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Targeting Prevention2013

Citation: Ministry of Health. 2013. Targeting Prevention.Wellington: Ministry of Health.

Published in November 2013by the

Ministry of HealthPO Box 5013, Wellington 6145, New Zealand

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This document is available at www.health.govt.nz

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ContentsWhat are health targets?

Increased immunisationOur targetWhy this target is important100 percent effort results in 100 percent coverageCoverage rates boosted by in-home immunisationsWorking with new mothers to boost immunisation ratesDetective work lifts immunisation rate

Better help for smokers to quitOur targetWhy this target is importantWalk-in clinic getting great results in helping smokers quitDianne proud to call herself a non-smokerHospital patients spread the word on quitting smokingSmokefree initiatives beat the odds in NorthlandCessation advice breaks the habit of a lifetime

More heart and diabetes checksOur targetWhy this target is importantPasifika focus the cornerstone for an Ōtara general practiceLeadership and innovation pay off for Western Bay of Plenty PHOThe Heart FoundationNurse-led patient care and teamwork are the key to a Wellington success

The last word

Targeting Prevention iii

What are health targets?Health targets are a set of national performance measures that are designed to improve the performance of key health services. The targets are a focus for action in areas of health that reflect significant public and government priorities.

There are six national health targets, three focus on patient access, and three focus on prevention.1

The Ministry of Health (the Ministry) and the district health boards (DHBs) are collectively responsible for achieving the health targets. Progress is reviewed quarterly and reported publicly in newspapers and on the Ministry and DHBs websites. Seven health experts have been appointed as ‘target champions’ to work with and provide support to the health sector for each of the respective health targets (two target champions have been appointed to the Better help for smokers to quit health target).

The set of six health targets is reviewed annually to ensure they are still relevant and align with current health priorities.

The health targets do not cover all the key health priorities nor should they be viewed in isolation. Each health target should be seen within the context of the broader programme of work and health priority they are part of.

In this publication, we look at how DHBs and their staff are working to achieve: increased immunisation better help for smokers to quit more heart and diabetes checks.

Integrating primary care with other parts of the health service is an important Government priority. Meeting the health targets requires a whole-of-sector commitment to achieving the target goals, strengthening relationships and finding better ways of working between DHBs and the primary care sector.

Figures 1–3 highlight performance trends in each of the target areas from mid-2009 to mid-2013.

In this publication, we look at some of the initiatives, innovations, organisations and people that have contributed to the sector improvements made in these three prevention-focused targets.

1 For details of health targets prior to 2009 see the Ministry of Health website www.health.govt.nz/healthtargets

Targeting Prevention 1

http://www.health.govt.nz/healthtargets

Increased immunisationThe target is for 85 percent of eight- month-olds to receive their six-week, three-month and five-month primary course of immunisations on time by July 2013, 90 percent by July 2014 and 95 percent by December 2014. There has been excellent early progress towards achieving this new health target.

Prior to July 2012 the target focused on two-year-old immunisation.

Better help for smokers to quitThe target is for 95 percent of patients who smoke and are seen by a health practitioner in a public hospital and 90 percent of patients who smoke and are seen by a health practitioner in a primary care setting to be offered brief advice and support to quit smoking. The national hospital component of the target has been met, and the focus is now moving to the primary care component of the target.

More heart and diabetes checksThe target is for 90 percent of the eligible population to have had their cardiovascular risk assessed in the last five years by July 2014. This target is to be achieved in stages. The first stage was to achieve 60 percent by July 2012 and 75 percent by July 2013. While we are still some way off achieving this target stage, data shows a steady uptake in cardiovascular risk assessment (note this target began January 2012).

2 Targeting Prevention

Increased immunisationOur targetNinety percent of eight-month-olds have their primary course of immunisations at six weeks, three months and five months on time by July 2014 and 95 percent by December 2014.

Why this target is important‘New Zealand is achieving record immunisation results, and the future is looking brighter for children’s health in New Zealand,’ says Dr Pat Tuohy, the Ministry of Health’s Chief Advisor, Child and Youth Health and champion for the Increased immunisation health target.

Dr Tuohy says that last year, immunisation rates of 93 percent were achieved for two-year-olds, the highest coverage ever in New Zealand. He adds, ‘The fact 90 percent of eight-month-old babies have been fully immunised, protecting them from deadly diseases such as whooping cough and hepatitis B, is also reason to celebrate.’

Dr Tuohy says that although the new target of immunising 95 percent of all eight-month-old babies was only set in July last year, we are already close to achieving it – more than a year before the deadline.

‘This represents an amazing effort on the part of our primary care and general practice teams and outreach and immunisation staff working out of DHBs.

‘Even better, we are seeing high immunisation rates across ethnic and socioeconomic groups. We now need to highlight to parents the importance of getting babies immunised on time, starting at six weeks of age, to protect them when they are most vulnerable.’

Dr Tuohy says the message is simple: please get your baby vaccinated as soon as they reach each immunisation milestone – that’s at six weeks, three months and again at five months of age. ‘We’re seeing just how vital on-time vaccination is. Our coverage for babies under six months is lower than we would like it to be, and this is of concern at the moment while the current whooping cough outbreak continues,’ he says.

‘It takes all three vaccinations for a baby to be fully vaccinated against the serious illnesses. Diseases don’t discriminate – anyone can catch them, and babies are at risk if they are not fully immunised. It’s vital these vaccines are given on time to limit the baby’s chance of catching the disease.’

General practices are geared up to provide vaccinations to young families. Through early enrolment they offer a range of appointment times that meet the needs of the families and are able to talk to them about the benefits of immunisation. Practices have lots of helpful immunisation tips for parents and are


the best places to get immunisations done. Dr Tuohy says making it as easy as possible for parents to have their children immunised has made a big difference to immunisation rates.

‘The four immunisation case studies discussed in this publication offer great examples of the ways nurses and other health professionals complement general practice teams by going the extra mile to immunise children – literally! Going to children’s homes and immunising them there removes a lot of barriers to immunisation, such as lack of transport, not having car seats and having to bring other children to the clinic.’

Dr Tuohy says a newborn enrolment policy introduced in October 2012 will mean every baby should be enrolled with a GP shortly after birth. Thanks to the multiple enrolment forms that DHBs are introducing into maternity units, babies can be enrolled in other important health services such as Well Child / Tamariki Ora and oral health at the same time. Having earlier access to these services means better health outcomes for babies.

‘One of the benefits of the new system is that practices will be able to remind parents when their baby is due for their first immunisation at six weeks of age.’

Dr Tuohy says he is really looking forward to the important gains that can be made to protect babies and children from deadly and debilitating diseases.

‘Having an immunisation target, tracking immunisation events on the National Immunisation Register and raising the importance of immunisation for our children will have huge benefits for the future health of our children.’

100 percent effort results in 100 percent coverageGiving your kids the best start in life by protecting them against deadly diseases. That is why the Mana Medical Centre is immunising as many babies and children as they can.

The Porirua-based centre recently reached 100 percent coverage for eight-month-olds and received a certificate of recognition for its work from its Primary Health Organisation, Compass Health.

Senior practice nurse Jenny Whitaker attributes their success to having well trained staff and good systems in place which ensures timely reminders for parents. ‘As soon as we are notified that a baby has been born to one of our patients, we send a letter congratulating them and it outlines what immunisations are due and when,’ says Jenny.

‘We know that immunisation is the single most important thing we can do for a child to protect them from deadly diseases, which is why it is such a focus for this practice.’

But if she is to attribute their immunisation success to any one thing, it would be that each of the eight practice nurses at the Centre have dedicated time each week to spend on patient precall and recall.


‘Every nurse here has three hours allocated each week to go through patient recalls, including sending out reminders to parents about when their babies and children are due for their next immunisations.‘Many years ago recalls were done as time allowed. To achieve the desired outcome of having as many of our babies and children fully immunised meant designated time needed to be set aside for precalls/recalls. By making sure everyone has time built in to do phoning has made a huge difference. Nurses get to know patients better and make sure that they follow up with them if they need to,’ says Jenny.

Some parents can be hesitant when it comes to immunising their babies and children. Jenny says it is important to understand why these parents are worried and to talk with them.

‘Parents want to do what’s best for their children so talking to them about their concerns and providing them with extra information can really help them feel more comfortable about deciding to immunise.

‘Sometimes it is also about providing practical help to parents to help them get to the clinic to have the immunisation or organise to immunise them when they are here for other appointments.’

Nurses also regularly check in with families who may have declined to have immunisations in the past, in case their circumstances have changed. Parents usually welcome a friendly call, to let them know that there might be cases of measles or whooping cough in their area, and an offer to revisit their decision at any time.

‘People do change their minds so it is always worth making a phone call to check if this is the case. They may still decline but occasionally they do say they would like to come in for immunising and nothing is more satisfying when they do!’ says Jenny.

Coverage rates boosted by in-home immunisationsAn in-home immunisation service has played a big part in lifting Hawke’s Bay’s overall immunisation rate for eight-month-olds to 94 percent.

The service is provided by the Tamariki Ora team at Hawke’s Bay’s largest Māori health provider, Te Taiwhenua o Heretaunga.

The Tamariki Ora team provides a kaupapa Māori service for children from birth to five years of age throughout Hastings, Napier and Central Hawke’s Bay. The professional nursing service, supported by kaiāwhina (qualified health assistants) provides in-home health screening that includes scheduled immunisations and developmental monitoring.

Te Taiwhenua o Heretaunga staff have given more than 400 vaccinations to children in the past 12 months, including children in hard-to-reach families who might otherwise have remained unimmunised.


Te Taiwhenua o Heretaunga Community Nurse Manager, Julia Ebbett, says in-home immunisation solves many of the issues whānau have in getting their children immunised, such as lack of transport, not having car seats and having to bring other children with them to the clinic.

‘The focus is on wellness, and the in-home immunisation service is accepted as just part of the wider service families receive for that child,’ Julia explains.

Hastings mum Kandice Lawrence is grateful a simple immunisation for one of her children no longer involves a half-day expedition to the doctor. Mum to Angel (five-years-old), Jahkobi (one-year-old) and Kylah Raukawa (four-weeks-old), taking one child to the doctor means taking all three.

Kandice used to take Angel to a GP for her immunisations, but when Jahkobi was born, she signed up with Te Taiwhenua o Heretaunga’s Tamariki Ora programme. Since Kylah was born, Kandice has been receiving even more regular home visits from her nurse and kaiāwhina as part of the kaupapa Māori service.

‘I like it because I don’t have to put all the kids in the car, then wait at the doctor’s,’ she says. ‘It’s hard, especially when you have to go into town.’

Kandice also enjoys being able to breastfeed Kylah while Angel or Jahkobi are being seen by their nurse and has noticed that Jahkobi is quite relaxed when he receives an immunisation at home and settles quickly afterwards.

‘At home, in your own whare, you are in a situation where you are in control,’ she says.

Working with new mothers to boost immunisation ratesMichaela Kamo is a familiar face at Tauranga Hospital’s maternity unit. In her role as immunisation advocate and outreach administrator for the Western Bay of Plenty Primary Health Organisation (PHO), she visits the unit three days a week to meet new mothers and give them information about the benefits of immunising their babies.

‘I’m not a nurse; I come in as a parent,’ Michaela says. ‘I have three children, so I’ve been through the system. I know how busy we all are as parents, and I know how it feels to bring your children in for vaccination.’

Michaela’s role was created two years ago in response to low immunisation rates in the area. There are similar lay advocates in other countries who work to increase immunisation rates in their local communities.

When Michaela visits the ward, she introduces herself to new mothers and gives them pamphlets and resources from the Immunisation Advisory Centre (IMAC). IMAC is a nationwide organisation based at the School of Population Health at the University of Auckland and supported by the Ministry of Health to promote immunisation around the country. Michaela also tells the new mothers about IMAC’s free 0800 phone number and website, which can help with any questions they may have about immunisation.


‘They can read the pamphlets while their babies are asleep, call a phone line or check out the phone and web resources later,’ she says.

Michaela also gives each new mother a fridge magnet that lists the date of their baby’s next immunisation.

‘I get the biggest response from the fridge magnets – mothers find them really helpful,’ Michaela says.

She supports parents through immunising their babies, including making follow-up phone calls and sending text messages, and says that mothers appreciate her visit, particularly if they are first-time mothers.

‘Parents are often grateful that they can access reliable information about immunisation and can talk it through with someone,’ she says.

Michaela used to visit the maternity ward to enrol babies with a GP, but now ward clerks have taken over enrolments. Maternity unit manager Esther Mackay says the system works well, with Michaela talking to parents about immunising their babies and the administration staff member going around the ward every day with a form parents can fill out to register their babies with the local PHO.

Michaela is also part of an outreach immunisation team that vaccinates babies in their own homes. She and another staff member take turns to accompany two vaccinators on home visits.

In addition, Michaela follows up on babies who are not enrolled with a GP – and talks to parents’ groups about immunisation.

‘Part of my advocacy role is to make sure everyone is working together to plug any gaps in the system,’ Michaela says. ‘It’s all about working together well and being more efficient.’

The team approach to immunisation is paying off. For the three months to 31 March 2013, the Bay of Plenty DHB achieved 88 percent immunisation coverage for children aged eight months, exceeding the national target of 85 percent. Chief Executive Phil Cammish says the DHB achieved its results by working closely with PHOs, GPs and practice nurses.

Detective work lifts immunisation rateTracking down children who haven’t been immunised involves lots of phone calls, door knocking and quick thinking. But perseverance has helped Counties Manukau DHB lift its immunisation rate for two-year-olds from 89 percent to 95 percent in just nine months.

The programme was a break with tradition for Counties Manukau DHB. For five years, its contracts with its Well Child / Tamariki Ora providers didn’t include giving vaccinations.

Carmel Ellis, Programme Manager, Child Health at Counties Manukau DHB says immunisation delivery wasn’t included in the contracts because the DHB wanted families to reconnect with primary care.


However, a study found that families who hadn’t had their children immunised would much rather have the injections given in their own homes than go to the GP. So, at the beginning of 2012, the DHB launched a pilot programme that involved all four Well Child / Tamariki Ora providers locating children who had missed their immunisations and vaccinating these children in their own homes.

At Plunket, outreach immunisation is carried out by five Plunket nurses and five community Karitane and Plunket kaiāwhina health workers. These people work in teams of two: one Plunket nurse with one health worker.

At the start of each day, the team is given DHB files of the children who need to be vaccinated. The children aren’t enrolled with a GP, but almost all are enrolled with Plunket.

‘We check every file to see which immunisations the children need, and then we start chasing them. We have high levels of transient families, so it’s not easy,’ Well Child / Tamariki Ora Nurse Sita Moala says.‘We ring family doctors and check the Plunket database for updated addresses. We phone families if we have phone numbers for them, but the phone numbers often don’t work, so we have to start door-knocking. Usually, we manage to find the families we’re looking for.’

The Plunket team concentrates on the under-two-year-olds but does opportunistic catch-up immunisations for any other children in the house who have missed out on their vaccinations. If Plunket discovers that a family on its referral list has moved out of the area, it sends the new address to the appropriate DHB.

Families are usually pleased to see Plunket staff on their door, Sita says.

Jayne Burch, Clinical Leader of Coxhead Manurewa for Counties Manukau Plunket, says Plunket involvement is welcomed because the organisation has already had contact with the families.

‘We’re readily invited into people’s homes, which is a privilege.’

Once the team have tracked down a family, Sita gives the immunisation and updates the child’s immunisation status in the records, while the accompanying health worker talks to the family and gives them safety messages. Details of each immunisation are sent to the National Immunisation Register, which sets up a timetable for the remaining vaccinations on the immunisation schedule.

The outreach immunisation programme’s work is reflected in Counties Manukau’s much-improved figures. By the end of 2012, the DHB had met the health target of fully immunising 95 percent of all two-year-olds. This included immunising 97 percent of Pacific children and 92 percent of Māori.

The DHB is now concentrating on meeting the new health target and ensuring babies receive their primary course of immunisations by the time they are eight months old.

Immunising babies earlier can help prevent them from ending up in hospital with respiratory problems. In July 2012 79 percent of eight-month-olds were fully


immunised. In the nine months since, coverage jumped to 86 percent in March 2013, including 88 percent of Pacific babies and 76 percent of Māori babies.

‘This programme is about everyone working together as a team – the DHB, Well Child / Tamariki Ora providers like Plunket, and doctors. That’s why it works,’ Sita says. ‘I do it because I want to make a difference.’


Better help for smokers to quitOur targetNinety-five percent of patients who smoke and are seen by a health practitioner in public hospitals and 90 percent of patients who smoke and are seen by a health practitioner in primary care are offered brief advice and support to quit smoking.

Why this target is importantResearch tells us that a smoker’s chance of successfully quitting is higher when advised to stop by their doctor or nurse.

‘We know that it is hard to quit smoking, and that people might make a number of attempts to stop before they’re successful,’ joint target champion Dr John McMenamin says. ‘Those chances increase with support and having someone check in with them, especially if that person is their doctor or nurse.‘Using appropriate nicotine products also increases people’s chances of success, and GPs provide those in conjunction with other specialist support services, such as quit clinics, iwi-based programmes like Aukati KaiPaipa and Quitline.’

Joint target champion Karen Evison says most people who smoke want to stop, and doctors, nurses and other health professionals, who see people who smoke every day, are perfectly placed to offer support and advice.

The Better help for smokers to quit health target has two target champions. Karen Evison is the target champion for the hospital target and Dr McMenamin has a focus on supporting smokers in the community as part of the primary care target.

When the Better help for smokers to quit health target was introduced in hospitals in 2009, some clinicians were sceptical that it could ever be achieved. Initial results showed only 17 percent of hospital patients were offered brief advice and support to stop smoking.

Now that percentage has risen to 95 percent across all DHBs. All hospitals offer these services to at least 90 percent of patients who smoke.

A similar target for GP-led health teams has seen over half of all smokers having discussions with their GP about quitting, and large numbers of people being successfully supported to quit. Karen says ‘It is fascinating to listen to clinical conversations now and see how much emphasis is placed on offering patients support and advice on stopping smoking. We are the only country in the world that


has a target that requires every health professional in the country to ask patients if they smoke and follow that up with help.’

How does Better help for smokers to quit work in practice?The majority of smokers want to quit, but most need help to do so. Health care professionals (such as doctors or nurses) are perfectly placed to provide such help, as they regularly treat people who smoke.

In 2007, the ‘ABC’ approach was developed to remind health care professionals of the key steps involved in providing Better help for smokers to quit. The key steps include:Asking each person about their smoking status and documenting their

responseproviding Brief advice to stop smoking to each person who smokes, andoffering evidence-based Cessation support (such as nicotine replacement

therapy (NRT) or a referral to a quit smoking service) to each person who smokes, regardless of their desire or motivation to quit.

Evidence has shown that around 1 in 40 smokers quit after being given advice by a health professional, and even more quit when this advice is coupled with an offer of cessation support.

Dr McMenamin says it’s important to make the most of the contact and relationships that smokers have with their doctors and practice nurses to keep talking about smoking, so even if people aren’t ready to stop, they can be confident that support is available when they need it in the future.

‘Many people need support from more than one source to quit smoking. Back-up helps, for example, we like to see people talking to their GP as well as receiving help from Quitline,’ Dr McMenamin says.‘We know some people don’t visit their doctor in any particular year, so we’re also supporting programmes that contact these patients to ask them if they’d be interested in having support to quit. A new pilot texting programme aimed at such patients is in its early stages but is already achieving very positive results.

‘There are some really exciting things happening. New Zealand is leading the world in becoming the first country to be smokefree by 2025, and other countries are following closely what we are doing.‘These case studies outlined over the following pages illustrate perfectly how important it is to have quit smoking support readily and easily available, both in hospitals and in the communities,’ Dr McMenamin says.

Karen Evison is Ministry of Health National Programme Manager and joint target champion for this target.Dr John McMenamin is a Whanganui GP, Clinical Director of Whanganui Regional Primary Health Organisation and joint target champion with a focus on primary care for this target.


Walk-in clinic getting great results in helping smokers quit

‘We offer a very warm, welcoming service that doesn’t judge. That surprises people because they think it’s going to be very clinical,’ quit coach Rosie Carpenter says.

Whanganui’s free walk-in clinic to help smokers quit is getting great results. Nearly half of the clients are smokefree four weeks after their set quit date. More than a third are still smokefree after six months.

The Whanganui Regional Primary Health Organisation set up the clinic two years ago. Nearly 900 people have registered at the clinic over the last two years.

Smokers can make an appointment or simply turn up. They are matched with a ‘quit coach’ who can provide them with free nicotine replacement therapies (NRTs), such as patches, lozenges and gum, and information about prescription-only quit smoking medications. Importantly, the coaches provide face-to-face personal support.

Quit coach Rosie Carpenter, herself a former smoker, says the key to the clinic’s success is tailoring a programme to each client.

‘Everyone has a different relationship with smoking.‘We have the time to engage with individuals and address all the issues behind their smoking. There’s usually a lot of fear involved in getting over an addiction like smoking. There’s also a lot of hardship and poverty in this area, and some people will spend an hour in the first visit getting to the bottom of their addiction and its role in their lives.

‘Most people’s smoking is stress-related, so we put coping mechanisms in place to help them with that. Our quit coaches need to have good interpersonal skills and a lot of patience.‘We want clients to walk out the door excited about what they’re about to do because they know they have everything to gain,’ Rosie explains.

Rosie says that the clinic likes to see people weekly for the first month or so, then maybe fortnightly, although it’s not a problem if a client wants to continue to come weekly.

‘And if they slip up and start smoking again, they know they will be welcomed back.’

Evaluation of the service has shown that it is reaching more Māori clients and young people than GP-based services generally do.

Nearly 80 percent of people visiting the clinic said the experience had ‘exceeded their expectations’, and 98 percent said they would recommend the clinic to other people. Not surprisingly, word of mouth is how most clients are referred.


Dianne proud to call herself a non-smokerDianne Bradey doesn’t miss smoking and has no desire to go back to it.

Dianne was recently named ‘Quitter of the season’ by Whanganui’s walk-in quit clinic and was presented with a bouquet of flowers and a beauty clinic voucher.

Her health was pretty low when she sought help to give up smoking from the clinic. The 62-year-old has had two strokes and had just finished chemotherapy for blood cancer.

Dianne had tried to quit smoking in the past.

‘I stopped for three months once and thought I could go back to just having the odd cigarette. Before I knew where I was, I was back smoking again.’

The clinic gave Dianne nicotine replacement patches and lozenges to help her quit, but she says most of the credit should go to her quit coach Rosie Carpenter.

‘Rosie is phenomenal. She’s an inspiration to me. I still come in every week to see her, even if it’s just to talk. It’s a huge help that Rosie is an ex-smoker. I feel when I talk to her that she can relate to me because we’ve been down the same path.’

Rosie Carpenter says that Dianne was struggling to walk when she first came into the clinic.

‘Now she’s almost running through the door.’

Dianne’s haematologist is also delighted she has given up smoking, as Dianne explains, ‘She’s so thrilled. She couldn’t believe it.’

Dianne sees less of her friends who smoke these days.

‘But that’s fine. They have to understand that I need to mix with people who don’t smoke. When I do see them, I’m on at them to give up.’

She’s also begun to notice the money she is saving and has treated herself to a manicure and pedicure with encouragement from her quit coach.

Hospital patients spread the word on quitting smokingMike Frear found a great way to support a friend in hospital – when she had to give up smoking, he decided he’d quit too.

Tara Loretz-Frear started smoking five years ago, at the age of 13 but had to give up her cigarettes when she was admitted to Whangarei Hospital with a broken back and was unable to leave her ward. It wasn’t easy, but she was cheered when Mike Frear announced that he’d give up smoking in solidarity.


The nurse educator on Tara’s ward referred Mike to the smokefree hospital facilitator Jan Marshall, who spoke with him about smoking cessation options and wrote him a quit card for nicotine patches and gum.

Mike, who had been smoking for only a year, found the first three or four days without cigarettes difficult. But he soon began to see the benefits of not smoking.

‘I’d had a cough for a few weeks, but within a couple of days of giving up smoking, the cough was gone. My dad was really pleased I’d given up – he had been on my case about it,’ Mike says.‘Giving up smoking was something I could do to support Tara. She couldn’t smoke in hospital, and I needed to stop too.’

Tara Loretz-Frear also used the nicotine patches and gum arranged by a hospital nurse.

‘I had been thinking about cutting back anyway, but I just hadn’t got around to it. When I got to hospital, I had to give up,’ Tara says.

‘It was hell at first, but I have got over the worst of it. It’s great that Mike has given up smoking. As long as we can stick to it, giving up cigarettes will be one positive thing to come out of breaking my back.’

Smokefree initiatives beat the odds in NorthlandWhen it comes to smoking, the Northland region has more than its fair share of challenges. A quarter of all Northlanders smoke and so do more than half of Māori living in the region.

‘I’ve always believed that getting people to stop smoking is one of the most important things you can do in health,’ says Northland DHB’s Chief Executive, Dr Nick Chamberlain.

Northland DHB’s smokefree team works across the region to introduce and support initiatives that discourage smoking, including providing a smoking cessation service at Whangarei Hospital. The team also trains and supports hospital staff to use the ABC memory tool to help patients quit smoking (see page 13 for a summary of the ABC approach).

Nick Chamberlain established and, for a time, chaired the local and national ABC steering groups. He says that more than 600 Northland DHB staff have now been trained in how to use ABC.

The Better help for smokers to quit health target requires DHBs to offer brief advice and cessation support to 95 percent of patients who smoke, and are seen by a health practitioner in a public hospital. In September 2012, Northland DHB moved from just under 95 percent to consistently achieving between 97 and 98 percent.

‘Better help for smokers to quit is not just about ticking boxes; it’s about giving staff the skills they need to talk to patients about giving up smoking,’


says Nick. ‘We’ve taken a collaborative approach, getting clinicians on board, supporting our staff and working hard to keep our grounds smokefree.’

ED nurse manager Margaret Dreadon says that simple changes have helped Northland DHB achieve that final few percent.

‘Changes to things like documentation and coding may seem small, but they’ve made a big difference.’

Whether providing advice and support to quit to smokers will reduce the burden of smoking on the Northland region, Margaret says, ‘I don’t think we’ll see the real results of the smokefree work until much further down the track – when the children of the people who have given up smoking decide not to take up smoking themselves.’

Cessation advice breaks the habit of a lifetimeA 64-year habit was broken when Margaret Hayes made a snap decision to give up smoking.

‘I’d been admitted to hospital, and a lovely nurse came up to me and asked me if I smoked. She said, “Do you want to give up?”, and I don’t know why but my mouth opened and I said “Yes.”’

Margaret, who is 82, was in hospital with a back problem when the nurse asked her if she wanted to quit smoking. The nurse put her in touch with Carmen Chamberlain from South Canterbury DHB’s smokefree team, who visited Margaret when she returned to her home, and as Margaret recalls, the pair clicked immediately.

Carmen offered Margaret the choice of nicotine patches, gum or lozenges. Margaret couldn’t use patches because of her fragile skin and hates the taste of chewing gum, so she chose the lozenges.

‘I had my last cigarette on 25 March 2012. When I told Carmen I had given up, you could have heard her without the phone; she was so excited. She is so proud of me, but I couldn’t have done it without her,’ Margaret says.

Margaret currently needs only three or four lozenges a day, which she usually takes at the times she would have smoked in the past: first thing in the morning, last thing at night and with her 10 am cup of coffee.

Carmen also gave Margaret a smokefree sign, which Margaret has put on her back door.

‘My house is smokefree now. If a visitor takes a packet of cigarettes out, I say, “If you don’t mind, read the sign on the back door.” And they say, “Oh, can’t I smoke in here?” And I say “No.”’

Margaret’s father and husband both smoked.‘In our day, it was cool to smoke,’ she says. ‘I’d tried to give up before but only by going cold turkey.’


Margaret still isn’t sure why she said yes when the hospital nurse asked her if she wanted to stop smoking, but she is glad she did.

‘I think I was ready to give up.’


More heart and diabetes checksOur targetNinety percent of the eligible population will have had their cardiovascular risk assessed in stages by July 2014.

Why this target is importantThe heart and diabetes health target is making a real difference to people’s lives. Heart disease and diabetes kills up to 6000 New Zealanders a year.

‘Targeting more heart and diabetes checks is helping GPs to better diagnose type 2 diabetes and cardiovascular disease and work with patients to manage these long-term conditions,’ says target champion Wellington GP, Dr Helen Rodenburg.

Helen Rodenburg is the Ministry of Health’s Clinical Director, Long-term Conditions. A big part of her role is supporting DHBs and groups of local general practices called primary health organisations (PHOs) to meet the More heart and diabetes checks health target.

Helen says that the target isn’t just a box-ticking exercise.

‘It’s a valuable tool to help make sure that people who have an unknown risk of heart disease and diabetes are checked and offered support to manage their condition.’

Helen explains that four DHBs have met the target, and nearly all have improved their performance since the target was introduced in January 2012. The number of assessments is continuing to increase.

She says the target is simple to understand and makes it easier for DHBs, PHOs and general practices to work together.

‘Doing heart and diabetes checks systematically and consistently helps GPs diagnose diabetes and cardio vascular disease more effectively. It also helps them to identify a person with pre-diabetes so that discussions can begin with regard to managing that person’s risk,’ says Dr Rodenburg.

Professor Norman Sharpe, Heart Foundation Medical Director, agrees.

‘The heart health and diabetes target is an unprecedented opportunity and challenge for primary care. All eligible adults are at risk of heart disease and should be assessed and supported with necessary changes through discussion and shared decision making. Achievement of the target offers an entry point


for effective lifelong management with the potential to provide large health benefits for many people.

‘Primary care is in the keystone position to systematically and effectively merge population and individual health improvement for which purpose this target is a timely incentive,’ says Professor Sharpe.‘It’s clear from the three case studies discussed on the following pages that PHOs and general practices, supported by their DHBs, are coming up with really creative and effective ways to work with patients to make sure that they fully understand their condition and how to manage it,’ says Dr Rodenburg.

‘The result is better management of people with diabetes and cardiovascular disease, which will ultimately help these patients to lead longer, healthier lives. In some cases, this is life changing for the people involved, and they also become partners in their own care.’

Helen says that, for people who need more help to manage their conditions, there are a range of options and funding available, such as Green Prescriptions for increased physical exercise and Care Plus, which is a primary health care initiative that targets people with high health needs due to chronic conditions, acute medical or mental health needs, or terminal illness.

Helen says that the target also helps GPs make the best use of their practice teams and practice nurses.

‘Practice nurses are very skilled and effective health professionals who work with patients to help them manage their long-term conditions,’ she explains.

Helen is encouraging general practices to appoint their own ‘target champions’ to drive the work needed to achieve this health target.

‘Having a good person in place to lead and coordinate is really useful. It’s about having a team approach, backed up with good systems,’ she says.

Pasifika focus the cornerstone for an Ōtara general practice

‘It’s about making people feel welcome when they come to our clinic and giving them information they can use, Ōtara diabetes nurse Pene Pati says.

The key to success in the general practice he works in is the practice’s connections with the local community and its support for families and all things Pasifika.

Pene is a diabetes nurse at South Seas Healthcare in the South Auckland suburb of Ōtara. He says many of the people coming to the clinic, which works with a predominantly Pacific population, have diabetes and have been told to take medicines or avoid certain foods, but they don’t fully understand the medical condition they are living with.

‘It’s different when they come here,’ he says. ‘We have Pacific artworks up on the walls, and we provide a Pacific-style health service. We promote a family


atmosphere so that people feel free to discuss their diabetes, and we can talk to them in a number of languages.’

Pene, who speaks Sāmoan, says the sense of community doesn’t stop at the clinic doors.

‘It’s all about relationships with people. I go for a walk around the shopping centre, and people know me. Everywhere I go, people greet me. We are like family, and we work as a team, both at the clinic and out in the community.’

One of his patients is 29-year-old Joyrose Ikiua, who was diagnosed with diabetes in November 2012 and now injects herself with insulin twice a day.

‘I didn’t have any symptoms but failed my eye test for my driver’s licence,’ says Joyrose. ‘I had to go for another eye test and then another, and then I was tested and found to have diabetes.’

She says she was initially overwhelmed by all the information she needed to absorb, but nurses like Pene Pati helped her navigate through the information.

‘I wasn’t happy at first, but now I go to the clinic and get one-on-one help to manage my diabetes. It’s really positive for my personal wellbeing, and I feel there is a lot of love and patience.’

Joyrose has a five-year-old son and says that the changes in her own life are flowing over into the type and amount of food she prepares for her son’s meals.

‘I’ve really thought a lot about the food I used to give him. I’ve cut it down, and now I make sure he has lots of healthy meals with meat and vegetables.’

She also incorporates a lot more exercise into both their lives.

‘It’s about re-prioritising and being healthy in both mind and body,’ she says.

The South Seas Healthcare clinic is part of the Alliance Health+ Primary Health Organisation, which is the only Pacific PHO in New Zealand and is responsible for 17 mainly Pacific-based general practices across both Counties Manukau and Auckland DHBs. The Alliance Health+ practices perform well against the national health targets, with the South Seas Healthcare clinic already performing well above the targets.

Allan Moffitt is the clinical director at Alliance Health+ PHO and also works as a GP one day a week at the South Seas Healthcare clinic. He says the key to their success lies in identifying opportunities to connect with people and encouraging them to be tested for diabetes and cardiovascular disease.

‘The reality is that most people see their GPs at some point, and every contact like that is an opportunity to conduct an interview to find out what’s going on with them.’

The PHO uses text messages rather than posted letters to communicate with patients and also provides weekly real-time feedback to general practices about how they are doing.


It’s about making people feel welcome when they come to our clinic and giving them information they can use.

Allan Moffitt says that it is important to set clear targets for the general practices and to individualise those targets so that they are relevant. He also supports using standardised processes and good auditing tools to track what is happening.

‘It’s about focusing on what’s realistic and relevant to both the patients and the clinicians,’ he says.

Leadership and innovation pay off for Western Bay of Plenty PHOClose relationships with medical and nursing staff are helping Tauranga man Syd Hirini-Thompson manage his diabetes.

Syd says that being diagnosed with type 2 diabetes was a shock.‘I didn’t know anything about diabetes, so I’ve had to learn a lot. I’ve had to change some of what I eat. I still have porridge for breakfast, but now I put green-top milk on it rather than blue-top, and I’ve really cut out the sugar. I’m also going to the gym six days a week, and I mow lawns for a bit of physical activity.’

To a large extent, the 55-year-old attributes his ability to make lifestyle changes to the information and support he has received from his GP and nurses.

‘Their support has been invaluable,’ Syd says.

It’s this team approach to patient care that is actively encouraged at the CentralMed Health medical centre in Tauranga. The practice has 14,000 people on its books and runs a healthy lifestyles clinic four days a week to help people with their food and exercise choices. Nurses are rostered onto the healthy lifestyles clinic, and Linda Kelly, who is the centre’s nurse team leader, says the lifestyles clinic is working well.

‘Most of the people coming to the healthy lifestyles clinic have diabetes, but not all do. We get people attending who have high cholesterol or high blood pressure, and we can provide closely targeted advice.’

She says the medical centre’s diabetes nurse manages all of the complex cases but is also supporting another nurse who is undergoing further diabetes education and looks after the impaired glucose patients as well as the better controlled patients. This means that the medical centre can monitor patients regardless of where they are in their diabetes health status.

All diabetes patients are also offered a cardiovascular risk assessment and, between March and July each year, a flu vaccination.

Cardiovascular risk assessments are a key aspect of every diabetes / healthy lifestyle clinic appointment.

‘That’s a big improvement on what we used to do, which was to test people as they came to us,’ Linda Kelly says. ‘It was quite opportunistic. The approach


we have now is a lot better, and the nurses and doctors work very closely together as a team.’

Donna McArley from the Western Bay of Plenty Primary Health Organisation believes that having a champion for this work is essential.

‘It’s really important to have commitment and buy in from everyone,’ Donna says. ‘It doesn’t matter if the champion is a doctor or a nurse; it’s about someone taking the lead.’

The PHO supports practices by developing best practice systems and audit tools and by providing opportunities for ongoing training. It also actively seeks out ‘hard to reach’ people by sending out teams of mobile nurses who offer workplace cardiovascular risk assessments, including to the kiwifruit industry, the local port and wharf, and to people working on road maintenance and construction.

And according to Professor Norman Sharpe, the Medical Director of the National Heart Foundation of New Zealand, the Western Bay of Plenty PHO offers an excellent example of leadership, quality improvement and innovation. It is the first PHO to assess risk of cardiovascular disease in more than 75 percent of its eligible population, a health target set by the Government for primary health care services to achieve by July this year.

‘This is a fantastic achievement, and it reflects considerable hard work over the past year to get it right,’ Norman says. ‘Three years ago, this PHO had one of the lowest assessment rates in the country, but they’ve managed to turn that around.’

The Heart FoundationThe Heart Foundation provides cardiovascular risk assessment and management-related guidance, clinical advice and leadership to the health sector. This is being used to support the achievement of the More heart and diabetes checks health target.

As the only national organisation with a sole focus on the prevention and management of heart disease in New Zealand, the Heart Foundation continues to work at multiple levels to support the health sector to achieve the target.

At the patient level the Heart Foundation provides a catalogue of cardiovascular disease (CVD) resources to support patients and works to raise public awareness through campaigns to promote heart and diabetes checks.

To enable a national, systematic approach to cardiovascular risk assessment and follow-up support for those identified as at risk, the Heart Foundation provides a suite of cardiovascular disease risk tools including: Taking Control, a workbook for people at elevated risk of cardiovascular disease

which uses evidence based techniques to support health literacy, self-management and development of a heart health plan. The workbook is a free resource available for order directly from the Heart Foundation

Your Heart Forecast, a risk communication tool for health practitioner use in consultation


Improve Heart Health e-Learning programme, an on-line training course to support health professionals design and deliver successful cardiovascular risk assessment and management services.

At the provider level the Heart Foundation offers support through ongoing training and sharing best practice. A series of case studies of top performing PHOs and practices in relation to the target are available at www.heartfoundation.org.nz/leadersinCVDRA

The Heart Foundation runs primary care training workshops in cardiovascular risk assessment and management. Workshops are tailored to individual needs and offer a selection of topics including pragmatic risk assessment and management advice, support and tools for practice nurses and PHO staff to pick up and use immediately.

The Heart Foundation can be contacted directly for support with cardiovascular risk assessment and management www.heartfoundation.org.nz

Nurse-led patient care and teamwork are the key to a Wellington successWhen Wellington man Colin Hyde was diagnosed with type 2 diabetes in March 2012, he says it was the wake-up call he needed.

‘I’m a typical bloke: I don’t go to the doctor unless I have to,’ says the 52-year-old software-company product manager. ‘And it was pretty obvious I had to. I was urinating every 40 minutes, always thirsty and I had cramps in my legs.’

Now Colin takes medicine to help manage his blood sugar and says his medication, food and lifestyle changes have made a big difference. He attributes his good management of his diabetes in a large part to the regular Care Plus clinic he attends at the Johnsonville Medical Centre.

The clinic offers patients one-on-one consultations with a nurse who specialises in managing long-term conditions such as diabetes, heart disease or obesity. The time is ‘protected’, which means a lengthy consultation free of interruptions.

Colin visits the clinic every three months or so and says the consultations have been very useful.

‘We talk about my blood test results, and I get advice on food, etc. Over time, you build a relationship with the nurse, and it’s really good. It feels as if you’re supported by a team of people instead of having to figure out everything for yourself.’

Susan Flynn-Couper is a diabetes nurse at the Johnsonville Medical Centre’s Care Plus clinic. She says the consultations provide an opportunity to really get to know patients and tailor assistance to their particular needs.

‘There are clinical benefits as well,’ she says. ‘We have noticed improvements in patients’ blood test results after they have attended these clinics and received focused attention on managing their long-term conditions.’


Susan says that the practice provides ongoing training and professional development for nurses, supports nurse-led patient care and promotes a team approach.

‘This provides us with a lot of job satisfaction, and it’s really beneficial for patients as well,’ she says. ‘We’re working to the maximum scope of our nursing practice, supported by the doctors we work with and the practice itself. It’s great, and it feels as if we are making a difference.’

It’s exactly this type of proactive team approach to managing diabetes and cardiovascular disease that Jo Wilson, the clinical facilitation team leader at Compass Health, is keen to foster.

Compass Health is a group of local general practitioners called a primary health organisation (PHO). The PHO covers 51 practices in Wellington, Porirua and Kapiti and another seven practices in the Wairarapa. Jo says that the challenge is to build relationships with all the practices so that the staff who work in them understand the importance of achieving the health target.

‘It’s about making the health target for heart and diabetes checks as real as possible,’ she says.

‘Once people understand that there are real clinical benefits to be gained from achieving the health target, then they’re on board and very focused.’

Jo says that nurses have a big input in achieving the health target as they deliver a lot of the cardiovascular disease and diabetes health care and have a rapport with their patients.

Compass Health provides practices with a number of resources to help with cardiovascular disease and diabetes checks, such as a sample recall letter and a list of frequently asked questions and answers. The PHO has also installed a ‘patient dashboard’ in most of its practices to prompt health professionals to ask patients if, for example, they have completed a cardiovascular risk assessment. The dashboard provides instant updates on how patients are measuring up against the health targets.

‘Practices are working hard to reach this health target,’ Jo says. ‘They just need good systems and processes, and lots of support from us. For example, they simply do not have time to track how they are doing and to identify who they are missing, so anything we can offer that allows them to do this easily is a plus.’

We’re working to the maximum scope of our nursing practice, supported by the doctors we work with and the practice itself. It’s great, and it feels as if we are making a difference.


The last wordKevin Woods, Director-General of HealthEvery day, there are many improvements being made to health and disability services to deliver better, sooner and more convenient health care to New Zealanders.

The six national health targets provide a focus for action, and success against the targets is just one measure of progress. This publication highlights some of the many innovative approaches that have been developed to deliver on the health targets.

As individual targets have been achieved, the focus has shifted to new areas. In addition to our ongoing goals of shorter stays in emergency departments and improved access to elective surgery, we are now also working to achieve: more comprehensive risk assessments for cardiovascular disease shorter waits for chemotherapy as well as radiotherapy increased immunisation cover for eight-month-olds as well as two-year-olds better help for smokers to quit in primary care settings as well as in hospitals.

It’s clear that we need to work together closely across the health sector to achieve our goals. Collaboration and commitment between the Ministry, DHBs and a wide range of community providers has been a key factor in our successes to date and will continue to be important as we make progress on these health targets.


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