midcentral district health board a g e n d a€¦ · 1.5.10 te runanga o raukawa governance group...

Distribution

Committee Members Brendan Duffy (Chair) Adrian Broad (Deputy Chair) Barbara Cameron Ann Chapman Nadarajah Manoharan Dot McKinnon (ex officio) Vicky Beagley Donald Campbell Tawhiti Kunaiti

Board Members Diane Anderson Michael Feyen Karen Naylor Oriana Paewai Barbara Robson

Management Team Kathryn Cook, CEO Craig Johnston, General Manager, Strategy,

Planning & Performance General Manager, Quality & Innovation Neil Wanden, General Manager, Finance &

Corporate Support Keyur Aujaria, General Manager, People & Culture Stephanie Turner, General Manager, Maori &

Pacific Scott Ambridge, General Manager, Enable New

Zealand Ken Clark, Chief Medical Officer Michele Coghlan, Acting Executive Director,

Nursing & Midwifery Steve Miller, Chief Information Officer Cushla Lucas, Regional Cancer Treatment Service

Manager Debbie Davies, Acting Service Director,

Community Lyn Horgan, Operations Director, Hospital

Services Muriel Hancock, Patient Safety & Clinical

Effectiveness Chris Nolan, Service Director, Mental Health &

Addiction Services Gabrielle Scott, Executive Director, Allied Health Chiquita Hansen, CEO, Central PHO Jill Matthews, PAO Megan Doran, Committee Secretary Communications Dept, MDHB External Auditor Board Records

National Health Board Peter Jane, Account Manager

Public Copies (9) www.midcentraldhb.govt.nz/orderpaper

MidCentral District Health Board

A g e n d a

Healthy Communities Advisory Committee

Part 1

Date: 17 October 2017

Time: 1.00pm

Place: Board Room Board Office Heretaunga Street Palmerston North

Contact Details Committee Secretary Telephone 06-3508928 Facsimile 06-3508926

Next Meeting Date 28 November 2017 Deadline for Agenda Items 10 November 2017

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Healthy Communities Advisory Committee Meeting

Tuesday, 17 October 2017

Part 1

O r d e r 1. APOLOGIES 1.00pm Kathryn Cook 2. NOTIFICATION OF LATE ITEMS 3. CONFLICT AND/OR REGISTER OF INTERESTS 3.1 Amendment to the Register of Interests Pages 5-7 3.2 Declaration of Conflicts in Relation to Today’s Business 4. PARTNERSHIPS & CONSUMER 1.05pm 4.1 Presentation by Home Care Medical – Mental Health Line 4.2 Health Charter Pages: 8-13 Documentation: report from General Manager, Strategy, Planning

& Performance dated 6 October 2017

Recommendation: that this report be noted 5. STRATEGIC & ANNUAL PLANNING 1.45pm 5.1 Health Needs Assessment Pages: 14-45 Documentation: report from Clinical Advisor, Data Quality &

Health Information dated 3 October 2017

Recommendation: the Executive Summary extracted from the final draft 2017 Health Needs Assessment for MidCentral & Whanganui DHBs (attached) be noted

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5.2 Equity Snapshot and Impact for Planning

Pages: 46-49Documentation: report from General Manager, Maori &

Pacific Health, dated 29 September 2017Recommendation: that progress on the Equity Snapshot and

Impact for Planning is noted

6. PERFORMANCE REPORTING 2.15pm

6.1 MidCentral Health Horowhenua STAR 4 Project Report

Pages: 50-58Documentation: report from Operations Director, Hospital

Services dated 3 October 2017 Recommendation: the Horowhenua STAR 4 project report be noted

6.2 Re-commissioning of Home & Community Support Services

Pages: Documentation:

59-64report from Senior Portfolio Manager, Healthof Older People & Palliative Care dated 5October 2017

Recommendation: that the DHB's intention to re-commission Home & Community Support Services is noted

6.3 Strategy, Planning & Performance Operating Report

Pages: 65-74Documentation: report from General Manager, Strategy,

Planning & Performance dated 29 September2017

Recommendation: that this report be noted

7. MINUTES OF THE PREVIOUS MEETINGS 2.30pm

Pages: 75-90Documentation: minutes of 25 July 2017 and 5 September

2017 Recommendation: that the minutes of the previous meetings

held on 25 July 2017 and 5 September 2017 be confirmed as a true and correct record.

7.1 Recommendations to the Board

To note that all recommendations contained in the minutes were approved by the Board.

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7.2 Matters Arising from the Minutes To consider any matters arising from the minutes of the meetings

held on 25 July 2017 and 5 September 2017 for which specific items do not appear on the agenda or in management reports.

8. COMMITTEE’S WORK PROGRAMME 2.45pm Pages: 91-95 Documentation: Report from Acting CEO dated 11 October

2017

Recommendation: that progress against the 2017/18 work programme be noted

9. LATE ITEMS To discuss any such items as identified under item 2. 10. DATE OF NEXT MEETING 28 November 2017 (Shared matters of interest) 13 February 2018 11. EXCLUSION OF PUBLIC Recommendation: that the public be excluded from this meeting

in accordance with the Official Information Act 1992, section 9 for the following items for the reasons stated:

Item Reason Reference “In Committee” minutes of the meeting held on 25 July 2017 and 5 September 2017

For reasons stated in the Agendas of 25 July 2017 and 5 September 2017

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Please advise all changes to Jill Matthews, Manager, Administration & Communication Page 1 of 3 *Reflects contract value to nearest 1000/100,000.

REGISTER OF INTERESTS: SUMMARY, SEPTEMBER 2017 Name Date Company/Organisation Nature of Interest Anderson, Diane 1.7.16 Nil Broad, Adrian 24.6.14 Manawatu Horowhenua Tararua Diabetes

Trust Trust Manager.

9.12.13 Palmerston North City Council Councillor. 3.5.16 ACROSS – Te Kotahitanga oTe Wairua Board Member.

Cameron, Barbara 25.4.13 Manawatu District Council Councillor. Member & Deputy Chair, Manawatu District Licensing Committee

1.11.16 Ministry of Social Development Member, MSD’s Community Response Forum. Chapman, Ann 17.12.13 Otaki Mail Part Owner.

18.5.12 Otaki Community Health Trust Member.

21.12.07 Gen-i Son is employee. 29.4.16 Central Region’s Technical Advisory Service Grandson is an employee.

Duffy, Brendan 3.8.17 MITO Board Member. 3.8.17 Local Government Commission Commissioner. 3.8.17 Electra Trust Trustee. 3.8.17 Environmental Legal Assistance Fund,

Ministry for the Environment Deputy Chair.

3.8.17 Business Kapiti Horowhenua Inc (BKH) Board Member. 3.8.17 Life to the Max, Horowhenua Chair.

Feyen, Michael 5.12.16 Horowhenua District Council Mayor.

Manoharan, Nadarajah

9.12.13 Surgical Educators of the Royal Australasian College of Surgeons

Educator.

9.12.13 Private Otorhinogology Practice, Palmerston North

Owner.

9.7.17 Aroha Ultimate Care Wife is an employee (facility manager) McKinnon, Dot 5.12.16 Whanganui DHB Chairperson.

Cousin of Whanganui DHB General Manager 9.2.17 NZ DHB Chairs’ National Executive Member. 9.2.17 Health Practitioners Disciplinary Tribunal Member.

9.2.17 Health Sector Relationship Agreement Committee

Member

9.2.17 Four Regions Trust (formerly known as Powerco Trust)

Chair.

9.2.17 Whanganui Eyecare and Medical Trust Husband is chair. 21.3.17 Moore Law & Associates Legal Executive, Director and Shareholder. 4.7.17 20 DHBs (Central Region’s Technical

Advisory Service) Member, National Health Workforce Strategy

21.3.17 Chardonnay Properties Limited Part owner. Naylor, Karen 6.12.10 MidCentral DHB Employee.

22.9.15 New Zealand Nurses Organisation Member & Workplace Delegate Board Member

9.10.16 Palmerston North City Council Councillor. Paewai, Oriana 1.5.10 Rangitane o Tamaki nui a Rua CEO.

1.5.10 Te Runanga o Raukawa Governance Group Member. 1.5.10 Manawhenua Hauora Chair.

Member, Child Health Tamariki Ora District Group.

13.6.17 Te Whiti ki te Uru Co-ordinating Chair. 13.6.17 Tararua Hauora Services Charitable Trust Trustee. 13.6.17 Central Primary Health Organisation Member, Alliance Leadership Team (Central

PHO Board). 13.6.17 Feilding Health Care Member, Clinical Governance Group. 13.6.17 Manawatu District Council Member, Nga Manu Taiko, a standing

committee of the Council. 13.6.17 Te Ohu Auahi Mutunga (TOAM) Member, Governance Board. 13.6.17 Before School Checks (B4SC) Collective Member. 13.6.17 Nga Kaitiaki o Ngati Kauwhata Inc Committee member. 13.6.17 Te Tihi o Ruahine Whanau Ora Alliance Member.

Robson, Barbara 19.7.16 Kind Hearts Trust Board Member.

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1.11.16 Royal NZ College of GPs

Member (consumer representative), Health Care Home Standard Working Group.

10.12.01

Federation of Women’s Health Councils Aotearoa NZ (Inc)

Co-convenor.

31.5.10 Medicines Review Committee Consumer Representative. Feb 13 Ministry of Health Member, Electronic Oral Health Record Design

Group. Member, Consumer Reference Group – National Workforce Strategy Project (MoH & HWNZ)

11.10.16 Ernst & Young Daughter is an employee – Business Advisor. COMMITTEE MEMBERS Beagley, Vicki 5.10.15 Massey University Employee, research office. 5.10.15 Arohanui Hospice Husband, John Freebairn, is the current chair. 5.10.15 Supportlinks/Enable New Zealand Son receives respite care. 11.10.16 Palmerston North City Council Member, District Licensing Committee. Campbell, Donald 2.7.14 Nil Emery, Dennis 1.9.15 Arohanui Hospice Employee. 1.9.15 Manawhenua Hauora Member. 1.9.15 Ngati Maniapoto me Ngati Kauwhata Iwi Iwi descendent of both tribes. 1.9.15 Nga Kaitiaki O Ngati Kauwhata Inc, Feilding

- NKOK Chairman

1.9.15 Feilding Integrated Family Health Centre Through the Iwi of NKONK 1.9.15 Te Tihi O Ruahine Whanau Ora Trust 1.9.15 Whanau Ora Strategic Innovation &

Development Group (WOSIDG), Palmerston North

Chairperson / Member.

1.9.15 Whaioro Mental Health Trust – P. North Board Member & Iwi Trustee. Hartevelt, Tony 14.8.16 Otaki Family Medicine Ltd Independent Director designate. 14.8.16 Merck Sharpe & Dohme (Merck)

(NZ operations for Global Pharmaceutical Company)

Elder son is NZ market access manager.

14.8.16 Fairfax Media Younger son is news director for Stuff.co.nz Kirkcaldie, Ewen 1.8.08 PKF Rutherfords Ltd Director. Kolbe, Anne 22.7.16 Kolbe Medical Services Ltd Director and joint owner. 22.7.16 Communio, NZ Senior Consultant and Contractor. 22.7.16 Whanganui DHB Member, Risk & Audit Committee. 22.7.16 Health Research Council of NZ Husband chairs the clinical trials advisory

committee. 22.7.16 Auckland University Holds an adjunct appointment (Associate

Professor level). Husband is also an employee of Auckland University (Professor of Medicine, FMHS).

22.7.16 Australian Medical Council Husband is a member of the Medical School Advisory Committee, and leads the Medical Specialties Advisory Committee Accreditation Team.

22.7.16 Royal Australasian College of Physicians Husband is a member of the College’s governance working party, and chairs the revalidation working party.

22.7.16 EXCITE International Board Member, and Chair of Advisory Council. 22.7.16 Medicare Benefits Schedule Review

Taskforce (Australia) Senior Advisor/ Government taskforce to review the Medicare Benefits Schedule.

22.7.16 Institute of Environmental Science & Research (ESR)

Daughter employed as forensic scientist.

13.3.17 Siggins Miller, Australia Senior Advisor & Associate. Kunaiti, Tawhiti 20.7.10 Central Primary Health Organisation Employee. Wife is an employee – Contracts Administrator.

(28.10.16) 28.10.16 Manawhenua Hauora Manawhenua representative on HCAC 28.10.16 Te Tihi O Ruahine Whanau Ora Alliance

Trust Employee – Pou Whakarae, Principal Cultural Leader.

28.10.16 Whanau Ora Strategic Innovation Development Group (WOSIDG)

Member.

28.10.16 New Zealand College of Clinical Council Member for NZCCP as Pou Whakarae,

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Psychologists Principal Cultural Leader. Temple-Camp, Cynric

3.2.15 Breastscreen Coast to Coast Lead Pathologist. 23.7.13 International Academy of Pathology Board Member.

1.7.08 Medlab Central Ltd. Business Unit of Sonic Health Care Ltd

CEO.

1.7.08 MidCentral Health (MCH) Wife is employed as a Medical Consultant by MCH.

1.7.08 National Coronial Pathology Services Advisory Group to Ministry of Justice

Member

1.7.08 T-Lab Director. 7.4.09 Ministerial Advisory Group Member. MANAGEMENT Cook, Kathryn 4.5.15 Aspen Pharma Sister is an employee. 1.7.16 Central Region’s Technical Advisory Service Director. Ambridge, Scott 20.8.10 Nil Anjaria, Keyur 17.7.17 MidCentral DHB Wife is a user of the Needs Assessment &

Service Co-ordination Service. Clark, Kenneth 3.8.10 Dr Kenneth Clark Ltd Private gynaecology practice, Palmerston

North. Coglan, Michele 3.2.16 Nil Hansen, Chiquita 9.2.16 MidCentral DHB Employed by MDHB and seconded to Central

PHO 8/10ths. 9.2.16 Central PHO Central PHO’s CEO. Johnston, Craig 19.2.16 Central PHO Member, Alliance Leadership Team. 19.4.16 MidCentral DHB Son is an employee of MidCentral DHB and

works within hospital services. Miller, Steve 18.4.17 Puriri Trust & Puriri Farm Partnerships Director. Farming business. Scott, Gabrielle 19.8.16 MidCentral DHB Son is a casual employee of MidCentral DHB

and works within various hospital services. Turner, Stephanie 17.2.16 Waingawa Ltd Director. Farming business. Wanden, Neil 16.2.16 Opus International Wife is a major shareholder. Matthews, Jill 1.3.16 Nil Amoore, Anne 23.8.04 Nil Small, Jeff 2002 Allied Laundry Services Limited (ALSL) Director (appointed by MDHB’s Board)

Horgan, Lyn 1.5.17 Coronial Services Sister is Coroner based in Wellington.

Hancock, Muriel 2.8.10 Nil Nolan, Chris Russell, Greig 3.10.16 City Doctors Minority shareholder. 3.10.16 NZ Medical Council Member, Education Committee. Downing, Eileen 2.9.10 Nil Andrews, David Smith, Jo 27.8.10 Nil Nepia-Tule, Claudine

1.9.10 Nil

Bradnock, Barb 26.8.10 Nil Jermey, David 31.8.17 Central Primary Health Organisation Member, Alliance Leadership Team Ayres, Vivienne 26.8.10 Nil Channing, Chris 27.8.10 Nil Els, Johan 28.10.16 Nil Tanner, Steve 16.2.16 Nil Brogden, Greg 16.2.16 Nil Manderson, John 16.2.16 Nil

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For:

Decision

Endorsement

X Noting

To Healthy Communities Advisory Committee

Author Craig Johnston, General Manager, Strategy, Planning & Performance

Endorsed by CEO

Date 6 October 2017

Subject Health Charter RECOMMENDATION

It is recommended that:

• that this report be noted

Strategic Alignment

This report aligns to the MidCentral Strategy and to the Charter. It is part of the 2017/18 Annual Plan.

Glossary

DHB – District Health Board

COPY TO: Strategy, Planning & Performance

MidCentral DHB Heretaunga Street

PO Box 2056 Palmerston North 4440

Phone Fax

+64 (6) 350 8928 +64 (6) 355 8926

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1. PURPOSE This report is to advise the Committee of the future development pathway for the MidCentral Health Charter.

2. SUMMARY

The DHB has had the intention of developing a Health Charter for a number of years. The purpose of the Charter was to set a health agenda for the district which would mobilise intersectoral partners to work collaboratively to achieve health gain. Two very successful workshops were held in 2014. A working group produced a draft document but further development was postponed pending advancement of the MidCentral Strategy, which sets the overarching direction for MidCentral DHB. More recently, attention has focused on the locality plans.

In order to take the Charter forward we have reviewed the draft document. The overall tone is still good and it was well received when it was ‘road tested’ in various forums. The purpose of mobilising collaborative efforts to achieve improvements in health and wellbeing is still relevant, but this is no longer a new idea. Our communities and our intersectoral partners now have quite a lot of experience in this space (eg, Child Protection, Social Investment and Kainga Whanau programmes). Furthermore, although the draft Charter attempts to place itself clearly in the intersectoral, collaborative space, in a number of places it becomes health service-centric. In conclusion, while the purpose of the Charter is still relevant, the draft Charter document needs a thorough refresh and a new approach. It is intended that it be redeveloped as a high-level, interagency agreement which provides an overarching framework for the locality-based Health and Wellbeing plans. These latter locality plans then provide the detail of what is to be achieved in specific communities. The first step in the redevelopment of the Charter will be engagement with our primary intersectoral stakeholders to establish their appetite for the Charter and to identify what value the Charter can bring. The second step is then to re-establish the working group to reconstruct the draft Charter. The third step is to reconvene the largescale intersectoral forum to fine tune and socialise the document. The final step will be the mobilisation phase, during which agency commitment to the Charter will be procured.

3. BACKGROUND

The draft Charter was the outcome of a large scale engagement process that centred on workshops held at the Manawatu Golf Club. These workshops were well attended and included representatives from a wide array of agencies representing a good cross section of health and social services. MidCentral’s key provider groups were in attendance, as were people from Education, Police, Local Authorities, etc.

After the Charter workshops, over a number of months a small working group produced a draft Charter document. This was “road tested” with a number of groups and at various forums and was very well received, but it still required further work. Once this was done, the anticipated next step was to present the draft Charter back to the larger group at a further workshop.

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For a variety of reasons, work on the draft Charter stopped. The most important of these was to allow the completion of the MidCentral Strategy, which provides the overarching strategic framework for the DHB.

The MidCentral Strategy and the Charter are seen as companion documents, with the Strategy focusing on the DHB and the Charter on the relationships between the DHB and its intersectoral partners. The relationship between the Charter, the Strategy, Service and Enabler Plans has been defined in graphical form:

Graphic 1: Overview of Strategy and Planning Architecture

The Charter continues to have a role within the strategy architecture outlined above. It is particularly important in terms of supporting Health and Wellbeing plans for localities. These in turn feed into the Integrated Service Model (Cluster) plans.

4. REVIEW OF THE DRAFT CHARTER DOCUMENT

The draft Charter has been reviewed in terms its continued relevance, the currency of its core concepts and its consistency. It is important to note from the outset that work on the Charter preceded the MidCentral Strategy. 4.1 Tone and Format

The overall tone and format of the draft Charter are good. It was intended to be a largely graphical document, although there was no graphic design input during the drafting process. The draft Charter is easy to read and readily absorbable for a non-health audience. Its tone is positive and motivational with a series of simple statements. It could easily be presented in the same format as the MidCentral Strategy.

4.2 Purpose

The purpose of the Charter to MidCentral DHB is still relevant. It is essentially to mobilise collaborative efforts to achieve improvements in health and wellbeing. At the time of its development, the Charter was in the vanguard of strategic

Procurement

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thinking, and positioned MidCentral ‘ahead of the curve’. A number of years have now passed and this is no longer so. Intersectoral collaborative activity is now central to the working of a number of our partner agencies, and there are examples of very good collaborative programmes within our district. For example:

• Kainga Whanau project under the auspices of Te Tihi

• Children’s Team

• More recently Child Protection work It is also worth mentioning that the Social Investment approach is now well established in people’s thinking, although this has been predominantly led out of social agencies rather than health.

Furthermore, the locality planning process has identified that there has already been a lot of intersectoral activity in most communities, and that often the DHB has not been present in these conversations. Tararua is the best example of this.

In short, the health and social service sectors have moved ahead over the last few years, and to be ahead of the curve we need to identify how to add value. Whereas in the past we might do this by setting an agenda and then bringing our intersectoral partners on board, now we would see it as appropriate to involve our partners in setting the direction.

4.3 Main Concepts

The Charter introduced a number of new themes to our strategic direction, with the tagline “People.Owners.Partners”. The key concepts were:

• Closer working with intersectoral partners

• Conceptualising people as “owners” of their health and of services

• Focus on vulnerable people (100 families). As already mentioned, the concepts of collaborative intersectoral activity and focusing intensively on identified vulnerable people are now well understood and to some extent well established. These need to be taken another step forward. The concept of “owner” is not so well established in practice. It is about thinking of patients as the ‘owners’ of health services and as the ‘owners’ of their own health. The draft Charter includes clear statements of what owners can expect from health providers and what they can do to help. These are not directly relevant to an intersectoral, collaborative charter. They would more appropriately fit within a ‘patient charter’ and therefore might be something that Consumer Council could take up.

The draft Charter is reasonably clear about addressing the needs of the most vulnerable populations. There is less clarity about the broader issues of population health, and personal wellbeing. These need to be drawn out and given some attention, because they are key dimensions of a holistic approach to health.

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4.4 Structure

While acknowledging the Charter’s role as a motivational document, it nevertheless needs to have robust planning framework to underpin it. At the moment the draft document does not. The vision, mission, goals and action statements are somewhat confused and not well organized. At present the draft Charter does not integrate well with the rest of our planning framework and because of the way it is framed it would be difficult to implement.

4.5 Other Comments

Health equity needs to be more prominent in the Charter. ‘Whanau’ are referenced on a number of occasions and a section on the principles of Whanau Ora is included, but these principles are not integrated into the Charter.

There are parts of the draft Charter that strongly focus on intersectoral collaborative action, but in other places it is very concerned with health services. For example, it has a section that celebrates success, but this is entirely health provider focused. There needs to be consistency here, and given its intended function, it should be focused on intersectoral collaboration.

5. MOVING THE CHARTER FORWARD

The purpose of the Charter is still relevant to the DHB. It is about mobilising intersectoral collaboration to achieve improvements in health and wellbeing. However, based on the preceding discussion, the draft Charter needs a thorough refresh and a new approach. It is intended that the Charter be redeveloped as a high level interagency agreement, which provides an overarching framework for the locality-based Health and Wellbeing plans. These latter locality plans then provide the detail of what is to be achieved in specific communities. In order to progress this approach, we need to touch base with our key intersectoral partners and identify the content that will ensure the Charter will add value to the collaborative activities that are already going on.

The large-scale forums that occurred at the beginning of the Charter process delivered a lot of value to MidCentral in terms of engagement, participation and ownership. This process can be incorporated into the further development of the Charter.

The Working Group did a good job translating the material from the forums into a draft document. It is suggested that this group be reengaged to further develop the charter.

Finally, when it is completed and ready to go, the Charter needs some sort of formal committal process. This would potentially involve the heads of major stakeholders signing the document. It could be done on a ‘agency by agency’ basis, or it could be done through a formal ceremony. This needs to be worked through as the process progresses.

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6. NEXT STEPS The suggested next steps for the Charter are as follows:

1. Engage with our primary intersectoral stakeholders to establish their

appetite for the Charter and to identify what value the Charter can bring to existing initiatives and programmes.

2. Reestablish the working group to refresh the Charter based on previous

and new material.

3. Reconvene the large-scale intersectoral forum to fine tune and socialise the document.

4. Develop a ‘mobilisation’ programme which achieves formal commitment

from agencies to the Charter. 7. RECOMMENDATION

It is recommended:

that this report be noted

Craig Johnston General Manager Strategy, Planning & Performance

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COPY TO: Strategy, Planning & Performance MidCentral DHB

Heretaunga Street PO Box 2056

Palmerston North 4440 Phone

Fax +64 (6) 350 8928+64 (6) 355 8926

For:

Decision

Endorsement

X Noting


Author Dr Richard Fong, Clinical Advisor, Data Quality & Healthy Information

Endorsed by Craig Johnston, General Manager, Strategy, Planning & Performance

Date 3 October 2017

Subject MidCentral and Whanganui District Health Boards Health Needs Assessment,2017

RECOMMENDATION


• The Executive Summary extracted from the final draft 2017 Health Needs Assessment for MidCentral and Whanganui DHBs (attached) be noted

Strategic Alignment

This report aligns to the MidCentral Strategy and to the Annual Plan.

Glossary

DHBs – District Health Boards

HNA – Health Needs Assessment

LCL – Lower control limit (computed from data)

MDHB – MidCentral District Health Board

MidCentral DHB – MidCentral District Health Board

MoH – Ministry of Health

NZ – New Zealand

NZDep – NZDep2013, New Zealand Index of Deprivation

UCL – Upper control limit (computed from data)

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1. PURPOSE The attached document provides the Committee with an edited copy of the Executive Summary of the final draft 2017 Health Needs Assessment that has been completed for MidCentral and Whanganui DHBs. It is for the Healthy Communities Advisory Committee’s information and discussion – no decision is required. 2. SUMMARY The update to the Health Needs Assessment for the MidCentral and Whanganui District Health Boards (DHBs) has now been completed to the final draft stage. Dr Richard Fong (MidCentral DHB) was the principal analyst and author for this undertaking. The 2017 Health Needs Assessment (HNA) document is the fifth internally produced health needs assessment and like the last three health needs assessments, it takes a people-first approach to analysing health data. This, and previous, health needs assessments try to take a strategically-oriented view of health need. It looks for common patterns and themes behind health status data, rather than trying to describe the data-patterns behind every disease or health situation across the health sector. The HNA was written to address the following objectives:

• Comment on how our health status is progressing • Comment on inequality and whether this is changing, and what this implies

for our health system’s current approach for tackling inequalities • Suggest a way health needs assessment information can be used for locality

planning • Highlight what planning direction the health needs assessment evidence

points to in attempting to achieve “quality living, healthy lives, well communities”

The HNA includes comment on the key demographic patterns of both MidCentral and Whanganui district populations (albeit still based on the 2013 Census, as reported in the 2015 HNA), an analysis of all-cause and amenable mortality data and the inequality patterns identified by mortality analysis. Additional topics covered in this document, which were not covered in the 2015 HNA, are acute hospital admissions (MidCentral only), disability information from Statistics New Zealand’s disability surveys and cancer registration patterns.

The attached document is a copy of the Executive Summary extracted from the comprehensive 300-page document. Once the final draft document (which has been prepared in a web-based format) has been peer reviewed and edited, it will be made available on MidCentral’s web-site rather than published in hard copy format.

The HNA is an important tool for planning with valuable reference material. The “Equity Snapshot” technical report, which is currently being completed, applies a different lens to the same kind of data and will be a useful complementary document.

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The information from both of these reports will be used to inform strategic and operational planning at a locality level, as well as informing service delivery options across the system to target improvements in the health and wellbeing of sub-groups within our population.

The information from the HNA and equity snapshot will also be useful for shaping the system’s capacity to respond to the growing demand on health and disability services as a consequence of our ageing population, population increase, changing socio-economic factors and unmet health need.

2.1 Key Points from the Health Needs Assessment The key points are:

• In addition to Horowhenua, Tararua is now an area of poorer health status (using mortality as a marker of health status).

• The people experiencing health inequalities within MidCentral are Māori, Pacific people, people experiencing socio-economic disadvantage, Horowhenua residents, and Tararua residents.

• The general health status of MidCentral and Whanganui DHBs, represented by mortality, has been improving over the years (i.e. decreasing age adjusted mortality rates). However, MidCentral’s mortality rates rose for the last two years of the data (2013, 2014). It is not clear whether this is an emerging trend or a random variation – another couple of years’ data is required.

• Health inequalities are caused by people’s circumstances, not by a handful of diseases. The disease patterns are a consequence of disadvantage (it’s always the same people who are disadvantaged across almost every topic: health, income, social, economic, educational, etc). So trying to eliminate health inequalities by just tackling a handful of diseases is not going to work; interventions need to be designed to fit the people targeted.

• Acute admissions to hospital have been rising over the past 10 years despite improved access to primary care and community health services (this is true whether acute admissions are expressed as age-adjusted rates, crude rates, or absolute numbers).

• There is evidence that improving access to primary care and community health services increases acute hospital admissions, rather than reduces them – probably because of identification of unmet health need by these services (notwithstanding the influence of changes in the demographic profile).

• Suggestions are made for how to use the health needs assessment material for locality planning – basically, plan according to the type of people who live in the locality (e.g. if you have a lot of older people living in the locality, then there will be a greater demand for health services, especially for chronic conditions and disability support).

• We have to plan for increasing health workloads caused by population ageing, growing population, identification of unmet health need, and other factors (e.g. changing socio-economic situation, among other factors)

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3. RECOMMENDATION


The Executive Summary extracted from the final draft 2017 Health Needs Assessment for MidCentral and Whanganui DHBs (attached) be noted

Dr Richard Fong Clinical Advisor Data Quality & Health Information

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2017 Health Needs Assessment: Extract – Executive Summary

MidCentral District Health Board: Health Needs Assessment, 2017 P a g e | 1

MidCentral District Health Board Health Needs Assessment 2017

Executive Summary Introduction

This document is the fifth internally produced health needs assessment, and the sixth one overall. The previous one was carried out in 2015, two years ago. Like the last three health needs assessments, this one takes a people-first approach to analysing our health data. This is because:

• The district health board’s ultimate goal is healthy people • The people-patterns are more consistent and universally applicable than disease

patterns • Any disease-specific pattern is usually only applicable to that disease

What’s this health needs assessment trying to achieve?

This health needs assessment was written to address the following objectives:

• Comment on how our health status is progressing • Comment on inequality and whether this is changing, and what this implies for our

health system’s current approach for tackling inequalities • Suggest a way health needs assessment information can be used for locality

planning • Highlight what planning direction the health needs assessment evidence points to in

attempting to achieve “quality living, healthy lives, well communities”.

The key themes from the 2015 health needs assessment are still valid

The 2015 health needs assessment conclusions are still valid. That document looked for the key themes and patterns behind most health situations, particularly concerning inequality. These themes and patterns tend to be slow to change across time, perhaps across generations. The main take home messages from the 2015 health needs assessment document were:

• The people experiencing inequality in our district are: o Maori o Pacific people o People experiencing socio-economic disadvantage o Horowhenua residents (because they have high proportions of the above people

among their residents) o Whanganui District Health Board (because they have high proportions of the

above people among their residents)

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• It is the same people who experience disadvantage across most social and medical conditions. It’s not necessary to discover who is disadvantaged for each disease, one disease at a time – repeatedly re-inventing the wheel. It’s the same people every time.

• The health status of our population has been gradually improving over time (as it has been for New Zealand overall). This is indicated by reducing age-adjusted mortality rates. However, Whanganui DHB’s mortality rates have been more static over time (the analysis stops at 2010, the latest year of mortality data we had at the time).

• The main conditions causing mortality were: o Circulatory diseases o Cancers o Respiratory diseases o Injuries and accidents

• These conditions are the same for the population overall and for disadvantaged populations. Therefore, these are the conditions which should be focused on to improve the health of the greatest numbers of people in those populations

• For population with a younger population age balance (for example Maori and Pacific populations), conditions that don’t cause mortality are important, for example, conditions affecting children and young people

• The health status of an area is determined by the type of people who live there. For example, if an area’s residents consist of a high proportion of disadvantaged people, then the “health statistics” for that area’s residents overall will be worse than average. If an area’s population has a large proportion of older people, then there will be greater demand for services that deal in long-term conditions and disability support.

What’s the difference between this health needs assessment and the last one?

This (2017) health status analysis still looks at mortality patterns, but to 2014, the latest data available at the time this report was written. The healthier a population is, the lower its mortality rate. Mortality is a good indicator of population health essentially because:

• There’s no confusion about what mortality means or its seriousness.

• It is equivalent to life expectancy, but much easier to calculate. Life expectancies are actually calculated from mortality data, so life expectancy is a measure of mortality. Mortality rates and life expectancy analysis will show the same patterns.

• Health service-use patterns, when used as measures of illness in the community, are difficult to interpret because they are influenced by many other factors (for example, patient access to services, changing methods of treatment, changes in methods of data collection or coding, deliberate efforts to steer patients from one type of care to another).

Mortality analysis has also been successful at identifying groups of people experiencing health inequality. A converse way of viewing this relationship is that there are some groups of people in our society experiencing inequality marked enough to shorten their lifespan. Also, the inequality patterns identified by mortality analysis are repeated across most health and social topics. Mortality analysis has revealed a fundamental underlying theme.

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There are additional topics covered in this document, which were not covered in the 2015 health needs assessment. They are:

• Acute hospital admissions to MidCentral DHB’s hospitals • Disability information from Statistics New Zealand’s disability surveys • Cancer registration patterns (cancer registrations are newly diagnosed cancers)

There is no mortality rate analysis of areas of high socio-economic disadvantage. This is because of the inability to obtain population data for socio-economically disadvantaged areas to use in the calculations. However, the three previous health needs assessments showed people who are socio-economically disadvantaged experience health inequalities. It is unlikely, and illogical, that this pattern has changed. Inequality experienced by socio-economically disadvantaged people has also been described in other New Zealand reports. The most current is “The Social Report 2016” from the Ministry of Social Development1 (page 22). There are other types of analysis which would have been desirable to include, but were not done because of lack of time, resources, and data, for example, mental health, acute hospitalisation analysis for areas other than MidCentral DHB.

The key messages from the 2017 Health Needs Assessment

Our health status has been improving – when you age-adjust our mortality figures From an age-adjusted perspective – compensating for differences in population age balance – the health statuses of MidCentral DHB, Whanganui DHB, and New Zealand’s populations are all improving. The age-adjusted mortality rates for all three populations have been declining. The previous static mortality rate for Whanganui DHB has changed since 2013, with Whanganui DHB’s population also showing improvement.

MidCentral DHB’s age adjusted mortality rates rise for the final two years, but it’s uncertain whether this is a trend or a random variation. This will be clearer with another one or two year’s data. MidCentral’s health status is slightly worse than New Zealand’s health status. Whanganui DHB’s population’s health status is more markedly worse than New Zealand’s. This is to be expected because MidCentral’s population has higher proportions of higher needs groups (Maori, socio-economically disadvantaged people, and older people) than New Zealand overall. Whanganui DHB has even higher proportions of these groups.

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The factors that influence all-cause mortality are much wider than health treatment service performance. They include:

• Lifestyle changes, for example, healthier eating, greater physical activity • Living conditions, for example, cold, damp, and mouldy homes • Economic conditions, for example, unemployment, wage levels, housing costs, food and

other living costs • Better preventive care, for example, immunisation These mortality patterns are from age adjusted figures. However, in real life, populations are not age adjusted. The non-age adjusted patterns tell us something different, which will be discussed next.

Non-age adjusted rates indicate increasing levels of illness and increasing need for health services As mentioned above, when MidCentral DHB, Whanganui DHB, and New Zealand mortality rates are age adjusted, they show the rates fall across the years. However, our populations are not age adjusted in real life – they are as they are. When the rates are not age adjusted they show the per capita mortality for populations as they are in real life. The patterns and implications are different to the age adjusted information. Age adjustment cancels out the effect of population age balances and population size. This is required when comparing health-related data from one population to another, to avoid different age compositions creating non-like comparisons. This is because most illnesses are at higher risk at some age groups than others (it’s usually older people who are at higher risk of illness). However, age adjustment creates some side-effects which can hide what is happening. For example, cancelling out the effect of population age balances also cancels out the effect of a continuously ageing population structure across time, as we are experiencing at the moment.

Crude rates are per capita rates which have not been age adjusted. They are the case numbers divided by the population size (and then usually multiplied by a number like 100,000, to avoid coming up with fractions). The result is the number of occurrences per 100,000 people in the population. Our mortality crude rates rise across time, implying greater numbers of people who are seriously ill. This is because of the

ageing population structure – older people are at higher risk of serious illness than younger people. This further implies there will be more people needing health care, and this is expected to increase in the future, as the ageing population balance continues.

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There will be increasing demand for health services in the future. The type of services required will be those associated with ageing: chronic diseases and their complications, and disability.

This is not only about a future trend. It is happening now. MidCentral DHB’s acute hospitalisations crude rates and numbers have been rising already. We have already started feeling the pressure of increasing demand for health services.

However, MidCentral DHB’s acute hospitalisation rates - when age adjusted - still show increasing rates across the whole ten year period. Age adjustment is meant to compensate for any differences in age structure, therefore should

cancel out any changes due to an ageing population balance. So what are the other causes for our rising acute hospitalisation rates? There is a suggestion that improved access to primary care increases, rather than reduces, acute hospitalisations There is evidence suggesting improved access to primary care and community health services increases acute hospitalisations. The prevailing belief behind MidCentral DHB’s strategic planning for the past 10+ years is that improving access to primary care and community health services will reduce acute hospitalisations. The evidence suggests the opposite has been taking place.

The evidence for this is:

• MidCentral DHB’s steadily increasing acute hospitalisation numbers and rates from 2006 to 2016, despite special emphasis on improving primary care access over that period

• The areas with the greatest increase in acute hospitalisation numbers from 2006 to 2016 were our lowest needs areas, rather than highest need areas (the most noteworthy was the Manawatu, the MidCentral territorial authority with the lowest proportions of high needs groups in its population, and with better than MidCentral-average mortality rates)

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• When age adjusted (any differences in age balance in the populations compensated for) again, Manawatu stands out by having MidCentral DHB’s second-highest hospitalisation rates, after the Horowhenua (MidCentral’s territorial authority with the highest proportions of high-needs groups and highest mortality rates)

• The group with the lowest percentage increase in acute hospitalisations from 2006 to 2016 was people living in NZDep2013 9 and 10 deciles – representing the socio-economically disadvantaged. They are among our highest-needs peoples.

• Manawatu’s malignant cancer registrations rates were the highest in MidCentral (15% higher than New Zealand overall when age adjusted), but its age adjusted cancer mortality rates were the same as New Zealand overall. This suggests cancers being picked up earlier, for example, by cancer screening activities, rather than a cancer epidemic.

• Lack of evidence so far, that improving access to MidCentral DHB’s primary care services improves acute hospitalisation rates, for example, Victoria University’s “The Evaluation of the Better, Sooner, More Convenient Business Cases in MidCentral and West Coast District Health Boards” report.2

MidCentral DHB Percent Change in Acute Hospitalisation Numbers Comparing 2006 to 2016

Acute hosp.

2006 Acute hosp.

2016 Percent change

2006 to 2016 Horowhenua 4182 4941 18.1 Palmerston North 8558 10066 17.6 Manawatu 3072 4105 33.6 Tararua 1675 1983 18.4 Kapiti Coast (MidCentral portion) 519 756 45.7 Maori 2874 3881 35.0 Pacific 378 571 51.1 Asian 359 881 145.4 Other ethnicities 14236 16448 15.5 MidCentral NZDep 9 & 10 8654 9339 7.9 MidCentral overall 18006 21851 21.4

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If this is a true pattern, then it implies that if:

• Patient access to primary care and community health services is improved, and

• Residents in the community feel comfortable and inclined enough to use those services (it takes two to tango), then …..

there are flow-on increases in workload for hospital services, including acute hospital admissions. This is probably because primary care and community health services are identifying unmet patient need.

From a patient’s perspective, this is a good thing because they are having an unattended health issue addressed. It’s also possible that some of these patients may have died had they not been seen. However, it also means demands on hospital staff and resources also increase. This might create difficulties if hospital departments are already over-stretched by current workloads. There are also other potential conclusions from the acute hospitalisation data patterns:

• Trying to achieve similar health gains in areas with high proportions of high needs peoples is harder than average (which is why the increase in acute hospitalisations was more modest across MidCentral’s other territorial authorities, compared to Manawatu)

• Health practitioners have difficulty identifying people experiencing socio-economic hardship - probably because they look just like everyone else. (More about this in the section “So if we want to target people who are socio-economically disadvantaged, we just go to NZDep 9 and 10 areas, right?”)

• Health service access for MidCentral DHB’s non-European ethnic groups is improving, which is a positive pattern. (There’s more about the imbalances in hospitalisation rates between MidCentral’s higher needs groups later.)

MidCentral’s portion of Kapiti District Council (Otaki and surrounds) also had a high percentage increase of acute hospitalisations from 2006 to 2016. However, its five-year age-adjusted acute hospitalisation rates are the lowest in MidCentral suggesting its increase may be due to Kapiti’s older population. Older people are at higher risk of falling ill, and Kapiti has an especially high percentage of older people in its population. There’s more about the different demographic profiles of MidCentral DHB’s territorial authorities later. Is this commentary meant to be the final word on this topic? No. This report was not designed to explore the connection between primary care access and hospital service use. The acute hospitalisation findings were incidental, but with strong strategic relevance. Commentary was provided on a completely counter-intuitive data pattern that is very difficult to explain in any other way. Why are acute hospitalisation figures increasing when primary care access has improved? Why were there bigger increases in MidCentral DHB’s least disadvantaged areas?

This information is also strategically important to highlight. If demand for health services will keep increasing, MidCentral District Health Board needs to plan for it, rather than assume whatever was suitable in the past will carry on being suitable in the future.

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Multiple factors influence MidCentral DHB’s rising hospitalisation rates and numbers

In summary, a range of influences is affecting MidCentral DHB’s rising acute hospitalisation rates and numbers: • An ageing population balance • A growing population • Possibly improved access to community health services revealing unmet health need • Possibly other influences that aren’t able to be identified by this analysis, requiring

another form of enquiry to find, for example, increasing socio-economic hardship in the community

What diseases should we tackle for the greatest improvement in health status of our population?

The disease groups with the biggest impact on populations are cardiovascular disease, cancers, respiratory disease and injuries and accidents.

• Four top causes of mortality

o Cardiovascular disease (which caused 35.7% of deaths) Most common diseases were: ischaemic heart disease (around 50%), cerebrovascular diseases (stroke and stroke-like, collectively around 25%), other forms of heart disease (heart failure, arrhythmias, valve disorders, inflammation of the heart or surrounding tissue - collectively around 10%), diseases of the arteries (around 5%), hypertensive diseases (around 5%)

o Cancers (which caused 28.8% of deaths) Most common cancers causing death were: lung cancer (around 20%), colo-rectal cancer (around 13%), prostate cancer (around 6%), breast cancer (around 6%), pancreas (around 6%), skin melanoma (around 4%).

o Respiratory disease (which caused 9.6% of deaths) Most common diseases were: chronic lower respiratory diseases (chronic obstructive respiratory diseases, asthma, bronchiectasis – collectively around 60%), respiratory infections (around 28%)

o Injuries and accidents (which caused 7% of deaths) Most common causes were: intentional self-harm (around 30%), falls (around 30%), transport accidents (around 19%), accidental poisoning (around 5%), accidental drowning (around 3%)

• Most common diseases causing hospitalisation o Chronic conditions, such as heart disease, chronic respiratory diseases (for

example, asthma, chronic obstructive pulmonary disease) o Infectious diseases, especially respiratory diseases, skin infections, gastro-

intestinal infections o Gastro-intestinal disorders o Mental health o Injuries

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This is true for all populations (whether by ethnicity, territorial authority, DHB-overall, or New Zealand overall). Populations who experience health inequalities are also more susceptible to infectious diseases and their complications (in addition to the ones mentioned above), such as respiratory infections, throat infections, rheumatic fever, skin infections, gastroenteritis, etc. New Zealand research, published in The Lancet in 20123, showed increasing incidence of serious infectious diseases from 1989 to 2008, especially for population groups already experiencing unequal health status (Maori, Pacific peoples, and socio-economically disadvantaged people). This article was titled “Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study”, and was authored by researchers at the Wellington School of Medicine and the Ministry of Health.

Disability will be increasingly important as our population age balance gets older

The risk of disability rises with increasing age. Therefore, caring for people with disability will become more prominent as our population age balance continues to get older. Statistics New Zealand carries out a disability survey after each census, creating a single sample of people drawn from across New Zealand for analysis. The key points from Statistics New Zealand’s 2013 disability survey reports4,5 are:

• Manawatu-Whanganui region has higher percentage of disabled people than New Zealand overall (27% compared to 23%/24%)

• The level of disability in New Zealand has been increasing over time, 20% in 2001 to 24% in 2013.

• The likelihood of disability increases with age. Eleven percent of children (younger than 15 years) were disabled, compared to 58% of adults 65 years or older.

• Maori and Pacific people have higher age adjusted disability percentages compared to other ethnic groups. After adjusting for age, 32% of Maori and 26% of Pacific people were disabled, compared to 24% for European and 17% for Asian New Zealanders

• Disabled people commonly experience multiple disabilities. And, the likelihood of multiple disabilities increases with age – 63% of disabled people aged 65 or older experience multiple disabilities, compared with 42% of adults aged 15 to 44 years

• The most common causes of disability among adults were: o Disease or illness o Accident or injury o Ageing o Maori have higher disability rates for the disability types:

Psychological/psychiatric problems Difficulty with learning Difficulty with speaking Intellectual disability

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What does the amenable mortality analysis tell us? Inequalities widen for amenable illnesses.

Amenable mortality is mortality due to diseases which are theoretically sensitive to the activity of health services (either prevention or treatment). It is restricted to mortality in people aged less than 75 years old to target premature mortality. In a broad sense, amenable mortality is meant to be a measure of the effectiveness of health services towards its population8. Amenable mortality analysis shows the same patterns and inequalities that exist for the all-cause mortality analysis: it’s the same groups experiencing inequality. However, inequality gaps widen. This suggests most of the narrowing of all-cause mortality rates across time is from non-amenable causes.

Who are the people experiencing health inequalities in our district?

Almost the same as previous health needs assessments:

• Māori. (MidCentral Maori age adjusted number of deaths was 68% higher than expected, compared to New Zealand overall. Whanganui DHB Maori 111% higher (over double), and New Zealand Maori 76% higher)

• Pacific peoples. (MidCentral Pacific age adjusted number of deaths was 53% higher than expected, compared to New Zealand overall. New Zealand Pacific deaths was 59% higher. Whanganui Pacific deaths were not significantly different from New Zealand, but was based on small numbers.)

• People experiencing socio-economic disadvantage. (In the last health needs assessment, people living in the two most socio-economically disadvantaged areas (NZDep deciles 9 and 10) had higher number of deaths than expected, compared to New Zealand overall by 24% for MidCentral, 31% for Whanganui DHB, and 29% for New Zealand).

• Horowhenua residents (because of higher proportions of the above people among their residents). Horowhenua’s age adjusted number of deaths was 13% higher than expected, compared to New Zealand overall.

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• Tararua residents (because of higher proportions of the above people among their residents). Tararua’s age adjusted number of deaths was 8% higher than expected, compared to New Zealand overall. This difference was statistically significant. The difference was slightly smaller (5%) in the 2015 health needs assessment, and not statistically significant. This is discussed more below.

• Whanganui DHB residents (because of higher proportions of the above people among their residents). Whanganui DHB’s age adjusted number of deaths was 14% higher than expected, compared to New Zealand overall.

There are some patterns that deserve further comment:

Tararua is probably an area of poorer health status.

Tararua’s age-adjusted mortality ratio (1.08) just reaches statistical significance (i.e. it is just beyond the expected range of random, chance fluctuation). This difference was only slightly less across multiple past health needs assessments but, the difference at those times has been within the range of chance fluctuation (i.e. not statistically significant). In retrospect, the difference was probably a true pattern, but not large enough to cross the arbitrary threshold of statistical significance. From the yearly data, there has been a small rise in the number of deaths in the last two years of the data, 2013 and 2014. This difference is just large enough to push the differences into statistical significance. Tararua’s all-cause mortality age-adjusted ratio of 1.08 means there were 8% more deaths than had its mortality rate had been the same as New Zealand overall. Tararua has higher proportions of Maori, people who are socio-economically disadvantaged, and older residents, which is consistent with an area with higher than average health needs.

Otaki has better health status than expected MidCentral’s portion of Kapiti (Otaki and surrounds) had fewer aged-adjusted deaths than expected, compared to New Zealand overall. This is surprising considering the make-up of their population: higher proportions of Maori and socio-economically disadvantaged people – people with higher health needs. It also has a higher proportion of older people than the MidCentral average. It’s all-cause mortality age-adjusted ratio was 0.836, meaning the number of deaths was approximately 16% lower than if its mortality rate was the same as New Zealand’s overall.

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0

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New Zealand All Cause Mortality by Ethnicity, Yearly Age Adjusted Rates per 100,000 people

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MidCentral DHB All Cause Mortality by Ethnicity, Yearly Age Adjusted Rates per 100,000 people

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0100200300400500600700800900

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2006 2007 2008 2009 2010 2011 2012 2013 2014

Whanganui DHB All Cause Mortality by Ethnicity, Yearly Age Adjusted Rates per 100,000 people

2006-2014

Whanganui Other Whanganui Maori

MidCentral DHB, Whanganui DHB Territorial Authorities All-Cause Mortality Age Adjusted Ratios (2010 to 2014)

Number Age Adjust.Ratio LCL UCL

Crude Rate/100,000 people

Age Adjust Rate/100,000 people

Tararua District 760 1.08 1.01 1.16 864.9 735.6

Manawatu District 1031 0.998 0.939 1.06 729.7 677.9

Palmerston North 2742 0.991 0.954 1.03 658.9 672.5

Horowhenua District 1819 1.13 1.08 1.19 1168 769.6

Kapiti Coast District 339 0.836 0.752 0.93 823.4 567.7

Ruapehu District 89 1.02 0.831 1.26 409.4 694.8

Whanganui District 2378 1.16 1.11 1.21 1091 786.3

Rangitikei District 582 1.07 0.991 1.17 795.4 729.8

New Zealand 150008 1.0 678.9 678.9

Inequalities are not going away – why not?

Inequalities show no sign of going away, with the gaps between ethnic groups, territorial authorities much the same as before. This is despite the health sector’s past and continuing commitment to reduce inequalities. Why is this?

(Just a warning: the MidCentral DHB Pacific peoples and Whanganui DHB Pacific and Asian peoples’ figures in the graphs above could not be reliably calculated for each year because of small numbers of deaths. The graph lines for MidCentral Pacific and Whanganui Pacific and Asian people have been removed because of this.)

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• Inequality is about people, not diseases Health inequality is not caused by a handful of diseases; it is caused by people’s circumstances in our society. The unequal disease and health patterns are the consequences of this inequality, and not the cause. It’s always the same people who experience inequality across most social and health situations. Because of this, tackling inequality through the perspective of diseases alone (without consideration of the people affected) is not enough. There are two recent reports which are very good at illustrating how widespread inequalities are across the range of economic, health, and social issues, and that it’s always the same groups of people affected. They are:

- “Indicators of Inequality for Maori and Pacific People” by Lisa Marriott and Dalice Sim, published in 2014 by the Chair of Public Finance, Victoria Business School, Victoria University5, and

- “The Social Report 2016” from the Ministry of Social Development1 The “Indicators of Inequality for Maori and Pacific People” examined inequality gaps, comparing Maori and Pacific peoples to European. The aim was to look for progress in closing these gaps. The authors looked at 21 measures across health, education, employment, standards of living, cultural identity, and social connectedness. For Maori, eight indicators (38%) showed narrowing inequality gaps, 12 indicators (57%) showed increasing gaps, and one was approximately the same. Although not all the indicators were available for Pacific peoples, the ones analysed again showed mixed results, with some narrowing (five or 29% of the indicators) and others worsening (11 or 65% of the indicators). Some of the indicators which showed narrowing of gaps did not reach statistical significance. This implies that they could also be interpreted as “no change” (because the degree of change was within the range of random fluctuation). However, some of the indicators - although showing widening gaps - were improving over time for all groups. For example, median weekly income had improved for all ethnic groups, but the gaps between European, and Maori and Pacific peoples had widened. The same pattern was seen for proportion of people obtaining a bachelor’s degree, and also tobacco smoking. Overall, the authors observe that the poorest outcomes for Maori and Pacific peoples were in health, income, and economic standard of living; while the best were in education (although there were still mixed results in this category). Most of the health indicators appeared to follow the pattern described in the previous paragraph: all ethnic groups improved with non-Maori, non-Pacific improving more than Maori and Pacific peoples. Result: widening gap. The report concludes:

“This research indicates that while New Zealand has had some successes in reducing inequalities, the gaps in inequality among the majority of the indicators investigated in this study show worsening outcomes for Maori and Pacific people. This growing gap in inequality between Maori and Pacific people, and the European population, warrants greater government attention if the gaps are not to continue increasing into the future.”

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The “Social Report 2016” looked at indicators across: • Health • Education • Paid employment • Economic standard of living • Civil and political rights • Cultural identity • Leisure and recreation • Safety (being a victim of crime, fear of crime, assault mortality, road casualties) • Social connectedness • Life satisfaction • Social wellbeing

Inequalities for Maori, Pacific people, and socio-economically disadvantaged people were evident for most indicators. The same pattern is evident in both reports: it is always the same groups of people who are disadvantaged across a range of societal wellbeing topics. The same pattern is also seen in this and past MidCentral health needs assessments: whenever there is disadvantage to be seen, it is always the same people who are affected. A very good report looking at MidCentral Maori health inequality across multiple conditions is “MidCentral District Health Board Maori Health Profile 2015” by Te Ropu Rangahau Hauora a Eru Pomare, Wellington School of Medicine (Otago University)7. However, commentary is given only within those conditions. No overall interpretation of Maori health status, the reasons for inequality, or what can be done to address inequalities are given.

So does that mean consideration of diseases is unimportant in tackling health inequalities?

No. But it does put diseases into proper perspective when considering how to tackle inequalities:

• Disease management is only one of the means by which inequalities can be addressed – although a very important one.

• Many diseases point to a root cause, usually sub-optimal living conditions or lifestyle, for example, respiratory infections suggest poorer home living conditions (for example, damp, cold home; or over-crowding); high cardiovascular disease rates is linked to poorer diet and physical activity

• Interventions have to be designed to fit the circumstances of the people and the type of people, rather than expecting them to comply with the design of the disease-management services.

There are some traps with focusing entirely on diseases – without considering people - as a way of reducing inequalities:

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• Only those diseases, conditions, or clinical situations frequently reported receive attention, all the others are left to their own devices. For example, ischaemic heart disease, stroke, breast cancer are commonly reported on; ENT disorders for children and adults, ease of access to general practice, disability needs for all ages, ophthalmology needs, pregnancy and childbirth needs are not

• Inequality within each disease or condition has to be demonstrated before any concerted action is taken. Considering it’s always the same people who experience inequality, that’s like re-inventing the wheel one disease at a time

• The disease approach fragments health into many pieces, concealing common patterns and hiding potentially common approaches to caring that can be applied to any clinical situation. It can be tempting to become too tightly focused on the technical aspects of disease management

• It’s harder finding diseases in the community than finding people. For example, finding diabetes within the Horowhenua is harder than finding people who are at risk of poor health (including diabetes) in the Horowhenua. It’s easier finding people than it is to find a disease.

However, as previously mentioned, consideration of diseases is still important. It can indicate what health areas or lifestyle root-causes have the biggest impact on people - as long as the information is used with consideration of people as the first frame of reference.

What diseases or conditions should we tackle for the greatest improvement of those experiencing health inequalities?

On the understanding that people are considered in the initial frame of reference, the diseases and conditions that have the greatest impact on populations are:

• The top four causes of mortality (which are the same for all groups of people) o cardiovascular disease o cancers o respiratory diseases o injuries and accidents

• Top causes of hospitalisation

o pregnancy and childbirth (including uncomplicated delivery) o infections (for example, respiratory infections, gastro-intestinal infections, skin

infections) o chronic diseases (including heart diseases, respiratory diseases, diabetes) o accidents o mental health conditions

• Conditions associated with inequality

Conditions previously identified by Ministry of Health as diseases of disadvantage (rheumatic fever, respiratory infections, bronchiectasis [lung damage from repeated infections], skin infections, etc).

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• Issues raised by other forms of enquiry

Of course, there are many perspectives of health which are not disease-oriented, and are just as important. From a practical perspective of providing care, they might even be more important. Some examples:

o Issues affecting access to basic health services, like primary care, for everyone across the district health board

o Issues affecting access to more complicated health services (such as secondary and tertiary care )

o Issues affecting access to support services and non-health social supports

o Cost of services and the effect cost has on health service access

o Support for health practitioners so they can manage increasing numbers and diversity of patients

These are not reported here, but should be kept in mind. Health can be seen from many angles and this report only shows one perspective.

There is a mismatch between patterns of acute hospitalisation and health status for groups experiencing inequality. Is this an area of concern?

Comparing ethnic and territorial authority mortality and acute hospitalisation patterns reveals some unusual patterns:

• Maori and Tararua residents age adjusted acute hospitalisation figures are lower than their age adjusted mortality figures would suggest. This comparison uses mortality as an indication of health need and acute hospitalisation as an indication of service use

• Manawatu residents have higher age adjusted acute hospitalisation figures than their age adjusted mortality figures would suggest. They seem to have more health service use than their relative health need would suggest

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A previous section has already discussed how acute hospitalisation numbers and rates have been steadily increasing over the past ten years. Maori, Pacific, and Asian increases were above the MidCentral average. Since both Maori and Pacific peoples are population groups experiencing health inequalities, this is potentially a good trend because it suggests people with health need are receiving care. However, when looking at the age adjusted ratios for accumulated five years’ worth of acute hospitalisations compared to the equivalents for all-cause mortality, it becomes clear the patterns don’t match each other. Mortality rates are a gauge of population health status – a high mortality rate suggests a less healthy population. Even though both have different baseline comparison populations – acute hospitalisations use MidCentral overall as the baseline and for mortality New Zealand overall is the baseline – the relative positions of the different groups should be somewhat similar.

• MidCentral Maori had mortality numbers 68% higher than expected, compared to New Zealand overall. This compares to MidCentral’s overall mortality, which was 3% higher than New Zealand overall. However, the number of hospitalisations was similar to what would be expected if MidCentral Maori had the same age adjusted acute hospitalisation rate as MidCentral overall.

• Tararua’s age adjusted mortality was 8% higher than New Zealand overall. MidCentral’s mortality ratio was 3% higher than New Zealand’s. By contract, Tararua’s number of hospitalisations was 12% lower than expected, compared to MidCentral overall. One figure is higher than MidCentral; the other figure is lower.

• Manawatu’s age adjusted mortality was about what would be expected compared to New Zealand overall (and lower than MidCentral’s figure). By contrast, Manawatu’s age adjusted acute hospitalisations were 5% greater than expected, compared to MidCentral overall.

• MidCentral Pacific peoples’ disparity in mortality appears greater than that for acute hospitalisations – both higher than expected compared to the comparison populations. It’s difficult to say whether these figures are out of kilter with each other because they reference different comparison populations.

What are the reasons for these contradictory patterns? It’s difficult to tell. The data can only tell us what happened; it often can’t tell us why it happened. Also, service-use patterns can be difficult to interpret because they are influenced by multiple factors. It is often difficult to know which factor or balance of factors led to the pattern. Another type of research is required to find the reason behind these patterns.

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Superficial consideration suggests Maori and Tararua residents are not accessing health services as much as they should. However, this pattern could also arise if Maori and Tararua residents were accessing community-based services instead of hospital care. It also suggests Manawatu residents have better access to health services – relatively lower needs populations with higher acute hospitalisation rates. Even though its cause can’t be determined, this mismatch of service-use to health status is something that shouldn’t pass unnoticed. It is consistent with the “inverse care law” - the people who are most need of health care receive it the least9.

What does the health needs assessment material imply for what the district health board should be doing for disadvantaged populations?

The health needs assessment information suggests we should be:

• Designing health interventions that take into consideration people’s circumstances and culture , for example, frequent check-ups with a health professional would be feasible for a middle-class household with no financial stresses but would be unrealistic for a household with limited income to pay for clinic fees or transport costs

• Helping health workers so they can interact with patients and clients as effectively as possible, taking into consideration people’s culture and circumstances. For example, helping them learn rules of etiquette, common styles of behavior, and communication styles when dealing with ethnicities different to their own.

• Prevention would be more effective than dealing with the subsequent disease, for example, preventing infections and complications of infections (diseases more associated with disadvantage) rather than relying on treatment alone

• Working with non-health social agencies to try and help disadvantaged people live healthier lifestyles

So if we want to target people who are socio-economically disadvantaged, we just go to NZDep 9 and 10 areas, right?

The NZDep information is an important research tool that allows analysis of people who are socio-economically disadvantaged. It does this using the association between areas and people living in those areas. People who are socio-economically disadvantaged tend to gravitate towards certain areas, probably because of rental and housing costs. Without the NZDep tool, doing research on population groups experiencing socio-economic disadvantage would be very difficult - sometimes impossible. We don’t have another way of linking socio-economic disadvantage with other information (like hospitalisation or mortality). However, NZDep is not appropriate for identifying individuals or families who are socio-economically disadvantaged. It’s not designed for that purpose. The NZDep system creates generalisations about the people who live in areas, but not all the people who live there fit the generalisation.

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Put another way, not all the people who live in socio-economically disadvantaged areas are disadvantaged; and disadvantaged people can live in areas other than NZDep 9 and 10 deciles. Past Ministry of Social Development research is helpful in identifying households experiencing socio-economic disadvantage. Ministry of Social Development research shows households experience socio-economic hardship because of multiple factors acting together, rather than a sole cause. The results were published in a report “New Zealand Living Standards 2004”10. The factors include:

• low income • low level of assets owned • housing rented rather than owned • people who have experienced marriage (or marriage-like relationship) breakup • adverse life event (“life shocks”—for example, bereavement, loss of job, etc) • personal health problems (multiple and enough to affect lifestyle) • children’s health problems (multiple and enough to affect lifestyle) • inability to afford childcare to work or study • when income is from income tested benefit rather than from employment or

superannuation • having dependent children • Maori or Pacific ethnicities • People with multiple financial payments they find difficult to meet

NZDep 9 and 10 areas have the highest concentrations of people experiencing socio-economic hardship. They also live in other deciles, in varying concentrations less than NZDep 9 and 10 areas (sometimes only slightly less).

How does this information help with locality planning?

MidCentral DHB has started planning services according to sub-areas: locality planning. The people-oriented approach of this and prior health needs assessments is still useable for locality planning. How? The health needs of an area are determined by the type of people who live there. This is logical because:

• By definition, health services care for the wellness and well-being of people • Areas are basically pieces of real estate. Health services don’t provide care for real

estate, but care for the people living on top of the real estate. The most important groups of people to consider are:

• Maori • Pacific people • People who are socio-economically disadvantaged • Older people • Mainstream population – basically, people of Anglo-Saxon European origin. Our

current health system fits this culture by default These groups live in all of MidCentral’s sub-areas, but in varying proportions and numbers. The services required for an area is a balance of services required for the type of people living there.

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Of course, there are other groups of people apart from the ones mentioned, for example, refugee communities, Chinese market gardening families in Otaki/Horowhenua (some of whom are becoming quite elderly), people from Africa and the Middle East. Our system should be flexible enough to recognize and cater for their needs as the situation arises. Trying to tackle inequalities from a disease-only perspective – without considering people – is very difficult, because there’s no specific disease that differentiates one location from another. All diseases are present in all locations. Any significant differing balances are usually because of the type of people who live there rather than any geographical feature of the area. There’s also the risk of mistaking random fluctuation of disease rates as a pattern and inappropriately diverting effort and resources to those fluctuations. Rates based on small numbers can swing markedly just from a difference of a tiny number of cases.

What are MidCentral’s sub-area demographic patterns that will help with locality planning?

The demographic material described in the 2015 health needs assessment, based on the 2013 Census, have not been repeated because that information is still valid. There hasn’t been another census since then. However, the key points relevant for health planning are outlined below.

• The 2013 Census the population of MidCentral DHB was 162,564, the population of Whanganui DHB was 60,120, and the population of New Zealand was 4,242,048 (“usually resident” population counts)

• MidCentral’s population has been growing over time, although at a slower rate than New Zealand overall

• Whanganui DHB’s population has been gradually declining

• Palmerston North is the dominant population centre in MidCentral. Although it may have lower proportions of specific target groups (compared to other MidCentral territorial authorities), it may have the greatest numbers of each group, for example, Maori, older people, and so on.

• Both MidCentral DHB and Whanganui DHB have higher proportions of older people than New Zealand overall (16.5%, 18.2%, and 14.3% respectively)

• MidCentral DHB and Whanganui DHB have higher proportions of Maori residents than New Zealand overall (17.4%, 23.5%, and 14.1% respectively).

• Maori and Pacific peoples have higher proportions of children and young people among their populations, so they have greater need for services affecting those age groups

• MidCentral DHB and Whanganui DHB’s numbers of Pacific people and Asian residents are small (which can make numerical analysis of their health status difficult). The case-numbers are often too small to show a reliable pattern, particularly for Pacific people.

• Both MidCentral and Whanganui DHB have higher proportions of their populations living in more socio-economically disadvantaged areas than New Zealand overall.

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The socio-economic disadvantage of Whanganui DHB’s population is particularly striking

Figure 1: New Zealand NZDep2013 decile population distribution Figure 2: MidCentral DHB NZDep2013 decile population distribution

Figure 3: Whanganui DHB NZDep2013 decile population distribution

Demographic profile of MidCentral’s territorial authorities

A brief outline of key health-planning related information is given for each of MidCentral DHB’s territorial authorities. As can be seen below, the territorial authorities which might have higher health needs are the Horowhenua, Tararua, and MidCentral’s portion of Kapiti Coast (Otaki and surrounds). This is because they have higher proportions of people known to have higher health needs in their populations. Horowhenua

• Population of around 30,000 people, or 18.5% of MidCentral’s population • Has a much older population profile than New Zealand overall or MidCentral overall

(23.4% 65 years and older, compared to 16.5% for MidCentral and 14.3% for New Zealand)

• Has higher proportion of Maori residents (21.6%, compared to 14.1% for New Zealand)

• Has very high proportion of people living in more socio-economically disadvantaged areas and very low proportion of people living in less disadvantaged areas. Almost half its population lives in NZDep 9 and 10 areas combined. By comparison, around 20% of New Zealand’s population lives in NZDep 9 and 10 areas combined.

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Figure 4: Horowhenua NZDep2013 decile population distribution

Palmerston North

• Population of around 80,000 people, or just under half of MidCentral’s population (49.3%). It is therefore the most dominant population centre compared to MidCentral’s other territorial authorities.

• Proportion of older people is less than the New Zealand average (13.1% and 14.3% respectively), but the number of people over 65 is higher than other MidCentral territorial authorities (just under 11,000).

• Has slightly higher proportion of Maori residents than the New Zealand average (15.7% versus 14.1% for New Zealand). But has the greatest number of Maori residents than the other MidCentral territorial authorities (even though the other territorial authorities might have a greater proportion of Maori residents).

• Not noticeably higher proportion of residents living in the most socio-economically disadvantaged areas than the national pattern (although this is not say there are none!)

• Best served by health services of MidCentral’s territorial authorities, purely because of its population size, for example, presence of regional hospital, greatest number of health practices.

Figure 5: Palmerston North NZDep2013 decile population distribution

Manawatu • Population of around 28,000, or around 17% of MidCentral’s population • Has a slightly older population profile than New Zealand (15.8% aged 65 and older

compared to 14.3% for New Zealand). However, Manawatu’s percentage of older people is less than the MidCentral overall average of 16.5%.

• Proportion of Maori residents is approximately the same as the national average (14.3% and 14.1% respectively). Manawatu’s proportion of Maori residents is less than the MidCentral average of 17.4%.

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• Not noticeably higher proportion of residents living in the most socio-economically disadvantaged areas than the national pattern (although this is not saying there are none)

Figure 6: Manawatu NZDep2013 decile population distribution

Tararua • Tararua’s population was roughly 17,000, or around 10% of MidCentral’s

population • Has an older population profile than the national average with 16.9% of its

population aged 65 and older, compared to 14.3% for New Zealand. The Tararua proportion is roughly the same as MidCentral’s proportion of people aged 65 and older.

• Tararua’s proportion of Maori residents is higher than the national average and MidCentral average (20.1%, 14.1%, 17.4% respectively)

• Most of Tararua’s population (82%) live in the five most socio-economically disadvantaged NZDep deciles. The national average for the five deciles is around 50%.

Figure 7: Tararua NZDep2013 decile population distribution

Kapiti (MidCentral portion) • Has a population of around 8,000 people, or around 5% of MidCentral’s total

population • Is part of the Kapiti District Coast territorial authority. The MidCentral portion is

just the Otaki, Otaki Forks, and Te Horo census area units. This is around 17% of Kapiti District Coast’s total population.

• It has the smallest population of MidCentral’s sub-areas • Has a much higher proportion of Maori residents compared to New Zealand and

MidCentral overall (24.9%, 14.1%, and 17.4% respectively). • Has a much higher proportion of older people (aged over 65 years) than New

Zealand overall and MidCentral overall (23.5%, 14.3%, and 16.5% respectively).

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• Has high proportion of its population living in highly socio-economically disadvantaged areas

Figure 8: Kapiti (MidCentral portion) NZDep2013 decile population distribution

Knowledge about people can be applied to areas

The health needs of an area’s residents are determined by type of residents among its population. From the demographic outlines give above:

• Areas with higher per-capita needs for services supporting older people are Horowhenua, Tararua, and Kapiti (MidCentral portion)

• Areas with higher per-capita needs for services supporting Maori are Horowhenua, Tararua, and Kapiti (MidCentral portion)

• Areas with higher per-capita needs for services supporting socio-economically disadvantaged people are Horowhenua, Tararua, and Kapiti (MidCentral portion)

• Because Palmerston North is the most dominant population centre, it may have higher numbers of high health needs groups, even though their proportions of these groups are lower than other territorial authorities

The health status of Kapiti residents, as determined by its age adjusted mortality rates, is much better than expected. Its age adjusted mortality numbers were 16% lower than expected, compared to New Zealand overall. Its population has high proportions of groups with higher health needs. Why are its mortality rates better? From a distance, possible reasons might be:

• Smaller population might mean it is easier for health and social services to support this area

• Smaller population might mean there is stronger social cohesion among its residents

• Being close to the southern edge of MidCentral DHB means residents may be able to access health services based in Capital and Coast DHB’s area, for example, at Paraparaumu.

However, a more thorough, and different kind of, analysis would be required to uncover reasons for its better health status. There may be lessons uncovered that would help with health planning across the rest of MidCentral DHB.

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National reports indicate chronic ill-health and need for health services will increase

What do national reports tell us about New Zealand’s population health trends and future need for health services? This information will apply to MidCentral DHB and Whanganui DHB populations as well. Two recent Ministry of Health reports describe New Zealand’s current state of population health and the major changes in recent years. These reports are:

• “Health and Independence Report 2016”11 • “Health Loss in New Zealand 1990–2013: A report from the New Zealand Burden of

Diseases, Injuries and Risk Factors Study.”12 The “Health and Independence Report 2016” is the Director-General of Health’s annual report on the state of New Zealand’s public health. “Health Loss in New Zealand 1990-2013” was written by Health and Disability Intelligence at the Ministry of Health. It describes changes in health loss from 1990 to 2013. Health loss can either be from early death, illness, or disability. The key points from both reports are:

• Our population age balance is getting older and this will increase the work required of health services

• Chronic conditions are becoming more prevalent as the population ages, for example, cardiovascular disease, cancer, mental illness, and dementia

• Life expectancy is improving faster than the length of life-time spent in good health. That means people will spend more years having impaired health

• The degree of health loss in the population is improving, when age-adjusted. However, when it is not age adjusted, the population’s total burden of health loss is increasing. Again, this is because of the ageing population balance.

• Health loss due to disability is now more prominent than health loss due to mortality. People are living longer, but the burden of non-fatal ill-health has increased.

• The proportion of the population who are disabled is increasing (from 20% of the population in 2001 to 24% of the population in 2013). This is because:

o The population is ageing. Older people are at higher risk of disability than younger people.

o People are more likely to report disability • Prevention could potentially relieve 30% of health loss • Health inequalities persist between genders, generations, ethnic groups, and socio-

economic groups. All these patterns are consistent with this health need assessment’s analysis of mortality and acute hospitalisation data. Our ageing population structure is increasing the amount of illness in the community and therefore the need and use of health services. Inequalities are not going away, and it’s the same people experiencing them across time.

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What questions does this health needs assessment raise for the future of this district health board?

The hardest task in achieving goals is not in conceiving the goals or describing why the goals are important; it’s working out how the goals can be accomplished. This is especially true when the goals tackle long-entrenched issues. Often, the reason why issues remain for a long time is because there are inadequate means or methods for solving them. It’s not because no-one knew the issues existed. Many of the questions this health needs assessment raises concern how negative patterns be changed to positive ones. Or how current challenges can be met.

Tackling inequalities • What is the best way of adjusting or changing current health services so they fit

people experiencing health inequalities? • What is the best way of preventing health problems among people experiencing

health inequalities (taking into consideration their circumstances, culture, and lifestyle)?

• Why is the health status (represented by the age adjusted mortality rate) of Otaki residents better than expected, especially since its population has high proportions of high health-needs peoples? Are there any lessons to be learned, which can be applied across MidCentral DHB?

Coping with increasing ill-health and disability • How can health services cope with increasing demand due to a growing population,

an ageing population structure, and identification of unmet need - especially if we cannot find or fund enough health workers to meet future demands? Can information technology specifically designed to help health carers carry out their work help us here?

(Coping with health needs of an ageing population balance and growing population is the health sector’s equivalent of global warming and climate change. However, unlike efforts to reduce the production of greenhouse gases, there’s no way of preventing or slowing ageing.)

Just one last thing: MidCentral DHB’s and Whanganui DHB’s small populations create data limitations

Both MidCentral District Health Board and Whanganui District Health Board have small populations when it comes to population health data analysis. Something should be mentioned of limitations this creates and also how these limitations were coped with. Despite this, not all the limitations can be negated. Analysis of small numbers creates the following difficulties:

• Numbers are too small to form reliable patterns This creates the danger of making conclusions based on unreliable patterns (patterns that might change with greater numbers)

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• Rates calculated from small numbers swing markedly from year to year (from small changes in numbers) This is seen in the yearly age adjusted or yearly crude rate graphs for the territorial authorities and MidCentral DHB and Whanganui DHB ethnic groups. The graph lines can swing markedly up or down year-to-year. By comparison, New Zealand’s yearly ethnic group graph lines change smoothly year-to-year.

• True patterns don’t reach statistical significance When a difference between figures is “statistically significant” or “statistically different” (both terms mean the same thing), it means that the difference is outside the range of expected random chance variation. The difference is therefore more likely to be a true difference, with a real underlying cause behind the difference. With small numbers, the expected range of random variation widens, meaning differences between figures are less likely to reach statistical significance. Sometimes true patterns don’t reach beyond the range of random fluctuation and are disregarded because of this. Some examples of this are:

o Comparisons of the top four groups of diseases causing mortality: cardiovascular, cancer, respiratory, injuries and accidents. As the numbers get smaller, the repeating pattern of disparities between groups no longer reach statistical significance.

o Tararua’s slightly higher age adjusted all cause mortality ratios in the past health needs assessments didn’t reach statistical significance. In retrospect, this difference was probably true, but was disregarded because it didn’t reach beyond the range of expected random fluctuation.

• Well-known national patterns cannot be reproduced using local data An example is actually in another report: “MidCentral District Health Board Maori Health Profile 2015” by Te Ropu Rangahau Hauora a Eru Pomare, Otago University7. Maori disparity in rheumatic fever hospitalisations compared to non-Maori could not be clearly demonstrated using MidCentral data because there was, on average, only one person hospitalised for acute rheumatic fever per year for MidCentral Maori and one person for MidCentral non-Maori. The differences did not reach statistical significance.

Actions to cope with these limitations involve accumulating data or keeping data together to increase numbers. Some examples in this document:

• Group diseases together o Analysis by all cancers together rather than each individual cancer. o All circulatory diseases together rather than each circulatory disease, etc.

• Group years together Analysis by five years data accumulated together (as well as year-by-year)

• Don’t split groups up For example, analysis of ethnic group data for MidCentral DHB or Whanganui DHB as a whole, rather than ethnic group data by each of the district health boards’ territorial authorities (splitting the population twice)

Patterns that cannot be seen with small numbers can often be seen with larger numbers, for example, differences in MidCentral’s ethnic disparity in cancer mortality and incidence wouldn’t be clearly seen for individual cancers because of small numbers.

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However, despite this, the effects of small numbers sometimes cannot be neutralized. The Tararua example given above is one instance of this. The inability to calculate yearly MidCentral DHB Pacific and Whanganui DHB Pacific age adjusted rates for some years is another example. New Zealand patterns should be used when MidCentral DHB and Whanganui DHB equivalents are not possible or are indistinct. Usually New Zealand patterns are repeated in each of New Zealand’s district health boards. [End]

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For:

Decision

Endorsement

X Noting

To HCAC Committee

Author Stephanie Turner, General Manager, Maori & Pacific Health

Endorsed by Kathryn Cook

Date 29 September 2017

Subject Equity Snapshot and Impact for Planning

Recommendation

• that progress on the Equity Snapshot and Impact for Planning is noted.

Strategic Alignment

This report is aligned to MidCentral DHB’s strategy and strategic imperatives, particularly, Achieving Equity of Outcomes Across Communities

Glossary

CPHO – Central Primary Health Organisation

DHB - District Health Board

ELT – Executive Leadership Team MDHB

Pae Ora -(Base /Platform of health) Healthy Futures (DHB Māori Directorate)

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1. PURPOSE This report updates the Committee on the progress of the Equity Snapshot project. 2. SUMMARY Work has been continuing on the Equity Snapshot project as a key priority area for the Pae Ora Māori Health Directorate. In summary, the trilogy approach has continued and progress has been made across all three components. The equity “thought piece” is in its final draft form and is ready for wider consultation and feedback. The technical report has been completed - methodological feedback is currently being sought and some limited visual design work is also being finalised. Scoping work is underway for the “toolkit” of practical resources to support local equity-focused approaches to health care service improvement, development and delivery. 3. UPDATE Work has been continuing on the Equity Snapshot project as a key priority area for the Pae Ora Māori Health Directorate. The trilogy approach has continued and further work has been done across all three components of the Equity Snapshot – 1) Equity “thought piece”, 2) Technical report, and 3) Toolkit. Since the last update to the Committee, the following progress has been made: • Equity “thought piece”

o The draft design for the document has been completed. This has included incorporation of local imagery and formatting to improve readability and appeal for the intended audience. The initial design is currently being considered in the context of the whole project and a face-to-face feedback meeting with the design team has been held to finalise the proof for publishing as a digital document.

o The document is being prepared for review by ELT before the final document is circulated

• Technical report o The final draft of the technical report has been completed. o The report has been produced to support positive action towards

“achieving equity of outcomes across our communities” - a key imperative of the MidCentral DHB strategy. It aims to highlight some key differences in the health and social circumstances of specific groups of people living in the MidCentral district, using Census data and health indicators based on mortality and acute hospitalisations.

o An equity-focused approach is taken throughout the report with comparisons of five population subgroups (MidCentral Māori, and residents of each of the four main localities) being presented and changes over time being described. Specific data for other important population subgroups (e.g. Pacific people and people living in areas with high deprivation scores) were not readily available for this report however it is intended that relevant information will be sought to

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enhance our understanding of inequities experienced by people in these groups for future reports.

o Key findings of the report clearly show that Māori are least advantaged in the MidCentral district with respect to both socioeconomic opportunities for good health as well as mortality outcomes, and that this situation may be worsening. The data also suggests that notable disadvantage may be emerging for Tararua residents and although a higher proportion of Horowhenua residents are experiencing socioeconomic disadvantage this does not appear to have resulted in significantly worsening mortality outcomes for Horowhenua residents over the past decade.

o The content of the report is currently being reviewed internally by staff with relevant expertise to make constructive comment on the methodology that has been used.

o A face-to-face meeting with the design team has been held and visual aspects of the report are currently being enhanced to ensure it is easy to navigate.

• Toolkit o Initial scoping is underway to determine a suitable approach for

developing a practical toolkit to support equity-focused approaches to health care development and delivery locally.

o A “stocktake” of currently available resources is underway. This is being led by Dr Janine Stevens (Public Health Physician - Pae Ora Māori Health Directorate) and is occurring in collaboration with a small group of Public Health Physicians from Wellington who are also working to address health inequities through their work.

o The intended next steps are to compile a collection of practical and relevant resources that can be used in their current form or adapted to meet local needs, and which can guide equity-focused approaches to various aspects of health care service improvement, development and delivery. For example, such resources may include planning and evaluation tools, measurement systems, workforce development initiatives, and health equity frameworks to guide research and policy development.

• Impact for Planning

o Pae Ora Māori Health Directorate is an active member of the Budget and Planning Workgroup and is advancing the imperative of including equity considerations across all of the 18/19 planning processes for MDHB.

o The Equity Thought Piece and Technical Report will be available across MDHB for the planning and prioritisation process for 18/19. This will assist to ensure that Equity is front of mind in the planning and prioritisation processes across MDHB.

o The Equity Snapshot will inform the Integrated Service approach once the Clusters are in place. The toolkit will be completed and further enable Clusters to consider and address the identified equity of healthcare outcome gaps when reviewing, developing or considering the current provision of care across the District

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4. RECOMMENDATION It is recommended:

that progress on the Equity Snapshot and Impact for Planning is noted. Stephanie Turner General Manager Maori and Pacific Health

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1

For:

Decision

Endorsement Noting

To Quality & Excellence Advisory Committee


Author Operations Director, Hospital Services

Endorsed by Kathryn Cook, CEO

Date 3 October 2017

Subject MidCentral Health Horowhenua STAR 4 Project Report

RECOMMENDATION


• the Horowhenua STAR 4 Project report be noted.

Strategic Alignment

The report is aligned to MDHB Strategy, particularly the strategic imperative ‘connect and transform primary, community and specialist care’. It is also aligned to the 2017/18 Annual Plan

Glossary

ARC - Aged Residential Care

ASMS - Association of Salaried Medical Specialists (Union)

AT&R - Assessment, Treatment & Rehabilitation

CPHO - Central Primary Health Organisation

ED - Emergency Department

FTE - Full Time Equivalent

GP - General Practitioner

HCP - Horowhenua Community Practice

HHC - Horowhenua Health Centre

HoP - Health of Older People

IFHC - Integrated Family Health Centre

IT - Information Technology

MCH - MidCentral Health

MDHB - MidCentral District Health Board

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2

1. PURPOSE

This report outlines the findings and recommendations from the Horowhenua STAR 4 project, with the final decision having been made by MidCentral District Health Board’s Executive Leadership Team. No decision is required. 2. SUMMARY

In November 2016 a project commenced to review the model of medical care delivered at Horowhenua STAR 4 due to clinical and financial sustainability concerns following recruitment challenges. The project concluded in April 2017 with a draft consultation document released to internal and external key stakeholders in June 2017. This paper identified the current model of care, medical workforce issues for both STAR 4 and the wider district (eg shortage of GPS, limited support for aged residential care, etc), and challenges to access of medical care. It also looked at the Horowhenua integrated family health centre and priorities, stakeholder perspectives and other small hospitals. As an outcome of the project, five scenarios for hospital medical care were developed and evaluated against criteria. MidCentral DHB’s Strategy was a key consideration, noting that MidCentral’s aim is to move to a fully integrated health system spanning primary, community and specialist care. Following consultation and consideration of the subsequent feedback a final decision on recommendations was made with two preferred scenarios identified. It has been decided to commence transition to the recommended Scenario 3 “District-wide model of care for older people”. A working group of key stakeholders to progress this transition will be set up within the next couple of months. The ultimate aim is to move to the maturity model of Scenario 5 “Rural Hospital with a wider range of services” which will occur along with the MidCentral DHB cluster development. The medical officer coverage for STAR 4 remains challenging and there is an immediate need to address this issue. Consequently priority will be the initial move to Scenario 2(a) “Specialist hospital model with changed responsibilities” and the consequential strengthening of medical coverage, maintaining a local out of hours roster. Implementation of the Integrated Family Health Centre and an alternative leadership model will occur in a planned way, with close collaboration between MidCentral DHB, Central PHO and key stakeholders involved in the provision of services from the Horowhenua Health Centre. Alignment with MidCentral DHB’s cluster model will be ensured. Development of the future model will fully consider future workforce requirements and ensure that workforce development plans are put in place with appropriate lead times so that the right number of appropriately skilled health professionals will be available to be placed within the service delivery arena to best meet the needs of the community. Nursing is recognised as a

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3

key component of this development, but it is also important to consider the requirements for allied health professionals. The Horowhenua STAR 4 project final draft for stakeholders document can be accessed via the link: http://www.midcentraldhb.govt.nz/Publications/AllPublications/Documents/Horowhenua%20STAR%204%20Project%20Report.pdf 3. BACKGROUND

The purpose of the project was to complete a review of the MidCentral Health Elder Health model of medical care in Horowhenua and deliver an internal report. The medical team are based within the Horowhenua Health Centre (HHC) and provide inpatient services (STAR 4 ward) and outpatient and community services. The project was initiated in response to clinical and financial sustainability concerns following recruitment difficulties for STAR 4 and also issues with medical care more broadly. This included workforce and workload issues experienced by the Central Primary Health Organisation (CPHO) owned general practice, Horowhenua Community Practice (HCP) situated within the HHC. In particular, HCP was having difficulties providing services to aged residential care (ARC) facilities. As well as looking at opportunities to work collaboratively towards a solution that would benefit older people across the whole Horowhenua district, the expectation was that the project would make recommendations to resolve the gap in medical cover that was imminent following the resignation of one of the three STAR 4 medical officers. Project management was outsourced and the project took place between November 2016 and April 2017. The draft report was released to Stakeholders for consultation, including unions, District Councils and Grey Power, in June 2017. 4. PROJECT PAPER SUMMARY

STAR 4 is a 20-bed inpatient ward based within the Horowhenua Health Centre (HHC) providing specialist level assessment, treatment and rehabilitation (AT&R), palliative care and medical services primarily for people over 65. STAR 4 sits within the MidCentral Health Elder Health service line. This project was initiated in response to clinical and financial sustainability concerns following difficulty recruiting a medical officer for STAR 4 and also issues with medical care more broadly. The project scope included exploring a more integrated approach for medical care within the HHC. STAR 4 is currently established at three medical officers (2.3 FTE) who provide 24/7 cover on a 1:3 roster. There is a 0.3 FTE post which is vacant and has proved too small to recruit to. In addition there is a part-time medical officer, providing outpatient and community services who has no cover for leave. A

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http://www.midcentraldhb.govt.nz/Publications/AllPublications/Documents/Horowhenua%20STAR%204%20Project%20Report.pdf

http://www.midcentraldhb.govt.nz/Publications/AllPublications/Documents/Horowhenua%20STAR%204%20Project%20Report.pdf

4

visiting geriatrician provides clinical and professional oversight to the team. The after-hours roster is unsustainable particularly as it reduces to 1:2 during absences. Furthermore, after-hours services are costly, there are inconsistent arrangements across the team and an audit showed low use of after-hours services outside weekend ward rounds. Medical workforce issues extend beyond the Elder Health medical team. There is a nationwide shortage of GPs with rural and smaller areas being the hardest hit. Although numbers in the Horowhenua/Otaki area have improved in the last decade, they are still less than ideal. Particularly concerning is the age profile of GPs. There are few young doctors coming through and over two thirds are aged 50 and over. Hosting trainee doctors is known to improve future recruitment chances but there are no interns placed in the area and only one GP registrar in Otaki. The CPHO owned general practice located in the HHC, Horowhenua Community Practice (HCP), has a high reliance on locums and has difficulty providing services to aged residential care (ARC) facilities. Problems include lack of continuity of care for ARC residents and GP dissatisfaction due to gaps in cover. The Horowhenua community-based Health of the Older Person’s (HOP) team was introduced to support general practice and ARC and prevent ED presentations and hospitalisations by providing services close to home. However, the team of 2.4 FTE has been reduced to 0.4 FTE so the potential impact of the HOP Team has been lessened. Overall, workforce issues for the medical teams are significant in Horowhenua. There are capacity issues and on their own the teams lack the critical mass to be sustainable and easily provide the range of services they are tasked to provide. The problems with medical cover are particularly troubling given the size, demographic and health status of the community. Horowhenua/Otaki has one quarter of the district’s population, the highest proportion of older people and those of Māori and Pasifika ethnicity and has high deprivation and low employment. These characteristics impact on the ability of residents to access health services, especially those provided some distance away at Palmerston North Hospital and contribute to the high burden of disease experienced by residents. Horowhenua has the highest mortality and amenable mortality of all the MidCentral localities. Projections indicate that aging population will have the most impact in the Horowhenua/Otaki area and the demand for ARC will continue to rise. Increased numbers of palliative patients are being cared for by general practice and ARC rather than specialist palliative care services. Horowhenua/Otaki residents receive more than 2,000 acute same-day discharges at Palmerston North Hospital per year. Two thirds are emergency speciality which indicates there may be opportunity to cater for more people locally. Similarly, some of the 8,000 odd annual ED presentations could be provided at the HHC.

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5

There are access issues to primary medical care, including urgent and after-hours services. General practice does not have the capacity to deal with all of the community’s needs and support other service providers. The impact of this gap is a lack of access or unnecessary transport of patients to Palmerston North Hospital. A range of small hospitals were contacted during the project. Most provide acute assessment services, host medical students or trainees and have developed nursing roles; several emergency/acute assessment services are nurse-led. Many sites have made considerable progress in the development of integrated working across teams e.g. in Clutha medical officers see people presenting with primary presentations overnight and in Buller a combination of remote cover and a GP roster provides after-hours cover for the hospital. The use of technology such as point-of-care-testing is commonplace and telehealth is expanding. Integrated working is seen as necessary for the long-term in order to have an attractive medical roster, decrease workforce vulnerability, make the most of capacity as well as strengthening primary services e.g. assisting with ARC. Stakeholders urged that development work occur to progress the Integrated Family Health Centre (IFHC) particularly local leadership, information technology (IT) and adequate facilities; expansion of services in Horowhenua/Otaki over the last decade has resulted in the number of staff at the HHC increasing from 100 to 170. The following five scenarios for hospital medical care were developed and evaluated against criteria. MidCentral DHB’s Strategy was a key consideration, noting that MidCentral’s aim is to move to a fully integrated health system spanning primary, community and specialist care. Because inpatient services in Horowhenua will always be limited due to the necessity to have specialist input, it is important that the future model strengthens primary care. The development of nursing and allied roles is an integral part of the overall model of care for smaller communities and needs to complement the chosen scenario.

Scenario 3 and Scenario 5 were evaluated as the best models to meet the future needs of the Horowhenua/Otaki population. Both options are aligned with DHB strategic imperatives. In particular the scenarios ‘connect and transform primary, community and specialist care’ by positioning the service to participate in integrated solutions. They provide more support for the Horowhenua medical workforce and expand local services.

Scenarios evaluated for hospital services 1. Status quo 2. Specialist hospital model with changed responsibilities

2a) Changed responsibilities with 24/7 after-hours 2b) Changed responsibilities with planned after-hours and cover from Palmerston North Hospital

3. District wide model of care for older people 4. GP managed beds 5. Rural hospital with a wider range of services

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6

The models have a different emphasis. Scenario 3 ‘District wide model of care for older people’ maintains the current focus on the over-65 population but expands services beyond the inpatient setting to proactively manage older people with frailty. The medical officers work across sites, including providing regular services to ARC facilities in conjunction with HCP. It is an integrated model which moves specialist care into the community, supports primary providers and can accommodate trainees. Medical capacity is increased though a post jointly-funded by MidCentral Health and Central PHO which would assist the parties to evaluate what will work best for Horowhenua. This scenario is aligned with the Healthy Aging Strategy (Ministry of Health, 2016). Scenario 5: ‘Rural hospital with a wider range of services’ has the potential to provide the most extensive range of services, including more acute services, and have the most impact on health outcomes. The service mix would be broader than current and cater for all ages and higher numbers of people with the lowest health status, including Māori and Pasifika. Like other small hospitals, Horowhenua could aim to move to a Rural Hospital Medicine (RHM) specialist workforce which could support the introduction of acute assessment services at the HHC. Scenarios 3 and 5 provide gains for different groups of the population. Both strengthen and better integrate health services to deliver more effective, efficient and sustainable care. Successful implementation of the preferred model necessitates careful and inclusive planning and management of multiple risks. This requires leadership at a local level, working across organisations and workforce development. 5. SUBMISSIONS

Nine submissions were received, both from internal and external sources. This feedback was appreciated and was carefully considered prior to the final decision being reached. The submissions did not support the concept of out of hours cover being provided from Palmerston North Hospital (Scenario 2 (b)); nor General Practice (GP) beds (Scenario 4). There was considerable feedback about the need to address the shortage of staff in the Health of Older Persons (HoP) team, the potential for increasing use of senior nursing roles such as Nurse Practitioners, and also some suggestions were made about increased services that might be able to be provided from within STAR 4 on a day patient basis. There was general support for a transition to Scenario 3, district wide model of care for older people, but with reservations about the proposed involvement with Aged Residential Care (ARC) facilities; and ultimately to Scenario 5, rural hospital with a wider range of services.

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7

6. FINAL DECISION

All feedback was considered in the final decision process. Table 1 outlines the recommendations in full together with the final decision in respect of each. Table 1: Recommendations and Final Decision

Recommendation Decision 1 That Scenario 3: ‘District-wide

model of care for older people’ is implemented forthwith. Scenario 3 is an extension of current service provision, which can be provided within current costs and implemented relatively quickly.

There is an immediate need to address the medical officer coverage for STAR 4, including 24/7 cover on a 1:4 basis. On this basis, there will be an initial move to Scenario 2(a), specialist hospital model with changed responsibilities, with priority being given to organizing the 2.8 FTE coverage with a 1:4 out of hours roster. In parallel with this, planning for transition to Scenario 3 will commence. A working group will be established with clinical representatives supported by management, representative of MDHB, the Central Primary Health Organisation (CPHO) and General Practice. It is expected that this will occur by the end of 2017, and the primary responsibility of this group will be to develop an implementation plan/ timeframe for the transition to the district wide model of care for older people. It has also been decided that the development to the maturity model of Scenario 5 will occur along with the MDHB cluster development.

2 That Scenario 5: “Rural Hospital with a wider range of services’ is considered as the future model of care for Horowhenua and an implementation plan developed. Scenario 5 requires extensive planning and some investment, including the introduction of acute assessment services.

3 That STAR 4 after-hours services are aligned to the future model of care and if 24/7 cover is maintained should be a minimum of 1:4.

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8

Recommendation Decision 4 That implementation of the IFHC

receives high priority so that the building blocks are in place for integrated working. This means alternative leadership and mechanisms and committed action to work on the enablers for the IFHC including appropriate space, IT and other technology (telehealth and point-of-care-testing).

This will occur in a planned way, with close collaboration between MDHB, CPHO and key stakeholders involved in the provision of services from the HHC, and alignment with MDHB’s cluster model will be ensured.

5 A Service Director, Horowhenua IFHC should be appointed to lead a rework of the concept of the IFHC and move from co-location to integrated working. The service director should have responsibility for all locally-based CPHO and MidCentral Health services and link services into the new service/ cluster model. The preferred option is an integrated model of care which will require leadership at a local level, work across a number of organizations and workforce development. This cannot occur via the current remote line management structure.

6 That development of the nursing

workforce achieves higher priority to support nurses to develop an expanded scope of practice. Nursing has a key role in managing the increasing and changing demand and achieving the goal of services closer to home by assisting the medical teams to provide services.

Development of the future model will fully consider future workforce requirements and ensure that workforce development plans are put in place with appropriate lead times so that the right number of appropriately skilled health professionals will be available to be placed within the service delivery arena to best meet the needs of the community. Nursing is recognized as a key component of this development, but it is also important to consider the requirements for allied health professionals.

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7. WORK PROGRAMMES

Medical Officer Cover A meeting has been scheduled with medical staff, Association of Salaried Medical Specialists (ASMS) union and ElderHealth leadership to further progress this workstream. This workstream with explore changed medical officer responsibilities with 24/7 after-hours cover. It will also look at a single medical team (inpatient and outpatient/community) with redistribution of FTE. District Wide Model of Care A working group will be established by November to develop an implementation plan and timeframe for the transition to the district wide model of care for older people. This will occur as part of the MDHB Healthy Ageing & Rehabilitation cluster development. Reporting will be through the ElderHealth line in the interim. The model of care will explore options such as: • Expanded role for medical officers to enable support for primary care to

proactively manage older people with frailty, eg HoP team, aged residential care, etc.

• A rapid response service for early assessment of unwell ARC residents • Development of a community based attachment for pre-vocational doctors • Nurse Practitioner involvement • 24/7 after hours to include ARC 8. RECOMMENDATION

It is recommended: that the Horowhenua STAR 4 Project report be noted Lyn Horgan Operations Director Hospital Services

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COPY TO:

Strategy, Planning &

Performance MidCentral DHB



Fax +64 (6) 350 8928 +64 (6) 355 8926

For:

Decision

Endorsement

X Noting


Author Jo Smith, Senior Portfolio Manager Health of Older People and Palliative Care Strategy, Planning & Performance

Endorsed by Craig Johnston

Date 5 October 2017

Subject Re-commissioning of Home and Community Support Services

RECOMMENDATION

• That the DHBs intention to re-commission Home & Community Support Services is noted.

Glossary EPA – Enduring Power of Attorney HCSS – Home and Community Support Services HOP – Health of Older People IF – individualised funding (funding follows the person) InterRAI – International Resident Assessment Instrument (national assessment tool for older people) NASC – Needs Assessment and Service Coordination OEP – Otago Exercise Programme for older people (leg strength & balance) TLA – Territorial Land Authority IBT – in-between travel (payment for support workers) SPP – Strategy, Planning & Performance

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1. PURPOSE This report is for information only to the Healthy Communities Advisory Committee. It gives forward notice of a formal RFP process occurring to procure around $13million of Home and Community Support Services (HCSS). It is intended to base a re-commissioning process on some broad high level requirements and work with the preferred Providers on implementing models of support that best support older people continuing to live in our communities. The process will include a formal tender process, contract negotiations and service development. 2. BACKGROUND The district has around 30,000 people over the age 65; of this around 3,100 older people receive personal care (showering and dressing) and home management (vacuuming) from one of six HCSS agencies at a cost of $13million. There is no recorded period of when the last time MDHB went out for tender to test the market on existing or new operators. In line with good Government practice and emerging models of care, it is proposed a re-commissioning process occurs. Re-commissioning HCSS this year is in part to test the market for new services and innovation and to consider better integrated care for consumers with greater choice and control and promote efficient use of resources district wide. Nationally, different models emerging include restorative aspects which are less about a ‘do for’ and more about a ‘do with’ the person or a case-mix model which is a term for using interRAI data to support restorative practices over eight to ten levels. Bulk funding models have emerged as DHBs look to manage latent demand and contain cost growth. National pricing rates are set at around $24.94 per hour of delivered care (excluding pay equity); DHBs are less able to draw down efficiencies from Providers. Only minor efficiencies can be gained by pursuing on price negotiations, given the legislative obligations DHBs now have related to guaranteed hours, in-between-travel pay equity. There will be two distinct phases of work. Firstly, the commissioning of providers to work with MDHB and the community and within these contract negotiations; secondly, a separate stream focused on service improvement and models of care that reflects local needs. The former is a business as usual process for the Strategy, Planning and Performance team. We will identify key providers based on current delivery to date and submission of a proposal; the latter involves key stakeholders district-wide on various areas we need to develop and link to enable joined up and seamless care. Work has already commenced with providers who are aware of our intentions to go to market and are actively involved in discussions. 2.1 Delegations The current delegations authority puts the activity of commissioning within Strategy, Planning and Performance. Approvals to change contracts are through the approved process outlined annually under the general approach to contract review and renewal process. Providers are evaluated against a number of criteria including strategic alignment, value for money, best practice and so forth. The intended procurement process falls within these parameters.

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Annually the Board approves the Funder budget and Funder commitments schedule of contracts for health and disability services. The delegations authority does not require SSP following a retender of current funded services to come back to the Board for approval but does require the information to be brought to the attention of the Board. The timeframe for this to occur in is likely to be between April and July 2018 in line with the Board calendar. 3. WHY NOW? Several reasons suggest that going to the market is timely. Currently, the Ministry of Health is working alongside DHBs to develop future models of care, we need to be positioned to respond to our local requirements and shape future services in a timely manner with an element of nimbleness. Appendix one highlights the fact that two providers tend to dominate delivery of services within each geographical area. The logistics favour fewer providers for better value. Fewer providers will result in better management of the workforce in each area of our district, bring about closer relationships with other primary care providers (general practice teams) and potentially give greater satisfaction amongst users of the service. We have several programmes of work specific to supporting joined up care across the continuum; the timing fits to bring the various components together. These include:

• Falls and fracture programme rollout across New Zealand partnering with ACC, locally this is about to get underway

• Investment in Calderdale Framework – workforce development and support • ‘Accelerate 25’ in Horowhenua – Affordable care and lifestyle for older people • The under 65 rollout of model of care in MidCentral DHB • Affordability around funding models – a need to do things differently • Focus on choice and control – doing things differently for the consumer • Integration and one team connections

The above list is not exhaustive but it does represent a general direction consistent with the Healthy Ageing Strategy and our own local strategic imperatives. 4. STRATEGIC ALIGNMENT Over time, the environment has changed; we have a new health strategy, a newer Healthy Ageing Strategy and other planned services which connect with Home and Community Services. Examples include the Calderdale Framework and the ACC strength and balance in-home exercise and community programme. We will deliver this piece of work with our strategic imperatives in mind, particularly that individually and together we will partner with people and whanau to support health and wellbeing and achieve this success through our people/partners and use of information.

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4.1 Partnering Sub-regionally Work on HCSS models of care is occurring nationally and regionally. Staff from Whanganui DHB and MDHB has collaborated over a joint project. Whanganui have fewer Providers than MDHB and while not considering a change, have engaged in joint service improvement work. Items such as shared electronic platforms between HCSS providers and the DHB (interRAI and Momentum), a stronger focus on restorative models and integration of elements of the falls and fracture programme are necessary in emerging models. Our commissioning process includes aspects of other DHB commissioning projects completed in the last 12 months. 5. WHAT DO WE WANT TO ACHIEVE WITH NEW PARTNERS Our focus in on high and complex needs for routine good care and for those with rehabilitative needs, older people will receive direction and support to sustain their functionality. The overall objectives and impacts for older people:

- Rehabilitation and restoration towards the promotion of independence - Rapid response to need when required including targeted intensive

intervention over a short period of time - Responsive to the cultural needs of older people - Greater choice of control for older people with services (IF and Contracts

with Retirement Villages) - More older people have EPA/ACP in place - Fewer providers working directly with other community providers - Reduced ‘failed discharges’ and re-admission rates to Secondary Care - Avoidance of ‘social admissions’ to Aged Residential Care/Hospital - Enabling older people to have greater autonomy over tasks and frequency of

intervention - More variety of services and options for older people - Joint assessment and care planning (using the same information)

6. OUR PROCESS

i. Stakeholder engagement and linkages

- Links to national work including workgroups - Current Contracted Providers – discussion and development/relative

meetings (prior to RFP) ii. Data and Environmental Scan (November to March 2018) - Feedback on system performance from sector - Consideration of funding models

iii. The RFP itself (November to April 2018) - Develop the RFP/Panel

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- Placement on GETs – the Government mechanism for tenders - Decisions/Contract negotiations - Award contract(s) iv. Partnering New Models of Care (April 2018 - October 2018) - Reconfirm national work and ideals - Implement (1 October 2018)

7. RECOMMENDATION It is recommended:

That the DHBs intention to re-commission Home & Community Support Services is noted.

Jo Smith Senior Portfolio Manager Health of Older People & Palliative Care

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Appendix 1. Spend by Territorial Land Authority (TLA)

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%

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Manawatu District Palmerston NorthCity

Tararua District Horowhenua District Kapiti Coast District

Personal Care & Household Management based upon percentage of total spend for 2016/17

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COPY TO:

Strategy, Planning &

Performance MidCentral DHB



Fax +64 (6) 350 8928 +64 (6) 355 8926

For:

Decision

Endorsement

X Noting


Author Strategy, Planning & Performance

Endorsed by Craig Johnston, General Manager, Strategy, Planning & Performance

Date 29 September 2017

Subject Strategy, Planning & Performance Operating Report

RECOMMENDATION

It is recommended that the Board:

• That this report be noted

Strategic Alignment

This report aligns to the MidCentral Strategy and to the Annual Plan.

Glossary

ACC – Accident Compensation Corporation

AP – Annual Plan

Capex – Capital expenditure

CEO – Chief Executive Officer

CNS – Clinical Nurse Specialist


FRAC – Finance, Risk and Audit Committee

GP – General Practitioner

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HCAC – Healthy Communities Advisory Committee

IFHC – Integrated Family Health Centre

ICT – Information and Communications Technology

MidCentral DHB – MidCentral District Health Board

MoH – Ministry of Health

NP – Nurse Practitioner

ODP – Organisational Development Plan

PHO – Primary Health Organisation

QEAC – Quality and Excellence Advisory Committee

SPE – Statement of Performance Expectations

TBC – To be confirmed

THG – Tararua Health Group

UCOL – Universal College of Learning

1. PURPOSE This report provides the Committee with an update on the activities of Strategy, Planning and Performance. It is for the Healthy Communities Advisory Committee’s information and discussion – no decision is required. 2. SUMMARY Work continues on developing Health and Wellbeing Plans for Tararua, Manawatu, Horowhenua and Otaki. Further engagement has taken place in Otaki to ensure adequate opportunity was given to the community to engage in the locality planning process. Within the Child Health portfolio, the Ministry of Health has requested each DHB develop a high level written plan outlining how the DHB plans to increase equity in access to Well Child Tamariki Ora services for vulnerable children and their families. MidCentral DHB and Whanganui DHB are working together on the development phase of the plans, however each DHB will have an individual plan to meet the specific needs of their district. This period has seen some changes to the team including the appointment of David Jack to the role of Regional Primary Care Emergency Planner. David has significant emergency planning experience and joins the team in October. The team has also seen the departure of Gopy Sundararajah, Clinical Support Portfolio Manager. The recruitment process to find a replacement is currently underway. 3. RECOMMENDATION It is recommended: that this report be noted

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4. STRATEGIC AND ANNUAL PLANNING 4.1 Locality Planning Work continues on Health and Wellbeing Plans for Tararua, Manawatu, Horowhenua and Otaki. Further engagement has taken place in Otaki to ensure adequate opportunity was given to the community to engage in the process. Over 115 surveys were received from the Otaki community as part of Locality Planning. Half a day was spent at the Otaki Library, an informative email and newsletter was sent through to key stakeholders in the community and an article was placed in the Otaki Mail. Staff within Strategy, Planning and Performance presented to the Kapiti Health Advisory group in September which was well received. In a similar process to other localities key themes have been identified and presented back at a local forum with a variety of community representatives in attendance. This group identified key priority areas from the themes presented. After further analysis of the feedback and data, including the draft health needs assessment, four proposed main headings have been identified at this stage under which the identified priorities for each locality sit:

1. Access (Easy and timely access to primary healthcare when needed) 2. Communication (A well informed, supported and connected community) 3. Health and wellbeing (Encourage and support healthy eating, physical

activity, spiritual health and a healthy environment) 4. Mental Health and Addiction (Easy and timely access to Mental Health and

Addiction services locally) Conversations with Portfolio Managers, Public Health, Mental Health and Addiction Community Services, some IFHC’s and the PHO have taken place looking at the opportunities for change. Each Locality will have a health and wellbeing plan that is unique their locality. Although the main headings are similar across all localities the actions for each locality are more specific to meet the needs of each locality. A package containing five draft documents has been prepared to present to the Steering Group and local advisory groups. Each document has a specific purpose and target audience. These will be developed for each locality once we have the concept right:

1) An info graphic stylized plan: this will be predominately for the community outlining on one page “ What we will do”,” How we will do it”,” How we will know we’ve been successful” and “What this will look like for the community”.

2) Table of Actions: This has been developed with input from Portfolio Managers, Mental Health & Addictions, Public Health and some IFHC’s and concepts from the Right choice Right Place campaign. This presents actionable steps that are possible over the next 1 – 2 years and then a more future focused 3 – 5 years. Further work is required on this.

3) An informative document: This is predominantly for internal MDHB use. This captures the Data for and Voice of each Locality. This is in essence a

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repository of information to ensure that the intelligence captured can be sourced and utilised going forward at any time (to inform clusters or new services).

4) Mapping document: This document takes the actionable steps within the plan and maps them to who will be responsible for owning and/or implementing the actions.

5) Insights document: This is an internal document and is a more conceptual document to provoke thinking, valuing a people powered approach and how better understanding our communities we can design interventions that best meet their needs.

Further engagement with each locality will take place over the next few months to socialise the documents, once completed.

4.2 2018/19 ANNUAL PLANNING Preparatory work has commenced for the 2018/19 planning round. We are commencing with setting the District Health Board’s high level planning parameters and financial planning assumptions, together with the strategic intentions and priorities the DHB intends progressing in the 2018/19 year. The approach will cover a parallel process of engagement with key service leaders for each of the “portfolios” (similar to the suggested integrated service groupings) between October and December to determine each service grouping’s known commitments and their proposed goals and objectives for the year (with a three year outlook) aligned to the DHB’s strategy and priorities. Additionally, the budget planning process over this preparatory period aims to determine the high level base financial position anticipated for the 2018/19 (minus any new activity) together with a high level financial analysis of potential for strategic investment. 4.2.1 Government and Ministry of Health Planning Expectations and Process It is too early to advise on the Government policy environment and the Ministry of Health’s expectations for annual planning for 2018/19. Usually the draft accountability documents (Service Coverage Schedule, Operational Policy Framework and the Non-Financial Performance Monitoring Framework and Performance Measures) are issued for feedback sometime in October or November. The usual annual health sector planning workshop occurs in mid-late November, which generally precedes delivery of the provisional Government planning priorities and the Minister’s Letter of Expectations in December or January. These timelines may all be delayed this year due to the post-election process. We are assuming that the Ministry-led planning timeframe will be similar to this current year. That is, the indicative, high level guidance and funding assumptions may be disclosed in December, but substantive material will not be received until the New Year, followed by receipt of the Funding Envelope post 2018 Budget announcements in May. However, we are also assuming that the draft financial budget will be required as usual at the beginning of March 2018, followed by a draft annual planning document at the end of March.

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4.2.2 DHB Planning Timeline Key Timeline High Level Outputs and Milestone Dates Phase one: October – December 2017

High level planning parameters Preparation of planning “toolkit” material Strategic development initiation Business improvement opportunities Base financial forecast / position High level financial analysis Indicative service changes Indicative regional and national priorities? Working draft service delivery and enabler group operational plans (including ODP) Indicative capital requirements Indicative information technology intentions

Phase one milestone dates:

19 October: Collective Group initiation 25 October: Executive Leadership Team 21 November: Finance, Risk and Audit Committee 28 November: Joint HCAC/QEAC Committee 13 December: Executive Leadership Team 19 December: Board meeting

Phase two: January – March 2018

Refinement – service delivery and enabler group operational plans Finalise draft capital intentions Finalise draft service change proposals Finalise draft production plan Prepare business proposals where required Overlay/incorporate MoH/Govt planning priorities Prepare draft financial templates Prepare (MoH) Annual Plan document and Statement of Performance Expectations Financial savings plan Regional Service Plan inputs

Phase two milestone dates:

30 January: Finance, Risk & Audit Committee 7 February Executive Leadership Team 27 February: Board meeting 02 March: Draft financial budget / templates to MoH? 09 March: Draft Production Plan to MoH 13 March: Finance, Risk & Audit Committee 20 March: Joint HCAC/QEAC Committee (Planning presentation) 28 March: Draft (MoH) AP and SPE to MoH?

Phase three: April - June

Finalisation of Service Delivery and Enabler Operational Plans Finalisation of financial savings plan Finalisation of Capex and ICT plan Finalisation of business improvement plan Finalisation production planning (including electives) Finalise approved draft AP and SPE to MoH ? Review and approvals process (DHB and MoH)

Phase three milestone dates

10 April: Board meeting (Draft MoH AP/SPE) 01 May: Joint HCAC/QEAC Committee June (TBC) Finance, Risk & Audit Committee (Remainder to be confirmed)

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5. LOCAL PORTFOLIO MATTERS 5.1 Health of Older People A key focus this quarter has been the on-going issues with the implementation of the Pay Equity settlement. This continues to be driven nationally. Concerns have arisen about the impact on the sustainability of some providers. Processes are in place to review the concerns when District Health Boards are approached on these matters. To date, no issues have been raised locally. Annual and operational plan initiatives are underway; the Healthy Aging Strategy continues to be the key vehicle for inspiring pathways of agreed focus. Some great work is progressing district-wide. For example, an aged residential care facility recently made a video of their integrated service improvement initiative to educate resident’s families and village residents on the diagnosis, services and impacts of dementia. The initiative illustrates three key providers, (the aged care facility, the general practitioner and the Alzheimer’s Society) working together to deliver the education in a coordinated manner. This video can be found at the following link and is well worth a look: https://www.youtube.com/watch?v=bc7VAnUKPUk&t=275s Work is underway to finalise the roll-out of in-home exercise programmes targeted at older frail adults who are at risk of falls. This programme will be funded in the main by ACC over a three year period. The programme will be linked in with other aspects of a district-wide falls and fracture programme. Previously we have run a local programme into aged residential care and more focus on falls has been adopted by retirement villages. Collectively these activities have succeeded in ‘bending the curve’ on the growing rate of falls (Graph 1 below). Implementation of the in-home programme and a yet to be developed community programme should significantly drive down falls and the cost of interventions that come as a result of a fall. Graph 1. Recent ACC falls data for MidCentral DHB on Community and ARC.

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https://www.youtube.com/watch?v=bc7VAnUKPUk&t=275s

5.2 Mental Health and Addictions The Mental Health and Addictions District Group continues to review its past and future activities in light of the end of “Rising to the Challenge”, the Mental Health and Addictions Service Development Plan. Achievements over the four year life of the work programme, have included the following:

• Establishing a Crisis Respite Service in the community, including procurement

• Scoping Report for Children of Parents with Mental Illness and Addictions issues

• Co-designed consumer engagement project • Developed fit for purpose scoping paper for integration and presented to the

Alliance Management Team • Held education forums across the sector regarding mental illness in attempt

to reduce stigma • Implemented the workforce development plan across all NGO’s, including

several non-mental health providers • Maintained consistent consumer representation on the District Group since

its establishment in 2012 • Enhance social inclusion opportunities and worked with justice agencies to

ensure more coordination of mental health services • Completed joint submissions to the City Council when relevant such as the

synthetic cannabis and social housing projects • Scoped the development of a DHB wide Suicide Prevention Action Plan and

reported this to the Ministry • Evaluated the service effectiveness for Māori and use this information to

inform future funding and service development decisions • Actively involve groups who experience disparities in health outcomes, in

service planning. Challenges going forward include the following:

• Public perception of mental health services continues to have an increasing impact. The effect of media reporting appears to be affecting staff recruitment into the Mental Health area. Stigma still plays a significant role in consumer and family/whanau experience

• High demand on alcohol and drug services and attempting to turn the curve on the desired outcome. The secondary services’ NGO partnership is an area for improvement with Alcohol and Drug services, as well as work being completed in the central regional review of AOD residential service; and planning for the implementation of the Substance Abuse Compulsory Treatment Act legislation

• Developing services for special population groups, such as refugees will be a focus, as the MidCentral region is a settlement area for former refugees

• Locality issues, particularly in rural areas of Tararua and Otaki As the work of community services broadens and becomes more complex, concerns about the capacity, capability and sustainability of NGOs will become more of an issue for funders and providers. These issues will need to be addressed in a systemic way in order for the sector to grow and evolve and move forward.

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5.3 Primary Health 5.3.1 St John Clinical Hub Launched The St John 111 Clinical Hub launched across MidCentral DHB on 29 September 2017, and now operates across all DHBs in the North Island. As well as reducing the number of inappropriate ambulance Emergency Department admissions, St John will be able to support patients in alternative pathways, such as facilitating an appointment with the patient’s GP or referring them to an urgent care clinic. 5.3.2 UCOL U-Kinetics Cessation UCOL has made a formal announcement of their intention to exit from the U-Kinetics service and the delivery of the Post Graduate Diploma in Clinical Exercise Physiology on 31 December 2017. From a service delivery perspective UCOL has advised that all MidCentral DHB clients currently enrolled in the programme will be able to complete their twelve week course of rehabilitation. For those MidCentral DHB clients on the waitlist UCOL has written to all of the affected clients advising them that the service is being withdrawn and to contact their physician to discuss alternative options. Additionally, referrers to the service have been notified about the pending closure to ensure that clients are no longer referred to the service. Since the announcement of UCOL’s decision to exit the service MidCentral DHB has received a number of letters from members of the community who shared their positive experiences of the U-Kinetics service. The next steps are to look at options for meeting the needs of people requiring this service before deciding on how to move forward. A meeting is planned for mid-October with stakeholders from cardiac, respiratory and diabetes specialist services, as well as primary care referrers and community providers of exercise / physical activity services, to understand if the current U-Kinetics service model met the needs of the target population and to identify additional requirements that a new service might include. By the end of October we intend to have identified and drafted a revised service specification on which a new service will be based. Based on the outcome of the stakeholder meeting and subsequent revision of the service specification we will go on to consider options for the re-procurement of services in early November, however at this stage it is likely that we will require a formal procurement process. A further update will be provided to the committee as further progress is made. 5.3.3 Update on Tararua Forum re Manawatu Gorge Closure Work has been underway following on from the Tararua Forum in late August 2017 where potential strategies and options were discussed to lessen the impact on health services following the closure of the Manawatu Gorge. It was identified that there was an opportunity to improve the scheduling of appointments at Palmerston North Hospital so that there are fewer trips over the hill and that appointments occur at times that reflect the added travel time those living in rural communities face. MidCentral DHB has an existing approach in place, however booking clerks have received email and verbal reminders at their team meetings to reinforce that where possible rural patients should be booked between 10am and noon for morning clinics and before 3pm for afternoon clinics. We have

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also started to analyse hospital booking data to ascertain if rural patients are receiving appointment times that reflect their added travel times. At the beginning of October GP Dr. Paul Cooper, Director of Acute and Urgent Care for Central PHO, started offering clinics two days a week at THG. Sharon Wards, CEO of THG indicated that Dr. Cooper’s presence has already had a positive impact for the community. THG has also secured additional CNS resource, with respiratory NP Victoria Perry providing clinics for THG patients. It was also identified that there was an opportunity to change the model of care delivery in Tararua. Dr. Cooper in his Central PHO role has also had an initial discussion with Mr Steve Miller to investigate possible telemedicine options for THG. Mr Miller is Chief Information Officer for both MidCentral DHB and Central PHO. Michele Coghlan, MidCentral DHB Director of Nursing has also been offering professional advice and support to THG to assist them in developing a new model of care. The committee will continue to receive ongoing updates. 5.4 Child Health 5.4.1 Increase equity in access to Well Child Services: The Ministry of Health has requested each District Health Board (DHB) develop a high level written plan outlining how the DHB plans to increase equity in access to Well Child Tamariki Ora services for vulnerable children and their families. The plan is required to be implemented from January 2018. MidCentral and Whanganui District Health Board are working together on the development phase of the plans but each DHB will have an individual plan to meet the specific needs of their district. A first hui was held 26 September 2017 with a range of providers attending. The feedback is currently being collated and once agreed will be revisited with each of the Maori/ Iwi providers who hold Well Child Framework contracts to ensure they are totally supportive of the direction. Not surprisingly initial feedback centred on improved data sharing, better communication across providers (including Oranga Tamariki) and the opportunity to extend the existing Newborn Enrolment programme to manage all children, especially transfers into the district. It was felt that this could be done with little new investment. This was a very worthwhile hui with good outcomes. The plan will be provided to the committee once completed. 6. REGIONAL: Regional Emergency Planner Due to a resignation MidCentral District Health Board has completed a recruitment process to employ a regional emergency planner. The role will work across, Hawkes Bay, MidCentral, Capital & Coast and Whanganui District Health Boards (DHB). Hutt Valley District Health Board has exited from the joint role preferring to

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employ their own planner. The role will sit with Strategy, Planning and Performance but will spend time each week across all the DHB’ and Central Primary Health Organisation. We have been fortunate to attract David Jack, who has with significant emergency planning expertise and he will commence the role Monday 16 October 2017. 7. FINANCE REPORT 7.1 Summary Income and Expenditure for the period ended 31 August 2017 was as follows:

The Funding result for the month of August 2017 was a $251k surplus, which was a favourable variance against budget of $10k. Revenue continued to be favourable to budget in August 2017 by $597k with the majority arising from receipt of revenue which is “pass through” to offset costs in provider payments. In July a provision of $222k was held back from Revenue in the financial result for non-achievement of the Elective budget and August saw a further $200k held back. This represents net delivery shortfalls in overall elective initiative inpatient services, with a range of overs and unders and the major factor being the orthopaedic shortfall. This revenue is deferred pending output delivery and, if we can achieve target volumes, the deferred revenue is potentially available by year-end. This remains a critical factor in managing our overall financial performance for the year. All other costs are tracking near or under the draft budget. Craig Johnston General Manager Strategy, Planning & Performance

$000 Aug-16 Aug-16 Actual Actual Budget Variance Actual Actual Budget Variance

Revenue 45,693 47,959 47,362 597 91,277 95,425 94,302 1,123

Expenditure

Other Outsourced Services 484 589 589 0 967 1,268 1,268 0Provider Payments 46,394 47,120 46,533 (587) 93,316 93,664 92,556 (1,108)

Total Expenditure 46,878 47,709 47,122 (587) 94,283 94,932 93,824 (1,108)

Surplus/(Deficit) (1,185) 251 241 10 (3,007) 493 478 14

Favourable to Budget Unfavourable to Budget but within 5 Unfavourable to Budget outside 5%

Funding August 2017 Result

Aug-17 Year to date

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Minutes of meeting held on Tuesday, 25 July 2017 at 1pm at MidCentral District Health Board Offices, Board Room, Gate 2, Heretaunga Street,

Palmerston North PRESENT Brendan Duffy (Chair) Adrian Broad (Deputy Chair) Barbara Cameron Ann Chapman Dot McKinnon (ex officio) Vicki Beagley Tawhiti Kunaiti IN ATTENDANCE Diane Anderson, Chair, Quality & Excellence Advisory Committee Barbara Robson, Committee Member, Quality & Excellence Advisory Committee Kathryn Cook, Chief Executive Craig Johnston, General Manager, Strategy, Planning & Performance Neil Wanden, General Manager, Finance & Corporate Services Megan Doran, Committee Secretary Stephanie Turner, General Manager, Maori & Pacific Gabrielle Scott, Executive Director, Allied Health Barb Bradnock, Senior Portfolio Manager, Children, Youth & Intersectoral Partnerships Gopy Sundararajah, Portfolio Manager, Clinical Support David Jermey, Portfolio Manager, Primary Health Jo Smith, Senior Portfolio Manager, Health of Older Persons Debbie Davies, Nurse Director Primary & Integration Erica Henderson, Coordinator Sheree Wilton, ASD Coordinator Amber Barry, Clinical Psychologist Trish Knight, Developmental Therapist Dennis Geddis, Communications Team Leader OTHER Public: (1) Media: (1) 1. APOLOGIES There were apologies from Nadarajah Manoharan and Donald Campbell

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2. NOTIFICATION OF LATE ITEMS There were no late items. 3. CONFLICT AND/OR REGISTER OF INTERESTS UPDATE 3.1 Amendment to the Register of Interests There were no amendments to the Register of Interests. 3.2 Declaration of Conflicts in Relation to Today’s Business No declarations were advised in relation to the meeting. 4. OPERATIONAL PLANNING 4.1 Child Development Service Update & Presentation Gabrielle Scott, Executive Director Allied Health, and Dr Jeff Brown, Clinical Director Child Health, presented to the Committee on Child Health Development service. A member expressed their concern regarding the current space occupied by the Child Health Team; although staffing numbers have increased the space used by the Child Health Team has not. The Clinical Director Child Health advised that an improvement in where the Child Health Team is housed would help with a much more effective collaboration between the team within the health and disability sector and all other agencies. There was a suggestion that perhaps there could be a public/private collaboration to enable the Child Health Team’s space to increase. It would have to be a cross sectoral approach. The Integrated Service Model was the ideal format for this to be looked at. It was noted that the Ministry was currently undertaking a review on ‘Good Start to Life’. There has only been one update provided which stated that Child Health Services were still being reviewed as part of the ‘Good Start to Life’. The update was on breastfeeding and the health target which was built into that piece of work. The Ministry was currently looking at what their model of funding is and it is trying to narrow it down, particularly to the disability sector, where they were funding one service and not multiple services. It was agreed that the Child Health Team would go back on the work programme to allow the committee to receive further updates on any progress moving forward. It was recommended: that the update on Child Development Service is noted.

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4.2 Proposed Multiagency Drinking Water Work Programme The Medical Officer of Health and Technical Manager Operations, Central North Island Drinking Water Assessment Unit introduced this report. The Committee was advised that the DHB has just submitted on Phase 2 of the enquiry. A committee member questioned what happens next in terms of Public Health’s evaluation of the provision of water services around the region MDHB was responsible for, as it was noted that one of the Councils has appealed? Every year there wass an annual water quality survey and there have been a number of Councils that have not met the appropriate questions. Horowhenua was one Council that had appealed that decision to the Ministry of Health. Advice had been sought from the Ministry of Health on what happens moving forward. It was recommended:

that the establishment of a multiagency work plan, developed in the aftermath of the Havelock North Drinking Water Inquiry, be noted.

5. PERFORMANCE REPORTING 5.1 Strategy, Planning & Performance Operating Report Locality Plans update Nearly 1000 people/groups have had input into the Locality Plans so far. Otaki was an area where community engagement got off to a slow start but the team were working hard to get it back on track. In response to a question from a member, the General Manager, Strategy, Planning & Performance advised that updates on locality planning, including feedback, analyses, etc, would be provided to the Board and Committee on a regular basis. Consumer & Clinical Council Update The first meeting of the Consumer Council would take place on 27 July 2017. There would be a joint meeting of the Clinical and Consumer councils in August, which would also serve as the first meeting of the Clinical Council. 2017/18 Funding Arrangements Document Update The General Manager, Strategy, Planning & Performance, asked for the members’ views on the continuation of the Funding Arrangements document. This document summarises the services that MidCentral DHB funds, including details of providers. The DHB has published this document each year for the last ten years, but was the only DHB to do so. The Funding Arrangements document is a useful reference point for staff and for the public, and was particularly useful for Official Information Requests. On the other hand, it was resource intensive to produce and indications are that it was not well used. It is largely available on line and in the last 12 months it was drawn down only 51 times.

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It was suggested that this year instead of publishing a full Funding Arrangements document, the DHB could publish a cut down edition that concentrates on the contracting/service tables. The committee agreed unanimously on the process going forward and that no Funding Arrangements Document would be produced for the 2017/18 year. Partnership project with Ministry of Social Development & Orion The General Manager, Strategy, Planning & Performance outlined this small exploratory piece of work that was being undertaken in conjunction with Orion Health and the Ministry of Social Development. It was looking at people with health related benefits and it was trying to identify whether by combining the data from across health and MSD insights can be gained into service changes that would make people’s lives better. From a health perspective the DHB was really interested in anything that flags up where early intervention could occur. It was an exploratory piece of work with a fixed six month timeframe. Horowhenua STAR 4 Staffing Report The timeframe for feedback has been extended at the request of the unions. To date only one letter has been received and that was from Grey Power. Pay Equity Implementing the Pay Equity Settlement has been a major piece of work for the Senior Portfolio Manager, Health of Older People, and the Contracts team. Feedback locally was that it has gone quite well. There were a few risks for DHBs in the changes which MidCentral was keeping a close watch on. In response to a member’s inquiry, the General Manager, Strategy, Planning & Performance, indicated that the Ministry had now clarified that its early direction to DHBs concerned the importance of not using Pay Equity funding to address pay equity issues relating to mental health workers. These issues were being dealt with through the Employment Court. The Ministry and DHBs were taking a facilitative role in supporting the parties to achieve a speedy resolution. Implementation of the St John 111 Clinical Hub in MDHB The Chair inquired about how the new service would be communicated to health services and the community. The Portfolio Manager, Primary Health Care, advised that St John has a formal roll-out process, which includes communicating with both health services (eg, MidCentral Health) and the community. In our district, the Urgent Care District Group would take an active role in supporting the new service. The CEO confirmed that the proposed approach to getting the information out to the community would be provided to the Committee in due course. The General Manager, Strategy, Planning & Performance, noted that the new service would potentially be a real advantage to rural communities, such as Tararua. At the recent board meeting in Dannevirke, ambulance responsiveness came up as an issue. The Clinical Desk, would be quite advantageous for those types of communities, particularly given the issues with the Manawatu Gorge, which impose an additional barrier in terms of people from Tararua travelling through for care. It was recommended:

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that this report be noted. 6. MINUTES OF THE PREVIOUS MEETINGS It was recommended:

that the minutes of the previous meetings held on 2 May 2017 and 13 June 2017 be confirmed as a true and correct record.

7. COMMITTEE’S WORK PROGRAMME In response to an inquiry from the General Manager, Strategy, Planning & Performance, the committee indicated it would like presentations from the following:

• Ministry of Health and Education on disability programmes • The Enabling Good Lives programme • Levin Children’s Team • Kaianga Whanau Ora.

It was recommended: that the progress against the 2017/18 work programme be noted 8. LATE ITEMS There were no late items. 9. DATE OF NEXT MEETING 5 September 2017 (Shared matters of interest) 17 October 2017 10. EXCLUSION OF PUBLIC It was recommended:

that the public be excluded from this meeting in accordance with the Official Information Act 1992, section 9 for the following items for the reasons stated:

Item Reason Reference “In Committee” minutes of the meeting held on 2 May 2017

For reasons stated in the Agenda of 2 May 2017

Confirmed this 25th day of July 2017 ………………………………………… Chairperson

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Minutes of the joint Healthy Communities Advisory Committee and Quality & Excellence Advisory Committee Minutes of meeting held on Tuesday, 5 September 2017 at 9am at MidCentral District Health Board Offices, Board Room, Gate 2, Heretaunga Street, Palmerston North The shared matters of interest section of the meeting commenced at 9.00am. This section of the meeting was chaired by Diane Anderson, Chair, Quality & Excellence Advisory Committee. PRESENT HCAC Members Adrian Broad (Deputy Chair) Barbara Cameron Nadarajah Manoharan Vicki Beagley Donald Campbell QEAC Members Diane Anderson (Chair) Karen Naylor (Deputy Chair) Michael Feyen Oriana Paewai Barbara Robson Dennis Emery IN ATTENDANCE Kathryn Cook, Chief Executive Craig Johnston, General Manager, Strategy, Planning & Performance Neil Wanden, General Manager, Finance & Corporate Services Keyur Anjaria, General Manager, People & Culture Stephanie Turner, General Manager, Maori & Pacific Scott Ambridge, General Manager, Enable New Zealand Michele Coghlan, Director of Nursing Gabrielle Scott, Executive Director, Allied Health Ken Clark, Chief Medical Officer Lyn Horgan, Operations Director, Hospital Services Chris Nolan, Service Director, Mental Health Services Muriel Hancock, Director, Patient Safety & Clinical Effectiveness Cushla Lucas, Service Manager, Regional Cancer Treatment Service Megan Doran, Committee Secretary Barb Bradnock, Senior Portfolio Manager, Children, Youth & Intersectoral Partnerships Vivienne Ayres, Manager, DHB Planning and Accountability Claudine Nepia-Tule, Portfolio Manager, Mental Health & Addictions Steve Tanner, Finance Manager

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Barry Keane, Nurse Director Maggie Oulaghan, Service Manager Geoff Anderson, Medical Head, Orthopaedics Robyn Shaw, Elective Services Manager Paula Spargo, Midwifery Director Robyn Williamson, Service Leader Greig Russell, Chief Medical Officer Daniel Hirst, Project Manager Lyndel Voice, Project Lead Dennis Geddis, Communications Team Leader OTHER Public: (3) Media: (1) 1. APOLOGIES Apologies were received from members Dot McKinnon, Cynric Temple-Camp, Brendan Duffy, Ann Chapman and Tawhiti Kunaiti. An apology for lateness was received from committee member Barbara Cameron. 2. CONFLICT AND/OR REGISTER OF INTERESTS UPDATE 2.1 Amendment to the Register of Interests Karen Naylor advised she was on the NZNO Board. 2.2 Declaration of Conflicts in Relation to Today’s Business Karen Naylor declared her conflict with item 3.5, MidCentral Maternity Review Report and item 14, Operations Report (Part 2), due to her role with the Women’s Health Unit. Denis Emery declared that for the visit to Ward 21 after the meeting it would not be appropriate for him to attend as he had family connections to two current inpatients. 3. STRATEGIC & ANNUAL PLANNING 3.1 MDHB Maori Health Plan 2016/17 and Tu Kaha Conference 2018

Update The General Manager, Maori & Pacific introduced this paper. This report highlighted how the Pae Ora Directorate was aligning their work to the Strategic Imperatives. It also gave the final update of progress against the Maori Health Annual Plan 2016/17 indicators. One highlight of the report was the increased numbers of patients accessing and staying at Te Whare Rapuora. In the 2016/17 year, the bed nights had increased by

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183 when compared to the 2015/16 year. A member questioned the total number of beds that were being used. Although the General Manager, Maori & Pacific did not know these at the time, they would be provided directly to the member. In regards to the Tu Kaha Conference to be hosted and convened by MidCentral, the date had been brought forward from November 2018 to July 2018. This was to enable Secondary Schools to participate in the conference. It was noted that the Secondary School Kapa Haka competition was also scheduled for July 2018. The General Manager, Maori & Pacific advised a steering group had already been formed made up of people from the six Central Region DHBs and they were aware they need to keep on top of any future events that may be held at the same time. The Committees’ acknowledged the depth and quality of this report. It was recommended: that progress against the MDHB Maori Health Plan 2016/17 be noted; and

that progress in hosting the Tu Kaha 2018 Conference be noted 3.2 Mental Health & Addictions Update 4 The Service Director and Portfolio Manager introduced this report and gave an overview of the contents, including the ward 21 development plan. At present there was high demand on the acute care (crisis) team. There was also pressure and demand on NGO providers for housing and accommodation support. Other discussion on the paper included the number of vacancies, high workloads, clients with intellectual disabilities, complex cases, increase in referrals including rural areas, in particular Horowhenua and that the number of referrals to the Alcohol & Drug service had increased by 100 per cent. The Service Director advised there are still vacancies within the mental health team. One of these vacancies had been in Horowhenua but that position had been covered by a secondment from Palmerston North. The service was actively recruiting staff. It was acknowledged that some nursing staff had at times worked a 15 hour shift, which could result in compromised care. The Mental Health team were currently working in partnership with Enable New Zealand in relation to clients with disabilities to ensure they received the level of care required. It was recommended: that this report be noted 3.3 Mental Health & Addictions Service Acute Care Continuum

Development Plan

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This report covered the four main areas of focus;

• Implementation of ‘Safewards’ programme which are used in England and Australia,

• Leadership & Culture development, • Stands of Practice – focus on updating protocols and procedures and • Professional Development plans linked to training & supervision.

A member questioned the Review Leave Assessment and Leave Management Policy, particularly the leave forms clients were required to sign. The Nurse Director, Mental Health & Addictions advised there were two types of leave. One related to people admitted under the provision of the Mental Health Act. Leave requests for these clients required doctor sign-off. Clients not under the provisions of the Mental Health Act they are classed as voluntary patients. The current focus around leave management had been on voluntary patients. If any client wished to take voluntary leave, be it overnight or for the afternoon etc. then they must complete and sign a leave form. The form provided confirmation of date and time of leave, where the client intended to go, and when they were due back. Most importantly it provided a contact number for the client to call is they got into difficulties. Completed leave forms were assessed by a nurse who determined whether or not leave was appropriate for the client at that time. The key considerations taken into account in this process were risk and safety. If the nurse considered the client should not go on leave due to safety reasons and the client was insistent leave should be granted, the nurse could invoke the provisions of the Mental Health Act. It was recommended:

that the Mental Health & Addictions Service Acute Care Continuum Development Plan be noted

3.4 National Elective Services Programme This report sets out for the committees’ information the National Elective Programme and how it is applied at MidCentral Health, particularly around First Specialist Assessments (FSAs). It also provided an update on the Theatre Improvement Programme of work. The Medical Head, Orthopaedic Service provided an overview of the referral process, including how referrals were declined, how often they were declined, what happens to a patient when their referral was declined and who was then responsible for the patient. The Operations Director, Hospital Services advised that one of the challenges for the clinicians moving from the six to five and then to a four month wait time, in clinics across the organisation was the triaging of referrals. With the previous target of 6 months, clinicians were able to triage referrals within their clinic time. Clinicians now dedicated one to two sessions per week to triaging referrals.

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It was recommended:

that the National Elective Services Programme report be noted

3.5 MidCentral Health Maternity Review Report The Committees’ noted Karen Naylor’s conflict with this report. The Operations Director, Women’s Health Service introduced this report. This report was a progress update on the implementation of the programme of work within the Women’s Health Service and set out the progress against the work programme which includes safe staffing, facilities, governance and quality & outcomes. A member raised concerns about appointment of Clinical Directors and how these appointments would not be put in place until the Cluster Model was confirmed. The CEO advised that the DHB currently had Acting Clinical Directors in place and in Women’s Health, the Acting Clinical Director had been in place for quite some time. The DHB had tried to appoint a Clinical Director to the role permanently however this had not been successful. In the meantime work on the Integrated Service Models had progressed. Consultation was currently occurring regarding the job descriptions for two critical roles - Clinical Executive and Operations Executive. A member expressed concern around the ratio of nurses to midwives. The Midwifery Director advised that this was a challenging space at present due to the shortage of midwives. The DHB was actively recruiting for Charge Midwives with no response. To help this, nurses had been employed on temporary yearly contacts. It was recommended:

that the Maternity Review report be noted 4. PARTNERHIPS & CONSUMER 4.1 Disability Support System Transformation Update The General Manager, Enable New Zealand introduced this report. Minister Wagner (Associate Health & Disability Issues) had announced a three month co-design process of transformation of the disability support system. The announcement identified that the initial region to be transformed would be the MidCentral Region. The co-design process was facilitated and lead by disabled people and family representatives. It focused on a transformation of the system. There had been a number of demonstrations and pilots around the country over the years. There is now a genuine commitment to look at what changes needed to occur.

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The new system at a high level completely inverts the way in which disability support services were provided. Rather than the system dictating to people, people would have choice and flexibility and control over how they wanted to design their own services and the system would then be put the services in place to support them. There were some key changes and key focuses around early intervention, working up front, walking alongside disabled people. A member sought clarification around which government agencies were working with the Ministry of Health and Ministry of Social Development on this initiative. The General Manager, Enable New Zealand advised the other main agency would be the Ministry of Education and there were times that ACC would also be involved. A member sought more information regarding Tuhono walking alongside to provide crisis support, particularly what was the meaning behind crisis support and whether it included vocational support within the funding model. Management advised this service was for people who were in crisis and dealing with situations in front of them. There was a strong recognition and intent to have a wraparound intensive case management or facilitation service to support the disabled person and their family move out of crisis. It was recommended: that the Disability Support System Transformation Update be noted 4.2 Update on the Roll out of the St John 111 Clinical Hub It was recommended: that this report be noted. 5. INTEGRATION 5.1 Tararua Forum re Manawatu Gorge Closure Member advised the report provided a good overview of the situation for the Tararua residents with the closure of the Manawatu Gorge. It was proving challenging for all staff and health providers in Tararua and for the residents. Members supported the collaborative approach being taken and the good relationships and partnerships being built to overcome the challenges that residents faced. The problems in the Tararua region around Primary Care, including GP recruitment, were discussed. The Portfolio Manager, Primary Health Care advised that Tararua Health Group required support in terms of their GP numbers. In the short term the Central PHO had provided Dr Paul Cooper to assist. In the long term, as it was with most rural areas, new models of care in terms of using telehealth for example, were required. The Chair acknowledged the solutions that had been put in almost instantly showed that there was some will there.

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A member noted the pressure on the shuttle service and was pleased to see that there would be easier access to air ambulance services, particularly those in hard to access places. It was recommended: that this report be noted. 6. PERFORMANCE REPORTING 6.1 Non-Financial Monitoring Framework & Performance Measures

Including Health Gargets – Summary Report for Quarter 4, 2016/17 The CEO highlighted the work that had been done around productive theatre. She advised that there was another piece of work currently being under taken by the Francis Group called Patient Flow. This was around the medical model of care and aimed to support improved performance around the ix hour shorter stays in Emergency Department target. The DHB’s performance was unacceptable in that area, however this new piece of work flowed on from quite a considerable focus on medical staff and medical rostering. Management advised there were three annual indicators this quarter which were different from the usual report. These were HPV for girls which continued to be achieved, the whanau ora programme of work, and the adolescent utilisation rate. For the first time, MidCentral DHB had achieved the smoking cessation target. In regards to the faster cancer treatment target, the DHB was continuing on a positive trajectory. There was a robust governance group in place. The real reason for this target is individual pathways and to make long term improvements. The General Manager, Strategy, Planning and Performance commented on the two child health indicators, being the immunisation indicator and raising healthy kids. In relation to the immunisation results, the DHB was currently behind compared to what it had been historically. The DHB had been working extremely hard, doing intensive work with the team to try and increase the rates. The anti-immunisation controversy has had an impact. There has been a slight increase in the number of decliners. In relation to the healthy kid’s target, the team was doing this properly and so when it stated children had been referred for appropriate services this did not mean just referred back to their general practice team. They were being referred to the appropriate services. Management advised that while the colonoscopy surveillance had not been achieved for quarter 3, it had been achieved for quarter 4, 2016/17. It was recommended: that this report be noted

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6.2 Regional Service Plan Implementation Update – Report for

Quarter 4, 2016/17 The Manager, DHB Planning and Accountability introduced this report. This was the final report for 2016/17. The priorities that had formed the focus of the plan of the year were; cancer, cardiac, mental health and complex care. MidCentral DHB had reshaped the way in which the DHB approached the plan which would in turn impact the DHB’s reporting as well. Support for Whanganui DHB in respect of ophthalmology workforce issues was raised. Management confirmed that MidCentral was currently working very closely with Whanganui regarding ophthalmology service, in particular regarding workforce shortages and on call arrangements for acute care. It was recommended: that this report be noted. 7. COMMITTEES’ WORK PROGRAMME The General Manager, Strategy, Planning and Performance introduced this reporting, noting that October would be a very busy month. A member sought clarification as to when the next Q&EAC report on the progress of the clusters development and implementation. It was noted that this report would go directly to the Board. A member noted that there was no update against the 2017/18 Annual Plan. It was agreed this report would be provided for the Committees’ next meeting. Members noted that the Star 4 report had been delayed to accommodate an extension of the consultation timeline. The report would be provided at the October meeting. It was recommended:

that progress against the 2016/17 work programmes, and, the Committees’ work programme for 2017/18 be noted.

8. DATE OF NEXT MEETING 17 October 2017 28 November 2017 (Shared matters of interest) QUALITY & EXCELLENCE MATTERS

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(Information only for Healthy Communities Advisory Committee) 9. STRATEGIC & ANNUAL PLANNING 9.1 Options Paper – Ward 21 Redesign The Service Director, Mental Health & Addiction Services introduced this report. The proposal was fully discussed. Members supported the need to create an environment which meets the needs of consumers and family/whanau, and addressed all the other things that were essential in an acute and intensive care unit for therapeutic care. The importance of providing a culturally appropriate environment was emphasised, ie, having an environment suitable for the needs of individual groups within the DHB’s population base. It was noted that seclusion rooms needed to be different from bedrooms. It was further noted that the needs assessment was silent on people who identified with a gender other than male and female. What provision would be provided for transgender people? It was considered than in an environment of this type, there should be flexibility create separate but not isolated areas where individuals could be grouped based on their needs. The CEO advised that if the Board endorsed option D “New Build”, this would need approval from the government. That approval would require the DHB to ensure all options have been looked at. The CEO agreed that it is important that the DHB created a welcoming, safe environment contusive to healing. The General Manager Finance and Corporate Services endorsed the CEO’s comments and noted that the focus was on a safe and therapeutic environment for all users but getting there expeditiously as the DHB can. It was recommended:

that the committee endorse to the Board the proposed development of a business case for Ward 21 comparing the alternatives of Option C “Extend & Refurbish” with Option D “New Build” against the Option “A” Counterfactual “Minimal Change”

10. PERFORMANCE REPORTING 10.1 MidCentral Health Operations Report for June/July 2017 The CEO introduced this report and highlighted the draft balanced score card which had been provided to give an indication to the Committees’ of the work the DHB was starting to do now that it had access to new business intelligence tools and systems which had been in the design phase for some time. This was still work in progress. The CEO confirmed that the health target champions were national roles.

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In respect of the contract with Crest, the likely range of additional costs was sought. The CEO advised that this was not the same contractual approach that had been used in the past. It was more a virtual theatre arrangement for the DHB together with Crest. The Operations Director advised that the Crest arrangement was for two surgical lists a week for three months. It was a lease arrangement with a mix of staffing arrangements across MidCentral and Crest. The CEO advised that the DHB had partnered up with Central PHO around acute demand. The DHB was also implementing the ”Choosing Wisely” programme, which would help the DHB with some of the conversations around what tests and other things clinicians and patients chose. However there was still more work to be done in that space. There were a number of other projects, the details of which would be provided in full detail at the next FRAC meeting to try and support the budget going forward. Members noted the failure to meet the target on annual leave which had a huge amount of focus on it. It was suggested that perhaps it was timely to look at a new piece of work to why the DHB was not achieving this. Management undertook to provide an update on capital expenditure for the Quality & Excellence Advisory Committee as it related to hospital and associated health services. It was recommended:

That the Operations Report for June/July 2017 be noted 11. MEETINGS 11.1 Minutes It was recommended:

that the minutes of the previous meeting held on 25 July 2017 be confirmed as a true and correct record.

11.2 Recommendations to Board

It was noted that the Board approved all recommendations contained in the minutes.

11.3 Matters Arising from the Minutes

A member requested more information regarding the delay in issuing clinical letters as highlighted in the recent Diabetes Report. The Operations Director advised that at times certain clinics that had longer than desired typing wait times. The Professional Advisor, Clinical Clerical reported daily

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on typing wait times to the Operations Director.. They also reported to the Clinical Board. Ms Horgan advised the DHB had been undertaking a significant piece of work, in and around clinic letters. Voice recognition was being trialled, and the DHB was currently consulting with medical secretaries regarding a proposed medical transcription service which would automatically ensure the letter with the longest wait time was delivered first. The lack of a medical typing career pathway from school was also proving challenging. When recruiting, the DHB looked for clerical staff that had good keyboard skills and would then providing training in medical typing.. MidCentral DHB had explored online training options, particularly for medical terminology, with UCOL . Two permanent, casual medical secretaries were employed to provide cover for medical secretaries leave. The CEO advised on the broader IT context the regional clinical portal had been implemented. The next deliverable was the Regional Radiology Information System which would go live on 11 September 2017. The DHB now had a road map of priorities to build on the current regional IT infrastructure. This was the pathway to full digitalisation which was where MidCentral DHB needs to be, particularly to address some of the concerns/issues raised. A member advised in regards to Te Hongonga (Maori Cancer Advisory Group to the Local Cancer Network) that they had been invited to attend the next meeting. The member had also been asked to provide wording around Manage my Health. 12. EXCLUSION OF THE PUBLIC It was recommended:

that the public be excluded from this meeting in accordance with the Official Information Act 1992, section 9 for the following items for the reasons stated:

Item Reason Reference “In Committee” minutes of previous meeting

For reasons stated in the previous agenda

UCOL Contract Contract Negotiations 9(2)(j) Operations Report: Potential Serious Adverse Events and Complaints and litigation

To protect personal privacy

9(2)(a)

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COPY TO: CEO’s Office MidCentral DHB

Heretaunga Street, PO Box 2056 Palmerston North 4440

Phone Fax

+64 (6) 350 8910 +64 (6) 355 0616

For:

Decision

Endorsement

X Noting


Author General Manager, Strategy, Planning & Performance

Endorsed by Acting CEO

Date 11 October 2017

Subject HCAC Work Programme

RECOMMENDATION


• progress against the 2017/18 work programme be noted.

Strategic Alignment

This report is aligned to the DHB’s Strategy and key enabler, “Stewardship”. It discusses an aspect of effective governance.

Glossary


HCAC – Healthy Communities Advisory Committee

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1. PURPOSE This report updates members on the 2017/18 work programme and subsequently scheduled reports. The report is for the Committee’s consideration and no decision is required. 2. BACKGROUND Each year the Board establishes a reporting framework for the DHB’s governance function. This purpose of the framework is to ensure the Board and its Committees receive the reports they require to enable them to carry out their function effectively. From the framework, work programmes for the Board and each committee are developed. The work programme sets out planned reporting points for routine reports and project updates. When events indicate a significant increase in risk within a project, that risk will be reported in an interim update. Brief updates are noted in Section 3 for a number of initiatives and, where relevant, an update on reporting dates. 3. 2017/18 WORK PROGRAMME - BRIEF UPDATES Changes to timing of reports that had been scheduled for this month and previous months are listed below. • Details of the 2018/19 annual planning approach and timeline are provided to

the Committee. We had scheduled to provide the financial assumptions but these will be provided next month.

• No update is provided this month on the NZ Disability Support Service Transformation given the detailed update provided to the Committee at its last meeting.

• Unfortunately, the Health Promotions Agency is unable to join us on the 17th October. It is very keen to meet with the Committee and will do so in the new year. Another presentation has been scheduled – Maryanne Thomson of Homecare Medical will join the meeting to discuss the mental health phone line. Homecare Medical is the national provider of telehealth services. This integrated service brings together many services as listed below. Healthline 0800 611 116 – registered nurse assess and provide advice

Quitline 0800 778 778 – support for people wanting to quit smoking and stay smokefree

Alcohol Drug Helpline 0800 787 797 and text 8681 – advice, information and support about drinking or other drug use

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http://www.health.govt.nz/your-health/services-and-support/health-care-services/healthline

http://www.quit.org.nz/

http://alcoholdrughelp.org.nz/

Depression Helpline 0800 111 757 and text 4202 – callers can talk through emotional and psychological issues with counsellors and via the National Depression Initiatives:

Depression.org.nz – helping people find a way through depression

The Lowdown and text 5626 – support to help young people recognise and understand depression or anxiety

The Journal @ depression.org.nz – an online programme to help people learn skills to tackle depression

Gambling Helpline 0800 654 655 and text 8006 – support for those worried about gambling or the gambling of others

Poisons advice for the public 0800 POISON (0800 764 766) – advice and initial triage (delivered through the National Poisons Centre)

Immunisation advice 0800 IMMUNE (0800 466 863) – providing advice to the public (in partnership with the Immunisation Advisory Centre (IMAC))

Ambulance secondary triage – clinical telephone assessment by registered nurses for low acuity 111 calls to St John and Wellington Free Ambulance

The Diver Emergency Service Hotline – advice and treatment of all diving related incidents, accidents or injuries, including the emergency management of decompression illness, 0800 4 DES 111 (0800 4337 111).

As previously advised, a workshop on the Strategic Property Plan for the Palmerston North Hospital campus will take place on 28 November 2017. Immediately following the workshop, I will take members to see the child health development service area which was discussed recently. The long term solution to this matter will form part of the strategic property planning work. In the short term, management continues to work to address physical space requirements within the restraints of the current site configuration. A copy of the Committee’s work programme is attached. 4. RECOMMENDATION It is recommended:

• that progress against the 2017/18 work programme be noted.

Craig Johnston General Manager Strategy, Planning & Performance

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http://www.depression.org.nz/

http://www.depression.org.nz/

https://thelowdown.co.nz/

http://www.depression.org.nz/thejournal

http://www.gamblinghelpline.co.nz/Home_452.aspx

http://www.poisons.co.nz/

http://www.immune.org.nz/

http://www.stjohn.org.nz/What-we-do/St-John-Ambulance-Services/Clinical-Hub-Auckland/

http://www.wfa.org.nz/emergency-ambulance

APPENDIX A – HCAC’s 2017/18 WORK PROGRAMME Healthy Communities Advisory Committee: Standing Items Frqncy Jul Sep

* Oct Nov

* Feb Mar

* May Jun

* Jul Resp

Strategic & Annual Planning

• C/f 2016/17: Update against 2016/17 Maori Health Plan Indicators Annual X S Turner • 2018/19 Annual Plan – approach, priorities and financial assumptions Annual X C Johnston • Health needs assessment –update and impact for planning Annual X R Fong • Equity snapshot – update and impact for planning Annual X S Turner • 2018/19 Annual Plan – draft and workshop Annual X* C Johnston • Locality Planning (via Ops report with separate reports if decision required) 12-weekly X X X X X K Isles • 2018-19 Regional Service Plan – priorities and approach X* V Ayres • 2017/18 Funding Arrangements Document Annual X V Ayres • 2018/19 Funding Arrangements Document Annual X V Ayres • Mental Health Programme 12-weekly X* X* X* X* C Nolan/C Nepia-

Tule • Business Cases o Strategic Business Case – Ward 21 One-off X C Nolan

Partnerships & Consumer

• Disability update Annual X J Smith • NZ Disability Support Service Transformation 12-weekly X X X X X S Ambridge • Health Charter update (with key stakeholders in attendance, eg Police) Annual X C Hansen

Performance Reporting

• Operational Report 12-weekly X X X X X C Johnston • 2017/18 Annual Plan – implementation progress – MoH priorities Quarterly X* X* X* X* V Ayres • 2017/18 Annual Plan - implementation programme – MDHB initiatives 6-monthly X X V Ayres • Non-financial reporting, including health targets and system level measures Quarterly X* X* X* X* V Ayres

Integration

• Central PHO report and presentation Annual X* D Jeremy • PHARMAC report and presentation Annual X* G Sundararajah • Health Promotions Agency report and presentation Annual X C Johnston Standing Items due in Out Years: Strategic Plan review 2019/20 *=joint meeting or report

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Healthy Communities Advisory Committee: Other Matters Raised by Committee and/or ELT

Item Raised Scheduled Resp Status • VRM & Hospital Operations Centre June 17 TBA L Horgan & N Wanden • Child health team update 2 July 17 Feb 18 B Bradnock & G Scott • Mental Health: regional residential review project Sep 17 rpt 28 Nov C Nepia-Tule & C Nolan • Presentations from: o Ministry of Health & Ministry of Education re disability programmes o Enable Good Lives Team o Levin Children’s Team o Kaianga Whanau Ora

July 17 TBA C Johnston

• Update of MDHB/Horizons hosted forum re water quality within district, including matter of trace elements in Horowhenua water and whether this was impacting the health (including mental health) of residents

Bd Sep 17 May 18 D Davies

Completed Items • Outcome of MDHB/Horizons hosted forum re water quality within district* May 17 July N Glubb Completed • Presentation re child area – areas of intersection, eg disability, mental

health and paediatrics May 17 July 17 B Bradnock & G Scott Completed

• Details of Tu Kaha Conference June 17 TBA S Turner Completed • Horowhenua Report Bd, June 17 October C Johnston & L Horgan Completed • Proposed approach to communicating St John’s 111 Clinical Hub July 17 Sep 17 D Jermey Completed • Update re accessing $1m for primary mental health services Bd Aug 17 Aug 17 C Johnston Completed

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