examples of shifts in organisational structure, skill mix focus and delivery configurations that demonstrate that these norms are being challenged and reframed, in some form, by the providers. The ongoing challenge and work needed to shift away from the ambulance at the bottom of the cliff to building the fence at the top is significant and will require increased resources and a broader system-level response that prioritises prevention.

Limitations

It should be noted that this paper discusses the results from the first phase of a three-phase research project. Analysis is at this point limited to providers and policy; whānau analysis will be reported in subsequent papers. The paper describes how MHSPs are thinking about prevention and how they are attempting to construct services with an emphasis on well-being. A more detailed description of prevention approaches and outcomes associated with those approaches will be reported at the conclusion of Phases Two and Three of the research in 2017/2018.

Acknowledgements

We thank the case study sites that have given so much of their time and energy to the research; we appreciate the partnerships that have been formed over the years that have enabled research focused on the needs of the provider community to be carried out.

Disclosure statement

No potential conflicts of interest were reported by the authors.

Additional information

Funding

We also wish to acknowledge the Health Research Council of New Zealand for funding the research; HRC 14/146 funded 2014 due for completion early 2018.