Kareen Carter is Health Sciences Librarian and library manager at the Wellington Medical and Health Sciences Library, a campus library of the University of Otago and clinical library of the Capital & Coast District Health Board.

During 2020/21 Kareen was a participant in the LIANZA Evaluation and Impact programme, basing her associated project on a future library service; within that she surveyed the DHB Library managers to elicit their knowledge and viewpoint on what a future health library might look like; some of that data is shared here.

The following article is based on Kareen’s presentation The Future of Health Libraries in New Zealand at the LIANZA 2021 Conference. Thriving Together. E huri tō aroaro ki te rā, Tukuna tō ataarangi ki muri i a koe. November 9-11, 2021. New Zealand.

The New Zealand Health Sector is in a period of extreme pressure and change, not least the libraries within the sector. The aim of this article is to give an overview on the Health Library landscape in New Zealand, and its role in developing a strong health workforce; particularly considering upcoming changes to the District Health Board (DHB) structure arising out of the Health and Disability System Review (2020).

The New Zealand health system is a mix of public and privately funded care. Most health and disability services in New Zealand are publicly funded for eligible people. Government funding of health and disability services means that those eligible may receive free inpatient and outpatient public hospital services, subsidies on prescription items and a range of community support services for people with disabilities.

“The health system’s funding comes mainly from Vote Health (or central government), which totalled just over $16.142 billion in 2016/17. Other significant funding sources include the Accident Compensation Corporation (ACC), other government agencies, local government, and private sources such as insurance and out-of-pocket payments. The Ministry of Health allocates more than three-quarters of the public funds it manages through Vote Health to DHBs, who use this funding to plan, purchase and provide health services, including public hospitals and the majority of public health services, within their areas.” (Ministry of Health, 2016)

There are 20 DHB’s in New Zealand, each governed by The New Zealand Public Health and Disability Act 2000. (Ministry of Health, 2021 September)

· promoting the integration of health services, especially primary and secondary care services

· promoting effective care or support of those in need of personal health services or disability support

· reducing health disparities by improving health outcomes for Māori and other population groups

New Zealand’s public hospitals are owned and funded by DHBs, with 84 registered public hospitals across the country as of 30 October 2021. (Ministry of Health, 2021 October)

Most of New Zealand’s eight Universities and a number of other tertiary institutions including institutes of technology and polytechnics, Wānanga and private training establishments, provide education in the health professions.

Medicine and Surgery and their associated specialties are taught out of the University of Otago and Auckland University, and there are currently four Schools of Medicine – in Dunedin, Christchurch, Wellington and Auckland; with Dunedin being the oldest (founded in 1869, with courses in Medicine commencing in 1875) and Wellington the youngest - in our 44th year. The Christchurch and Wellington Schools are part of the University of Otago.

Medicine and Surgery are six-year degree courses; it takes several additional postgraduate years of study, experience and learning to attain a professional specialty.

In the Health Sciences, Otago’s Dunedin campus also teaches Dentistry and Dental Technology, Medical Laboratory Science, Pharmacy and Physiotherapy. The Otago Wellington campus teaches Radiation Therapy at both under- and post- graduate levels. Auckland also teaches Physiotherapy and Pharmacy as well as Optometry and Vision Science.

Nursing is mostly taught at the undergraduate level out of Polytechnics (although Auckland and Massey Universities and the Auckland University of Technology offer a Nursing degree). Postgraduate nursing is taught out of Otago, Auckland, Massey and Victoria Universities.

Graduation, however, is just the beginning of the health workforce learning, with most professions requiring registration and ongoing professional development. The medical and surgical specialties also have professional colleges for the support, development and regulation of specialists.

The NZ health workforce is around 220,000 people, making it the largest single industry in New Zealand, with 75,000 people working in the DHBs. (Health and Disability System Review, 2020)

There are around 26 health science libraries in New Zealand, within the Ministry of Health, the Universities and the District Health Boards; additionally, there are libraries within Non-Governmental Organisations, Polytechnics and private training establishments which have a health component.

All 20 DHBs have some form of Library service, however staffing and services vary considerably across the country from 0.5 FTE to around 5 staff, sitting on average at 2-3 FTE. Library funding varies significantly also, with resource budgets ranging from around $40k to over $1 million NZ dollars for some of the libraries.

The sector Librarians have the opportunity to come together annually via the LIANZA Health Special Interest Group (Health SIG) which co-ordinates a 1-2 day study programme for information sharing. This provides a forum for the sector librarians to work together and support each other while providing relevant professional development opportunities.

There is a trend towards regional consortia access for some resources and the Librarians in this sector are strongly supportive of each other, but there has been no consistency of approach and no support from the Ministry to move consortia access forward on a national basis. Anyone involved in the purchase or management of subscriptions in libraries will understand that this is a complex area, without a one-size-fits-all solution. This is the same in the health sector where we often need to remind the funders that information resource pricing is not based on their more familiar consumable model with its discount for volume.

The DHB libraries exist primarily to support the evidence-based practice of the clinical, nursing and allied health workforce within their DHB area.

“They have a direct impact on the quality of patient care, by helping physicians, nurses, allied health professionals and researchers to stay abreast of new developments in their specialty areas. They work alongside education providers and trainers to support staff in gaining qualifications and knowledge to strengthen their practice.” (Carter, 2021)

Research underpins the role of today’s clinicians and nurses, tied to their professional status, development, and evidence-based practice. Tertiary hospitals are involved in research and compete for funding. Quality improvement is also integral to corporate and clinical practice in all the DHBs.

The libraries have a role to play in supporting the workforce at corporate and clinical levels, using the expertise of the Librarian to save the organisation time and money.

The 20 DHB Libraries are staffed by small but highly dedicated library teams. They provide a wide range of resources and services to their users, with one of the core services being literature searching – most of these dedicated people would be classified as expert information searchers within the sector and indeed the profession. Additionally, they manage the collections and resources required by their organisation to provide excellent care. This involves navigating constricted budgets, analysing usage data, and negotiating with multinational vendors to provide the best value for money.

In 2018 the then Health Minister Dr David Clark announced a wide-ranging review designed to future-proof our health and disability services. The final report was presented in March 2020. Among its recommendations was a reduction of the number of DHBs, to between 8-12, from the current 20, in the next 5 years.

On 21 April 2021, the Government confirmed the details of the health system reforms as a white paper (Department of the Prime Minister and Cabinet, 2021), in response to the Health and Disability System Review (2020).

A new organisation, Health New Zealand / Hauora Aotearoa, is to be created to manage our health system day-to-day.

“Health NZ will manage all health services, including hospital and specialist services, and primary and community care. Hospital and specialist services will be planned nationally and delivered more consistently across the country. Primary health, wellbeing and community-based services will be planned and then purchased through four new regional divisions of Health NZ. Each region will work with their district offices, located closer to local communities, to develop and implement plans based on local needs to improve the health and wellbeing of communities.” (Future of Health, 2021)

The Māori Health Authority / Te Mana Hauora Māori will be established alongside Health NZ with shared decision-making, planning and delivery. The Māori Health Authority will have dual responsibilities: it will support the Ministry in shaping system policy and strategy to ensure performance for Māori, and will work in partnership with Health NZ to commission care across New Zealand, ensuring that the needs and expectations of Māori communities are also centred in design and delivery. The future health system will have more deliberate investment in equity of access and outcomes for Māori, increased accountability, and a much greater role for iwi and Māori in shaping service design and provision for Māori communities.

The Ministry of Health will also host a new Public Health Agency responsible for public health policy, strategy and intelligence.

Health NZ will include a national public health service, bringing our Public Health Units together under a national banner. This agency will be better able to coordinate public health services, responding to threats like COVID-19, measles outbreaks, and smoking.

These changes require change to current legislation and the Pae Ora (Healthy Futures) Bill, which sets up the legal platform for the reformed health and disability system, was introduced to Parliament on 19 October 2021. (2021 (85-1))

The Bill will legally establish Health New Zealand as the national organisation to lead and coordinate delivery of health services across the country and the Māori Health Authority as an independent statutory authority to drive improvement in hauora Māori.

In the short term there is likely to be little difference in how the current libraries operate, however, the organisation and governance changes provide an opportunity to implement changes the Librarians in this sector have been advocating for several years.

To do this, we need to be part of the conversation as we have extensive experience and expertise in both procurement and service delivery and most importantly the information needs of the health workforce. Being part of the conversation includes being able to demonstrate value and return on investment (ROI). The work of ALIA and Health Libraries Australia to calculate return on investment of Australian health libraries, has been utilised by many libraries in the New Zealand health sector over the years as a comparable model of ROI. (ALIA, 2013, 2014, 2017)

Health libraries in New Zealand are valued. A University of Otago review of Health Sciences Libraries indicated ...that Libraries and Librarians are highly valued at all levels of the institutions consulted. There was, however, a clear lack of understanding of the complexities and costs associated with publishing, licensing, and the provision of resources, as well as the variety and value of services provided by librarians. (University of Otago, 2017)

There is still value in ‘library’ as place within the hospitals. Offering a space for busy clinicians, nurses and allied health staff to study, research, collaborate and write, away from the pressures and distractions of busy offices, wards, and homelife. “Library space is no longer associated with collections but is linked to study, research, reflection and collaboration. There is evidence of libraries being well utilised by staff throughout the country… these spaces do not need to be managed as ‘Library’… however with ‘Library’ comes trust, a particular headspace, and neutrality.” (Carter, 2021)

Our libraries need to capture and report on the value we bring to the organisation, not just transaction counts, but narrating the return on investment. For data to be meaningful and to be able to communicate return on investment, it should be linked to values which may be associated with the organisation’s strategic plan. With the proposed changes, these values are linked to the health workforce, health equity, and the health outcomes of all New Zealanders.

It is not just the number of literature searches performed, but also the purpose of those literature searches... to provide evidence to a service review or audit, and for quality improvement projects; to support patient care; for a presentation or publication; to update or inform policy or guidelines; to support an expert clinical witness in a court case or media interview... these are just a few examples.

A New Zealand health library service is not a new concept. A New Zealand National Library of Medicine was initially recommended as an outcome of the Hodgson Report in 1987, based around a national supply centre for Interloan requests. (Hodgson, 1987)

Regional networks operate informally based around the wider DHB region relationships and the DHB Librarians are collegial and supportive of each other within these networks and more widely.

The LIANZA Health SIG has a working group currently formulating a response to the proposed changes to ensure that Libraries and Librarians are part of the picture. The working group is looking at the proposals and at overseas health library models, translating the information into a New Zealand context that might inform a future model.

Health sector libraries internationally have undergone significant change in recent years. With publications from the USA on closure and consolidation of health sector libraries, and Scandinavian examples of national networks for information provision, there are several international examples to draw upon.

Australia provides some examples at the state level, that indicate how different health library models may work. These include the South Australian Health Library Service (Harris, 2017), and in Queensland, the Clinical Knowledge Network (CKN). (Sayers, 2021)

In Canada, the Winnipeg Regional Health Authority Virtual Library managed by the University of Manitoba Libraries (UML), is another interesting model. (Cooke, 2021)

The UK ‘s National Health Service, Knowledge and Library Services is an obvious model to look at… in January 2020, in a letter to all NHS library service managers, Sue Lacey Bryant announced that Health Education England had approved an ambitious programme ‘to provide NHS staff with a single, coherent national gateway to their trusted library and knowledge service, connecting them seamlessly to quality resources, services and support tailored to their needs’. (Bingham, 2020)

There are Health Library standards that have recently been reviewed and updated, including Canada (Frati, 2021) and we eagerly await the revised Australian standards. And Health Education England (2020) have a policy statement outlining their recommendations to improve the staff ratio for the number of qualified library and knowledge specialists per member of NHS workforce.

There is no one model that would address the needs of the New Zealand health system, which is why it is important to review and take the best of what is already available and create a service model that is right for New Zealand and Hauora Māori, that is people centric and sustainable.

There are definitely merits for a centrally funded and centralised structure for the provision of health information, and discussion with Ministry of Health and Health Workforce representatives as part of the University of Otago 2015 review, indicated that they were generally supportive of the idea, but unwilling to commit any level of governance or leadership at that time.

There are also barriers to change and definite risk to services currently provided, and to the profession within the sector. To minimise these, we need to be engaged in the process, which is where the work of the LIANZA Health SIG comes into play. Collectively representatives of the DHB Librarians via the LIANZA Health SIG are close to releasing a document that will present a path for equitable access to knowledge and health information in the NZ Health Sector and help to inform members of the Health Reform Transition Unit.

Librarians will need to be prepared to give up some aspects of their roles and for those aspects to be managed by others, some services and resources can be effectively managed at a central/regional level. There will be a trust component here, that needs to be communicated both ways. Collections and resource access can be managed centrally… although this is not a simple procurement process and needs mahi (work) to remain financially sustainable. There needs to be recognition of regional specialties and tiering of access to some resources.

The DHB Librarians know, and are protective of, “their people”. Some believe that their clinical workforce will lose the excellent level of service currently provided if services become regionalised. This could happen, if Librarians are removed from the hospitals they currently serve, however the other side of this is that for hospitals with one Librarian, there are advantages such as working as part of a larger integrated if distant library team, an opportunity to specialise, and cover for when the Librarian is on leave.

It is important not to get too tied up in the detail at the early stages – it is currently about strategy and potential, not about wrangling a core collection of centrally funded resources (that is the longer-term outcome). The mahi of the Health SIG working group is ongoing, producing a briefing document for the stakeholders to outline the complexities and offer ideas and solutions. It’s a period of exciting potential, particularly if we get it right!

Wānanga - tertiary institution that caters for Māori learning needs - established under the Education Act 1990.

ALIA (2013). Worth every cent and more: an independent assessment of the return on investment of health libraries in Australia. Canberra, ALIA.

ALIA (2014). Putting a value on 'priceless': An independent assessment of the return on investment of special libraries in Australia: 16.

ALIA (2017). 10 ways that library and information services power the health sector. Deakin, ACT.

Carter, K. (2021) LIANZA Evaluation & Impact Programme survey: Exploring a future Health Library service. [Data set]

Cooke, C. (2021). Beyond traditional library spaces: the practicalities of closing hospital libraries and opening a virtual library. Journal of the Canadian Health Libraries Association/Journal de l'Association des bibliothèques de la santé du Canada, 42(1). Open access https://journals.library.ualberta.ca/jchla/index.php/jchla/article/download/29434/21756

Department of the Prime Minister and Cabinet. (2021). Our health and disability system: building a stronger health and disability system that delivers for all New Zealanders.

Frati, F., Oja, L.A., & Kleinberg, J. (2021). CHLA Standards for Library and Information Services in Canadian Health & Social Services Institutions 2020. Journal of the Canadian Health Libraries Association / Journal De l’Association Des bibliothèques De La Santé Du Canada, 42(1).

Harris, L., & Peterson, M. (2017). The economic value and clinical impact of the South Australian Health Library Service 2011–2016: A case study in organizational performance and survival. Business Information Review, 34(1), 18–24. https://doi.org/10.1177/0266382117692451

Health Education England (2020). NHS Library and KnowledgeServices in England: recommendations to improve the staff ratio for the number of qualified library and knowledge specialists per member of NHS workforce. Knowledge for Healthcare Policy Statement, Health Education England: 8.

Hodgson, P. (1987). Discussion paper: New Zealand’s health and medical libraries.

University of Otago, Division of Health Sciences. (2017). Health sciences library services plan. Unpublished manuscript.

Kareen Carter | Wellington Medical & Health Sciences Library

The following article is based on Kareen’s presentation The Future of Health Libraries in New Zealand at the LIANZA 2021 Conference. Thriving Together. E huri tō aroaro ki te rā, Tukuna tō ataarangi ki muri i a koe. November 9-11, 2021. New Zealand.