Process Evaluation of the. Kootuitui ki Papakura/Mana-ā-riki Programme

Transcription

1 Process Evaluation of the Kootuitui ki Papakura/Mana-ā-riki Programme Dr Ausaga Faasalele Tanuvasa Dr Jenny Neale Dr Marianna Churchward Dr Sue Buckley Professor Jackie Cumming Health Services Research Centre Victoria University of Wellington June 2017

2 Executive Summary Introduction Background: Kootuitui ki Papakura/Mana-ā-riki Programme Integration The Evaluation The Partnership Middlemore Foundation Board and Papakura Kootuitui Trust Middlemore Foundation for Health Innovation Papakura Kootuitui Trust Manaiakalani/Education Health Homes Methodology Key Evaluation Question Evaluation Approach Methods Findings Roles and involvement with the Kootuitui ki Papakura/Mana-ā-riki initiative Foundation Board and Trust Principals Papakura High School Enhanced Health Services Primary Schools Health Services Homes Participants views concerning the Programme to date Foundation Board and Trust Views Principals Papakura High School Enhanced Health Services Views Primary Schools Health Services Views Homes The most successful aspects of the Programme Foundation Board and Trust Principals Papakura High School Enhanced Health Services Primary Schools Health Services Homes What Could Work Better? Foundation Board and Trust... 30

3 4.4.2 Principals Papakura High School Enhanced Health Services Primary Schools Health Services Homes The Integrated Approach Foundation Board and Trust Principals Papakura High School Enhanced Health Services Primary Schools Health Services Homes Reflections Advice Participants Had For Other Schools Considering Joining the Programme Foundation Board and Trust Principals Papakura High School Enhanced Health Services Primary Schools Health Services Conclusions/Recommendations Appendix 1: Evaluation Deliverables Appendix 2: CMH Health Outcomes Appendix 3: Evaluation Plan Appendix 4: Intervention Logic Appendix 5: References... 59

4 Executive Summary The evaluation addressed the success of the implementation of the health and homes strands of the Programme and their respective initiatives, and integrated these findings with those from Woolf Fisher Research Centre regarding the Manaiakalani education strand of the Programme, to report on the initial effects of all three strands of the Programme. A summary of key findings are as follows. Working well Areas for Improvement Implementation Papakura Kootuitui Trust The leadership team members share the same vision for the Integrated Programme Those in leadership positions understand the community and have worked successfully to develop positive relationships with key people in the community and schools Those participating in the Programme expressed very positive endorsement of the work of the Trust and what it was aiming to achieve Communication about the Integrated Programme could be further enhanced by dissemination of information to health staff and teachers about the three strands Integration of the three strands at the level of health and education management would be assisted by meetings and information sharing between NHC managers, the marae manager, and school managers Implementation Education/ Manaiakalani The introduction of the Chromebooks has been successful with a high uptake, high levels of payment and positive learning outcomes reported Students were seen to have become very competent digital users and their confidence in learning had improved Schools enjoyed and benefited from being part of a cluster and sharing information and resources Independent funding meant Principals could work with the project autonomously, in ways that suited the needs of their school and students Schools appreciated the collaboration and that children and their families were supported with health and social welfare alongside education within the school There is general goodwill between school staff and health/pastoral care staff There are some ongoing challenges in debt management for the Chromebooks There is a natural tension in situating health services within schools that needs ongoing careful management There is a need to manage the tension between schools and health services concerning privacy and confidentiality 1

5 Schools appreciated having health services available on-site Papakura marae were helping to finance Chromebooks for families who were unable to afford payments Implementation Health (Enhanced Health Service at Papakura High School) Students had improved access to nursing and GP health services GP services meant nurses now had standing orders so medication could be provided freely and quickly The health centre was seen as being youth friendly and students were now attending independently Health services had broadened with nurses involved in health education, and the development of fitness programmes in the school The youth worker had integrated well, and he was making a significant contribution to the health centre The youth worker is making connections with teaching, health and pastoral care teams, as well as with students and their families. This is a key position for the integration of the three strands of the programme at the school level The benefits of sexual health services on-site were apparent with a greater uptake of contraception and lowered (zero this year) pregnancy/abortion rates There is a significant issue concerning confidentiality and the sharing of information between health and pastoral care personnel, and teachers/schools that needs to be worked through There is still room for better communication to students, families and teaching staff about what services the health centre can provide Improved sharing of information, such as with meetings and communication (including the integration of databases) between health and pastoral care staff and teachers, would assist all services Health staff would appreciate learning more about the other Strands of the Programme Health staff would also appreciate development of communication with nursing staff from the Cluster primary schools so that students health history could be followed up when required Health services were now available for the on-site Activity Centre whose students had high-needs A website had been developed that would enhance the communication between teachers, nurses, students, and their families regarding the health services There was good collaboration between the health and pastoral care teams who supported each other Communication and relationships between health staff and school staff had greatly improved over the period of the evaluation Staff understood and supported the need for integration across homes, health and education if students were to flourish 2

6 Implementation Health (National Hauora Coalition and Papakura Marae) There has been greatly improved treatment and follow-up of children, particularly with skin infections and rheumatic fever There was a high uptake (92%) of families opting for the school health services Nurses are able to contact and treat the families of pupils with identified infections Children s health literacy had improved and they were now presenting independently to the nurses with health concerns Working relationships between nurses and teachers were better at some schools than others; these were dependent on the support of the Principal and leadership team in the school There are still some challenges concerning schools understanding of the roles of nurses in schools There is a need to manage communication and the issues concerning confidentiality With standing orders, medication to pupils and their families is free and accessible Being in the school enabled the nurses to get to know the families of students Implementation Homes Schools had provided the Homes Strand with 18 families and they now have eight core representatives. Two workshops had been held by April 2017 and three prototypes had been developed Whānau had already benefited from the workshops, in meeting with agencies and advocating for improved services Whānau had gained confidence, were competent to advocate for other families, and were developing a virtual service to support building the capability of other families Whānau were very positive about the Programme and were already envisaging how it could support them and their children/young people in education as well as Homes There was full engagement, and families were recruiting others to join the project Whānau and agencies had embraced the co-design approach and it was working well Whether families are seen as centered in, and belonging to, schools or the community is a tension between families and schools that might need to be addressed The nature of the co-design process means that it does not fit well with externally imposed timetables, so there are concerns about present and future funding and expectations regarding the pace of development There was some criticism of the Integrated Programme in that it lacked a theory of change. The implications of this for the Homes strand were that it made change/improvements difficult to assess. 3

7 1. Introduction The Middlemore Foundation for Health Innovation (MFHI) commissioned Health Services Research Centre / Te Hikuwai Rangahau Hauora (HSRC) through the Research Trust of Victoria University of Wellington (RTV) to undertake an independent evaluation of the Mana-ā-riki/Kootuitui ki Papakura s Programme 1 of Education/Manaiakalani, Health, and Homes at Papakura, South Auckland. The evaluation was conducted from 1 st July 2016 to 30 th June The evaluation focused on: The effectiveness of the implementation of the Mana-ā-riki/Kootuitui ki Papakura programme; The initial impact of the Programme in Year 1; and The features of the Programme that can support success in Years 2 and 3. The evaluation process included analysis of available documentation, 16 key informant interviews (10 individuals and 1 focus group of 6), and 22 interviews (11 individuals and 1 focus group of 11 people) delivering services within the schools, to families and the community. The report provides document analysis and findings from qualitative interviews with key stakeholders involved in the three strands of the Programme. Section 2 of this report explains the background, and the evaluation purpose and design. Section 3 discusses the contextual background of the partnership between Middlemore Foundation Board and Papakura Kootuitui Trust; Education; Health; and Homes, and Sections 4, 5, 6 and 7 presents the analysis of findings from interviews with stakeholders from the Partnership (i.e. Sponsor and Trust), Education, Health, and Homes, followed by an integrated analysis/synthesis of the programme successes across the integrated approach, and identification of areas needing work on to improve service delivery. We appreciate the time, general engagement and information sharing from all those we approached who are associated with the initiative and to Vee Walker who was involved with early stages of data collection. 1 See Appendix 1 for Evaluation Deliverables 4

8 2. Background: Kootuitui ki Papakura/Mana-ā-riki Programme The MFHI partnered with the Papakura Kootuitui Trust to provide an integrated approach for the Mana-ā-riki programme in order to make a fundamental difference to the wellbeing of children and young people, working with families and community, education, health, and homes in the Papakura community cluster schools. 2.1 Integration Much discussion on integration is driven from a concern about fragmented health and social services provision in New Zealand. It is important to ask what integration means as integration means different things to different people according to different contexts and countries where people operate from (Cumming, 2011; Kodner D.L. & Spreeuwenberg, 2002). Integration comprises the processes, methods, and tools that seek to connect health services together. Integration can include sharing information, co-ordinating care and jointly planning care for the individual service user or family (at the micro level, within a particular health provider organisation); co-locating service delivery and designing agreed care pathways (at the meso level, with connections across health provider organisations); through to the planning of services, the combining of budgets, and the merging of organisations (at the macro, or organisation-to-organisation level) (Cumming, 2011; New Zealand Productivity Commission, 2015; Valentijn et al., 2015). In the broadest conception of integrated care, health services will also be co-ordinated with social services (such as housing, work and income, education, and employment) (New Zealand Productivity Commission, 2015). In NZ, the emphasis has been on achieving more integrated care horizontally within primary health care (PHC) and community settings, and vertically between PHC/community and hospital settings (Cumming, 2011), as well as between health and social services through recent whānau ora policies (Taskforce on Whānau-Centred Initiatives, 2010). In this evaluation, we refer to integration as inter-sectorial integration between education, health and social services such as housing to provide a healthy home (OECD, 2015). Thus, service integration for the three strands of Education, Health, and Homes is an important goal for the Middlemore Foundation Board to make a difference in the lives of children in Papakura. 2.2 The Evaluation This is a process evaluation which explores what is working well and what needs improvement in the three strands of the programme namely Education, Health and Homes. 2.3 The Partnership Middlemore Foundation Board and Papakura Kootuitui Trust Mana-ā-riki is an umbrella name chosen by MFHI, which means the mana of the child, achieved through investing in many small (riki) changes to make a powerful (mana) impact (Middlemore Foundation for Health Innovation, 2016). Mana-ā-riki takes a holistic, integrated approach tackling education, health and home simultaneously. One of the key features is, it is led by a local community trust, Papakura Kootuitui to ensure it has buy in from local leaders (Papakura Kootuitui Trust, 2017). The overarching goal of the Kootuitui ki Papakura/Mana-ā-riki Programme is to help children to reach their full potential and be successful. As a community-based programme, it aims to improve outcomes for underprivileged children through a three strands, integrated approach: education, 5

9 health, and homes. The programme is a three-year pilot to deliver a number of key child health, healthy homes, and educational outcomes for children in Papakura. The programme is based in a cluster of six schools: five primary, four decile 1 and one decile 4, and Papakura High School, decile 1. It involves: Local community leadership through Papakura Kootuitui Trust (the Trust); Digital Enablement through Manaiakalani Education: a digital e-learning innovation offering students full digital citizenship to achieve improved educational outcomes; Establishment of school-based public health clinics, that also work with children and their families to access a range of health services; and A healthy homes initiative to make homes healthy (warm/dry) and safe (free from violence). The key stakeholders involved in the pilot include: Middlemore Foundation for Health Innovation (the Sponsor) Papakura Kootuitui (the Trust) Counties Manukau District Health Board (CMDHB) National Hauora Coalition (NHC) health providers Principals or Senior Manager representatives from the cluster schools Woolf Fisher Research Centre, Auckland University Manaiakalani Education Trust Southern Initiative, Auckland Council Papakura Marae The children involved in the programme, their parents and whānau. The Trust overseas the implementation of the three strands of the Kootuitui ki Papakura/ Mana-āriki Programme. The education strand provides digital learning in the classroom and is supported by the Manaiakalani Trust. This strand has been operating for over two years and is being evaluated by the Woolf Fisher Research Centre, Auckland University. The health strand has been implemented in the six schools (5 Primary and 1 High School) at different stages. The health strand has a variety of different funding sources which include MFHI funding National Hauora Coalition (NHC) to provide health services to five Primary schools, delivered by Registered Nurses. NHC collaborates with Papakura Marae to provide whānau support workers to work together with the nurses and families. The health strand delivered by NHC began in MFHI funds CMDHB to provide enhanced health services to Papakura High School, which commenced in July The Homes strand is still in the co-design process working with the Southern Initiative and at the time of preparing this report, the implementation process has not yet begun. 6

10 2.4 Middlemore Foundation for Health Innovation Vision: That our people live in good health and are able to fulfil their potential. This evaluation has drawn on the reports that have been provided to the MFHI on the progress that each of the initiatives has made over the past 12 months. The full education evaluation for 2016 and the school-specific results have been made available to the schools and the Trust. Therefore, in this evaluation, information on the education strand concentrates on the views of the school personnel and how the integration between the education and health aspects is progressing. 2.5 Papakura Kootuitui Trust The Trust was established by the Middlemore Foundation specifically to provide local leadership and oversight for the pilot programme but the project was also envisioned as a boost for Papakura young people in the longer term, not just the immediate health/education/homes aspect. The aspiration is that the integrated initiative will get Papakura young people into training and jobs. Therefore, underlying the Programme there is a big long-term ambition for making a significant social change really (to quote one of the interviewees). 2.6 Manaiakalani/Education The overarching objective of the education strand of the Programme is to enable, enhance and accelerate student achievement using the Manaiakalani methodology. The Manaiakalani methodology is a digital e-learning innovation offering students full digital citizenship to achieve improved educational outcomes. The specific outcomes the education strand of the Programme is seeking to achieve are: Significantly and measurably reduce truancy rates; Significantly and measurably increase NCEA level one pass rates; Increase student engagement in learning; Accelerate student learning; A positive shift in student capability; Full digital citizenship among students; and Widespread family/ whānau participation and support for children s learning. The initiatives through which the education strand of the Programme is seeking to achieve its objective and specific outcomes include: Developing and delivering a professional learning and development programme that supports a shift to more effective teaching and learning practices; Implementing a visible digital learning environment supported by skilled teachers; Establishing family/ whānau and caregiver programmes that are well structured and endorsed by the community; 7

11 Establishing IT infrastructure that fully and reliably supports digital learning environments and one to one student devices; and Establishing and supporting a community entity that is well funded and has arrangements in place to supplement cluster resources. Evaluation of the education strand of the Programme is not included and contemplated within the scope of this report as this strand is being evaluated by the Woolf Fisher Research Centre. However, relevant findings from the education strand are reported alongside the findings from the health and homes strands of the Programme, especially with regard to the integration of the three strands of the Programme. 2.7 Health The overarching objective of the health strand of the Programme is to work with families and the communities to ensure children are healthy, confident and reach their full potential 2. The initiatives through which the health strand of the Programme is seeking to achieve its objective and specific outcomes include: Assisting in the provision of accessible school health clinics during school terms to identify and treat children with preventable illnesses; Assisting in the provision of follow up support, intervention and engagement with other health and social service providers to facilitate treatment, support service access, intervention and engagement, as appropriate; Working with families / whānau and the community to help parents / guardians access the healthcare that their children needs; and Supporting school-based and community health teams with the knowledge and skills required to provide high quality services. 2.8 Homes The overarching objective of the homes strand of the Programme is to work with families and communities to ensure children s homes are healthy (warm/dry) and safe (free from violence). The specific outcomes and proposed initiatives for the homes strand of the Programme are still being developed by the Southern Initiative and the Trust. Evaluation of the homes strand of the Programme will be undertaken in 2017/18, as the homes strand is implemented. 3. Methodology While as stated earlier in the report, different strands of the initiative have been implemented at different times, a process evaluation was appropriate to consider the integrated approach which is the unique feature of the Programme. Process evaluations are undertaken to establish whether a programme is being implemented the way in which it was envisioned. It provides the opportunity to gain information that will assist with further activities, planning and future programme delivery. The education initiative has been under way the longest. Education initiatives by their very nature are clearly school-based and provide pupils with the tools to learn effectively in the digital environment. 2 The specific outcomes the health strand of the Programme is seeking to achieve are set out in Appendix 2. 8

12 However, children cannot learn if they are unhealthy or live in a cold or unsafe home. Thus, the Kootuitui ki Papakura/ Mana-ā-riki programme takes a three-strands approach to work with the whole child in the context of their family/whānau. 3.1 Key Evaluation Question The key evaluation question is, Does the integrated approach of education, health and homes make a difference in the lives of the underprivileged children and their families in Papakura enabling them to better realise their potential? This question was examined by investigating the following: The roles and involvement with the Kootuitui ki Papakura/Mana-ā-riki initiative of selected key participants; Participants views as to how it is working to date; What are the most successful aspects? What needs to be changed to make it work better? How well the three initiatives are working together to achieve the overall goals of the Programme?, and What advice would participants give to other schools considering joining the Programme? 3.2 Evaluation Approach The evaluation used a realist methodology that explored the contexts within which the Programme operates, the key features and mechanisms that lead to success, and the outcomes of the Programme. Rather than focusing only on whether or not a particular programme achieves its goals, a realist methodology recognises that programmes such as Mana-ā-riki/Kootuitui ki Papakura operate within complex environments, and it is likely that programmes will be successful because a combination of contexts and mechanisms align to support the achievement of programme goals. In some contexts, key mechanisms will work to successfully achieve the programme s desired outcomes; but in other contexts, key mechanisms will not work as well. A realist approach aims to identify the combination of contexts and mechanisms that do work to achieve programme goals. In particular, the evaluation explored: The contexts within with the Programme is being introduced (e.g., community, school and family socio-economic and political contexts, including overall resources to support the Programme); The key components of the Programme and how each is being implemented; The experiences of key participants with the Programme including the Trust leadership; programme leaders; school Principals; other school programme leaders; teachers; school nurses; whānau support workers; students and their families; The mechanisms that support the Programme (i.e. how participants respond to the components of the programme and use or do not use the resources from the Programme); The strengths of the Programmes and areas for improvement; The resources required for the Programme; and The outcomes of the Programme. 9

13 3.3 Methods The evaluation used a mix of methods, including document review, key informant interviews and/or focus groups to explore the components, implementation and experiences of the Programme. It also identified a range of before-and-after administrative data that can be used to more objectively explore the outcomes from the initiative. This included for example health and education reports on respiratory and skin infections; rheumatic fever; truancy; overcrowding; and safe homes. A draft evaluation work plan and an intervention logic model (see Appendices 3 & 4) that discussed the methodology, scoped the evaluation in depth, identified priority issues for the evaluation, and finalised data collection tools and processes was also developed. These were approved at the MFHI Board meeting on 22nd September As a result of the delayed start of the Homes strand, its activities and indicators were not included in the intervention logic and work plan in 2016/17. Since the logic model and work plan are evolving documents, the Homes activities and indicators will be added in 2017/18. The first phase of the evaluation involved initial meetings between the research team and key stakeholders to develop relationships and gain an in-depth understanding of the rationale and importance of the Programme, the key components of the Programme and how they are envisaged to work to achieve the desired Programme outcomes (i.e. an intervention logic that shows exactly how aspects of the Programme are designed to work), and views on the implementation of the Programme to date. Alongside document analysis of reports and other information, perspectives were obtained from key informants involved in the Programme through semi-structured interviews and focus group discussions undertaken from September to October 2016 and March The evaluation received ethics approval from the Victoria University of Wellington Human Ethics Committee (reference ) on 30 August

14 Table 1: Qualitative interviews and focus groups Agency Interviews Number of Participants MFHI Board Members 3 3 Trust 2 2 Focus Group 1 6 Education Interviews 1 2 NHC 3 3 Health (NHC/CMDHB/Marae) CMH (one of the interviewees was interviewed in 2016 and 2017) 9 8 Marae 1 1 Focus Group (This included 2 student nurses, 2 whānau support workers from non-cluster schools, Nurses and whānau support workers from NHC and Papakura Marae) 1 11 Homes

15 4. Findings The next sections present the findings from the evaluation, drawing on the views of those interviewed and the documentary evidence. The findings are organised under the five themes: roles and involvement with the Programme; how the Programme is working to date; what is working well; what could work better; and the integrated approach. Within each theme the group to which interviewees belong is identified but no further identifying information is included to maintain confidentiality. 4.1 Roles and involvement with the Kootuitui ki Papakura/Mana-ā-riki initiative In this section, we explore issues relating to the roles and involvement of each key stakeholder with the Programme Foundation Board and Trust The Vision: The South Auckland Health Foundation was established in 1999 to raise money for South Auckland Health and Kidz First Children s Hospital was their first big project. While the focus of the MFHI was on Well Child Services through building Kidz First as an inpatient service, a critical need to reduce hospitalisations was identified by CMH. They came to the Foundation to ask for assistance with the growing number of children coming through the Kidz First Emergency Department and being admitted with preventable illnesses such as Rheumatic fever, skin infections and respiratory infections. Looking more closely at what was happening in the community was seen as one way to tackle the problem: there was always that focus to do it better out in the community. Board and Trust members share the same vision of improving the life outcomes of the tamariki, both in the short term through improved health, improved school attendance and education achievement, as well as in the longer-term with pathways to employment and safe, secure, well-housed communities. The leaders shared the vision that a child living in a warm and violence-free home, who experiences good health, will learn in the classroom and will be successful in life, and that all children should have the same opportunities for success. They suggested that interventions that worked across all three areas in an integrated approach would have the best chance of making fundamental changes for the children: while health is a problem we will never solve it [children s disadvantages], housing is a big issue and if we are really serious about getting kids out of poverty and into better housing then we need to invest in them which is education, so those are the three that are the cornerstone, if you like, unfortunately justice and the others sit around it for when we fail, but we need to do something about health immediately, to do something about health immediately it s an immediate service but that s never going to answer the problem, it will fix the immediately day to day stuff, we need to look at housing because housing generates the health issues and it s not just warm, dry house, it s a safe, warm, dry house. The leadership from the MFHI members and others who were passionate about making a difference in Well Child health was evident in the development of the Mana-ā-riki programme: there s absolutely no doubt that Kidz First fulfils exactly what we wanted it to do, its design, the focus is great but what really was becoming apparent was that while we had a 12

16 very effective Kidz First public health team and community team which managed kids post discharge from hospital the health of children wasn t actually improving and that overall we still had these continual problems. Anecdotal and personal experiences of many health professionals and evidence-based reports on poverty, inequality, poor housing, social issues, low achievement in education and poor health status of children provided the impetus for the integrated three strands approach of education, homes and health: There has to be a better way of doing this, there has to be something that we can do that would start to address some of these problems rather than just putting a band aid on something and everyone doing their own thing, how do we do this joined up approach the architect is really (Name) There was a common view expressed by participants from the Foundation and the Trust that to improve the opportunities and outcomes for the children in the area, the Programme needed to work across the three critical areas of education, health, and housing, and that it needed to be sustainable. For this reason, the focus was on integration of the three strands at various levels, and the requirement that the Programme be community-led, firstly to ensure that it worked for the community, and secondly that it would endure. The Programme is overseen by a Director whose role is to undertake fundraising to make sure the Foundation Board has sufficient funding to run the project, put budgets together, organise Memoranda of Understanding (MoUs) and contracts, and engage with key community stakeholders. While the Foundation has its own priorities, it was crucial for the Foundation s vision to align with CMH s strategy. Foundation board members have various roles and backgrounds in making decisions to ensure that Programmes are aligned with CMH strategy in improving health outcomes for vulnerable populations. The main purpose of the Middlemore Foundation is to raise money in order to complement core funding for initiatives which the CMHB might be struggling to fund otherwise. As one member said, [we] assist the Board to ensure that programmes and projects that the board decides to invest in and support are ones which are going to be well aligned with the DHB strategy, with the health needs of our community and with, perhaps, the gaps or pressure points in health service provision that aren t so readily met by our core funding. Participants also wanted to work with and build on the DHB approach taken with the successful Mana Kidz. This is a free, nurse-led, school-based programme that provides comprehensive healthcare for children in the Counties Manukau Health region led by the National Hauora Coalition in partnership with Counties Manukau Health, supported by local providers 4. The Foundation Board and Trust members engaged with the Programme at different stages of its development. The Director was involved with the Programme from the beginning while the others became involved later. One participant was conscious of not being there at the beginning but was very supportive of the concept as it really does make sense. Along with other Foundation Board and Trust members interviewed, this participant recognised it was critical that the Programme was evaluated as it needed to show that it was working or not

17 The strategic partnership between the Foundation and a community organisation was considered an enabler for effective community ownership of the Programme. Papakura Kootuitui Trust was formally established in September 2015 to oversee the Programme. The name Kootuitui was chosen in consultation with manawhenua for Papakura schools participating in the Manaiakalani Outreach Programme. It means connecting/linking or weaving together as the programme it is about connecting the dimensions of Digital Education, Students Health, and Healthy Homes (Papakura Kootuitui Trust, 2017). The Trust is led by a very experienced Chair who has lived in and knows the community well, and has had strong leadership and governance roles in local government and community organisations. His background to the role of the Trust Chair was seen as very appropriate, as the Trust needed a strategic plan to demonstrate good governance, i.e. having the right people in the right place, strategy, systems, space, culture. Several participants suggested that the success of the project depended on the development of good working relationships across agencies and with the community. In the longer term, the vision for the Trust, as well as for Foundation members, is to move into a sustainable model which is independent of the Foundation. The departure of one of the prominent leaders of the Manaiakalani Education stream helped the Trust to build capacity and enhanced capability in recruiting more staff breaking and [then] strengthening the umbilical cord. Supporting the Trust s strategic direction was enhanced with the appointment of a very experienced Education Leader for the Manaiakalani education strand, who is also the executive officer of the Papakura Kootuitui Trust which involves building relationships and networks with the sponsors and the funders and pulling the work of the strands together Principals With one exception, the Principals were well aware of Kootuitui ki Papakura Programme. Some confusion arose around the terms Papakura Kootuitui Trust and Mana-ā-riki, with most referring to Kootuitui as the cluster. Digital learning, leadership, forming relationships and trust attracted some Principals to join the cluster. The cluster provides the Principals with an opportunity to strengthen the sharing of knowledge, resources and experience between them, particularly for those who are less experienced, who found this helpful: The reason for coming on board not only for the 1-on-1 devices or the opportunity to be able to get into houses and help some of our families that struggle and have health concerns and have family needs, we wanted to see how we could actually tap into resources and support beyond the resources that we can provide The real strengths of Kootuitui cluster is actually the relationships of the Principals and the sharing of knowledge and resources and experience, it s been really beneficial for myself personally High collaboration within and across schools, I think are incredibly powerful, we re all learning together Involvement was described by one Principal as: working within a cluster that isn t an imposed form of working is you actually develop your own way of doing things, there s much more ownership, we haven t been told by the Ministry or by the Government that we have to do this, we are doing it out of choice and that choice aspect creates ownership and a desire to be successful, so we re going to work to overcome the difficulties and the problems and we re going 14

18 to celebrate all the achievements together, there is going to be a corporate sense of ownership of what s happening and a desire to see really positive outcomes for the children Papakura High School Enhanced Health Services The school health service at Papakura High school receives base funding from the Ministry of Health and additional funding as part of the Kootuitui ki Papakura/Mana-ā-riki Programme. There has been a growing understanding of the complexity of the health needs of the Papakura community more generally. Because of the roll size of the school, Papakura high school would qualify for only 1.2 FTE nurses, but under the Programme there is funding for 1.6 FTE nurses, 1 FTE youth worker, and for a General Practitioner for up to six hours a week, plus some operational costs and equipment. One school nurse had been in the role for 15 years (this role in not funded by Kootuitui), and the new nurse, GP and youth worker started in There are two contracts, one for the nurses and youth worker and one for the GP, both of which are monitored by CMH. CMH reports quarterly to the Ministry and schools are required to report quarterly and annually to CMH. The model for the Papakura school health service was developed in discussions with the school Principal and nurse; it was decided to enhance the service that was already there, based on evidence from an earlier CMH review of youth services which recommended a school-based model of health services. As the Papakura High School Enhanced Health Services quarterly reports for July to December 2017 (Papakura High School, 2016a, p. 3; 2016b, p. 3) point out, while most young people report good health and wellness, in Counties Manakau in particular there are continuing high rates of suicide, mental distress, obesity and risk taking behaviours. There are proportionately more Māori students at Papakura High School in comparison to the other secondary schools in the CMH catchment area and groups of students, particularly those attending the Alternative Education Activity Centre who have limited or no access to health services. To enhance the offerings of the existing staff at the school health service, funded through other means and including a specialist mental health practitioner, physiotherapist, guidance counsellor, asthma nurse and social worker, the Kootuitui ki Papakura initiative funded more school nurse hours, attendance by a GP for three hours a week and a youth worker. The aim of the enhanced service was to provide an extension of existing practice to include the off-site Alternative Education Activity Centre, to provide youth-friendly GP services on site, which would support the nurses in their practice as well as support students to make good choices around use of health services in the community especially when they transition from school, and to mentor and support youth and their whānau with good links into the wider community from the school base. In the first six months of operation, the enhanced school health service reported a number of positive outputs that were able to proceed because of the availability of extra staff and staff hours. These included both proactive and reactive initiatives including scheduled time at the off-site Alternative Education Activity Centre, health promotion activities, and working with the GP to care for students on site thus expediting treatment. More engagement with whānau rather than working just with the students has become possible which assists with the more holistic approach. The case studies reported on in the reports, provide evidence of how the enhanced service has made a difference in the health of individual students. After six months in operation, it was reported that there was growing cohesiveness in the operation of the team and a better understanding of how the integrated approach was intended to work. All health staff, whether funded under the Programme or through other sources, meet regularly. The changes in the school s pastoral structure from home form classes to three whānau groupings that 15

19 include students from across the school is expected to enhance the relationship between the educative and pastoral functions. Previously, many of the students at Papakura High School received limited or late health care interventions because their families were unable to pay for GP visits or prescriptions. Having health services on site at the school enables many injuries and illnesses to be treated on the spot and for the students health care to be followed up. The GP already had a loose relationship with the high school, the nurses would take their student there when they needed to but there was no funding for that GP, she saw them as and when she could, it was all done on the smell of an oily rag. Whereas this way now there is a direct contract for that general practice to provide a clinic on site, once a week, potentially twice a week. The school also host an Activity Centre (on a different site) for students from local high schools, and the nurses can now dedicate one or two mornings a week to these students Primary Schools Health Services The National Hauora Coalition (NHC) and Papakura Marae are supported by the Middlemore Foundation to deliver health services to high needs schools in Papakura, including the five Kootuitui ki Papakura cluster primary schools. The service is located on the Papakura Marae, enabling close collaboration with the Papakura Marae Whānau Support Worker team. At the end of 2016, the nurse-led school-based programme in the five primary schools had been operating for a year. They provide free throat assessment treatment and follow-up (to reduce the incidence of rheumatic fever), and diagnosis and management of skin infections along with child health assessments including hearing and vision checks, new entrant immunisations, child protection work, enuresis and encopresis, behavioural and developmental assessments (National Health Coalition, 2016a). Quarterly reports for 2016 provided a record of how the initiative was working and what had been achieved in terms of rheumatic fever prevention, skin infection management, and child health and well-being assessments. Both aggregated data and data for each of the five cluster schools was presented. A high percentage of families has opted in to the health services offered. Of the 1057 children in Kootuitui cluster schools, 968 (92%) had consented to inclusion in the programme in Only one cluster school had under 90% participation. The comment was made that there needed to be some further work to ensure that the programme was available to all. In terms of outcomes for 2016, 100% of identified positive GAS children were treated. Overall, the rates of rheumatic fever in 5-12 year olds in South Auckland has significantly reduced with it being reported that Kootuitui Health making an important contribution to this result. The health team is also dealing with a wide range of skin infections, a significant problem for children in CM. With the child health and wellbeing assessments, nearly half resulted in the development of intervention plans. At the end of 2016 it was reported that branding was in place with new banners and badges to distinguish the Mana-ā-riki -funded service. The NHC report stated that it was planned to get a more formal relationship with the schools and an agreed school health plan to continue the positive developments (National Health Coalition, 2016b). The success of the rheumatic fever and Mana Kidz programme was the motivation for MFHI and CMH to contract the NHC to deliver the nurse-led school based health programmes in Papakura. The previous Mana Kidz programme involved nine Primary schools, however, only five of the nine schools joined the Kootuitui school-based health programme in the beginning of

20 Several people in the health stream play different roles in the Kootuitui Programme including project manager, project coordinator, clinical coordinator, and registered nurses who are employed by NHC, together with Papakura Marae which provides social support through their CEO and whānau support workers. The Kootuitui nurse-led school based health programme has evolved initially from the rheumatic fever and Mana Kidz programme under NHC. The project manager of NHC oversees the Kootuitui nurse-led programme with support from a project coordinator who had assisted in the design of the Kootuitui nurse-led clinics adopting the Mana Kidz model, while the CEO of Papakura Marae oversees whānau support workers. The nurse-led school based clinics in the five primary schools are delivered by registered nurses with the assistance of whānau support workers, and are supported by a clinical coordinator Homes The development of the Homes strand was facilitated through meetings with Kootuitui Trust Chair and the Middlemore Foundation project manager, and two members of The Southern Initiative (TSI). TSI and Kootuitui work in partnership to provide support for the Homes strand. The TSI project coordinator and a member of Papakura Kootuitui Trust are the main personnel working on this project. The key is to have people with the right skills and capability to work with whānau. There were many discussions around how this third strand of homes would look and how it was going to fit in with the other two strands of health and education. The discussion centred around what the group envisaged would happen in this strand. There was a clear focus from the start asking the question was this strand exploring issues about the physical home environment such as insulation, warm, dry housing, or was it about enabling whānau to support Tamariki? Rather than the group making the decision, the challenge was to ask whānau about what they wanted included in the strand that would make a difference for whānau in Papakura. When that was agreed, TSI offered to support Kootuitui with expertise and resources to undertake the co-design process with whānau. 4.2 Participants views concerning the Programme to date In this section, we explore participants views concerning the Programme to date. The question as to how the Programme was working to date was a challenge for some, as it often felt it was too early to make a judgement, particularly as the three strands, Education, Health, and Homes, started at different times. However, there were some key themes identified and these are discussed below Foundation Board and Trust Views Having the right person with the right attitude for the community has to be celebrated as a success, and particularly as it is an essential component for a Programme like Kootuitui ki Papakura/Mana-āriki to work. The Foundation s Director acknowledged the several people who had helped the Foundation to make the Programme worked, [Name] was my conduit in the community but also my ears, s/he was the ticket into the community if I had done a couple of things that are right, one was [Name], [Name], [Name], and [Name] in the first instance. Choosing the right leaders with the right skills and people with community focus were skill sets the Foundation was looking for. Participants recognised the importance of the development of right relationships at all levels and between all the key players. It was clear that this aspect had been successful and that the leaders had worked hard to develop relationships. This was particularly so in the education stream, where schools were 17

21 collaborating and sharing, and systems were now in place that would enable collaborative relationships to continue in the future. It was acknowledged by participants that there was still some work to be done in developing the relationships between the schools and the nurses. This is understandable, given that there are some significant structural barriers that need to be overcome between schools and health. While both are focused on working with children for optimal outcomes, they are quite separate institutionally and can have different ways of working for these outcomes. There are, in particular, issues concerning confidentiality (discussed later) that still need to be worked through. However, although it was expected that schools/teachers would accept a school nurse and a whānau worker into the school, and why wouldn t you, it s easy, it doesn t impact on them at all why wouldn t you accept someone who is going to help with some of the family and school issues, seeing schools as hubs for the health input was a potential risk for the Programme, given the different foci for schools and health, one which has not arisen as schools are clearly enthusiastic about this role. Funding the Trust to oversee the Programme is a long-term vision in sustaining the Programme, driven by and owned by the community, we had to have a community trust for sustainability we would fund it as best we could for three years, but at the end of the three years the Trust had to be strong enough and sustainable, the project had to be sustainable to carry it on. The success of this remains to be seen, but Trust and Foundation member/s share the same vision for the Trust. While Middlemore Foundation is committed to funding the Trust, community ownership of the Programme was a key driver to the partnership as one respondent noted at the end of three years they should stand on their own and what year four looks like is entirely up to them, and they also need to fund whatever they want to do. Part of that was, of course, about us fostering the community development and empowerment and sense of ownership. One interviewee noted that it requires a lot of work in building relationships with stakeholders in each strand as well as an understanding of the working model. To be successful required managing the interface with the Principals, putting in place other resources and structures, and having the strategic leadership from all the three strands working together. I think it s gelling, I can see a pathway forward, a lot of it is building relationships and understanding, managing the interface with the Principals I m interested in sustainable, the model going forward, is not only getting the funding but I am really interested in how we are layering it over the 10 years Principals All Principals were supportive of the Programme, being described by one as exciting and challenging. It appeared that the Programme has brought some positive changes such as parent engagement and commitment to purchasing Chromebooks is high; there is high level collaboration across the school despite the fact that only half the school is digital, which includes high level teacher collaboration at leadership meetings and at toolkit training sessions attended by most staff including support staff. Digital learning is ticking over effortlessly. Teachers report that they could not possibly return to teaching in a non-digital immersion classroom. Everyone is excited to learn, create, and share The Programme has been enhanced through strong collaboration across the school cluster, thus, enhancing children s learning. The Trust Board members, teachers, students and whānau commitment and engagement with the Programme has helped to break down the hierarchical 18