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All District Health Boards

National Expectations for the Prevention and Management of Long Term Conditions

Work in progressSTATUS: Work in Progress as at 2 May 2017

Development Process Date

This document was developed by the Long Term Conditions Advisory Group to support a range of commissioning /contracting models and outcomes frameworks. The Group’s members were nominated by the DHBs GM Planning and Funding supported by the CVD Diabetes Long Term Conditions Team.

LTC population outcomes framework and a range of current LTC population level measures that show reduction in NZ health loss are used with this expectations document. Refer to: https://nsfl.health.govt.nz/service-specifications/long-term-conditions-outcomes-framework

First published March 2017

Updated Palliative Care section 2 May 2017

The sponsor for this work is Karen Evison, National Programme Manager, CVD Diabetes Long Term Conditions Ministry of Health. Karen’s team will be updating and maintaining these documents. They can be contacted at cvddiabetes@moh.govt.nz.

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National expectations for the prevention and management of long term conditions

Contents1. Introduction................................................................................................................................ 3

2. Purpose......................................................................................................................................4

3. Achieving Health Equity for all New Zealanders........................................................................5

Achieving Health Equity for Maori.................................................................................................5

Maori Children’s Health Outcomes............................................................................................6

Pacific Peoples Health Outcomes.................................................................................................6

The Disability Sector.....................................................................................................................6

4. Successful Approaches to Delivering Long term Conditions Services.......................................7

Service Design..............................................................................................................................7

5. Prevention focused health topics.............................................................................................10

5.1 Risk Factors.......................................................................................................................11

Obesity.....................................................................................................................................11

Smoking...................................................................................................................................12

Reducing harm of alcohol and other drugs..............................................................................12

LTC disease groups specific service information........................................................................13

Cancers....................................................................................................................................13

Cardiovascular disease............................................................................................................13

Chronic Kidney Disease...........................................................................................................13

Chronic pain.............................................................................................................................14

Chronic Respiratory Disease...................................................................................................14

Dementia..................................................................................................................................14

Diabetes...................................................................................................................................14

Gout......................................................................................................................................... 15

Mental Health and Addiction....................................................................................................15

Musculoskeletal disorders........................................................................................................15

Palliative Care..........................................................................................................................16

Stroke.......................................................................................................................................16

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3National expectations for the prevention and

management of long term conditions

1. IntroductionAll New Zealanders1 live well, stay well and get well is central to the New Zealand Health Strategy (2016). Prevention is the key to reducing the impacts of long term conditions (LTC). However people also need to be supported by an integrated health system to manage their long term conditions to live longer, healthier and more independent lives.

People with LTCs constitute the largest health loss in New Zealand. Health loss (or burden of disease) measures how much healthy life is lost due to premature death, illness or impairment2. Co-existing/multiple LTC are more common in older people. Research findings3 support that 88% of health loss in this country is now caused by long-term mental and physical conditions (non-communicable diseases), while 8% is attributable to injuries and 4% to infectious diseases, nutritional deficiencies and neonatal disorders.

The New Zealand Health Strategy’s approach to reducing the health loss from acute and chronic disease is for services to reach priority populations/groups4, contribute to equity of health outcomes,5 and for people with long term conditions:

being supported to manage their condition6, 7,8

being enabled to stay in their own homes and communities9, and

experiencing independence and quality of life.10,11

In this document LTCs, chronic conditions or non-communicable diseases (NCDs) are defined as: any ongoing, long-term or recurring condition that can have a significant impact on people's lives, such as12:

cancers

cardiovascular disease

chronic kidney disease

chronic respiratory conditions

diabetes

enduring mental health conditions13 and addiction1 The relationship between Māori and the Crown under the Treaty of Waitangi, underpins both the refreshed NZ Health Strategy and the National expectations for the prevention and management of long term conditions.2 www.health.govt.nz/publication/health-loss-new-zealand-report-new-zealand-burden-diseases-injuries-and-risk-factors-study-2006-2016 3 Ministry of Health. 2016. Health Loss in New Zealand 1990–2013:A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study. Wellington: Ministry of Health.4 Ibid. Action 5 (pg 8).5 Op.cit. Theme 2 Closer to Home Action 9 (pg12) Theme 3. Value and high performance Action 14, 15 & 17 (pg 15-16).6 Refer www.health.govt.nz/publication/new-zealand-health-strategy-2016 Wellington: Ministry of Health. The Part I. Future Direction: Theme 1.People-powered. Pg 16. Part 22. Roadmap of Actions. Actions 1,(pg 7) 2 (pg 8) & 5.(pg 11).7 Ministry of Health. 2016. Self-management Support for People with Long-term Conditions (2nd ed). Wellington: Ministry of Health. Pg 11. www.health.govt.nz/publication/self-management-support-people-long-term-conditions8 www.tpk.govt.nz/en/whakamahia/whanau-ora/outcomes/ 9 Theme 2.Closer to Home, (pg 19-24). 2 Roadmap of Actions, Action 6 & 8 (pg 10-11).10 Ibid. Theme 2 Closer to Home (pg 22).11 Ibid. 2 Roadmap of Actions, Action 2 (pg8) 8 &9 (pg11-12).12 This list is indicative of a range of long term conditions. 13 Enduring mental health conditions – People who experience serious mental illness or addiction issues can lead full lives and have valued social roles. Historically, however, they have experienced: significant and unnecessary disparities of outcome in relation to mental and physical health; social exclusion; a significantly reduced life expectancy; high rates of unemployment; and housing difficulties (UK Department of Health 2011).

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4 musculoskeletal conditions.

2. Purpose This guidance document, together with the long term conditions population outcomes framework (Part A Line of Sight) and Part B (Population Outcomes) sets out service design expectations that contribute to reducing the health loss from long term conditions (LTC). It includes people of all ages and recognises current strategies and frameworks. Part B includes a range of population outcomes and supporting measures for people to choose from that best fit their service. Where specific service national consistency is required, links are provided in the Appendix to guidelines and service standards for the most common LTC conditions.

This set of documents will be further developed and refined with support and input from the sector.

The prevention and management of LTC services acknowledges the social determinants of health, and the continuum of health care from prevention, early identification and intervention, self-management, management and treatment, support, rehabilitation to palliative care.

Prevention and management of LTC services are guided by key government documents including:

The 2016 NZ Health Strategy- Future direction and its Roadmap of Actions,14 in particular Action 8 Tackle long term conditions and obesity

He Korowai Oranga15

Equity of Health care for Māori: a Framework16

Primary Health Care Strategy17

New Zealand Disability Strategy: make a world of difference18 (to be revised 2016)19

Disability Support Services, Strategic Plan 2014-201820

Healthy Ageing Strategy21

Positive Ageing Strategy22

‘Ala Mo‘ui: Pathways to Pacific Health and Wellbeing 2014–201823

The Crown Funding Agreement and its schedules, the Operational Policy Framework and the Service Coverage Schedule and the Nationwide Service Specifications.24

The following section describes how the above key documents and other publications can be used in the design and delivery of services.

14 New Zealand Health Strategy www.health.govt.nz/publication/new-zealand-health-strategy-201615 This link provides a description of the elements of He Korowai Oranga-Maori Health Strategy– including its aim: Pae Ora– Healthy futures for Māori. Pae Ora (Healthy Futures) is the Government’s vision and aim for the refreshed strategy. It builds on the initial foundation of Whānau Ora (Healthy Families) to include Mauri Ora (Healthy Individuals) and Wai Ora (Healthy Environments) www.health.govt.nz/our-work/populations/maori-health/he-korowai-oranga 16 www.health.govt.nz/publication/equity-health-care-maori-framework17 www.health.govt.nz/publication/primary-health-care-strategy18 www.health.govt.nz/publication/new-zealand-disability-strategy-making-world-difference 19 Revising the New Zealand Disability Strategy www.odi.govt.nz/nzds/ 20 The Disability Support Services’ (DSS) Strategic Plan, reflects commitment to the United Nations Convention on the Rights of Persons with Disabilities 2008, which aims to ‘promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity’. www.health.govt.nz/publication/disability-support-services-strategic-plan-2014-2018 21 www.health.govt.nz/publication/healthy-ageing-strategy22 The Office for Senior Citizens www.msd.govt.nz/what-we-can-do/seniorcitizens/positive-ageing/strategy/23 ‘Ala Mo‘ui: Pathways to Pacific Health and Wellbeing 2014–2018 www.health.govt.nz/our-work/populations/pacific-health/strategic-frameworks24 www.nsfl.health.govt.nz

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53. Achieving Health Equity for all New Zealanders

The World Health Organization defines equity as the absence of avoidable or remediable differences among groups of people. The concept acknowledges that not only are differences in health status unfair and unjust, but they are also the result of differential access to the resources necessary for people to lead healthy lives. Some individuals, youth, families/ whānau face multiple barriers to accessing services, particularly where there is a lack of service coverage, for example in areas of high deprivation, for transport disadvantaged groups and geographic isolation.

Groups most disproportionately affected by some long term conditions, are characterised as having high needs and multiple risk factors that have more significant impacts from ill health and earlier mortality include:

Māori population

Pacific population

people living in low socioeconomic circumstances

people with disabilities, and

people with mental health and addiction issues.

Achieving Health Equity for MaoriMāori life expectancy is considerably lower than that for non-Māori. Research findings confirm that Māori health status remains unequal from non-Māori across almost all chronic and infectious diseases as well as injuries, including suicide.25 Health providers are expected to contribute to the improvement of health outcomes and reduction of health inequalities for Māori. This may be achieved through mechanisms such as:

facilitating access to services

providing appropriate pathways of care, and

ensuring that the service practitioners are culturally competent.26

The guide to He Korowai Oranga27 provides a description of its various elements – including its overarching aim: Pae Ora – Healthy futures for Māori. The Equity of Health Care for Māori: A Framework, guides the health system to achieve equitable health care for Māori.

25 See New Zealand Burden of Diseases, Injuries and Risk Factors Study, 2006–2016 for more information. www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/new-zealand-burden-diseases-injuries-and-risk-factors-study26 Including the importance of Whānau, Hapu and Iwi structures, and the role the Service User, particularly Koroua and Kuia, hold within these structures.27 He Korowai Oranga www.health.govt.nz/publication/guide-he-korowai-oranga-maori-health-strategy

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This framework has been informed by f ive background reports with the objectives to:

increase the health sector’s understanding of the issues affecting Māori access to health services

provide an evidence base for action to improve access to health services for Māori, and

a. Provide solutions to improve access to health services for Māori.

Maori Children’s Health OutcomesTe Ohonga Ake28: The Determinants of Health of Māori Children and Young People in New Zealand: Series Two, is part of a series of annual monitoring reports focusing on the underlying determinants of health for Māori children and young people. The report:

provides a snapshot of progress in addressing many of the determinants of health including child poverty and living standards, housing, early childhood education, oral health, tobacco use, alcohol related harm, and children’s exposure to family violence.

assist those working in the health sector to consider the roles other agencies play in influencing child and youth health outcomes related to these determinants.

Pacific Peoples Health Outcomes‘Ala Mo‘ui: Pathways to Pacific Health and Wellbeing 2014–201829 sets out the priority outcomes and actions that will contribute to achieving better health outcomes for Pacific people, families and communities.

Life expectancy at birth continues to improve for Pacific peoples, as for the total New Zealand population. However, Pacific peoples still have shorter life expectancy compared with the total population. Adult Pacific peoples have a high level of chronic diseases such as diabetes, ischaemic heart disease, and stroke. The incidence of these diseases is higher than that for other ethnic groups, and mortality rates for cardiovascular disease and diabetes account for a large part of the differences between the overall mortality rates for Pacific peoples and those for other ethnic groups. Pacific peoples continue to have high rates of diabetes in New Zealand. Better management of conditions within local communities and primary healthcare has the potential to reduce the number of avoidable hospital admissions (and to moderate demand on hospital resources). More Pacific health resources publications are available on the Ministry’s website30.

Health and Pacific Peoples in New Zealand31 is the third report in the Pacific Progress series. It presents findings on Pacific peoples’ health outcomes, discusses the socio-economic factors that influence these outcomes, and offers suggestions for improving Pacific peoples health outcomes.

The Disability SectorDisability Support Services, Strategic Plan 2014-201832, reflects Disability Support Services’ commitment to the United Nations Convention on the Rights of Persons with Disabilities 2008 that aims to ‘promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity’.

Whāia Te Ao Mārama: Māori Disability Action Plan 2012 to 201733 establishes priority action areas to enable Māori disabled to achieve their aspirations, and to reduce barriers that may impede them

28 www.health.govt.nz/publication/te-ohonga-ake-determinants-health-maori-children-and-young-people-new-zealand-series-two29 ‘Ala Mo‘ui: Pathways to Pacific Health and Wellbeing 2014–2018 www.health.govt.nz/our-work/populations/pacific-health/strategic-frameworks30 www.health.govt.nz/our-work/populations/pacific-health/pacific-health-resources31 www.stats.govt.nz/browse_for_stats/people_and_communities/pacific_peoples/pacific-progress-health.aspx32 www.health.govt.nz/publication/disability-support-services-strategic-plan-2014-2018

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7and their whānau from gaining better outcomes.

Faiva Ora National Pasifika Disability Plan 2014–201634 sets out priority outcomes and actions that will contribute to achieving its vision – Pasifika disabled people and their families can live in their home and take part in the community in the same way other New Zealanders do.

The ‘voice’ of disabled people and their whānau/families is represented by a number of well-established consumer forums, including the New Zealand Convention Coalition Monitoring Group, Disabled Persons Assembly New Zealand, People First New Zealand, Deaf Aotearoa, Blind Citizens New Zealand, Balance NZ, Deafblind New Zealand and Ngati Kāpo) and with key government agencies (including the Ministry of Health Disability Support Services).

4. Successful Approaches to Delivering Long term Conditions ServicesServices are recommended to focus on wellness through prevention, early identification and integrating management and treatment in community-based services. This focus can both stop the occurrence, and slow the progression of many long term conditions35 and contribute to achieving health equity for all New Zealanders.

Service DesignThe following design elements set up LTC services for success in improving outcomes for people:

b. Targeted prevention

c. Being evidenced based

d. Holistic/integrated approach to service design and delivery

e. Based on collaborative programmes and/or co-design

f. Health literacy

g. Workforce capacity and capability

h. Services delivered closer to home

i. Self-management support/programmes

j. Appropriate leadership and governance

k. Effective information technology solutions

Explanation of the above design elements follow:

a. Targeted prevention of LTC with a focus on achieving health equity and providing quality, responsive and effective services for priority population groups.36 Only a few common preventable risk factors are responsible for most of the major LTCs: unhealthy diet, physical inactivity, excess alcohol and tobacco use. Elimination of these modifiable risk factors would prevent 80 percent of premature heart disease, 80 percent of premature stroke, 80 percent of type 2 diabetes and 40 percent of cancer.37 Further detail see 4.0 Prevention below.

33 Whāia Te Ao Mārama: Māori Disability Action Plan 2012 to 2017www.health.govt.nz/publication/whaia-te-ao-marama-maori-disability-action-plan-disability-support-services-2012-201734 Faiva Ora National Pasifika Disability Plan 2014–2016 www.health.govt.nz/our-work/disability-services/pasifika-disability-support-services/faiva-ora-national-pasifika-disability-plan35 Planning Priorities for Annual Plans and Regional Service Plans 2016/17. www.nsfl.health.govt.nz/dhb-planning-package/timeline-201617-planning-package-and-review-plans/consultation-draft-planning. 36 People are often defined as being in a priority population group as are those who are most at risk of adverse outcomes, such as poor health, low educational attainment, unemployment, economic disadvantage.37 World Health Organization, 2009. Interventions on Diet and Physical Activity: What Works: Summary Report www.who.int/dietphysicalactivity/summary-report-09.pdf

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8b. Being evidenced based supports decision making, implementation of quality improvement

and clinical integration of LTC services that contribute to prevention38 of long term conditions. The design and delivery of health services need to be based on current best practice, evidence based information, and accurate data. Feedback loops and evaluation of the experience of the service user and their whanau are important to inform ongoing service improvement.

c. Using evidence based informationHealth loss39 or burden of disease information on the levels and trends in health loss and health expectancy by age, sex, cause, year and country provides the ‘big picture’ of health need and how well a health system is performing.

Information on health loss and life expectancy also demonstrates:

the impacts of different diseases, injuries and risk factors on population health

assessment of what proportion of health loss is attributable to known modifiable risk factors, and is therefore potentially preventable

comparative trends in life expectancy with the corresponding trends in health expectancy – are we succeeding in adding life to years as well as years to life.

Health loss and health expectancy in New Zealand from 1990 to 201340 uses New Zealand data, along with optimal standards and statistical models, to maximise comparability with the results for other high income countries.

Information on a number of the risk factors for many adult diseases such as diabetes, heart disease and some mental health conditions such as depression that arise in childhood are published on the Ministry of Health website41.

d. A holistic/integrated approach to service design and delivery that is inclusive of indigenous knowledge and frameworks of health that is linked across the age ranges, particularly the transition from child to youth to adult services. Tailoring health care and the style and content of communication to the needs, aspirations and goals of the person and their family/whānau, (especially if the person is a child) will support efforts to understand people’s health beliefs and preferences towards improvement in the quality of health interactions from the provider to the service user, and consequently health literacy.

e. Collaborative programmes/ co-design gives people and communities (especially priority groups, including the disability sector) opportunities to have input into their service’s design, development and implementation to support the development of strong and resilient communities. Person/whānau and community-centred approaches to health and wellbeing have significant potential to improve outcomes for individuals, and to develop appropriate actions for the prevention, identification and management of long term conditions42. A person/whānau centred approach to service planning and delivery should also balance available skills and resources and manage community expectations and those of people

38 Eating and Activity Guidelines for NZ Adults (MoH 2015), Guidelines on Physical Activity for Older People MOH 2013), Food and Nutrition Guidelines for Healthy Pregnant Breastfeeding Women: A background paper (MOH 2008). www.health.govt.nz/publications/eating%20and%20activity%20guidelines 39 Health loss is measured in disability-adjusted life years (DALYs). One DALY represents the loss of one year lived in full health. Health expectancy is a generalisation of life expectancy that estimates how long a person can expect to live in good health40 www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/new-zealand-burden-diseases-injuries-and-risk-factors-study-study 41 www.health.govt.nz/our-work/life-stages/child-health/child-health-publications and www.health.govt.nz/publication/food-and-nutrition-guidelines-healthy-children-and-young-people-aged-2-18-years-background-paper42 DHBs and Public Health Units should collaborate with their local Primary Health Organisations and local partners eg, Iwi, education providers, local government, government agencies, non-government organisations, and businesses.

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9with LTC. Over time, it helps to reduce demand on formal health and social care services by reducing ‘waste’ in the system to deliver value and high performance43.

f. Health LiteracyPeople face a series of demands on their health literacy, including obtaining and understanding health information. The higher needs of people with a mental health diagnosis or disability should also be considered. A health-literate health system reduces these demands by providing high-quality services that are easy to access and navigate, and clear relevant health messages for people to make informed decisions about their health. Health literacy is integral in quality service improvement in design, delivery, and performance evaluation.

The Health Literacy Review44 a guide and a Framework for Health Literacy45 have been developed to support organisations to make health literacy a priority.

g. Workforce capacity and capability to support workforce development of both the unregulated and regulated workforce, up skilling and enhancing their capability. See links to publications relating to New Zealand health and disability workforce46 47.

h. Services delivered with a closer to home focus for the end user, by providing primary health care and community services convenient for people, and well-coordinated care that is accessible to the person, their family/whānau and other carers.

i. Self-management support/programmes48. People are empowered through their own health self-management. Supporting people with LTCs to manage their conditions is important as the population ages and people are increasingly managing more than one condition. Self-management support can be viewed as a portfolio of techniques and tools that help people choose healthy behaviours; and as a fundamental transformation of the patient/caregiver relationship into a collaborative partnership49.

j. Self-management support for people with long-term conditions50 shares best practice and innovation for the primary and community health sectors for New Zealand. Any self-management support must:

be appropriate for the person with the LTC and their family and whānau be developed in partnership with the person with the LTC focus on reducing inequities in health.

Self-management programmes, and particularly group programmes, must be culturally appropriate, health literacy friendly and recognise the role of personal support (including whānau) of the person. Health professionals must tailor their communication style to the individual needs of people with LTCs (and their family/whānau and other carers) to support self-management.

A report from the UK At the heart of health: Realising the value of people and communities51 describes a wide range of approaches that aim to support individuals and communities to be at the heart of their health and wellbeing.

43 www.nesta.org.uk/publications/heart-health-realising-value-people-and-communities 44 Health Literacy Review: a guide www.health.govt.nz/publication/health-literacy-review-guide 45 www.health.govt.nz/publication/framework-health-literacy46 www.health.govt.nz/our-work/health-workforce/workforce-publications 47 www.treasury.govt.nz/publications/informationreleases/health/quality-improvement-strategies-dhbs/qual-imp-strat-dhbs-mar16.pdf 48 Planning Priorities for Annual Plans and Regional Service Plans 2016/1749 Health Foundation 2011 http://www.health.org.uk/publication/annual-review-201150 www.health.govt.nz/publication/self-management-support-people-long-term-conditions51 www.nesta.org.uk/publications/heart-health-realising-value-people-and-communities

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10It provides examples of current practice to demonstrate the value that these approaches can have in:

mental and physical health and wellbeing service sustainability, and wider social value.

k. Appropriate leadership and governance structures including Māori participation, supporting clinical integration across the spectrum of LTC services, such as: Health Alliances, Clinical Networks, DHB regional networks.

l. Effective information technology solutions. Service delivery will be supported by relevant clinical pathways that reflect best practice, improved modes of communication, adherence to ethnicity data protocols, smart ways to share innovation and support consistency of information collection. As well as utilising data through feedback loops to add value to analysis for planning towards improving service delivery and performance.

5. Prevention focused health topicsBetter prevention of long-term conditions can bring major benefits, as 88% of health loss in New Zealand is now caused by long-term conditions. There is evidence of major health gains from preventive services that address not only individual behavior but also the environments in which people live. Because many of the strongest influences on health and wellbeing come from outside the health sector, this requires coordinated action which addresses a broad range of social, economic and lifestyle issues. Prevention models are important in addressing risk factors which may contribute to LTC.

Targeting Prevention (2013)52 looks at some of the initiatives, innovations, organisations and people that contributed to sector improvements made in three prevention focused health targets.

We may be living longer, and living longer in good health, but we are also living longer in poor health. Potentially, over one-third of all health loss is preventable53. Beyond the benefits to health, a strengthened focus on prevention could help the health system to become more sustainable clinically, fiscally and economically (by reducing demand pressure), depending on the affordability and effectiveness of relevant interventions.

Successful prevention implementation also requires:

clinical and cultural competence 54 working with Māori and Pacific Peoples requires specific skills, expertise and experience

whānau centred delivery:55 interventions that recognise the diversity and capability of whānau, and

monitoring and evaluation: on service effectiveness for Māori and Pacific would improve delivery.

52 http://www.health.govt.nz/publication/targeting-prevention53 http://www.health.govt.nz/publication/health-loss-new-zealand-1990-201354 Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations. Refer: Cross T, Bazron B, Dennis K, Isaacs M. Towards A Culturally Competent System of Care, Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center, 1989.Ewen S. Cultural Literacy: An Educational Approach for Health Professionals to Help Address Disparities in Health Care Outcomes. Journal of Australian Indigenous Issues 2010;13(3);84-94.55 Whanau Ora Taskforce report www.msd.govt.nz/about-msd-and-our-work/publications-resources/planning-strategy/whanau-ora/ www.msd.govt.nz/about-msd-and-our-work/work-programmes/initiatives/whanau-ora/

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115.1 Risk FactorsEvidence supports that common modifiable risk factors underlie many LTC. Different risk factors contribute to health loss, biological, behavioural, environmental and occupational risk factors are particularly important from the point of view of prevention.56

Dietary risks are the leading cause of health loss among the specific risk factors impacting on health loss (9.4% of total DALYs), high body mass index (BMI) is now the second-ranked risk factor after diet, accounting for 9.2% of total DALYs in the whole New Zealand population in 2013. The biggest contributors to the BMI health loss are cardiovascular disease (47%) and type 2 diabetes and its renal complications (29.5%)57. International research supports the findings that these risk factors explain the vast majority of chronic disease, across all ages, in men and women, globally. They include unhealthy diet, physical inactivity and tobacco use.

The following sections set out information and prevention strategies for the main risk factors for long term conditions.

ObesityObesity is a major risk factor for many chronic, debilitating and life-threatening diseases. New Zealand has the third highest adult obesity rate in the OECD, and our rates are rising. Almost one in three adult New Zealanders (over 15 years) is obese, and one in ten children58. Obesity is more common in Māori, Pacific and South Asian populations compared with other New Zealanders.

Obesity in children is also associated with musculoskeletal problems, asthma and psychological problems including body dissatisfaction, poor self-esteem, depression and other mental health problems. The Childhood Obesity Plan59 provides information on obesity related initiatives that aims to prevent and manage obesity in children and young people up to 18 years of age:

For adults, obesity is also associated with the following health conditions including Type 2 diabetes, ischaemic heart disease (IHD), stroke, several common cancers, osteoarthritis, sleep apnoea and reproductive abnormalities.

A range of obesity related publications and guidance related to eating and activity is on the Ministry’s obesity publications60 website page including tips for improving sleep, healthy eating and being active developed for parents, and for teenagers. Further information on weight management61 is available from the Health Improvement and Innovation Resource Centre.62

SmokingSmoking causes a significant amount of preventable disease and premature death in New Zealand and contributes to health disparities due to the difference in smoking rates between Māori, Pacific and the rest of the population. Between 4500 – 5000 New Zealanders die prematurely each year from a smoking related illness. Tobacco control services focus on Māori, Pacific, pregnant woman and other priority populations because they experience a high level of harm caused by tobacco.

56 Ministry of Health. 2016. Health Loss in New Zealand 1990–2013:A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study. Wellington: Ministry of Health.57 WHO. Preventing chronic diseases: a vital investment: WHO Global report. WHO 2005.58 www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/obesity-statistics59 www.health.govt.nz/our-work/diseases-and-conditions/obesity/childhood-obesity-plan60 www.health.govt.nz/our-work/diseases-and-conditions/obesity/obesity-related-publications61 www.health.govt.nz/our-work/diseases-and-conditions/obesity/weight-management-hiirc62 Health Improvement and Innovation Resource Centre http://www.hiirc.org.nz/

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12The New Zealand Guidelines for Helping People to Stop Smoking63 provide health care workers with advice they can use when supporting people who smoke. Refer to information about New Zealand’s Smokefree 202564 tobacco control programme, including smoking cessation support.

Services commissioned must be aligned with the Ministry's tobacco control programme, including the other functions and services of health promotion, health protection, infrastructure (eg. information systems), capacity and capability building and clinical leadership.

Reducing harm of alcohol and other drugsThe National Drug Policy 2015–202065 seeks to minimise alcohol and other drug (AOD) related harm, and promote and protect health and wellbeing. This can be achieved by effective collaborative action, a cross community and primary care organisations to maximise physical activity, good nutrition, quit smoking and reduction in the harmful use of alcohol (including demand reduction and control), and support for mental health promotion programmes.

Multi-faceted health promotion efforts to minimise AOD harm should be based on community need and focused on reducing inequalities including giving children the best start. This should include involvement in the adoption of healthy public policy, such as Local Alcohol Policies.

Healthy Families NZ66 is focused on enabling families and communities to make good food choices, be physically active, smokefree, and reduce alcohol-related harm.

Taking Action on Fetal Alcohol Spectrum Disorder: 2016-201967: An action plan identifies the Government’s priority actions for preventing Fetal Alcohol Spectrum Disorder (FASD) and supporting people with FASD and their family/whanau to live the best possible lives.

63 http://www.health.govt.nz/publication/new-zealand-guidelines-helping-people-stop-smoking64 www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/smokefree-2025 65 http://www.health.govt.nz/publication/national-drug-policy-2015-202066 http://www.health.govt.nz/our-work/preventative-health-wellness/healthy-families-nz67 http://www.health.govt.nz/publication/taking-action-fetal-alcohol-spectrum-disorder-2016-2019-action-plan

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13APPENDIX

LTC disease groups specific service informationThis Appendix provides links to disease specific information, service standards, requirements and best practice guidance that reflects the key current resources. Where there are no New Zealand standards and guidelines, internationally accepted best practice guidelines may be used, such as those provided by National Institute for Health and Care Excellence (NICE) and National Health Service (NHS).

CancersCancer is a major health issue for New Zealanders. Cancer is the country’s leading cause of death (28.9 percent) and a major cause of hospitalisation. Summary information68 69 is provided about the Ministry's work in cancer including:

The New Zealand Cancer Plan: Better faster cancer care 2015-1870

National tumour standards71 are used by the DHBs as the benchmarks for high quality care for different types of cancer and help ensure patients receive timely, good quality care along the cancer pathway. The Ministry has published 10 sets of provisional tumour standards for bowel, breast, gynaecological, lymphoma, myeloma, head and neck, thyroid, melanoma, sarcoma and upper gastrointestinal cancer.

Cancer data and statistics72 are available on the Minis try of Health website.

Cardiovascular diseaseThese documents provide information on cardiovascular disease73 in New Zealand.

The 2013 Cardiovascular Disease Risk Assessment Update 74

Influences in Childhood on the Development of Cardiovascular Disease and Type 2 Diabetes in Adulthood75

Chronic Kidney DiseaseChronic kidney disease numbers are rising, driven by the high prevalence of diabetes. Chronic kidney disease is usually first identified by primary care clinicians. ‘Managing Chronic Health Disease’76 outlines best practice for identifying and managing chronic kidney disease in primary care, and is intended as a guide for primary care clinicians and managers in both funder and provider organisations. This link provides information on kidney disease related publications77:

68 www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme?mega=Our%20work&title=Cancer69 www.health.govt.nz/publications/cancer70 www.health.govt.nz/publication/new-zealand-cancer-plan-better-faster-cancer-care-2015-201871 www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme/faster-cancer-treatment-programme/national-tumour-standards72 www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/cancer-data-and-stats73 www.health.govt.nz/our-work/diseases-and-conditions/cardiovascular-disease74 www.health.govt.nz/publication/new-zealand-primary-care-handbook-2012 75 www.health.govt.nz/publication/influences-childhood-development-cardiovascular-disease-and-type-2-diabetes-adulthood76 www.health.govt.nz/publication/managing-chronic-kidney-disease-primary-care77 www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/kidney-disease

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14Chronic pain

The 2011 Patterns of Chronic Pain in the New Zealand population study78 describes the prevalence and impact of chronic and recent pain in the New Zealand population and the groups most likely to report and use treatment for their chronic pain. Results are compared with international estimates.

Chronic Respiratory DiseaseOver 700,000 people live with a respiratory condition in New Zealand and respiratory disease is the third most common cause of death. Children, people on low incomes, Māori, and Pacific people have a greater level of respiratory ill health than other New Zealanders.

Te Hā Ora: The Breath of Life National Respiratory Strategy79- a plan for all involved to reduce the impact of largely preventable deaths and human suffering.

Chronic obstructive respiratory/pulmonary disease (CORD or COPD) is a lung disease which is usually caused by smoking. Emphysema and chronic bronchitis are both forms of COPD. COPD is common in older age groups. The Thoracic Society of Australia and New Zealand has published March 2014 Position Papers and Guidelines on their Thoracic Society of Australia and New Zealand website80.

Chronic Obstructive Pulmonary Disease (COPD) Australian and New Zealand Management, Guidelines and the COPD Handbook81.

The Asthma and Respiratory Foundation’s Adult Asthma Guidelines82 2016- provide practical and evidence-based guidance for the diagnosis and treatment of asthma in adults.

DementiaNew Zealand has a growing number of older people. For most, their older years will be active years, with many working longer and remaining involved in their local communities. However, an increasing number of older people will also have health problems that require ongoing support such as dementia.

While people with dementia may not be expected to 'self-manage' when their dementia is advanced, it is important to retain self-management. Refer to The New Zealand Framework for Dementia Care Ministry of Health 201383.

Improving the Lives of People with Dementia 84 Ministry of Health 2014. This publication outlines nine key areas the Ministry of Health will support over the next three years to maximize the health, independence and wellbeing of people with dementia.

DiabetesDiabetes is a priority long-term condition affecting an estimated 257,000 New Zealanders. Diabetes is a chronic condition that can cause kidney failure, eye disease, foot ulceration and a higher risk of heart disease if not well managed.

A summary link85 provides Ministry of Health information for health professionals on managing diabetes and other information including:

78 www.ncbi.nlm.nih.gov/pubmed/21946879 Blythe,F. Dominick,C Nicholas,M. NZ Medical Journal (NZMJ) 24 June 2011, Vol 124 No 1337; ISSN 1175 871679 www.asthmafoundation.org.nz/news-and-events/publications/80 www.thoracic.org.au/81 www.asthmafoundation.org.nz/wp-content/uploads/2012/03/COPDguidelines.pdf 82 www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control83 www.health.govt.nz/publication/new-zealand-framework-dementia-care 84 www.health.govt.nz/publication/improving-lives-people-dementia85 www.health.govt.nz/our-work/diseases-and-conditions/diabetes

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15Living Well with Diabetes86: A health care plan for people at high risk of or living with diabetes 2015 to 2020 aims to address the needs of people with a high risk of developing diabetes, including those with pre-diabetes and existing diabetes.

The Diabetes Quality Standards87 and toolkit provides guidance for clinical quality service planning and implementation of equitable and comprehensive patient-centered care.

Diabetes Retinal Screening, Grading, Monitoring and Referral88 Guidance 2016 updates previous guidelines with new evidence to provide high quality and equitable screening for all those at risk of diabetic eye disease.

GoutHealth Literacy and the Prevention and Early Detection of Gout89 (2014) reports on a project that focused mainly on Māori as a population group with a high incidence of gout compared with some other population groups. It looked at effective approaches to strengthen health literacy in relation to the initial prevention and early detection of gout. Gout is a serious condition, knowing the risk factors can help prevent it or recognize it early.

Mental Health and AddictionThe World Health Organization predicts that by 2020 major depression will be one of the major causes of disability in the developed world, second only to cardiovascular disease. Mental illness is a very significant part of the health care of New Zealanders and the majority can be diagnosed and managed appropriately in primary care.

This link provides information about the Ministry's work in the areas of mental health, alcohol and other drug dependency, gambling, depression and suicide prevention.90 Including:

Rising to the Challenge: The Mental Health and Addiction Service Development Plan 2012–201791.

Commissioning Framework for mental Health and Addiction92

The National Depression Initiative (NDI)93.

The ‘Knowing the people planning’94 (KPP) toolkit is designed to be used to assess how well mental health services are meeting the needs of people using their services. The information gathered provides clinicians with an overview of their clinical work and can help identify gaps in service delivery to inform planning and funding, workforce development and service development decisions.

Equally Well: resources95 are available to help organisations to improve the physical health of people who experience mental health addiction issues.

Musculoskeletal disordersMusculoskeletal symptoms are common presentations in general practice with 8.9 percent of consultations attributed to these conditions96. They affect all age groups, and range from acute to

86 www.health.govt.nz/publication/living-well-diabetes87 www.health.govt.nz/our-work/diseases-and-conditions/diabetes/quality-standards-diabetes-care88 www.health.govt.nz/publication/diabetic-retinal-screening-grading-monitoring-and-referral-guidance89 www.health.govt.nz/publication/health-literacy-and-prevention-and-early-detection-gout90 www.health.govt.nz/our-work/mental-health-and-addictions?mega=Our%20work&title=Mental%20health%20and%20addictions91 www.health.govt.nz/publication/rising-challenge-mental-health-and-addiction-service-development-plan-2012-201792 www.health.govt.nz/our-work/mental-health-and-addictions/commissioning-framework-mental-health-and-addiction93 www.health.govt.nz/our-work/mental-health-and-addictions/national-depression-initiative94 www.tepou.co.nz/outcomes-and-information/knowing-the-people-planning/3195 www.tepou.co.nz/initiatives/equally-well-resources/13496 www.health.govt.nz/publication/family-doctors-methodology-and-description-activity-private-gps refer www.rnzcgp.org.nz/assets/documents/Training-and-Beyond/Curriculum-Documents-2014/Musculoskeletal-CS.pdf National expectations for the prevention and management of long term conditions. V1.9 2 May 2017

16chronic, simple to complex. They may be injury-related or linked with a wide range of other conditions and factors, including normal ageing.

Musculoskeletal disorders (MSD) are currently the leading cause of disability in New Zealand, affecting nearly 1 in 4 adults. People with MSDs are also likely to have depression or anxiety problems related to their conditions. This can affect the severity of the condition, the ability of the individual to remain at work, the length of time they spend away from work and the ease with which they can be rehabilitated. The following documents provide useful information on health loss and economic costs of musculoskeletal disorders.

Fit for Work97 Musculoskeletal Disorders and the New Zealand Labour Market provides information about the New Zealand health loss due to musculoskeletal disease.

Access Economics report98 ‘The economic cost of arthritis in NZ in 2010.

The Ministry, ACC and the Health Quality & Safety Commission New Zealand worked with Osteoporosis NZ and other key stakeholders to drive the implementation of Fracture Liaison Services99 by all District Health Boards in New Zealand in accordance with the requirement of the 2014-15 District Annual Planning guidance from the Ministry of Health.

Mobility Action Programme100 (MAP) models of care, is a range of programmes for people with musculoskeletal health conditions that are designed to deliver improved health outcomes. These outcomes include reducing pain and the impacts of the musculoskeletal conditions.

Palliative CarePalliative care is best delivered through an integrated approach to care for people of all ages with a life limiting illness and their family, whanau, caregiver according to need. It may be suitable whether death is days, weeks, months or occasionally years away and sometimes when treatments are being aimed at improving quantity of life. This palliative care summary link to the Ministry’s web page provides information relating to palliative care in New Zealand101 such as:

Review of Adult Palliative Care 102and the Palliative Care Action Plan103

Palliative Care and Maori from a Health Literacy Perspective104

Te Ara Whakapiri: principles and guidance for the last days of life.105

StrokeThe New Zealand Clinical Guidelines for Stroke Management 2010106 published by the Stroke Foundation provides a series of evidence-based recommendations related to recovery from stroke and transient ischemic attack. These guidelines provide guidance on appropriate, evidence-based practice, to support clinical judgment that takes into account the preferences of the person with stroke and their family/whānau.

97 www.arthritis.org.nz/wp-content/uploads/2012/09/fitforwork.pdf98 www.arthritis.org.nz/wp-content/uploads/2011/07/economic-cost-of-arthritis-in-new-zealand-final-print.pdf99 osteoporosis.org.nz/resources/health-professionals/fracture-liaison-services/100 www.health.govt.nz/our-work/preventative-health-wellness/mobility-action-programme101 www.health.govt.nz/our-work/life-stages/palliative-care/palliative-care-publications102 www.health.govt.nz/publication/review-adult-palliative-care-services-new-zealand103 www.health.govt.nz/publication/palliative-care-action-plan104 www.health.govt.nz/publication/palliative-care-and-maori-health-literacy-perspective105 www.health.govt.nz/publication/te-ara-whakapiri-principles-and-guidance-last-days-life106 www.health.govt.nz/publication/new-zealand-clinical-guidelines-stroke-management-2010

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