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The role and functions of community health councils in New Zealand’s health system: a document analysis Gagan Gurung, Sarah Derrett, Robin Gauld

ABSTRACT BACKGROUND: Community/consumer health councils (CHCs) are a relatively new phenomenon in New Zealand. CHCs are usually established within district health boards (DHBs) to help address gaps in community engagement in the health sector. Little is known about the establishment, structure, roles and functioning of these councils. AIM: To undertake a literature review, including grey literature, related to the structure, roles and functioning of CHCs in New Zealand. METHOD: A document analysis of the New Zealand-focused website materials and newspaper articles related to CHCs was conducted. Data were analysed thematically using a qualitative content analysis approach. RESULTS: The search identified 251 relevant web sources and 118 newspaper articles. The main role of the CHCs appeared to be to advise and make recommendations to their respective DHBs (and DHB governance and management structures) about health service planning, delivery and policy. All CHCs discussed in the identified sources comprised di erent demographic backgrounds and expertise. Although the CHCs were mainly engaged in information sharing and consultation, their influence on DHB decision-making could not be determined from the sources. CONCLUSION: This is the first study of CHCs throughout New Zealand investigating their roles, structure and type of engagement. As the concept is evolving and more CHCs are being established, this information may be useful for future CHCs. With increasing longevity of CHCs in New Zealand, future studies could usefully investigate CHCs’ potential to represent the health interests of their local communities, and their influence on DHB decision-making.

he broader community can bring British Crown in 1840 (although since its unique and valuable perspectives to signing, full and genuine recognition of Te Tthe health system.1 There has been an Tiriti has been, and is still being, called for increasing focus globally on community en- in our health system by Māori leaders and gagement in health,2 and there is a growing others).4–7 More recently, other government body of evidence to support the relationship documents have articulated the importance between community engagement and im- of community engagement, including The proved health outcomes.1 In New Zealand, New Zealand Health Strategy 2000,8 The community engagement in health has a long New Zealand Disability Strategy9 and the tradition.1,3 Much of the earlier experience Primary Health Care Strategy 2001.10 In in New Zealand came from the disability New Zealand, the health sector is required and mental health sectors.1 to involve patients (sometimes referred A fundamental document underpinning to as consumers). Efforts in engaging the engagement in New Zealand is Te Tiriti o community have been devolved to the 3 Waitangi (Treaty of Waitangi) signed by local level, and engagement initiatives Māori chiefs and representatives of the include mainly elected members of district

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health boards (DHBs), DHB requirements to consult with their communities, estab- Methods lishment of advisory committees, and A document analysis was conducted for collecting and reporting patient feedback this study.18 Eligible documents included to the healthcare system, usually through minutes of meetings, terms of reference, patient surveys.11,12 It has been argued that organisational or institutional reports, plans community engagement in the general and strategies, webpages and newspaper health sector lags behind the disability and articles (including media releases) related mental health sectors.3 to CHCs in New Zealand. We undertook an initial search of all sources available The concept of a community health electronically up to 19 February 2017. The council (CHC; also referred to as a search was subsequently updated to 13 consumer health council) is a relatively November 2019. We conducted manual new phenomenon in New Zealand. Health searches of websites of DHBs, CHCs, the consumer councils exist elsewhere, but Ministry of Health and the Health Quality their scope and contexts may differ from and Safety Commission (HQSC) to fi nd New Zealand’s. In the UK, community health minutes of meetings, terms of reference and councils were established as statutory bodies annual reports related to CHCs. in 1974 to represent the interests of the public in local health services.13 The concept In the case of newspapers, we conducted of participation has been described as an electronic search. Two news data- being rooted into two ideological streams— bases, Newztext and Factiva, which index consumerism and citizenship.14,15 The New Zealand newspapers were chosen. private sector notion of markets underpins Simple keywords search (“consumer health the consumerist approach and its emphasis council*” OR “health consumer council*” is on the rights of consumers to access, OR “district health board health consumer preferences, information and complaints in council*” OR “district health board relation to a specifi c service.14,15 On the other consumer council*” OR “community health hand, the citizenship approach is related council*” OR “consumer council*”) were to people in their capacities as citizens performed to identify relevant news stories with their rights to use public services and about CHCs in New Zealand. As noted, the duties to participate collectively in society.15 date limit applied to search was up to 13 Although contested, CHCs tend to be placed November 2019. The keywords could be within the citizenship approach.15,16 anywhere in the full-text article. In New Zealand, CHCs were formed to help Data were analysed thematically using address gaps in community engagement in a qualitative content analysis approach.19 the health sector. They are usually estab- In both newspaper and website items, we lished within DHBs to advise the executive coded items for one of the following cate- and clinical teams in their regions, and to gories: history of CHC, rationale/purpose, develop partnership and communication roles, meetings, representation in CHC and pathways with their communities. Yet little consultation/engagement. Within these is known about the establishment, structure, broad categories, sub-categories (themes) roles and functioning of these councils. were developed inductively. The purpose of this study was to undertake a literature review, including Results grey literature, related to the structure, roles Manual searches of websites of DHBs, and functioning of the CHCs in New Zealand. CHCs, Ministry of Health and HQSC identifi ed Furthermore, healthcare has been a priority 251 documents including: minutes of 134 concern of the New Zealand public in meetings, 10 terms of reference, one annual opinion polls, with the New Zealand media report to CHCs and 16 webpages with back- giving close attention to the events in the ground information. The manual searches health system.17 Hence, this study also aims of these documents provided information to report how the New Zealand media has about rationale and purpose, functions and covered aspects of CHCs. roles, structure and representation of CHCs,

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types of engagement, issues raised by CHCs structure and representation, rationale and and infl uence in decision making. purpose of CHCs, and the function and roles The media search identifi ed 799 articles of CHCs. Of the 118 stories, 48 were from (Newztext—549, Factiva—250); 441 after the period 1996 to 2002 covering old CHCs duplicate articles were removed. Each news formed under the Area Health Board Act story was then checked by one member 1983 (which ceased to operate when the Act of the research team (GG) against broader was abolished). Among the older CHCs, most inclusion criteria related to the CHC. The of the stories related to the Nelson CHC and fi nal 118 articles relating to a CHC had been the Wairarapa CHC. The remaining 70 news reported by 25 newspapers. The articles stories from 23 newspapers were about included information about CHC formation, CHCs formed in New Zealand covering the period 2007–2019 (Table 1).

Table 1: Number of media reports of CHC activity according to year of publication (2007–2019) and publishing newspaper.

Newspaper 2007 2008 2013 2014 2015 2016 2017 2018 2019 Total

Otago Daily Times 1 5 1 3 10

Stu 1 1

Hawkes Bay Today 4 1 3 1 2 11

The Press 1 1 2

Nelson Mail 1 1

Scoop Independent 1 1 5 6 1 4 1 19 News

Northern Advocate 2 2

Waikato Times 1 1

Manawatu Standard 1 1 1 3

Radio New Zealand 1 1 Newswire

Whanganui Chronicle 1 1

Bay News 1 1

Kati Kati Advertiser 1 1

Bay of Plenty Times 1 1

Te Puke Times 1 1

Weekender Rotorua 1 1

Te Awamutu Courier 1 1

The Timaru Herald 1 1 2

Horowhenua Chronicle 2 2 4

Dannevirke News 1 1

The Northern Advocate 1 1 Saturday

Southland Times 3 3

New Zealand Doctor 1 1

TOTAL 1 2 4 2 11 13 17 15 5 70

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Table 2: Community health councils and their date of establishment.

SN Council's name Establishment 1 Canterbury DHB Consumer Council 2008

2 Hawke’s Bay Health Consumer Council 2013

3 Northland Health Consumer Council 2014

4 West Coast DHB Consumer Council 2014

5 Taranaki DHB Consumer Council (Interim) 2014

6 Counties Manukau DHB Consumer Council 2015

7 Southern Community Health Council (for the Southern DHB and WellSouth 2016 Primary Health Network)

8 Whanganui DHB Consumer Representative Group 2016

9 Wairarapa DHB Consumer Council 2017

10 Mid Central DHB Consumer Council 2017

11 Nelson Marlborough Health Consumer Council 2017

12 Capital & Coast DHB Citizens Health Council 2016

13 Waikato DHB Consumer Council 2018

14 South Canterbury DHB Consumer Council 2018

15 Bay of Plenty Health Consumer Council 2018

16 Hutt Valley DHB Consumer Council 2019

17 Waitematā DHB Consumer Council 2019

CHC developmental history that (the then) Health Funding Authority According to the media articles, CHCs had decided to adopt a national approach existed during the era of area health boards to community consultation rather than (1980s–1993), but most of these earlier continuing with the decentralised approach CHCs appear to have been abolished by with regionally elected community health 20,21 early 2000.20–23 The lack of other supporting boards (councils). documentary evidence means that available Nelson and Wairarapa CHCs were information about their developmental reported most frequently in newspapers history, role and functions is scant. These and appeared to have been active in organ- earlier CHCs were set up to liaise between ising public meetings on health issues, such the public and government-funded health as funding cuts, hospital cuts and quality services, and to meet the needs of commu- of care concerns. An article published in nities that had particular cultural or the Dominion Post in 2002 showed the geographic needs.21 Apparently, the selection Wairarapa CHC was among the few which of these CHC members was through remained active prior to ﬁ nally being voting at public meetings.24 The Nelson abolished.21 The analysis of newspapers Mail reported that members of the Nelson and website data found that the ﬁ rst of the CHC were elected at a public meeting at more recent wave CHCs was established which approximately 50 people turned by Canterbury DHB in 2008. By 2019, 17 of up to vote.24 With successive government the 20 DHBs in the country had established changes and health sector reforms and cuts CHCs or were in the process of developing to resourcing, CHCs were abolished.20–23 In one (Table 2). All CHCs were directly related, 1998, The Dominion and The Nelson Mail and accountable to, their respective DHB. reported that the funding would be cut and One CHC, the Southern Community Health

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Council, was also directly related to their “Prior to the Hawke’s Bay Health Consumer regional Primary Health Organisation (PHO). Council, consumers were represented across Two other DHBs had initiated community several statutory advisory committees such representatives onto their clinical gover- as a Community Public Health Advisory nance committee, or community and public Committee, the Hospital Advisory Committee health committees, with the intent of facili- and Disability Services Advisory Committee. tating community input in a similar manner ‘Our consumer representatives on those to the 17 other CHCs. We were unable to committees were generally pretty frustrated locate information on the remaining DHB. with the way things were’, Norton [Graeme Rationale and purpose Norton, ex-chairperson Hawke’s Bay Health The document review found the main Consumer Council] said. reason behind the initiation of the recent ‘The problem was that they only met once wave of CHCs was to address the existing a quarter for half a day and mostly it was gaps in community engagement in the consumer members catching up on the last health system and to become more three months of reports from the system as patient-focused in decision making. The to what was happening or had happened, gaps included a lack of a systematic way most of which the majority of other members for patient and public engagement, lack of around the table already knew because mechanisms which cover all areas of health they were either board members or clinical rather than focusing on speciﬁ c interests members’, he said.”28 such as mental health only, and lack of The purpose of forming a CHC was to public accountability of DHB boards (which act as a bridge between the community are comprised of both democratically and DHB by representing the voice of elected representatives and government the community in strengthening district appointees) and other advisory boards, and health services planning, design and the selection of some DHB board members delivery, working collaboratively with the 25–28 by the Ministry of Health. In one district, DHB: it was reported that: • To have a direct, practical input of “The move comes after some commentators consumers into DHB plans.26,29 and district health board candidates criticised • To develop communication pathways boards for their lack of public accountability by receiving, considering and dissem- and the high number of members appointed inating information from and to the by the Ministry of Health.”26 DHB and communities.30 Elsewhere, a DHB Chief Executive Oﬃ cer • To develop an effective partnership (CEO) suggested: between the DHB (governance and “‘Ensuring we hear the perspectives management team) and community of patients and consumers is not new’, by providing a strong and viable voice comments Southern DHB Interim CEO Chris for the community and consumers/ Fleming, who points to existing systems patients as a collective perspective in including consumer advocates in mental health services planning, design and health services, community representa- delivery.30–34 tives in regional networks, patient feedback • To enhance consumer experience surveys and the In Your Shoes listening and service integration across the sessions undertaken as part of the DHB’s sector, promote equity and ensure Southern Future programme. However, he that services are organised around the says, ‘there have been gaps, and we have not needs of people.30,33 always been systematic about how we should seek and make best use of the perspectives • To ensure patient perspectives are 25 patients bring’.”25 embedded across health service and contribute to patient and family/ In another district, it was reported that, whānau-centred care by working with despite the representation of consumers in patients and whānau to co-design the DHB advisory committees, they were not care, facilities and strategies.35 happy with the way they were involved:

• To engage people earlier with the representatives of any specifi c organisation health system and encourage them to or community.30,33,40–43,46–48 Furthermore, it take responsibility to actively self- has been emphasised that council members manage their own treatment and need to bring a broader perspective not care.36 limited to an individual personal experience • To create strong links between of the health system: communities and district and national “More than 80 applications were received health systems.37 for the Community Health Council, which was • To act as vehicle for consumers to advertised in October. Representatives were participate in improving health chosen by a selection panel comprised of inde- outcomes.38 pendent community leaders, Iwi Governance, University of Otago and Southern DHB.”44 • To ensure a focus on improving health equity for populations (Māori, people “‘While Council members will need personal living in rural communities and experiences of the health system, they should people living with disabilities).39 not be focused on a single issue. Instead, we want them to advocate for all patients, Governance of CHCs whānau and their communities, and ensure Governance includes sub-themes such as the processes across the health system for the structure of CHCs, their representation, hearing the voices we need to hear are strong’ roles and functions, meeting processes and [Quote from Sarah Derrett, establishment functional relationships and infl uence. chair of the Southern health system’s CHC].”25 Structure and representation The review of meeting minutes revealed Information about structure was only that CHC members were also co-opted into available for 16 of the 17 CHCs. Analysis of other committees and governance mecha- the eight CHC structures showed that the nisms such as the Hand Hygiene Governance number of members in the council ranged Group, HQSC Consumer Network, Mental from 5–16, with a mean 10.8. The media Health panel, Clinical Governance Board and other document analysis showed that and the Ministry of Health Long Term Condi- selection processes involved nomination tions Advisory Council. following open advertisement through DHB websites or media/newspapers, emails Roles of CHC The analysis of the news media articles to local community groups, or advertise- and website documents found that the role ments requested via specifi c groups, and of CHCs encompassed fostering patient and sending calls for expressions of interest public engagement in the health system, from suitable consumer organisations and advising DHBs and their governance, and non-government organisations. The management and clinical teams on health appointment of members was generally services planning, delivery and policy. In a made by CEOs or the chair of the DHB few CHCs, roles went beyond DHB hospital selection panel after consultation with local boundaries to encompass the wider local consumer and community groups.30,33,40–45 health system (ie, to include advising Different criteria for representation primary health organisations) and national included having a demographic balance that health systems.25,33,34,45 The roles of the CHC refl ects the DHB population, age, gender, in different DHBs included the following disability, social economic status, people to functions: have a particular interest, understanding • Advising the DHB on policy, planning, and knowledge in selected areas (eg, mental implementation and evaluation of health, alcohol and other drugs, long-term services. conditions, disability, Māori health, women’s health and primary health), potential • Working with DHBs to improve the to bring skills, perspectives and ability quality of patient journeys.32,33 to enhance work of the CHC. Although • Communicating with the community appointed to refl ect a patient or popu- and specifi c interest groups.25,46 lation voice in particular areas of interest, • Promoting and facilitating patient and members do not tend to be regarded as public participation across the DHB.49

• Advising on health system and Consultation with CHCs and services, and also the development influence in decision making of health service priorities and The review of website documents, partic- strategies.25 ularly terms of reference, showed that • Helping ensure appropriate consul- CHCs were, variously, involved in policy tation occurred while developing DHB and governance with authority to give reports, plans or services.25,46 advice and make recommendations to • Collecting and using feedback from DHB management, without direct deci- service users.25 sion-making power.30,33,40–42,45 In some cases • Contributing to the design or redesign (Northland Health Consumer Council, of services.32 Nelson Marlborough Health Consumer Council, Southern health system’s CHC), the Many councils also specifi ed the func- level of infl uence of the CHC was specifi cally tions which were out of the scope, mentioned to be equivalent to the Clinical including:30,33,40–42,46 Council and Iwi Health Board.30,33Analysis • Providing clinical evaluation of health of meeting minutes showed that CHCs services. did discuss aspects of DHB governance. • Discussing or reviewing issues that Information and updates by DHBs and the are (or should be) processed as formal Ministry of Health on a range of issues complaints, for which full and robust related to plans, policy, care and services processes exist. of DHBs were shared with CHCs. DHBs • Being involved in DHB contracting and the Ministry of Health also involved processes. CHCs in consultation on a range of issues (Table 3). Examples of issues discussed in Meetings CHC meetings for included: accessibility Most CHC meetings were held monthly, and availability of services (availability of except in the case of the West Coast and drugs, changes in provision of services, DHB Waitematā where it was bi-monthly. facility development, funding issues and Payment for attending meetings varied, but transportation), information and education was often set at the rate of other advisory (different tools and forms for patients, groups. In some CHCs, meetings were open leafl ets and newsletters and websites), to the public (Hawke’s Bay Clinical Council, quality improvement (hand hygiene, Nelson Marlborough Health Consumer patient surveys, patient fi les, credentialing, Council, and Northland Health Consumer complaints processes and privacy concerns Council); others were closed. There was a on electronic health records); planning practice of publishing agendas and meeting and policy development (smoking policy, minutes or key messages on the DHB or partners in care policy, New Zealand Health 33,40,41,43,50,51 related websites. The term of Strategy, visiting policy, DHB annual plans CHC membership varied in different DHBs and disability action plans).52–54 ranging from 1–3 years. In some CHCs, half Recent newspaper articles also high- of the members were appointed for a year lighted the positive infl uence of CHCs in and a half, and some for two years. In all DHB decision-making in a number of areas, CHCs there was a provision for renewal for for example: the development of a primary 1–3 terms.33,40,41,43,50 and community care strategy; hospital CHC functional relationships rebuilding; improvement of feedback; Generally, CHCs had functional rela- complaints and resolution system; devel- tionships with their communities, other opment of a new pain service; improvement consumer groups and networks, the DHB of renal health services; improvement of the chief executive, executive management emergency department service; installation team, clinical councils and other advisory of proper signage in the day patients’ wing; groups.42,43 CHCs reported to, and were and undertaking of a disability services accountable to the CEO of their respective stock take.55–58 DHBs (and in one case a PHO).

Table 3: Consultation with CHC by DHBs and the Ministry of Health.

Consultation issues Examples of issues DHB level policy, plan Health literacy strategic review, consumer engagement principles and and strategy frameworks, obesity strategic plan, youth health strategy, disability strategic plan, DHB annual plan, complaint management manual, visitor policy, health and social care network, Alcohol strategy, Best start healthy eating, Working together for Tamariki.

National policy and National health strategy, National organisational healthy food and drink strategy policy.

Booklet/pamphlet Complaints pamphlets, a CPR booklet, pamphlets related to reducing the development/survey risk of falls in the hospital, a falls brochure, patient stories leaflets, patient forms survey questions, and patient assessment forms.

Website/social media Wifi booklet, health website, social media policy

Care/services Acute care plan in PHO, end-of-life care, co-design partnership care programme, quality account, hand hygiene month (campaign), access to health service for rural communities, virtual health.

Physical facilities Use of CCTV in the Acute Services Building Theatre, a Go Well Travel Plan, Bilingual Signage, bus services and car park facilities.

stories covered by newspapers, these were Discussion mostly related to establishment, rationale Main findings of the study and purpose of the CHCs. However, stories The current CHC concept in New Zealand also covered the infl uence of CHCs in has been building since the fi rst of the ‘new improving health services. In the case of style’ CHCs formed in Canterbury DHB in website content, these incorporated issues 2008. The rationale for forming a CHC was covered by the newspaper plus the type usually reported as needing to address the of issues discussed by CHCs and feedback existing gaps in consumer engagement provided by CHCs. in the governance and policy level of the The number of members in the council health system. The main role of the councils ranged from 5–16 representing different appeared to be to advise and make recom- population demographic characteristics and mendations to concerned DHBs’ governance expertise. The appointment of members and management structure about health was generally made by CEOs, or the chair services planning, delivery and policy. of a DHB selection panel, after consul- The study found few stories relating tation with local consumer and community to CHCs reported by newspapers. Stories groups. While the present study showed covering the modern CHCs were still infre- that councils in New Zealand tried to quent but, in recent years, the number of ensure representation of people from reports has increased (nationally there different demographic backgrounds and was an average four newspaper stories expertise, it is too early to comment on per CHC for 2007–2019 period, with the whether they adequately represent socio- actual range being 1–18 for the individual demographic features and interests of CHCs). Southern CHC (for the Southern DHB the local communities. Elsewhere, studies and WellSouth Primary Health Network), reported that representatives may not Hawke’s Bay Health CHC and Mid Central adequately represent the views of an entire DHB CHC were among those whose stories population which limits the potential for were most frequently covered by news- divergent groups to be represented in the papers. Most of the newspapers covered decision-making process.59–61 Representing stories of a particular CHC in the region, but the entire population can be unrealistic, Scoop Independent News covered stories of especially when there are no specifi c nine different CHCs. Regarding the type of communication channels to connect the

representatives with communities they are a cultural change towards openness and supposed to be representing. Hence, an improvement in community engagement, alternative is to simply focus on the personal there was no evidence that there was a perspectives of health service users in order direct impact of elected members.12 Other to illustrate shared experience—captured in studies have suggested that electoral mech- the notion of ‘experiential participation’.61–63 anisms provided a limited role in promoting There are different theoretical models of participation, indicating a need for comple- engagement, most of which specify levels mentary participatory channels to increase 12,67 and degree of engagement.64–66 Charles and participation. Since CHCs were set-up DeMaio, following Arnstein,65,66 describe to address participatory gaps in the health a multi-dimensional framework based on system, it will be important to investigate decision-making domains, role perspectives over time what value CHCs really add to and levels of engagement in healthcare deci- community engagement in the New Zealand sions.65 The fi rst dimension refers to types health system, especially in relation to of healthcare decision-making contexts addressing the needs and values of their or domains, ranging from ‘treatment’ communities in health services. to ‘service delivery’ to ‘broad macro- or The CHC scope of participation was limited system-level decision-making contexts’. The to their region, and usually to healthcare second dimension focuses on two alter- and services within the scope of DHBs, with native role perspectives participants can occasional consultation from the Ministry of adopt in healthcare decision-making: as Health. In one instance during this study’s ‘user of health services’ or with a ‘public review period, a CHC (Southern health policy perspective’. The third dimension system’s CHC) was established with clear depicts ‘level of participation’ in healthcare relationships to both a DHB (the Southern decision-making. DHB) and a PHO (the WellSouth Primary This New Zealand study found that CHCs Health Network). It would be interesting were involved in a range of issues related to examine the effect of such cross-sectoral to service delivery, DHB governance and CHCs, and also to understand the impact of planning and policy development. Hence, CHC engagement and infl uence on broader regarding ‘decision-making domains’, national health policy agenda and priorities. CHCs were involved in ‘service delivery’ Regarding the two ideological streams of and in ‘broad macro- or system-level deci- participation discussed previously, it seems sion-making contexts’. In the case of ‘role that the CHCs had both elements of consum- perspectives’, while not easy to defi ne, CHCs’ erism and citizenship.15,16 The present CHCs roles appear more inclined towards a ‘public appear to be representing the interests of policy perspective’. In the case of the level individual patients, families /whānau, specifi c of engagement, it appears that CHCs were health groups and larger geographic commu- mainly engaged in ‘consultation’, and have nities. Furthermore, it seems the focus of no direct decision-making powers in DHB the membership was not to represent a governance and policy levels. However, it single specifi c interest, but on appointing is beyond the scope of this study to explore CHC members who could bring broader to what extent the CHC’s advice actually community perspectives to health services. infl uenced the decision-making of DHBs. Although the word ‘consumer’ (rather than This is an important issue to consider ‘community’) has been chosen to name most because other mechanisms, such as elected of the CHCs, in practice all CHCs had a clear community members sitting on DHB boards community/population orientation. (albeit serving a different governance role in Despite wide acceptance of patient and contrast to CHCs), and public consultations, public involvement in shaping healthcare, have been identifi ed as not producing strong internationally, evidence of the effectiveness positive results in relation to genuine and of specifi c mechanisms in health service 11,67 effective public participation. An interim planning and delivery and healthcare report from the New Zealand Health and policy is limited.68–70 Furthermore, partici- Disability System Review that is currently pation strategies can be directed towards underway noted that although elected achieving intrinsic goals (engagement for community members in DHBs prompted the democratic process, accountability,

empowerment, etc) or can be focused on are not likely to be comprehensively ascer- achieving instrumental goals (engagement tained based on newspaper and website for health outcomes). The goal of a sources alone. However, the use of the community participation strategy can also different types of documents, such as media infl uence which outcomes or impacts are sources and websites, helped to complement sought (and achieved).68 This review found and triangulate the fi ndings. Furthermore, the infl uence of New Zealand CHCs in their although we conducted a primary source local health systems to be advisory, with update by manually searching websites in no direct operational role in health service November 2019, we could not include all design and delivery. It now seems important CHC meeting minutes in the analysis for this to consider whether (and exactly how) period. Instead, we purposively selected the new engagement structures such as CHCs most recent minutes, especially of the CHCs contribute to achieving genuinely improved whose reports were not included in the health systems for New Zealanders—or initial search to 2017. This study is intended if they are located towards the tokenistic to provide a starting point for investigation ‘consultation’ end of engagement as has into CHCs in New Zealand, and points to been found in the UK.13 the merits of more comprehensive and What is already known on this in-depth research on their role and impact. This could involve collecting quantitative topic? and qualitative data on CHC member and There was limited published literature community experiences, knowledge and related to CHCs. Earlier work in CHCs came viewpoints around the role and activities of from the UK where CHCs were the main CHCs, as well as analysis of CHC impact on statutory body in the UK’s National Health health services delivery and outcome. Service to represent the public interest in local health services until this abol- ishment in 2001. CHCs in the UK were the Conclusion most dominant form of user involvement.15 The concept of CHCs in New Zealand is Although the membership refl ects a range of a recent phenomenon, and the rationale political and organisational interests, CHCs behind establishing CHCs was to address in the UK had been criticised for not being the existing gaps in community engagement representative of a wide range of concerns in the health system. The main role of the and interest in local communities.15,71 councils appeared to be to advise and make In the UK, CHC infl uence on decision recommendations to concerned DHBs, making, especially service development and their governance and management and health improvement priorities, was structures, about health services planning, considered to be fairly limited.13 delivery and policy. Representing different demographic backgrounds and expertise, What this study adds CHCs were involved in service delivery This is the fi rst study of CHCs in New as well as policy and governance areas. Zealand which investigated their roles, Although they were mainly engaged in structure and engagement levels and types. information sharing and consultation, As the concept is evolving and more CHCs their infl uence in DHBs’ decision-making are being established in New Zealand, this is not known. In a broader sense, it is information may be useful for future CHCs important to consider how new engagement in New Zealand and elsewhere. CHCs were structures, such as CHCs, contributes in mainly engaged in information sharing improving the health system and health and consultation, their infl uence on DHB outcomes for New Zealanders, rather than decision-making is, as yet, not empirically merely becoming another type of (possibly understood. tokenistic) engagement. With increasing Limitations of the study longevity of CHCs in New Zealand, future This study used document analysis to studies could usefully investigate CHC develop the arguments in this article. potential to represent the interest of local This certainly has limitations related to communities and their infl uence on DHB the comprehensiveness of the data. For decision-making related to service delivery, example, the types and levels of engagement governance and policymaking.

Competing interests: Professor Sarah Derrett was the establishment chair for the Southern health system’s Community Health Council (Dec 2016–January 2019). Professor Robin Gauld was Independent Chair of Alliance South from 2013–2017, which strongly supported the establishment of Southern Community Health Council. Author information: Gagan Gurung, Department of Preventive and Social Medicine, University of Otago, Dunedin, Centre for Health Systems and Technology, University of Otago, Dunedin; Sarah Derrett, Department of Preventive and Social Medicine, University of Otago, Dunedin, Centre for Health Systems and Technology, University of Otago, Dunedin; Robin Gauld, Otago Business School and Division of Commerce, Dunedin; Centre for Health Systems and Technology, University of Otago, Dunedin. Corresponding author: Gagan Gurung, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054. [email protected] URL: www.nzma.org.nz/journal-articles/the-role-and-functions-of-community-health-councils-in- new-zealands-health-system-a-document-analysis

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