“I wake up every day with the taste of expectation in my mouth.”
It’s a loaded challenge, taking up the mantle of leadership in an overwhelmed, complex health system amidst a global pandemic – arguably the most important, some might say “impossible”, job in Hawke’s Bay. Answerable to so many constellations of need and demand, and not least, as the first wahine Māori CEO of a district health board in the country, to the full weight of the iwi’s hopes for change.
But Keriana Brooking (Ngāti Pāhauwera, Ngāti Kahungunu) is waiting serenely in the hospital rose garden when we come to take her picture. Within her busy schedule, we’ve found this small wedge of time, which she inhabits with enviable ease and good grace.
Born and raised in Otago, with frequent summers spent in Wairoa with her father’s whānau, Keriana is both intimately familiar with parts of Hawke’s Bay and a newcomer to its gravitational centres (until her appointment she had never been to Hastings, Havelock North).
She comes to the job from years working passionately in primary health (she was the inaugural executive of the Tairāwhiti primary health organisation in the early 2000s), and a stint in the Ministry, most recently (and famously) alongside Ashley Bloomfield as the deputy director-general of the Covid-19 Health System Response.
She’s long had her eye on a DHB crown: “ a) It seemed like the lynch-pin of being able to make changes and decisions; and b) given that there had been a particular, traditional way boards had appointed chief executives, what would you need to do to be appointed if you were Māori and a woman and didn’t have a hospital-career pathway?”
She laughs, “I think it appealed to the competitive nature of my spirit.”
Big things on her plate
When Keriana started the job in August 2020, there was no way she could have anticipated, she says, that late this February there would be an expectation to vaccinate all of the eligible population above the age of 16 by Christmas.
“Covid vaccination for this year, without a doubt, is our number one priority.”
But equity in the way the DHB provides services, both from a care and an experience perspective, is another: “We can’t continue as a country to accept such large variations in things like access and experience, and life expectancy, principally based on ethnicity, but at times based on gender and rurality, and other demographic factors.”
There’s a lot to weave together in order to get better integration between secondary services and community and primary services, says Keriana, and “for more people to get consistent experience, access and outcomes.”
Like her predecessor Kevin Snee, Keriana believes some of the integration activity required isn’t dependent on receiving additional funding, but can be resourced through creating more “efficiencies” in the system and changes in culture and ways of working.
“We need to be adapting the way we design and develop services, and then deliver and assess those services in a way that more adequately meets the needs of the populations we want to serve… there’s quite a big re-engineering that needs to occur.”
Long-term planning includes new facilities and things like workforce and technology. Regular day-to-day service priorities at the front of mind: “our ageing population, the importance the first 1,000 days have on your life, the growing mild-moderate to enduring mental health and addiction conditions.”
And of course, the social determinants of health, which require a cross-regional, multi-sectoral approach.
As signalled by Minister Andrew Little’s ‘scene-setting speech’ on the government’s impending reforms of the health and disability system when he visited HB in March, the direction from the ministry is towards “a more person-centred, whānau-centred, Te Tiriti world”.
And while these concepts are not new, Keriana believes there’s more of a convergence around what that means and “a larger groundswell of people now wanting to work that through.”
A relationally-driven CEO
The DHB employs around 3,600 people; across the whole health sector in Hawke’s Bay (from primary care to aged-residential care and private laboratories) there are some 7,000 people employed. As Keriana notes, “that’s a lot of people to keep on the same page.”
But essentially, for those working within the health system, “most want clarity, and they want to be recognised and valued.”
In an organisation of this size, “it’s a never-ending pursuit of engagement”, managing the reciprocity and the “cascade up or down” of communication, which “will never be quite enough, (nor) as individualised and focused as we would like it to be.”
She takes heart from the fact that she gets “emails and moments with staff about a whole host of things”, not just concerns but letting her in on the loop of what’s happening in their area. She works hard to keep that channel open.
Presence. Visibility. “You have to keep your face up and out.”
With her distinctive moko kauae, Keriana gets stopped a lot in her life: at the supermarket, walking down the street, out for dinner. Strangers introduce themselves, wanting to chat.
“I spend a lot of time talking with people and hearing their story, and I think there’s incredible value in that, because a number of things that need to occur (in the health system) I’m not going to see from my desk. Given the complexity, and given the sheer volume of information and knowledge that’s available, and misinformation too, you really have to get back to the people.”
She says many (mostly Māori) would say, it’s not often in their normal everyday environment they’d have the opportunity to talk to the chief executive while she’s washing dishes at some event!
“I haven’t changed the way I live my life, and that may in fact open up a whole range of people to have access” and feel seen at the table.
Current state of play
In the DHB’s March board meeting, Keriana referenced the “significant acceleration” of numbers coming through the doors of the hospital, with over 110 consecutive days of consistent high-levels of admittance. Similar upwards trajectories can be seen across all government services, both in Hawke’s Bay and around the country.
In our interview, she acknowledges burn-out in the health sector is real, and unsurprising.
“We are working harder than we ever have to catch up and we’re still seeing an increase in waiting times.” She continues, commenting on the ageing boomer generation and its healthcare needs and the surge in comorbidities: “…we have known for the last 20 years that the ‘tsunami of age’ was coming, it may just be that it’s arrived (at the same time as the virus), or maybe as part of the post-Covid experience it has been accelerated.”
Across time, the need presenting has also become more highly complex, often tethered to what’s happening (or not) in the social space (for instance, the housing crisis, and lack of supported residential places, is directly impacting the DHB’s ability to discharge patients, and thus free up beds).
“We are one of the few government agencies open 24/7, and so after 5pm or on the weekend … where is the door that is open for you to go? It’s the emergency department.”
“We have 44,000 presentations to the emergency department a year, a department that was built to cope with 22,000. It’s not the community’s job to work out how to get a bigger hospital. But part of the conversation we need to have with the community is what does it look like, while we have the hospital we have for the next five years, maybe the next 10 years, when we expect that the number of presentations may increase by a quarter or by a third or 100% – who knows?”
There’s a “growing necessity” for health to interact with other local government agencies. An example of ‘interaction’ being the 24/7 mental health crisis hub the DHB has co-developed as part of a government pilot and set to open in May, offering walk-in integrated, wrap-around services, including peer support and emergency overnight beds.
This will be one lever to help reduce pressure on ED and is the kind of model of integrated care, Keriana indicates, we can expect to see more of.
Broadening the metrics
BayBuzz editor Tom Belford, who’s accompanied me to the interview, notes that despite talk over many years from the DHB leadership about the social determinants of health, and the need for an “all-hands-on-deck” approach, the public at large have a more simple set of metrics by which to judge the DHB’s performance: “The public’s barometres are pretty much, what’s the emergency department story these days and can I get surgery, where am I on the list, or is the hospital too hot? … Does this bigger social-context thing mean anything to the potential client or patient on the street, does that get across?”
“I’m also very thoughtful of the people on the unsealed road,” Keriana replies. “Because if I talk to the people of Tuai, they might not be necessarily using the metrics you’ve produced. I feel I have an obligation to stretch the metrics … We need to look to all four corners of our region.”
For some communities, she notes, more pressing barometres are whether there’s even a dentist in town (in Wairoa, currently no), or a GP to see, or a pharmacy that’s open when you need it.
Quantitative metrics are easier to get than qualitative; service metrics in the secondary and tertiary service easier to get than those from the broader primary/community service. “For a long time, there was an incredibly strong focus (in the DHB) on ‘hips & knees’, or on the emergency department waiting target. There was also focus on childhood immunisation and smoking, but we talk about that less.”
In general, population health has been prioritised less, though efforts in that space have long-view, far-reaching benefits.
In the health sector, “We’re quite binary, and also we’re not experiential. In other service industries, people do spend more time really thinking about service insight. At some stage, Air NZ worked out how to get us all to check ourselves in and print our own boarding pass and drop our own bags off. At some stage, they put that real deep thought into what the experience should be, and they tested it in such a way we participated in the process, without realising we were participating in the process.”
Strengths and challenges
We locals like to know how people see us – I ask Keriana, fresh to the region, what Hawke’s Bay has going for it in our health sector. She names the rich tapestry of community-driven programmes happening around the region, and the fact that in every Hawke’s Bay community she’s visited there’s a strong group of people who are proud of the work they do, with or without government involvement.
Hawke’s Bay has a pretty strong public health unit, she notes, that expands into a supportive broader team, contributing to the region’s success in managing its Covid response. The PHU has also risen to the task with the Napier flooding, the hydrochloric acid spill into Napier’s waterways, the fire on the ship in the port – we are really quite quick to respond to events like that, she observes.
“People will say, ‘that took longer than we thought’ but I see an awful lot of what I would describe as ‘cut-through’, where by the strength of people’s relationships they are able to get what they need.”
And she perceives a culture of pitching in that holds us in good stead. “If someone’s asking for help, I very rarely hear someone say, ‘well, that’s not my job.’ There’s a certain amount of leaning in that’s really helpful here.”
As for what surprises she’s encountered so far, “I had under-appreciated the amazingly complex decisions and rationalisations that need to be made by district health board CEOs every day, by the bedside, by the roadside and by the deskside. These are often, for privacy reasons, incredibly discrete and have a massive difference on people’s lives.”
Keriana describes herself as an “actual optimist”, and eight months into the job remains undaunted by the road ahead.
“When we formed as a new executive at the ministry of health, Ashley (Bloomfield) said in his change document, ‘we are who we are waiting for, nobody else is coming’. We often remind ourselves of that here (at the DHB) and that we just need to get on with it.”
“I think the best thing to do is to go in with your eyes open. And ultimately you can’t do more than what everyone else is able to do as well. My grandmother counselled me when I was a teenager, about some teenage dilemma, and it’s stayed with me always: ‘This too will pass’.
“That’s the bit I hold on to on the days when I’m the statue not the pigeon!”