Key elements and contextual factors that influence successful implementation of large-system transformation initiatives in the New Zealand health system: a realist evaluation.

BACKGROUND: Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Maori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system. METHODS: This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented. RESULTS: The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances. DISCUSSION: Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives. CONCLUSIONS: Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish. OTHER: This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).

Flourishing together: research protocol for developing methods to better include disabled people's knowledge in health policy development.

BACKGROUND: To positively impact the social determinants of health, disabled people need to contribute to policy planning and programme development. However, they report barriers to engaging meaningfully in consultation processes. Additionally, their recommendations may not be articulated in ways that policy planners can readily use. This gap contributes to health outcome inequities. Participatory co-production methods have the potential to improve policy responsiveness. This research will use innovative methods to generate tools for co-producing knowledge in health-related policy areas, empowering disabled people to articulate experience, expertise and insights promoting equitable health policy and programme development within Aotearoa New Zealand. To develop these methods, as an exemplar, we will partner with both tangata whaikaha Maori and disabled people to co-produce policy recommendations around housing and home (kainga)-developing a nuanced understanding of the contexts in which disabled people can access and maintain kainga meeting their needs and aspirations. METHODS: Participatory co-production methods with disabled people, embedded within a realist methodological approach, will develop theories on how best to co-produce and effectively articulate knowledge to address equitable health-related policy and programme development-considering what works for whom under what conditions. Theory-building workshops (Phase 1) and qualitative surveys (Phase 2) will explore contexts and resources (i.e., at individual, social and environmental levels) supporting them to access and maintain kainga that best meets their needs and aspirations. In Phase 3, a realist review with embedded co-production workshops will synthesise evidence and co-produce knowledge from published literature and non-published reports. Finally, in Phase 4, co-produced knowledge from all phases will be synthesised to develop two key research outputs: housing policy recommendations and innovative co-production methods and tools empowering disabled people to create, synthesise and articulate knowledge to planners of health-related policy. DISCUSSION: This research will develop participatory co-production methods and tools to support future creation, synthesis and articulation of the knowledge and experiences of disabled people, contributing to policies that positively impact their social determinants of health.

Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences.

BACKGROUND: During the first COVID-19 pandemic 'lockdown' in Aotearoa/New Zealand (March-May 2020, in which strict 'stay at home' measures were introduced), general practices were advised to use telephone and video consultations (telehealth) wherever possible instead of the usual in-person visits. This was a sudden change for most practices and patients. This research aimed to explore how patients accessed general practice during lockdown and evaluate their experiences with telehealth, to inform how telehealth could be most effectively used in the future. METHODS: Using a mixed-method approach, we undertook an online survey and in-depth interviews with adults (> 18 years) who had contact with practices during lockdown, recruited through social media and email lists. We present descriptive statistics from the survey data (n = 1010) and qualitative analysis of interview data (n = 38) and open-ended survey questions, using a framework of access to health care, from the patient's perspective. RESULTS: In general, patients reported high satisfaction with telehealth in general practice during lockdown. Telehealth was convenient and allowed patients to safely access health care without having to weigh-up the fear of COVID-19 infection against the need to be seen. Telehealth worked best for routine and familiar health issues and when rapport was established between patients and clinicians. This was easier with a pre-existing clinical relationship, but not impossible without one. Telehealth was less suitable when a physical examination was needed, when the diagnosis was unknown or for patients who had a strong preference to be seen in-person. CONCLUSIONS: Even in this disruptive lockdown period, that prompted an unexpected and rapid implementation of telehealth services in general practices, most patients had positive experiences with telehealth. In the future, patients want the choice of consultation type to match their needs, circumstances, and preferences. Technological issues and funding barriers may need to be addressed, and clear communication for both patients and clinicians is needed about key aspects of telehealth (e.g. cost, appropriateness, privacy). Maintaining telehealth as an option post-lockdown has the potential to increase timely and safe access to primary health care for many patients.

Implementing new forms of collaboration and participation in primary health care: leveraging past learnings to inform future initiatives.

Introduction 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. Aim 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. Methods 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. Results 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. Discussion 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.

Seeking Healthcare During Lockdown: Challenges, Opportunities and Lessons for the Future.

BACKGROUND: In Aotearoa/New Zealand, the first nation-wide coronavirus disease 2019 (COVID-19) lockdown occurred from March 23, 2020 to May 13, 2020, requiring most people to stay at home. Health services had to suddenly change how they delivered healthcare and some services were limited or postponed. This study investigated access to healthcare during this lockdown period, whether patients delayed seeking healthcare and reasons for these delays, focusing on the accessibility of primary care services. METHODS: Adults (aged 18 years or older) who had contact with primary care services were invited through social media and email lists to participate in an online survey (n = 1010) and 38 people were recruited for in-depth interviews. We thematically analysed qualitative data from the survey and interviews, reported alongside relevant descriptive survey results. RESULTS: More than half (55%) of survey respondents delayed seeking healthcare during lockdown. Factors at a national or health system-level that could influence delay were changing public service messages, an excessive focus on COVID-19 and urgent issues, and poor service integration. Influential factors at a primary care-level were communication and outreach, use of technology, gatekeeping, staff manner and the safety of the clinical practice environment. Factors that influenced patients' individual decisions to seek healthcare were the ability to self-manage and self-triage, consciousness of perceived pressure on health services and fear of infection. CONCLUSION: In future pandemic lockdowns or crises, appropriate access to primary care services can be improved by unambiguous national messages and better integration of services. Primary care practices should adopt rapid proactive outreach to patients, fostering a calm but safe clinical practice environment. More support for patients to self-manage and self-triage appropriately could benefit over-burdened health systems during lockdowns and as part of business as usual in less extraordinary times.

Integrated Care in Aotearoa New Zealand 2008-2020.

INTRODUCTION: Ten years ago, progress towards integrated care in Aotearoa New Zealand was characterised as slow. Since then, there has been a patchwork of practices occurring under the broad umbrella of integrated care. These include: collective planning approaches (i.e., alliancing), agreed pathways of care, chronic care management initiatives, shared patient information systems, co-located centres and indigenous models of holistic care (e.g., Whanau Ora). DESCRIPTION: Although integrated care is often mentioned in national policy documents, implementation has been left to regional and local decision making, and very few initiatives have spread beyond their initial locations. DISCUSSION: System incentives that preserve organisational "sovereignty" and path-dependent funding have slowed progress towards more integrated care in some areas. There is some evidence about specific initiatives and their impact, but it is difficult to discern significant trends and commonalities around the country. CONCLUSION: In the last ten years, the broad range of initiatives designed to achieve integrated care has absorbed regional and local attention and produced some evidence of progress, but the national picture of change is mixed.

Tomato fruit as a model for tissue-specific gene silencing in crop plants.

Use of CRISPR-Cas9 (Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)-CRISPR-associated 9)-mediated genome editing has proliferated for use in numerous plant species to modify gene function and expression, usually in the context of either transient or stably inherited genetic alternations. While extremely useful in many applications, modification of some loci yields outcomes detrimental to further experimental evaluation or viability of the target organism. Expression of Cas9 under a promoter conferring gene knockouts in a tissue-specific subset of genomes has been demonstrated in insect and animal models, and recently in Arabidopsis. We developed an in planta GFP (green fluorescent protein) assay system to demonstrate fruit-specific gene editing in tomato using a phosphoenolpyruvate carboxylase 2 gene promoter. We then targeted a SET-domain containing polycomb protein, SlEZ2, previously shown to yield pleiotropic phenotypes when targeted via 35S-driven RNA interference and we were able to characterize fruit phenotypes absent additional developmental perturbations. Tissue-specific gene editing will have applications in assessing function of essential genes otherwise difficult to study via germline modifications and will provide routes to edited genomes in tissues that could not otherwise be recovered when their germline modification perturbs their normal development.

A Realist Evaluation of Local Networks Designed to Achieve More Integrated Care.

INTRODUCTION: Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand. THEORY AND METHODS: Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices. RESULTS: The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions. DISCUSSION: Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes. CONCLUSION: Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating "a moving target".

Saving 20 000 Days and Beyond: a realist evaluation of two quality improvement campaigns to manage hospital demand in a New Zealand District Health Board.

Background: The current paper reports on a realist evaluation of two consecutive quality improvement campaigns based on the Institute for Healthcare Improvement's Breakthrough Series. The campaigns were implemented by a District Health Board to manage hospital demand in South Auckland, New Zealand. A realist evaluation design was adopted to investigate what worked in the two campaigns and under what conditions. Methods: A mixed-methods approach was used, involving three phases of data collection. During the first phase, a review of campaign materials and relevant literature, as well as key informant interviews were undertaken to generate an initial logic model of how the campaign was expected to achieve its objective. In phase II, the model was tested against the experiences of participants in the first campaign via a questionnaire to all campaign participants, interviews with campaign sponsors and collaborative team leaders and a review of collaborative team dashboards. In phase III, the refined model was tested further against the experiences of participants in the second campaign through interviews with collaborative team leaders, case studies of four collaborative teams and a review of the overall system-level dashboard. Results: The evaluation identified four key mechanisms through which the campaigns' outcomes were achieved. These were characterised as 'an organisational preparedness to change', 'enlisting the early adopters', 'strong collaborative teams' and 'learning from measurement'. Contextual factors that both enabled and constrained the operation of these mechanisms were also identified. Conclusions: By focusing on the explication of a theory of how the campaigns achieved their outcomes and under what circumstances, the realist evaluation reported in this paper provides some instructive lessons for future evaluations of quality improvement initiatives.

Widening participation of Maori and Pasifika students in health careers: evaluation of two health science academies.

Objective The aim of the present study was to evaluate the short-term outcomes of two health science academies established by a district health board in South Auckland, New Zealand, to create a health workforce pipeline for local Maori and Pasifika students. Methods A mixed-methods approach was used, involving background discussions with key informants to generate an initial logic model of how the academies work, followed by secondary analysis of students' records relating to retention and academic achievement, a survey of senior academy students' interest in particular health careers and face-to-face interviews and focus groups with students, families and teachers. Results Academy students are collectively achieving better academic results than their contemporaries, although selection decisions are likely to contribute to these results. Academies are retaining students, with over 70% of students transitioning from Year 11 to Years 12 and 13. Senior students are expressing long-term ambitions to work in the health sector. Conclusions Health science academies show promise as an innovative approach to supporting Maori and Pasifika students prepare for a career in the health professions. Evaluating the long-term outcomes of the academies is required to determine their contribution to addressing inequities in the local health workforce. What is known about the topic? Despite progress in health workforce participation for underrepresented indigenous and ethnic minority groups in New Zealand, significant disparities persist. Within this context, a workforce development pipeline that targets preparation of secondary school students is recommended to address identified barriers in the pursuit of health careers. What does this paper add? We provide an evaluation of an innovative district health board initiative supporting high school students that is designed to ensure their future workforce is responsive to the needs of the local community. What are the implications for practitioners? The findings have implications for decision makers in health workforce planning regarding the benefits of investing at an early stage of the workforce development pipeline in order to build an equitable and diverse health professions workforce.

Corrigendum to: Widening participation of Maori and Pasifika students in health careers: evaluation of two health science academies.

Objective The aim of the present study was to evaluate the short-term outcomes of two health science academies established by a district health board in South Auckland, New Zealand, to create a health workforce pipeline for local Maori and Pasifika students.Methods A mixed-methods approach was used, involving background discussions with key informants to generate an initial logic model of how the academies work, followed by secondary analysis of students' records relating to retention and academic achievement, a survey of senior academy students' interest in particular health careers and face-to-face interviews and focus groups with students, families and teachers.Results Academy students are collectively achieving better academic results than their contemporaries, although selection decisions are likely to contribute to these results. Academies are retaining students, with over 70% of students transitioning from Year 11 to Years 12 and 13. Senior students are expressing long-term ambitions to work in the health sector.Conclusions Health science academies show promise as an innovative approach to supporting Maori and Pasifika students prepare for a career in the health professions. Evaluating the long-term outcomes of the academies is required to determine their contribution to addressing inequities in the local health workforce.What is known about the topic? Despite progress in health workforce participation for underrepresented indigenous and ethnic minority groups in New Zealand, significant disparities persist. Within this context, a workforce development pipeline that targets preparation of secondary school students is recommended to address identified barriers in the pursuit of health careers.What does this paper add? We provide an evaluation of an innovative district health board initiative supporting high school students that is designed to ensure their future workforce is responsive to the needs of the local community.What are the implications for practitioners? The findings have implications for decision makers in health workforce planning regarding the benefits of investing at an early stage of the workforce development pipeline in order to build an equitable and diverse health professions workforce.