WHAT SKILLS AND KNOWLEDGE WERE REQUIRED AND HOW WAS INFORMATION ACCESSED?

A level of understanding about the health environment and the primary health care strategy was an essential requirement for those working towards PHO establishment. The Ministry of Health website was the primary source of information about PHO establishment and provided all detail of key milestones and requirements to be met during the planning phase. Some members of the Steering Committee were not computer literate. This had implications for access to Ministry documentation and for internal communications within the Steering Committee such as distribution of meeting minutes. As time progressed it became apparent that it was not only computer ownership and literacy which influenced this access, but also the capability of the individual member’s personal computer system and the level of technology support available to them when problems arose. Frustration was expressed at Committee Meetings on numerous occasions about lack of personal infrastructure support. To illustrate when the Chairperson was attempting to keep to deadlines in the lead up to the provider meeting:

My computer is down, my telephone has been out of order twice since Christmas and was out all day today. And my car is in the panel beater’s! 30

Chairperson, Steering Committee meeting, 20 January 2004 There was another illustration at the 3 February 2004 Steering Committee Meeting when reference was made to the Ministry of Health “Starter Pack”. The Pharmacy Representative raised the question: “Why didn’t we know about the Starter Pack when we started?” The reply from the Steering Committee Chairperson: “It’s on the Ministry of Health website”, quickly prompted an emotional response by the Pharmacy Representative: “That assumes everyone is IT literate.”

There was much evidence at Steering Committee meetings that members had varying degrees of knowledge about project management, the health sector generally, the primary health care strategy and DHB and Ministry of Health requirements and responsibilities for PHO establishment. To illustrate, at the 20 January 2004 Steering Committee meeting, just over five months before project completion, the Chairperson raised the following questions for the Funding Division:

¾ What we want to know are things like the role and responsibilities of the PHO and the role and responsibilities of the Funding Division – what practical assistance the Division will provide. What is the PHO governing? ¾ We need to have detail so that we can be informed.

¾ Who writes the policies? How are we going to get all this done? What will be the practical help?

¾ What resources are available to inform the community? And at the 3 February 2004 Steering Committee meeting:

What do we have to get done by 1 July? ibid. Frustrations experienced in obtaining and assimilating the information available for PHO planning were expressed by a number of Steering Committee Members:

Yes, over the time there was lots of information that came from lots of areas. And the DHB was one. …The government sort of had a launch on PHOs and a whole lot of information followed after that. And even though, with all that information coming out you can see what it’s about, but to me unless you begin to work it through, some of the questions remain unanswered until you actually get to do it and then it starts to become more clearer. So my understanding of the PHOs now is a wee bit better than it was when we started off.

Steering Committee Iwi Representative II from interview, 2 September 2004 We wasted an awful lot of time floundering around figuring what on earth we were

supposed to be doing. ibid.

and:

I’d have to say information generally is a lack and that relates to my own – my inability with this computer and it’s always going wrong. It’s just being stuck out in the wilds. And I did try to access a couple of books through the public library and they were not available – they had to go through the loan system - the national loan system and they weren’t available because they were university texts or they were from a university library and they weren’t going to lend them out – So! [showed expression of frustration]. ………. MIPA produced some bits and pieces and I got stuff from the Ministry’s website and then I was getting information from the Reference Group. That actually was very useful for me.

Steering Committee Chairperson from interview, 18 August 2004 The DHB Representative acknowledged that there were issues associated with access to useful information when the Steering Committee was preparing their Establishment Plan:

To my mind the material from the Ministry plus our own DHB requirements, etc., don’t make for a logical user-friendly establishment plan.

Funding Division Representative B from interview, 19 August 2004 The broad scope of knowledge and expertise expected of the Steering Committee was further highlighted when they received feedback from their initial Establishment Plan for PHO establishment. Examples of additional information required by the funder before the proposal could be approved have been discussed in section 5.3.1.

The Steering Committee Pharmacy Representative summed the situation up: There’s a hell of a lot of learning we have to do.

Steering Committee Meeting, 3 February 2004 To ensure effective implementation of the national and DHB primary health care strategy the Steering Committee needed not only to be conversant with the tasks and timeframes, but also have a sound knowledge of the broader social factors and an appreciation of the context within which the government policy for primary health care was set. During the planning period minimal reference was made to either The Primary Health Care Strategy

(King, 2001) or the Primary Health Care Strategy (MidCentral DHB, 2004b) documents at Steering Committee meetings. The primary health care strategy involved new direction for primary health care with greater emphasis on population health and the role of the community. The Steering Committee members needed an in-depth understanding of these directions and the context in which the overall strategy was set.

Accessibility of information was one issue, but equally important was the need to place it within the context in which it was going to be applied. Funding Division personnel along with Steering Committee Members agreed that determining in advance strategy implementation would have been difficult. The Steering Committee Chairperson identified the need to have some facilitation of what to do with the information if and when it was obtained:

Nobody had any entrenched views about how a PHO should work specifically - but in saying that, I harp back to the information we didn’t have. From my perspective, we didn’t have adequate information or support from anybody in relation to the information.

6.9 CONCLUDING COMMENTS

The voices presented in this chapter provide a rich tapestry of perceptions, understandings, energies and emotions. In addition, using this approach to presenting this section of the findings provided a vehicle for ensuring the contextual influences were presented in a way which accurately depicted the impact they had on the sequence of events and human responses to these events. The interconnectedness of networks maintained by the Steering Committee generally and the community representatives specifically, had a significant impact on PHO planning processes. The invisibility of these interrelationships emphasised the importance of legitimising the “ways of doing” established by the community. The findings highlighted the complexities of representation and the need to consider interests beyond simply interest group representation. The sequences of events highlighted the challenges posed by the tasks that needed to be completed, the lack of project planning and the impact of inadequate resourcing. The tension between having people involved who have the necessary skill and knowledge and using the participatory process for building competency and community capacity was highlighted. Power relationships had an enormous impact on planning process. The traditional roles held by health professionals and bureaucrats accorded them with influence over selective decision-making and secured their position of dominance throughout the project. These traditional power relationships superseded the accustomed role and responsibilities of Committee Chair – a position held by a community representative. For community inclusiveness to be of maximum benefit for both the specific project being undertaken and the individuals who contribute, considerations of how best to facilitate individuals engaging in community initiatives must go beyond the scope and life of any one particular project.

In the light of the findings presented in Chapters Five and Six, the analysis in Chapter Seven will conclude with identification of key determinants which would strengthen the notion of community participation both for individuals who participate and the ongoing development of community capacity.