Precio

The first important achievement was the approval of the Establishment Plan by MidCentral DHB to form a PHO in the Horowhenua District. Formalising the legal entity, determining PHO Board membership and completing the Ministry of Health requirements for establishing patient databases which would support the transfer of GP practices to capitation-based funding were among the other important tasks to be completed during the establishment period.

The Funding Division deliberately left the Steering Committee to determine how it was going to commence planning:

We put some frameworks in terms of requiring them to ... present an establishment plan, but we didn’t ... structure them a heck of a lot. We sort of at that stage took a reasonably passive approach to PHO establishment, saying we want this to come out of the community rather than us ushering them through the process.

Funding Division Representative B, from interview, 19 August 2004 Agendas were circulated prior to each meeting and minutes distributed normally within one week of the meeting. At times there was an expectation that Steering Committee members did prior reading or agreed to undertake specific tasks between meetings. My observations were that this often did not occur, with explanations invariably relating to heavy workloads. On numerous occasions discussions resulted in the Committee digressing from the agenda for lengthy periods. This, along with the variability in knowledge about primary health care strategy and the actual process for PHO establishment, posed challenges to the Committee in general and the Chairperson specifically.

I suppose in terms of being clear as to what we were wanting to do in the establishing stage of the PHO, I think we sort of did have problems with people grasping the overall picture one wanted to get to and we got trapped into the nuts and bolts of it. … And because we got trapped into the nuts and bolts we did, in my view, waste a lot of time and energy, sort of debating little things, when we were not at the stage to debate that. It was a matter of looking at the bigger picture and as we moved one step then perhaps those other issues could have been discussed at that stage. I think we were discussing some issues before we actually got to that stage. … And looking back I think we could have achieved what we have achieved in perhaps less time.

From interview, 2 September 2004 Steering Committee GP Representative I was in agreement regarding the time taken to achieve tasks:

The whole lot could have gone through at least about five times as quickly. So great for getting on and efficiency, but in fact a lot of that time was spent with relationship building inside the PHO Committee. So by the end of the time people got to know each other very well. And that would make a huge difference, I would think, long-term.

From interview, 19 August 2004 Consequently, frustration was expressed towards the end of the project about the perceived tight timeframes for achieving specific tasks. These tight timeframes, particularly in the two months immediately prior to the commencement date, were largely a result of the Committee not having some form of project management approach which would have provided certainty about achieving key tasks within a predetermined timeframe.

I really thought in May, June [2004] that it was going to be an impossible situation – that we would have to delay the introduction …I’m surprised it ended up sneaking through. I’m quite sure some of the deadlines that were officially laid down - we broke a fair chunk of them but we seemed to get in OK. I think MidCentral had to go flat out at the end to get it organised.

ibid. Steering Committee Members expressed anxiety at times about the tasks that had to be achieved and their expertise in achieving them, as illustrated at the 20 January 2004 Steering Committee meeting:

We have to be realistic. We are looking at problems. We’re an establishment group and as we face problems we will get the right people to help us.

Iwi Representative I We need to be tapping people on the shoulder.

Steering Committee Chairperson I don’t understand everything, but we can move forward.

Iwi Representative I Humour often helped alleviate anxieties when it appeared that no progress was being made:

We’re swimming in porridge

Pharmacy Representative, Steering Committee Meeting, 3 February 2004 and:

We’re like a 737 [aircraft] without headlights

Pacific Representative, Steering Committee meeting, 3 May 2004 Throughout the planning process there was an acceptance of the likely changes to primary health care services which would result as a consequence of this policy implementation. Frustrations were expressed on occasions when there appeared to be minimal progress being made. To manage this, when time frames were tight, an increasing amount of project business was undertaken outside the Committee. Frequently the need for this to occur was not identified as part of Steering Committee business and often completion of such tasks were not reported back to the Committee.

The lengthy time taken for the Committee to establish a strategy for progressing the planning process could be attributed to the Committee’s failure at the outset to establish expectations and legitimise the role of the Chairperson along with each member within the Steering Committee so as to ensure positions of power held by each member external to the Committee had minimal impact on decision-making processes. Process considerations

such as determining shared goals, understanding vested interests, and agreeing on preferred ways of doing were not addressed by the Committee at the commencement of planning but rather unfolded over time in response to tasks and challenges. This resulted in decision- making and achievement of milestones taking a long time and health professionals and the MIPA capturing decision-making opportunities.