Implementing the New Zealand Health Strategy 2003
The Minister of Health’s third report on progress on the New Zealand Health Strategy
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Date of publication: December 2003page 5 of 6 This is the full text online version of this document.
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Chapter 6: Timely and Equitable Access to Services
The principle of ‘timely and equitable access for all New Zealanders to a comprehensive range of health and disability services, regardless of their ability to pay’ reflects the fact that fairness is a fundamental value for New Zealanders. The health sector must ensure New Zealanders with similar health conditions are able to achieve similar outcomes, and are able to access health care within a reasonable period of time.
This chapter explores four important dimensions of timely and equitable access to services:
- improving access to primary health care and the delivery of primary health care services by implementing the Primary Health Care Strategy
- progress towards ensuring access to public hospital services, specifically elective (nonemergency) services and oncology services
- activities to retain and recruit a skilled primary health care workforce for people living in rural areas
- initiatives to develop an integrated continuum of care that is responsive to the older people’s health needs.
6.1 Taking primary health care forward by implementing the Primary Health Care Strategy
Policy context
Primary health care is the first option for people when they are ill or injured. Therefore, a strong primary health care system is central to improving the health of New Zealanders and to removing health inequalities. The primary vehicle for improving primary health care access and services is the implementation of the Primary Health Care Strategy (Minister of Health 2001). This is also one of the health and disability sector’s seven key service priorities.
The strategy builds on the population health focus and the objectives of the New Zealand Health Strategy and the New Zealand Disability Strategy, and outlines how a different approach to primary health care will improve the health of all New Zealanders through:
- a greater emphasis on population health, health promotion and preventative care
- bringing together a range of professionals and encouraging multidisciplinary approaches to decision-making
- improving service accessibility, affordability and appropriateness
- improving co-ordination and continuity of care
- providing and funding services according to the population’s needs as opposed to a fee for services when people are unwell.
Over the three years from 2002/03, $479 million in funding will be allocated to the implementation of the Primary Health Care Strategy. In 2002/03, $50 million was allocated to the strategy’s implementation, increasing to $165 million in 2003/04, and to $264 million in 2004/05 as the coverage of the strategy expands.
PHOs are local structures that are being progressively established across New Zealand by DHBs and provider groups to deliver primary health care services. DHBs fund PHOs to provide primary health care services to the PHOs’ enrolled populations. PHOs provide essential primary health care services to a defined population, including first level general practice services, some health promotion services, and services specifically designed to improve access for groups known to be in most need.
PHOs are funded by either the Access or Interim funding formula. The Access formula allows PHOs to provide low cost access to primary health care and is available to PHOs, or individual practices within interim funded PHOs, when more than 50 percent of their enrolled population belongs to recognised high need groups. Access PHO practices have the same co-payment charges for patients with Community Services Cards and patients without cards.
The Interim funding formula is for PHOs in areas with populations of a lower level of health need. Interim-funded PHOs continue to charge the fees they did before becoming a PHO, including reduced costs for Community Services Card holders. Over time, the levels of funding through the Interim formula will be raised so that all New Zealanders will receive low cost access to primary health care. The process of increasing the Interim formula began in October
2003 for children and people aged 6–17, and will continue in 2004 when funding for older people enrolled in interim PHOs is increased.
Progress in 2003
Progress in establishing PHOs has been rapid since the first two formed in July 2002. The rapid expansion of the Primary Health Care Strategy meant that within the first quarter of the 2003/04 fiscal year, approximately 860,000 people were funded under the access formula, and 835,000 people were funded under the interim formula through PHOs. Figure 23 shows the actual and forecast populations enrolled with PHOs.
Figure 23: Actual and projected Primary Health Organisation enrolments, 2002/03 to 2005/06
At October 2003 an estimated 2 million New Zealanders (about 50 percent of the total population) were enrolled in PHOs. Those enrolled in Access-funded PHOs, who receive low or reduced cost access to general practice services, in most cases pay less than $20 per visit. The Ministry of Health estimates that 85–90 percent of the population will be enrolled with a PHO by the end of the 2003/04 financial year.
At 1 October 2003 there were 53 established PHOs comprising 34 Access PHOs, eight Interim PHOs and 11 Mixed PHOs (Interim with Access practices). These PHOs provide primary health care to the more than 2 million people enrolled in their practices, comprising of an estimated 970,000 access enrollees and 1,300,000 interim enrollees.
Figure 24 indicates the percentage of each DHB’s population enrolled in PHOs. In some areas, such as Counties Manukau, Bay of Plenty, Lakes, Whanganui and Tairawhiti, almost all the DHB’s population receives the benefits of enrolment with a PHO. Established PHOs are clustered in the North Island with only three established in the South Island. The South Island has yet to see widespread establishment of PHOs because there is little opportunity for receiving access funding due to the lower level of need.
Figure 24: Percentage of District Health Board population enrolled in Primary Health Organisations, October 2003
 .
Taking the New Zealand Health Strategy forward
The Primary Health Care Strategy provides a unique opportunity to improve services to people who would otherwise have difficulty accessing primary health care services. New funding has been made available to improve access for high need groups and to develop health promotion programmes that suit the specific needs of each PHO’s population.
PHOs are using this new funding to provide a wide range of services, including:
- schemes to provide transport options to people who have difficulty getting to their PHO’s health services
- projects to better manage diabetes and respiratory conditions in the community
- outreach screening initiatives
- marae or school based clinics
- home visits for patients who are terminally ill
- mobile primary health care clinics
- additional Maori primary health care nursing and general practitioner services
- cultural competency training for primary health care providers.
All of these services are designed to promote better health, and reduce or remove barriers to services that have contributed to poor health outcomes for many New Zealanders.
PHOs are also working with iwi and Maori communities to develop innovative ways to improve health outcomes for Mäori. PHOs also need to demonstrate effectiveness in meeting the health needs of the Pacific communities they serve, and identify mechanisms for addressing health inequalities.
PHO funding is capitated, so is flexible, allowing a diverse range of professionals to take a key role in delivering primary health care services. Some services to improve access are led by primary health care nurses and community health nurses with input from other health providers and in collaboration with organisations such as schools, marae and community groups.
The strategy’s implementation also provides the opportunity to expand the role of nurses in primary health care beyond its ‘traditional’ limits. Eleven innovative models of primary health care nursing have been allocated a total of $7.1 million over three years. In addition, 183 nurses have been awarded scholarships for post-graduate study related to primary health care nursing.
The Care Plus initiative is being piloted and will be rolled out nationally across PHOs in 2004. This initiative targets the 5 percent of the population who need intensive management in primary health care.
 | Care Plus provides fence at the top of the cliff
An Auckland PHO, piloting a funding model targeting people with high health needs, has found it is able to offer patients a more active approach to health.
In January 2001, Health West PHO in Waitemata became the first PHO to be established along interim funding lines.
CEO Alan Greenslade says the PHO is made up of 33 practices covering an enrolled population of 140,000 and including a large sector with high health needs.
The Care Plus model acts as an add-on to the interim funding model and targets people with high health needs.
He says the Ministry of Health, the Independent Practitioners’ Association Council of New Zealand and DHBs worked together with the pilot PHOs to develop the model before Health West launched the Care Plus pilot in July 2003.
‘It enables practices to target the people in need as opposed to the pure access model where the whole practice has to qualify for funding.’
He says practice nurses play a key role in the Care Plus pilot.
‘The practice nurses initially identify potential Care Plus patients in the practice using the eight basic codes we have been working with for three years as a reference point for identifying patients with more than one chronic illness.
‘Some practices have been very proactive, using their clinical knowledge of patients to identify and approach Care Plus patients.
‘Others have been more opportunistic – telling patients about Care Plus when they come in for an appointment.’
Alan says once a patient has been identified as eligible for Care Plus funding, practice nurses explain the initiative, which provides additional funding for comprehensive assessment and care including regular reviews at a low cost to the patient.
‘From a practice point of view the funding means nurses can pester the patient to get them in for regular, quarterly reviews which is good active management instead of waiting until they get really sick.
‘It removes the big hurdle of cost, allowing the nurses to focus on the need for reviews without the patient feeling like the practice is touting for business.
‘It’s definitely about being a fence at the top of the cliff rather than an ambulance at the bottom.’
While the pilot is still at an early stage Alan says the model seems effective.
‘Practice nurses are enjoying the opportunity to be more involved in taking a proactive role with patients.
‘Patients enjoy the additional time that they have with the practice nurses and many enjoy a more holistic approach – they are encouraged to exercise and think about their diet – it’s not just about waiting until they are sick.’ |
6.2 Reducing waiting times for public hospital servicesPolicy context
A key priority for the Government and health sector is to reduce waiting times for elective (non-emergency) surgery. It is the Government’s expectation that all patients seeking publicly funded elective services will be clearly advised about whether or when they will receive treatment.
The four key objectives underpinning this policy are:
- a maximum waiting time of six months for first specialist assessment
- all patients with a level of need that can be met within the resources available are provided with surgery within six months of assessment
- the level of publicly funded service ensures treatment for patients before they reach a state of unreasonable distress, ill health and/or incapacity
- national equity of access to elective surgery so that patients have similar access to elective services regardless of where they live.
Progress in 2003
Waiting times for elective services
Over the 2002/03 year, progress towards meeting the Government’s national minimum standards for elective services has been mixed. The number of patients waiting in limbo on residual waiting lists fell from 8,295 on 31 July 2002 to 1,702 on 30 June 2003. This decrease represents a significant improvement from the situation in 1996 when 89,000 New Zealanders were waiting without certainty of treatment or a plan of care.
However, the number of patients certain of receiving treatment but waiting more than six months for their treatment increased from 4,839 to 9,577 between 1 July 2002 and 30 June 2003. This indicates that some DHBs have committed to treat more patients than they have the capacity for. DHBs will implement systems to ensure offers of treatment and the ability to provide it are more closely aligned in the future.
The number of patients waiting longer than six months for their first specialist assessment has decreased from 39,414 at the end of the 2001/02 year to 26,525 at the end of 2002/03. This reduction reflects an ongoing improvement with 20,000 fewer people waiting longer than six months for their first assessment than was the case two years ago.
Funding for elective surgery in 2002/03 remained at the same high level as for 2001/02. A total of $492 million (GST incl) was allocated in 2002/03, compared with $353 million (GST incl) in 1995/96. With a three-year funding path in place, DHBs have greater certainty about their budgets, so are more able to undertake long-term planning.
In the 2002/03 year, 157,754 publicly funded operations were performed (both acute and elective), which is approximately the same number as the previous year. The level of surgery has increased considerably compared with the 1998/99 year when more than 6,000 fewer procedures were performed.
While DHBs have shown improvements in elective service waiting times in the 2002/03 year, few DHBs are performing at a consistently high standard. Table 3 shows the progress towards elective services goals for each DHB as at 30 June 2003.
Table 3: District Health Board progress towards goals for elective services waiting times1
| District Health Board | Numbers waiting more than six months for first specialist assessment2 | Numbers waiting more than six months for treatment2 |
| Auckland | Partially Achieved | Achieved |
| Bay of Plenty | Partially Achieved | Achieved |
| Canterbury | Partially Achieved | Achieved |
| Capital and Coast | Partially Achieved | Achieved |
| Counties-Manukau | Partially Achieved | Partially Achieved |
| Hawke's Bay | Not Achieved | Not Achieved |
| Hutt | Partially Achieved | Achieved |
| Lakes | Partially Achieved | Achieved |
| MidCentral | Partially Achieved | Achieved |
| Nelson-Marlborough | Partially Achieved | Partially Achieved |
| Norhtland | Partially Achieved | Partially Achieved |
| Otago | Partially Achieved | Partially Achieved |
| South Canterbury | Partially Achieved | Not Aciheved |
| Southland | Partially Achieved | Achieved |
| Tairawhiti | Partially Achieved | Not Achieved |
| Taranaki | Partially Achieved | Achieved |
| Waikato | Partially Achieved | Achieved |
| Wairarapa | Partially Achieved | Partially Achieved |
| Waitemata | Partially Achieved | Not Achieved |
| West Coast | Partially Achieved | Partially Achieved |
| Whanganui | Partially Achieved | Partially Achieved |
1 This table was devised using the Elective Services Performance Indicators data from the website www.electiveservices.org.nz
2 'Achieved' indicates the DHB's goal has been or is very close to being achieved: 'partially achieved' indicates performance is near the acceptable range, but there is room for improvement; 'not achieved' signifies improvement is needed.
Figure 25: Standardised discharged ratios for Maori access to all surgery, and to coronary artery bypass operations, 1997/98–2002/03
Equity of access
As patients are increasingly treated in order of priority, with the assistance of the clinical priority assessment tools, individuals from populations with a comparatively poorer health status such as Maori, stand to gain substantially increased access to elective services. Steady improvement has been made in access to elective services for Maori compared with non-Maori in the last four years. The increase since 1997/98 in the ratio for coronary artery bypass operations is especially encouraging. Figure 25 shows standardised discharge ratios that have been adjusted for age and deprivation to enable a comparison between Maori and non-Maori access to elective services. The ratios in figure 25 rise as the use of services by Maori increases relative to non-Maori. When the ratio equals one, Maori age-specific rates of service use will be the same as those of non-Maori. As Maori levels of need are higher than those of non-Maori, the ratios are expected to climb above one in the future.
Figure 26: Standardised discharge ratio for Maori access to all surgery by District Health Board, 1997/1998 and 2002/03
Waiting times for oncology treatment
The increasing rate of cancer – estimated at 7 percent per annum – and the subsequent increasing need for treatment are creating pressure on New Zealand’s cancer services. In addition, there is an international cancer workforce shortage. All publicly funded health care systems such as in the United Kingdom, Canada and Australia are experiencing similar problems.
Access to radiation oncology treatment was a specific focus of performance monitoring in the 2002/03 year. During the year DHBs were required to report the interval between a patient’s referral to the oncology department and their first assessment. These data are intended to contribute to a more comprehensive indication of radiation oncology waiting times by measuring the most clinically relevant interval. DHBs are now providing these additional figures, which appear on a monthly basis on the Ministry of Health website. Figure 27 indicates the percentage of patients at each cancer treatment centre waiting less than eight weeks between first specialist assessment and the start of radiation treatment (from September 2002 to June 2003).
Figure 27: Percentage of patients at each cancer treatment centre waiting less than eight weeks between first specialist assessment and the start of radiation oncology treatment, September 2002 to June 2003
Taking the New Zealand Health Strategy forward
Publicly accessible, web-based reporting of elective services performance by service and by DHBs commenced in November 2002. A series of Elective Services Performance Indicators have been developed to help DHBs assess their performance and address any areas that need improvement, and to provide the community with an opportunity to access information about the provision of health services. The website www.electiveservices.org.nz heralds a new level of transparency in elective services performance, and contains information that is unavailable publicly in any other country.
Clinical priority assessment tools have been introduced in the majority of specialities that include a surgical component. These criteria assist clinicians to make consistent decisions when assessing the patient’s level of need relative to others seeking similar treatment.
As a part of a work programme aimed at ensuring people with a similar level of need are treated in a similar manner regardless of where they live, the Ministry of Health has initiated a pilot project to assess equity of access to orthopaedic services across five DHB sites — Southland, Otago, Nelson-Marlborough, Waitemata and Counties Manukau. The project is focused on improving prioritisation processes, decisions about treatment, and the timeliness of treatment. As the pilot project unfolds, a greater focus on clinical consistency is being encouraged. The findings and approaches of the project are informing other specialist areas and DHBs, and a similar programme is being developed for cardiac surgery.
Progress has been made in more effectively managing the relationship between primary and secondary care. The introduction of referral guidelines and primary health care management guidelines have helped to ensure general practitioner (GP) requests for specialist assistance are comprehensive, timely and clinically necessary. Increased primary health care management of patients with common conditions has required some quite fundamental changes in the way that specialists and GPs work together. The appointment of GP liaisons within DHBs and the establishment of primary-secondary liaison groups within DHBs have been critical to this process. GP liaisons provide feedback to their GP colleagues on referral quality as well as ensuring referrals are prioritised appropriately when they are received by the hospital. In addition, many GPs now have direct access to diagnostic tools to undertake further primary health care assessment, and when specialist advice is necessary, speedier channels of
communication are available.6.3 Accessible and appropriate health services for people living in rural areas
Policy context
Retaining and recruiting a skilled primary health care workforce is critical to maintaining access to sustainable services for rural communities. Features of rural practice that discourage retention and recruitment include onerous on-call rosters, the difficulty of taking leave and professional isolation. These problems in turn mean workforce shortages in some areas create heavy workloads for the remaining practitioners that can adversely affect access to services for those rural communities.
While the health of rural people overall compares favourably with that of urban people, the health of many rural Maori is poor when compared with urban Maori as well as rural non- Maori. Therefore, it is critical that rural communities, particularly those with higher Maori populations, receive the potential benefits of the implementation of the Primary Health Care Strategy without delay.
Progress during 2002/03
Rural workforce data (available for GPs only) indicates that sustained effort will be required to retain a skilled primary health care workforce. A workforce survey for the 2002 calendar year indicates a net loss of five GPs out of a total of 477 rural GPs. It is of concern that the survey indicated 32 rural localities (shared roster areas) experienced GP (full-time equivalent) to population ratios that exceeded 1:2000.
The Government has shown its commitment to addressing rural workforce issues by providing $32 million of additional funding over three years. Much of this funding is in the form of a rural primary health care premium, designed as a flexible resource to support locally devised solutions to primary health care workforce issues affecting the achievement of sustainable and accessible primary health care services in rural areas. While the rural premium is channelled through PHOs when they form, funding is made available to DHBs ahead of PHO formation to
address rural workforce issues.
The rural primary health care premium is made up of the following new funding components:
- workforce retention funding – a flexible resource for supporting and retaining the primary health care team
- reasonable roster funding – a targeted resource aimed at practitioners sharing onerous rosters; for example, a locum was recruited at Great Barrier Island to provide relief to the long-serving solo GP.
Thirteen PHOs encompassing rural areas were established in the 2002/03 financial year, all but one of them funded under the access formula (two of those have some interim practices), which reflects their higher proportion of Maori population and/or level of deprivation. These PHOs are located in the Bay of Plenty, Hawke’s Bay, Taupo, Northland, East Cape, Taranaki, Waikato and the West Coast.
The key recommendations in Implementing the Primary Health Care Strategy in Rural New Zealand (Rural Expert Advisory Group to the Ministry of Health 2002) have been implemented.
These were to:
- develop a primary health care premium to provide extra financial support to PHOs encompassing rural areas to allow them to ensure sustainability of services and retention of the rural workforce
- recommend a rural premium at a level sufficient to enable PHOs to support shared roster arrangements for out-of-normal hours care towards achieving, as a minimum, a one in three on-call roster with one in four as more desirable
- support national initiatives for recruitment of primary health care workers, encouraging them to work in rural areas on both short-term and long-term bases, for example through nationally organised recruitment programmes, including the recruitment, placement and support of locums.
Taking the New Zealand Health Strategy forward
Rural workforce retention funding has been utilised in different ways to create more favourable working conditions for the rural practice team, including the following.
- Direct financial incentives to rural practitioners: Most DHBs applied at least half their workforce retention funding to direct incentives to rural practitioners. Northland DHB, for example, funded rural practitioners who committed to remaining in their rural practice for the financial year. Many rural practices applied their additional funding to locum services so they could undertake continuing education and additional leave.
- Purchase of equipment or improving or merging practice facilities to expand the workforce were uses of the funding in parts of Taranaki, Canterbury and Otago.
- Professional development of nurses and/or expanding nurse employment.
- Stabilising rural primary health care services in difficulty, such as in Turangi after a GP’s resignation.
Reasonable roster funding was directed at practitioners sharing rosters in 15 DHB districts to improve their rosters. For example:
- Canterbury DHB organised a weekend roster service using mainly Christchurch-based GPs
- the West Coast is recruiting additional nurses to support the rural nurse specialists who provide services in remote areas.
Locally devised solutions to rural workforce retention and recruitment problems are supported by national initiatives.
- Funding has been budgeted to continue the rural locum scheme, which employs locums to provide rural GPs with regular breaks from practice.
- Funding has been committed to a new rural recruitment service due to start later in 2003. The rural recruitment service will assist with the recruitment of GPs, longer-term locums and nurse practitioners with prescribing competencies to practice in rural areas.
- In 2003, the Government agreed to increase the number of medical students at the Universities of Auckland and Otago by 40, from 285 to 325 each year. The first students will start in the 2004 academic year and will be selected from applicants brought up in rural areas with the aim of improving the likelihood that qualified doctors will choose to practice in rural New Zealand.
Between May 2000 and June 2003, the Ministry of Health piloted Healthline, a free 24-hour telephone triage and health advice line in Northland, Tairawhiti, Canterbury and the West Coast of the South Island. An independent evaluation of the service showed that Healthline was an effective and safe way for New Zealanders to get expert health advice (Kalafatelis et al 2002). During 2002 alone, Healthline received more than 48,000 calls, and during the pilot period had a usage rate of almost 5 percent of the total population in the pilot areas. Service users in pilot areas acknowledged Healthline’s value in directing them to the ‘right care, at the right place, at the right time’. Healthline reporting also indicates that the service was being well utilised by Maori. This service will be extended to all New Zealanders in 2004 and will help optimise proper utilisation of existing services.
| Nurse-led clinics take health services to the community
A nurse-led self-referral clinic scheme is successfully encouraging an isolated rural community to seek access to health services.
Lakes DHB Funding Manager Andrea Jopling says the Health Reporoa’s Nursing Innovation Service was prompted by the withdrawal of general practice services in the area.
‘Last year in July we had notice that the local GP was exiting his satellite surgery because he had been unable to sell it and considered it commercially non-viable.
‘That meant people, some of whom have no access to transport, would have to travel more than 40 kilometres to Rotorua or Taupo to see a health professional.
‘The potential adverse impact on the health status of the population who had accessed that GP surgery was of huge concern to the DHB and the community.’
She says the Greater Reporoa and Waikite Valley area bounded by Rotorua, Taupo, the Waikato River and the Kaingaroa Forest covers a diverse population in terms of health needs.
‘Reporoa itself is not a particularly poor area but it is one of extremes encompassing both comfortable and highly deprived families.
‘It is also close to the Kaingaroa Forest, which is acknowledged as one of the most deprived areas in New Zealand.’
Using Ministry of Health funding specifically allocated for innovative nursing projects, the DHB and Health Reporoa — a not-for-profit community organisation — set up the nurse-led selfreferral clinics that are run from community rooms and halls and include a recently-launched marae-based programme and workplace clinics.
Andrea says these workplace clinics are particularly successful in capturing people who are traditionally unlikely to seek medical advice.
‘One of the challenges we face in the Lakes is increasing access to health services for forestry workers who are often working in the middle of nowhere.
‘This group includes a high proportion of middle-aged men, often Maori, who do not always take good care of themselves and often don’t access services until they are seriously unwell.
‘By taking the clinics to workplaces such as the timber mill Health Reporoa nurses not only focus on illness but have the opportunity to offer health and wellbeing checks and services such as diabetes and cardiovascular risk screening.’
Andrea says the free, accessible service encourages local people to seek health advice at an early stage, which has huge benefits for the community.
‘The beauty of the self-referral clinic is that people are triaged by the nurses.
‘They can make a decision about whether they can treat patients themselves or whether they need to point them to a GP in town.
‘People who wouldn’t go all the way to town will come to these clinics.
‘That means a child’s wheezy asthma may be managed before it becomes out of control and will result in a better health outcome for the child and potentially a reduction in hospitalisations, which benefits the child, whanau/family and the DHB.’
The service is also organising rural health days when community members can meet all of the health professionals in the area including the nurses, public health nurses and Plunket nurses.
Andrea says the project’s success lies in it being driven and managed by the rural community.
‘It’s a community-led initiative, not something that’s been driven by the DHB telling the community what to do.
‘The nursing staff employed are excellent and very experienced in working with rural communities so they know the needs and are trusted by the locals.’ |
6.4 Health of older peoplePolicy context
Like many other countries, New Zealand has an ageing population. The proportion of people aged 65 and over is predicted to increase, particularly from 2010, so that by 2051 25 percent of the population will be aged 65 and over. Increases in the proportion of Maori and Pacific people aged over 65 will be significant – a 250 percent and 400 percent increase from current proportions respectively. Although other ethnic minorities have relatively young populations, their proportions of older people are also expected to increase significantly.
Figure 28: New Zealand population aged 65+, 75+ and 85+ as a percentage of the total population, 1961–2051
The Heath of Older People Strategy (Associate Minister of Health and Minister for Disability Issues 2002) provides a national direction for an integrated approach to service planning, funding and delivery that will require change at all levels. The primary aim of the strategy – to develop an integrated continuum of care that is responsive to the varied and changing needs of older people – is also consistent with the policy framework launched by the World Health Organization at the Second World Assembly on Ageing in Madrid in April 2002.
The Health of Older People Strategy is also a key means of implementing action to meet the health goals of the New Zealand Positive Ageing Strategy, which provides an overarching direction for all government agencies.
Progress in 2003
DHBs have until 2010 to implement the Health of Older People Strategy, depending on their capacity and local priorities. Funding for disability support services for older people was devolved to DHBs on 1 October 2003, and this will assist DHBs to provide more integrated health care and support services for older people.
Legislation to change the asset test for older people requiring residential care is forthcoming. This is a key step in the Government’s commitment to progressively remove asset testing from all forms of long-term care for older people. The current system of asset testing requires people aged 65 and over to use up their assets to contribute to the cost of their care, whereas younger people are not required to do so. The new policy balances human rights considerations against the substantial costs involved in removing asset testing.
Because of generally higher need than younger sectors of the population, older people are high users of health and disability support services. Good information on which to base planning and service developments will become increasingly important as the proportion of older people increases. Information system developments during 2003 are designed to support consistent data and to improve the quality of client, contract and service information collected. These developments include a new needs assessment and service co-ordination form to collect more information about disability clients, and payment management system changes to ensure providers and clients are paid the right amount by the right funder. These improvements will provide a sound basis for DHB planning and management and better data for service utilisation analysis and monitoring.
Taking the New Zealand Health Strategy forward
DHBs are working with their local communities as they develop an integrated continuum of care. DHBs are at various stages of this development, from planning and establishing relationships with key stakeholders, to having older people advisory groups and projects to progress integrated service development in place.
- The three Auckland DHBs (Waitemata, Counties Manukau and Auckland) are working together to plan for a continuum of care for older people. They have collectively set medium and long-term goals. Each DHB has its own specific service development projects, but they are all working to an agreed plan for the region. Northland DHB also has a strong collaborative relationship with the Auckland region DHBs and shares in many of the regional activities.
- Northland and Tairawhiti DHBs, with significant proportions of Maori in both populations, have taken different approaches to planning for the needs of older Maori. Northland DHB is drawing together extensive project work already under way into an Agewell in Northland project to develop the continuum of care within its region. The needs of Maori are well identified and a Kaumatua and Kuia Reference Group will report on significant service needs for older Maori across Northland.
In Tairawhiti DHB, where 5 percent of Maori are aged 65 and over (compared with 3 percent for all Maori in New Zealand), there is a strong focus on services to identify needs early and reduce levels of disability and mortality among Maori. The early establishment of access funding formula PHOs in Tairawhiti provide an opportunity for integrating services through that model and successfully implementing a continuum of care for older people. The total population of people aged 65 and over in the Tairawhiti district are enrolled in PHOs. They will also build on already successful dedicated kaumatua/kuia services being delivered.
In 2003 a number of Ageing in Place initiatives, providing alternative community support options to residential care for older people who require support as they age, were established across the country. Three of these will be part of a three-year national evaluation of programmes to assist older people who have high and complex needs and are at risk of entering residential care.
- The Community First initiative, provided by Presbyterian Support in the Waikato, provides slow rehabilitation and ongoing support in the community.
- In the Hutt Valley, the Masonic Slow Rehabilitation Service offers a residentially based service for up to three months with ongoing support offered by existing home support providers.
- The Co-ordinated Services for the Elderly needs assessment and service co-ordination service in Canterbury is community based and works across primary health care, Disability Support Services, DHB and ACC funding pools (see the case study in this chapter).
Stay on Your Feet Canterbury is a collaborative project that aims to raise the awareness of the risks and consequences of falls among older people and how to prevent them.Those who are most at risk of having a fall are referred to a home-based exercise programme. On referral by their GP, people are paired with volunteers who support them during the first six months of their individualised exercise programme. People are also encouraged to join gentle exercise classes at their local community centres. The programme has also prepared a checklist for
people that identifies hazards in the home that can lead to a fall.
Two key national level projects that will improve the way the health system functions for older people are best practice evidence-based guidelines for assessment processes for older people, which were released in October 2003, and the development of a sound practice framework for specialist geriatric and psychogeriatric services for older people. Both projects aim to provide a sound basis for consistent practice throughout New Zealand and support better service coordination and links between providers — an essential component of an integrated continuum of care. In addition, the action plans arising from a review of needs assessment and service coordination agencies against their current operating guidelines will also contribute to greater consistency and give older people more confidence in the system.
| Community-focused service helps older people age in place
A Canterbury support service, which works across funding streams and primary and secondary care, is making life simpler for older people and their families and caregivers.
Canterbury DHB Planning and Funding Division Project Manager Gill Coe says the Co-ordinated Services for the Elderly (COSE) Project has been operating in Canterbury since October 2000.
The community-based needs assessment and service co-ordination service works across Ministry of Health, Disability Support Services, DHB and ACC funding pools and aims to avoid duplication in service provision.
‘The Elder Care Canterbury (ECC) Project, which has been running in Canterbury for six years, was working on projects to improve services for older people.
‘Both the community stakeholders and the health professionals from the ECC Project identified that there were so many different funding streams involved with accessing services for older people that it could be a bit of a nightmare for people trying to work their way through the system.’
The key worker (COSE) is based in primary health care and assigned to several general practice teams.
Gill says the COSE model shifts the focus of the needs assessment and service co-ordination agency workers, who work in a hospital-based setting, into the community.
‘It allows the COSE to identify resources and opportunities within the designated community, funded or non-funded, voluntary and community.
‘This in turn offers older people a greater choice of service support, which enables them to remain safely in the community as long as they wish to.
‘This means they can arrange transport so Mrs Smith can still get to church on Sunday if that’s what she wants to do.
‘But we also have to recognise that some people don’t have the confidence to stay in their own home.’
In addition to identifying services COSE also has a positive long-term impact on older people’s health.
‘It’s really important to identify any social or health issues early and by working with the general practice team and other health providers, family/wha¯nau needs are identified earlier, instead of waiting until everything has turned to custard and someone has to be hospitalised.’
Gill says health professionals and families are very supportive of the COSE model and feedback indicates greatly improved communication between service providers.
In September, the COSE model of service became part of a two-year national Assessment of Services Promoting Independence and Recovery in Elders (ASPIRE) trial co-ordinated by the University of Auckland, which aims to evaluate the effectiveness of the key worker case management ‘Ageing in Place’ model of care. |
Chapter 7: A High-performing System in which People have Confidence
The health sector must continue to perform to the highest standards and reflect the needs of New Zealanders within available resources. The quality of health services needs to be continuallymonitored and improved. Services must be co-ordinated, and providers must collaborate to ensure institutional boundaries do not compromise quality of care.
This chapter examines the components of the health system that underpin the ongoing improvement in the quality of health services and the overall health of New Zealanders. In particular, the chapter focuses on:
- strategies and initiatives to incorporate quality improvement across all health system activities
- examples of innovation within the health system that enhance quality and timeliness of services and facilities
- activities in public health services, which by linking with activities within and outside the health sector, build on the foundations of New Zealanders’ health
- actions to develop a health workforce with the capacity and skills to deliver future health services
- initiatives to improve the quality of the health system’s physical infrastructure through capital investment programmes
- ongoing activities to protect and enhance the fundamental rights of individuals within the health system
- activities to enhance the information infrastructure that is critical to health decision-making and positive health outcomes for New Zealanders.
7.1 Quality improvement
Policy context
Quality is the cornerstone of a high-performing public health and disability system that people trust. The foundations of quality assurance and quality improvement in the New Zealand health and disability sector are the partnership, participation and protection principles of the Treaty of Waitangi. Built on these foundations are the key dimensions of quality in the New Zealand health and disability system.
- People-centredness – the extent to which a service involves people, including consumers and their families /whanau, and is receptive and responsive to their needs and values. It includes participation, appropriateness, adherence to the Code of the Health and Disability Services Consumers’ Rights 1996, and adherence to other consumer protections, such as the Health Information Privacy Code 1994.
- Equity and access – the extent to which people are able to receive a service on the basis of need and likely benefit, irrespective of factors such as ethnicity, age, impairment or gender. It includes the physical environment, and the extent to which this is a barrier to accessing health and disability support services. Being able to physically access health and disability support service facilities can be a significant issue for people with disabilities.
- Safety – the extent to which harm is kept to a minimum.
- Efficiency – the extent to which a service gives the greatest possible benefit for the resources used.
- Effectiveness – the extent to which a service achieves an expected and measurable benefit.
Progress in 2003
In the last year, the following advances were made.
- The Minister of Health released Improving Quality (IQ): A systems approach for the New Zealand health and disability sector. It provides a shared approach and shared language to enable enhanced quality improvement in the New Zealand health and disability system and is a commitment to supporting continuous quality improvement by each person who works within the system, by people affected by the system, and by the system itself. The approach also forms the Minister of Health’s response to advice from the National Health Committee on Safe Systems Supporting Safe Care and is being used to meet the Minister of Health’s obligations in section 9 of Part 2 of the New Zealand Public Health and Disability Act 2000.
- The National Health Epidemiology and Quality Assurance Advisory Committee (EpiQual) was established. EpiQual will provide advice to the Minister of Health on any health epidemiology and quality assurance matters. Its advice will deal specifically with perinatal, infant, child and adolescent morbidity and mortality issues.
- During 2002/03 the Ministry of Health reinstated quarterly reporting by DHBs on patient satisfaction rates and improved the data, so individual and comparative information is provided. Further developments are also planned, including an electronic patient satisfaction prototype, weighting patient satisfaction rates with demographic data, and a benchmarking exercise.
- Toward Clinical Excellence: A toolkit to develop consumer participation in credentialling (Ministry of Health 2003l) provides a resource for the health and disability support sector to meet the requirements of the national credentialling framework. The toolkit has been designed to provide specific information on the appointment and support of consumers in credentialling. It also includes introductory information for providers that wish to develop effective partnerships with consumers to plan and evaluate other aspects of health and disability support services.
- The review of the medical misadventure provisions of the Injury Prevention, Rehabilitation, and Compensation Act 2001, led by the Department of Labour and ACC, has developed options that seek to increase fairness for claimants and support a quality improvement culture by shifting the focus from finding errors to learning how to prevent adverse events.
- The Ministry of Health has a contract with the Paediatric Society of New Zealand for it to deliver up to five evidence -based clinical guidelines. These guidelines will represent the latest clinical evidence and will be useful tools for clinicians treating selected child health conditions. In addition, the Ministry has contracted the society to work with a recognised standards development organisation to develop an audit tool or workbook, interpreting the generic health and disability sector standards for the child and adolescent population.
- The New Zealand Health Information Service analysed orthopaedic data to produce quality of care indicators and evaluate the usefulness of current data collections for assisting clinicians to make decisions and identify areas for improvement.
- The Ministry of Health developed a DHB Mental Health Service Profile to assist mental health services to better understand service quality and organisational issues, and thereby to assist DHBs to improve service quality. The profile compares DHB performances against key mental health indicators, including access rates, discharge rates, acute admission rates, and length of stay.
- In the last year the New Zealand Guidelines Group (NZGG) published guidelines about cardiac rehabilitation, diagnosis and treatment of adult asthma, hormone replacement therapy, the assessment and management of people at risk of suicide, prevention and management of hip fracture among people aged 65 years and over, acute management and immediate rehabilitation of hip fracture among people aged 65 years and over, the diagnosis and management of soft tissue knee injuries, internal derangements, and assessment processes for older people. The NZGG is also developing training for professionals and consumers in the development of evidence-based guidelines.
- The National Screening Unit has developed a screening programme quality framework that applies a quality improvement approach to screening programmes in New Zealand. It defines a set of key quality principles and essential quality requirements to ensure the best possible outcomes from screening programmes in New Zealand.
- Since 1995, under the Medical Practitioners Act 1995, medical practitioners have been able to seek to have certain quality assurance activities (QAA) ‘protected’. To encourage frank and active participation in peer review and other activities that have the potential to generate improvements in competence and practice, these ‘protected’ QAA provided confidentiality to information that became known solely as a result of such activities and documents brought into existence solely for the purposes of such activities. They also gave immunity from civil liability to persons who engage in such activities in good faith.
The Health Practitioners Competence Assurance Act 2003 (HPCA) now extends this concept to all health practitioners covered by the HPCA, including chiropractors, dentists, dietitians, medical practitioners, midwives, nurses, pharmacists and many other health professionals. Importantly, recognising the multidisciplinary nature of much health care, protected QAAs under the HPCA will be able to cover multidisciplinary review processes.Taking the New Zealand Health Strategy forward
- The third Asia Pacific Quality Improvement in Health Care Forum was held in Auckland 3–5 September 2003. The forum was hosted jointly by the BMJ Publishing Group (London) and the Institute for Healthcare Improvement (Boston) in conjunction with the Ministry of Health. Additional support was received from the Accident Compensation Corporation and Standards New Zealand. Approximately 1,000 people attended the forum.
This event gave New Zealand the opportunity to heighten the profile of quality issues and showcase the good work being done locally in quality improvement. Internationally renowned experts on quality improvement spoke, including Dr Don Berwick, President and Chief Executive of the Institute of Health Improvement, United States; Helen Bevan,
Innovation and Knowledge Group Director for the NHS Modernisation Agency, United Kingdom; and John Oldham, Head of the National Primary Care Development Team, United Kingdom.
To capitalise on the forum’s high profile Improving Quality (IQ): A systems approach for the New Zealand health and disability sector was released by the Minister at the forum, and a meeting was held to progress the establishment of a quality network in New Zealand.
- DHBs continue to develop systems for improving the quality of the services they provide and fund. DHB provider arms have focused on achieving certification before October 2004, as required under the Health and Disability Services (Safety) Act 2001. DHBs are also initiating new structures to improve quality. For example, Canterbury DHB has established a Quality and Patient Safety Council. Its purpose is to provide advice to the DHB chief executive on quality matters, promote quality improvement and act as a forum for the wider DHB to discuss quality issues.
- The Royal New Zealand College of General Practitioners validated Aiming for Excellence (Royal New Zealand College of General Practitioners 2002) as the standard for New Zealand general practice. It provides a useful basis for measuring the level of care provided and identifies opportunities for developing practice systems. It contains both legislative standards and standards considered essential by the College.
- The threat posed by the emergence of Severe Acute Respiratory Syndrome (SARS) led the Ministry of Health to develop an interim National Clinical Response Plan and establish a project to utilise the lessons learned locally, nationally and internationally from SARS. This information will be used to develop the National Clinical Response Plan for SARS or other emergent novel infectious diseases.
- Capital and Coast DHB held a Pacific fono for the region to address cultural competencies, Pacific models of care, quality systems and approaches for maintaining quality in Pacific health and disability provider organisations, and relationships between spirituality, faith and health.
- The Waitemata Health Skin Lesion Service has a new single point of entry and triage at North Shore Hospital for all GP-referred patients. This has reduced waiting times from an average of 290 days in 2000 to less than 42 days. Primary health care-based services are also offered to reduce the waiting lists and save administrative costs. This initiative was a finalist in the Health Innovation Awards (see below).
- The Ministry of Health contracted a national non-government mental health sector membership organisation to undertake workshops with non-government mental health providers on implementing the Mental Health Sector Standards, the Health and Disability Sector Standards, the Infection Control Standards and the Restraint Minimisation and Safe Practices Standards, and to develop guidelines for non-government organisations on implementing the standards.
- Tairawhiti DHB, in collaboration with MidCentral DHB, implemented a teleradiology service to provide CT scanning services for Tairawhiti cancer patients. Using this service, Tairawhiti patients receive a CT scan in Gisborne on a specially-made carbon fibre bed. The images are sent via the Health Intranet to the team at Palmerston North who undertake the mapping and arrange radiotherapy. The carbon fibre bed allows for precision mapping of the patients, and a forthcoming replacement CT scanner will allow the service to expand. Until the inception of the service, cancer patients from Tairawhiti needing radiotherapy treatment usually travelled to Palmerston North twice: in the first instance for a CT scan for mapping the radiotherapy treatment, and on a second occasion for the radiotherapy. The development of teleradiology removes the need for patients to travel to Palmerston North for the CT scan, providing a more timely delivery of CT services within their own DHB area.
- As at 13 November 2003, 121 providers had been issued with a certificate under the Health and Disability Services (Safety) Act 2001. Another 321 have applied for certification and are planning their certification audit programme. The Act replaces the traditional focus on inputs and the licensing of premises and facilities with a more modern regime focusing on the standards of services delivered and outcomes for consumers. There is a two-year transition period for providers to move from licensing to certification. This period ends on 30 September 2004.
There is evidence of quality improvements among those providers already certified. When the implementation of the Act is nearer completion the Ministry of Health will be able to report on trends in quality improvement.
| RadPlat cancer treatment turns heads in Waikato
A new approach to treating head and neck tumours, on trial in the Waikato, is offering hope to cancer patients.
Waikato Hospital Ear Nose and Throat Department Clinical Director Theo Gregor says a combined team of head and neck surgeons, radiation and medical oncologists and radiology staff at the hospital is working with an international team, based at the Dutch National Cancer Institute in Amsterdam, to trial the RadPlat treatment.
He says the experimental treatment involves a combination of radiotherapy and direct arterial injection of the chemotherapy drug Cisplatin.
The chemotherapy, which offers an alternative to the standard intravenous injection, works mainly by making the radiation more effective.
‘RadPlat allows the chemotherapy dose to be placed directly into the tumour in higher than normal concentrations while an antidote is injected into the patient’s veins to reduce the toxic effects of the chemotherapy agent on the rest of the body.
‘This means the chemotherapy dose can be 50 percent higher than a standard dose and the side-effects are much more limited.’
Waikato Hospital, the first hospital to offer the treatment in the southern hemisphere, began accepting patients for the trial last year following a one-year pilot period during which five patients were treated with RadPlat therapy.
Dr Gregor says the new treatment can be used in cases that were previously inoperable.
‘There has been massive progress in surgery in the last 20 years, which has improved the type of reconstruction possible to deal with smaller tumours, but in some cases the result is still too disfiguring.
‘This is what is known as functionally inoperable. For example it would be possible to remove a tumour in a tongue by taking out the entire tongue but the patient would end up with a very poor quality of life.’
He is optimistic that RadPlat will prove to be a superior treatment.
‘The results speak for themselves.
‘It is exceptionally good for very large tumours where we wouldn’t expect half the results from traditional treatment.’
Dr Gregor says Waikato has contributed results from two patients to the international trial that aims to study 220 patients worldwide.
‘The trial involves 180 patients at this stage, we hope to contribute between 10 and 16.
‘Of the patients we have treated some are still clear of cancer after two years and they are obviously delighted.’ |
7.2 Health Innovation Awards 2003The inaugural Health Innovation Awards were announced in 2003. These awards recognise excellence and leadership, promote a culture of continual quality improvement, and facilitate the dissemination of innovations throughout the health sector.
- The supreme award was won by the Wellington Independent Practitioners Association retinal screening programme. This programme is profiled in chapter 3.
- The individual award went to Malcolm Battin for a cooling cap to protect infants from brain damage developed by Auckland’s National Women’s Hospital and Liggins Institute.
Brain injury through lack of oxygen during birth can cause death or long-term disability. Studies suggest brain damage develops over several days, rather than as a single event. The cooling cap is a simple system that may protect the infant brain from evolving injury during the days after birth.
The team performed animal studies and safety studies on newborn infants before undertaking a large multicentre clinical trial. Before this innovation, care for this group of infants was limited to cardiorespiratory treatment and seizure management. The cooling cap system offers, for the first time, the possibility of long-term improvements. It will benefit children in New Zealand and overseas.
- MidCentral DHB won the organisation award for their Hospital in the Home programme for patients with acute or chronic illness.
Since March 2000, 450 patients have received specialist-level medical care in the privacy and comfort of their own homes. The majority of patients have required intravenous antibiotic therapy for some form of infection, or intravenous fluids for complications during pregnancy. In addition, some patients who are extremely susceptible to infection can opt for this type of care, including people who have had chemotherapy treatment for leukaemia.
The patients are considered external inpatients. They remain under the supervision of a specialist and can be fast-tracked back into hospital if necessary. The DHB’s district nursing service and a range of allied health care services provide care.
7.3 Public health servicesPolicy context
Public health services take a population approach to improving health and reducing levels of disease and injury, by identifying strategies and planning interventions that target a wide range of factors that determine health. Although occupying only a small proportion of total health services (slightly under 2 percent of Vote Health), public health services play a significant role in improving population health outcomes and reducing inequalities in health status. Within the New Zealand Health Strategy, public health is identified as a priority service area.
Public health action is not just about the actions of public health service providers, it also requires action from all parts of the health sector and other sectors such as local government, housing and education if society is going to make headway in addressing the determinants of health and reducing inequalities.
The planning and funding of public health services remains the responsibility of the Ministry of Health. However, DHBs are charged with promoting and protecting the health of their populations, so the Ministry and DHBs work collaboratively to plan and fund services aimed at improving population health.
Progress in 2003
Nutrition and physical activity
The Healthy Eating, Healthy Action Strategy was completed and launched in March 2003, meeting an identified need for a strategic framework to address the burden of nutrition and physical-activity related health needs. The strategy will assist with the prevention of type 2 diabetes and some common cancers. Public health providers are progressively reorienting their service provision towards the goals and objectives outlined in the strategy. The strategy is discussed further in chapter 3.
Tobacco control
New Zealand played a prominent role in the work leading up to the unanimous adoption of the World Health Organization Framework Convention on Tobacco Control by the World Health Assembly in May 2003. The convention is the first World Health Organization initiated international convention and the first public health treaty ever negotiated. The convention seeks to provide a framework for tobacco control measures at national, regional and international
levels in order to reduce the prevalence of tobacco use and exposure to tobacco smoke. It is an international response to the current global death rate from tobacco use of approximately 4 million people per annum – estimated to increase to 10 million people per year by 2030. Of those deaths, 70 percent will occur in developing countries.
Severe acute respiratory syndrome
The severe acute respiratory syndrome (SARS) corona virus potentially presented a worldwide public health emergency. In New Zealand a dedicated SARS response team at the Ministry of Health and many local teams around the country managed a successful public health response to SARS. This involved implementing and co-ordinating operations as varied as border control and infection control systems in hospitals. Although no SARS cases reported to the Ministry of Health returned positive tests for the virus, many lessons were learnt during the New Zealand health sector emergency response to the threat posed by the emergence of SARS overseas. It became apparent that the New Zealand health sector as a whole is only moderately prepared for an outbreak a disease such as SARS or any other emergent novel infectious disease. While each individual facility has its own response plan, the regional and national issues associated with the escalation pathway for potentially dangerously infectious patients have not been fully developed. Therefore, the Ministry of Health is undertaking a project to develop a National Emerging Novel Infectious Disease Clinical Action Plan to describe the response, management and co-ordination required by primary, secondary and tertiary providers to a national-level threat. The Hawke’s Bay DHB response to SARS is profiled below.
Counter-terrorism
Cyanide threats to water supplies during 2002/03 led to an increased focus on public health preparedness. DHBs and the Ministry of Health worked with operators of potential targets, such as organisers of large-scale events, to reduce the potential risk from cyanide poisoning threats.
Taking the New Zealand Health Strategy forward
Achieving health for all people
The Ministry of Health has completed a framework for public health action called Achieving Health for all People: Whakatutuki te oranga hauora mo nga tangata katoa (Ministry of Health 2003a). The framework provides guidance for public health action within the New Zealand Health Strategy. A wide range of DHBs, providers and others have been involved in the framework’s development. It is aimed at both public health planners and providers and other sectors whose policies and actions influence the determinants of health.
Public Health Bill
The Public Health Bill will be the primary legislative framework for promoting and protecting public health. It will allow the identification, assessment and management of risks to public health, recognise the importance of health determinants and health information as a basis for effective planning and action for public health, provide appropriate strategies to prevent ill health, and focus on environmental health and issues relating to communicable diseases. The significance of non-communicable diseases in New Zealand society will also be taken into account. A public consultation process for the proposed Public Health Bill has been completed and work is under way to develop proposals for the new legislation. It is intended that the Bill will be introduced into the House in the 2004/05 year.
Primary Health Organisations
The first PHOs were established in July 2002. Public health providers have been working closely with the developing PHOs to assist their development of health promotion programmes. The Ministry of Health and DHBs have supported the collaboration developing between the existing public health sector and emerging PHOs. For example, in the Auckland region the three DHBs have pooled the funding designed to support PHOs with their health promotion planning, and employed health promotion advisors to support this development.
| Hawke’s Bay steps up to SARS challenge
Faced with New Zealand’s first probable case of SARS, Hawke’s Bay DHB found that planning was the key to managing the crisis effectively.
Hawke’s Bay DHB’s rapid response to the Severe Acute Respiratory Syndrome (SARS) case won praise from Ministry of Health Director-General Karen Poutasi and the community.
Hawke’s Bay Emergency Response Advisor Sandra Bee says SARS tested the DHB’s pandemic plan prepared following Exercise Virex conducted by the Ministry of Health in 2002.
‘The challenge begins a long way before you have to deal with an event – it’s about preparation.
‘We were fortunate that we had spent the time preparing our pandemic plan last year, so it was in place at the beginning of February before most of the world was aware that SARS was about to become a problem.’
The SARS alert took place in late April after a woman who had recently travelled to mainland China became unwell and contacted her GP by telephone.
The GP asked her to remain at home where she was contacted by DHB staff and advised to drive to the emergency department where she was met and assessed in an isolation room by a team wearing protective clothing.
‘She met all the criteria for SARS so she was admitted to an isolation suite where she was treated for five days and then discharged into seclusion in the community for a further two weeks.’
Sandra says Hawke’s Bay’s success hinged on effective planning, good teamwork and the sound relationship between the hospital and its Public Health Unit.
‘It comes down to all of the different services of the DHB working together.’
Sandra says a proactive approach to emergency response is imperative.
‘In New Zealand we don’t place a lot of emphasis on the weird and wonderful because we think it will never happen.
‘But when SARS came along people suddenly realised why you do things like write a pandemic plan – it’s for the “what ifs” that might just happen.’ |
7.4 Workforce development
Policy context
The success of the New Zealand Health Strategy depends on the availability of a health workforce with the capacity and skills to deliver the health services of the future. Developments such as changes in service delivery and technology, the shift from hospital care to primary health care, increased consumer expectations and a population that is ageing and becoming more ethnically diverse may call for a different workforce.
The Health Workforce Advisory Committee was established in 2001 to advise the Minister of Health on workforce issues, including capacity, capability, supply, demand and development issues, and strategies for addressing these issues. In 2002, the committee produced an assessment of the current health and disability workforce, which provided a snapshot of the New Zealand health workforce and factors influencing it. This stocktake estimates that approximately 67,000 health workers are employed (together with a further 30,000 informal workers). Nurses and
doctors make up the biggest component of the workforce with 38,000 and 8,500 respectively employed in active practice in 2002 (Health Workforce Advisory Committee 2002a).
Overall, the number of health practitioners per 100,000 New Zealanders is increasing. However, there are variations within that number that need to be managed to ensure optimum delivery of health services. These include:
- an ongoing need for more Maori and Pacific health providers to meet the needs of Maori and Pacific peoples
- the need to manage some specialities more closely (eg, medical radiation technologists) as new technology drastically increases the demand for the services that these practitioners provide
- geographical variations (eg the number of many types of rural health care provider is less than the New Zealand average)
- recruitment and retention problems in specific areas in some professions (eg, a shortage of nurses in aged care and mental health)
- the implications of the ageing population for the types of service that need to be delivered in the future (eg, the need for more chronic disease management and community support services).
In October 2002, after consultation with the sector, the Health Workforce Advisory Committee produced a second report, The New Zealand Health Workforce: Framing future directions: A discussion document (Health Workforce Advisory Committee 2002b). This report identified six priority areas:
- addressing the workforce implications of the Primary Health Care Strategy
- promoting a healthy workplace environment
- educating a responsive health workforce
- building Maori health workforce capacity
- building Pacific health workforce capacity
- developing the health and disability support workforce capacity for people who experience disability.
These six priority areas were discussed at a Health Workforce Advisory Committee summit in March 2003, and will form the basis of the committee’s future work plan.
Progress in 2003
In August 2003, the Health Workforce Advisory Committee presented the Minister of Health with its report The New Zealand Health Workforce: Future Directions: Recommendations to the Minister of Health 2003 (Health Workforce Advisory Committee 2003). This report consolidates the committee’s work and incorporates feedback from submissions on the 2002 discussion document and the March 2003 summit. These recommendations represent a major milestone for the committee, and enable workforce development to be on the agenda of key stakeholders. In
addition to the six priority areas discussed at the summit, the committee has amalgamated the research and evaluation recommendations into a seventh priority area for health and disability workforce development.
The committee recommends a strategically guided process of evolving change that enables the health sector and its workforce to constantly adapt to the challenging health sector environment (Health Workforce Advisory Committee 2003). The challenge for health and education organisations is to use these recommendations strategically as a platform for health workforce development initiatives. A major part of the committee’s work programme for 2003/04 involved working with the sector to implement its recommendations around the seven priority areas, and to address the concerns of the medical workforce.
The Ministry of Health and DHBs have established or made progress on several initiatives over the last year that aim to guide the future development of the health workforce. These initiatives include the following.
- The Health Practitioners Competence Assurance Bill received the Royal assent on 18 September 2003. This Health Practitioners Competence Assurance Act 2003 protects the public from the risk of harm from the practice of health practitioners by providing a consistent framework for the regulation, maintenance of competence, and discipline of health practitioners. The Act also accommodates flexibility and innovation in the workforce by enabling health practitioners to work to their level of competence in a defined scope of practice.
- In May 2003, District Health Boards New Zealand and DHBs prepared, through their Workforce Development Group, a Workforce Action Plan. This plan is based on the Health Workforce Advisory Committee’s work and on District Health Boards New Zealand earlier strategic document Health Workforce Development: Context and strategic directions for District Health Boards (New Zealand Institute of Economic Research 2002).
The plan identifies three priority areas around which collaborative workforce development by DHBs will take place:
– improving information on workforce trends and issues
– building relationships to improve co-ordination
– developing a strategic workforce development capacity and capability.
- The Clinical Training Agency has updated its framework document Clinical Training Agency Strategic Intentions 2003–2012 for purchasing post-entry clinical training for health practitioners for the next 10 years (Clinical Training Agency 2002).
Taking the New Zealand Health Strategy forward
The Government, the Ministry of Health, DHBs, and the sector have put in place initiatives to develop the health workforce, including:
- developing the role of nurse practitioners, including the first nurse practitioner to have prescribing rights
- providing locum support for rural general practitioners
- developing the Rural Primary Health Care Practitioner Recruitment Service
- enabling a further 40 positions in the medical schools from 2004
- establishing the Maori and Pacific Workforce Development Funds to promote and develop Maori and Pacific capacity and capability in the workforce
- allocating $7 million to model and evaluate primary health care nursing practice initiatives and assist DHBs with the transition to PHOs
- the establishment of a Mental Health Workforce Steering Committee by the Ministry of Health and District Health Boards to evaluate and fund initiatives including a national recruitment plan, benchmarking of best practice methods for retention, organisational development, training development and infrastructural development
- developing a Pacific Health Workforce Strategic Action Plan to address work shortages in health, focusing on priorities in child and youth health, promoting healthy lifestyles and wellbeing, primary health care, and promoting the participation of disability services
- establishing an intersectoral group to advise the Government on a policy and service framework for ensuring the safety and quality of support services delivered in the community or residential care settings.
In addition, the Ministry of Health and DHBs are exploring initiatives for healthy workplace environments, which promote professional practice and development.
The sector needs to take advantage of the opportunities provided by the Health Practitioners Competence Assurance Act 2003, the District Health Boards New Zealand and DHBs Workforce Action Plan, the Tertiary Education Strategy, the Health Workforce Advisory Committee’s priority areas, innovative models of practice in the sector, and improved technologies to develop a more flexible approach to using health practitioners’ skills in the workforce.
The Ministry of Education’s Tertiary Education Strategy, which sets out a five-year blueprint for developing New Zealand’s tertiary education system, provides an opportunity for the health sector to ensure the education sector is responsive to the future needs of the health sector and the type of health workforce needed to deliver health services. The Ministry of Health, the Health Workforce Advisory Committee and DHBs have been working with the Tertiary
Education Commission to meet this challenge. Each tertiary education organisation providing health courses has had to develop a charter and profile setting out its strategic goals in relation to the health sector, for implementation from 1 January 2004. The Ministry of Health, in conjunction with the Health Workforce Advisory Committee and DHBs New Zealand, has developed criteria for health courses (for example, to provide programmes that support an easy transition to the workplace and provide access to viable career paths in health).
7.5 Capital investment
Policy context
The delivery of services required to meet the New Zealand Health Strategy requires building and maintaining high quality, well-located, and safe public health facilities. To meet this responsibility tools are required to build community trust and deal with conflicting community expectations. Clear criteria for business cases and transparent decision -making are also necessary. To achieve these objectives, new Guidelines for Capital Investment were introduced in 2003.
The new capital investment framework contributes to building a high performing and trusted public health system by introducing innovations in five key areas:
- a four-year capital budget envelope
- expert DHB-led advice on prioritisation and quality of capital investment decisions
- collaboration between DHBs on service requirements and capital needs
- asset management planning
- clear criteria for business cases.
Progress in 2003
The Government has established a four-year capital budget of $657 million for health. Substantial capital investment is under way. New hospitals will be opening in Wellington, Christchurch and Invercargill soon, while a new Auckland hospital opened in October 2003.
Major capital investment programmes around New Zealand include the following. Some of the projects have been funded from prior years’ capital funding, separate from the $657 million referred to above.
- Auckland DHB’s $447 million building programme was completed. At the heart of the building programme was the construction of a nine-level hospital, combining the acute services of Auckland, Green Lane and National Women’s hospitals. Built next to the existing Auckland Hospital and linked to Starship Children’s Hospital, it encompasses 80,000 square metres.
- A comprehensive $70 million hospital development is under way in Invercargill. The project includes a new clinical services building that will include inpatient beds, one endoscopy and four operating theatres, an emergency department, and outpatient and support services.
- Burwood Hospital in Christchurch completed a $6 million redevelopment in late 2002, including a new ward for orthopaedic rehabilitation, refurbishment of the Spinal Unit and a new, covered, all-weather ambulance bay.
- Waitemata DHB is working towards completing a $120 million redevelopment of North Shore and Waitakere hospitals, which will expand the range and volume of services on both sites. The expanded facilities at Waitakere Hospital were opened officially in October 2003.
- Capital and Coast DHB has begun a $303 million redevelopment, which includes major construction of new facilities and refurbishment of existing facilities at Wellington Hospital and Kenepuru Community Hospital. The project also involves construction of a new Kapiti Health Centre at Paraparaumu.
- A $35 million redevelopment of Nelson hospital was completed in March 2003 (see the profile later in this chapter).
Other major developments are planned for after the first annual capital allocation round at the end of 2003. This includes a phased replacement and expansion programme for linear accelerators.
Taking the New Zealand Health Strategy forward
To ensure the health sector’s expertise and local knowledge on health facilities is valued, a National Capital Committee has been established to deliver expert capital advice from DHBs to the Ministry of Health. Its membership is drawn from senior DHB chairs, a chief executive and a Ministry of Health deputy director-general.
To enable DHBs to demonstrate that every possible opportunity has been taken to maximise health gain from capital expenditure, Regional Capital Groups have been established. Regional Capital Groups facilitate local and regional contributions to the capital decision-making process and ensure DHBs are consulted before decisions are made by neighbouring DHBs.
Another important new requirement is for DHBs to undertake a Health Development Initiative to inform every major business case. This is a process for all DHBs in a region to prioritise and agree the allocation of health services and the consequential capital impacts.
DHBs must now undertake formal asset management planning to ensure capital planning decisions are better informed. Development of a business case is complex and potentially expensive and time consuming. Therefore, a staged process with a clear set of expectations has been introduced to ensure DHBs address all the risks and all the complex requirements of planning for major health capital projects.
In a review of the new policy and further options for health capital investment the New Zealand Institute of Economic Research concluded that ‘once fully implemented, the current arrangements in New Zealand (involving DHB ownership, requirements for strategic asset planning and business cases, and the regional and national capital committees) would be close to international best practice for capital management’ (New Zealand Institute of Economic Research 2003).
| New look Nelson Hospital offers effective care
A major upgrade to Nelson Hospital has transformed an outdated set of buildings into a welcoming, efficient facility.
Nelson Marlborough DHB Finance And Information General Manager Nigel Trainor says the existing hospital consisted of 10 major and numerous minor buildings scattered haphazardly across the site, which proved confusing for the public and inefficient for health professionals.
These buildings, erected between 1924 and 1960, could not cope with modern changes in medical practice and were unable to support Nelson/Tasman’s fast growing community, which includes a large elderly population.
Objectives for the $35.5 million redevelopment, completed in July, included ensuring the accommodation and site facilities were appropriate for efficient, safe, effective and sustainable service delivery, improved access to the site and made the hospital more user and visitor friendly.
Australian firm Bligh Voller Nield, the project’s health architects and planners, worked with New Zealand firm Architecture Warren and Mahoney to make the plans a reality.
Bligh Voller Nield Project Lead Consultant Sarita Chand said a key issue in the three-year redevelopment project was allowing the hospital to continue to operate as the work was carried out.
‘The challenge was to transform a fragmented, ageing facility into an efficiently integrated campus that would allow the delivery of sustainable, efficient, safe and effective clinical services into the next century.’
Key redevelopment included staged demolitions of existing buildings and new emergency, outpatient and radiology departments, ambulance bay, mortuary, kitchen, cafeteria and chapel.
Chief Medical Officer Ed Kiddle says one of the most obvious changes is the revamped main entrance, which includes a bigger reception area where switchboard operators can monitor traffic 24 hours a day.
‘Previously we had over 20 entrances and exits, which was not only a problem from a security point of view, but was very confusing for visitors and patients.’
A ‘hot floor’ groups obstetrics, the neonates special care unit, theatres, a day stay unit, radiology, intensive care, the emergency department and the mortuary, because they all have similar external access requirements or need to be adjacent to theatres.
Inside, the new layout has improved privacy with a higher ratio of single beds and ensuites in ward areas.
Corridors overlook a series of landscaped gardens, many of which can be accessed by patients seeking a private retreat.
In consultation with community groups, a chapel, family meeting rooms and stayover rooms have been incorporated into the hospital,
Nelson Marlborough DHB Property Manager John Williams says the project’s success can be attributed to several groups, including staff at all levels and the community, working together to gain the most effective outcome.
‘It means we will now be able to provide appropriate, co-located, compliant facilities that will enable the staff to deliver and the patient to receive timely quality care.’ |
7.6 Individual rights
Individuals have fundamental rights within a quality health care system. They include rights under the Privacy Act 1993, Human Rights Act 1993, Health Information Privacy Code 1994, Health and Disability Commissioner Act 1994 and Code of Health and Disability Services Consumers’ Rights 1996. The Health and Disability, Privacy, and Human Rights Commissioners continue to promote and educate health and disability providers about consumers’ rights under the respective jurisdictions.
Progress in 2003
The New Zealand system for health and disability consumer complaints emphasises rehabilitation of practitioners, rather than punishment. This is consistent with modern understanding the nature of error and the importance of a culture of learning to improve patient safety. The introduction of the Code of Health and Disability Services Consumer Rights, and the Health and Disability Commissioner complaints system (both in 1996), combined with the implementation of competence reviews by the Medical Council, have resulted in a four-fold reduction in the number of medical practitioners facing disciplinary proceedings (Health and Disability Commissioner 2003).
The Human Rights Commission has begun work on a National Plan of Action for Human Rights. As part of this work the commission will be consulting on issues related to the realisation of economic, social and cultural rights, such as a right to health, which New Zealand has guaranteed by ratifying the International Covenant on Economic, Social and Cultural Rights (Office of the United Nations High Commissioner for Human Rights 2003). The commission’s
consultation includes discussions of whether the realisation of a right to health is an area New Zealand needs to improve on and, if so, what the appropriate actions might be to realise the right to health.
In May 2003 the Government decided to remove from legislation discrimination on the grounds of sexual orientation and marital status that is potentially unjustifiable in terms of section 5 of the New Zealand Bill of Rights Act 1990. The objective of this decision is to ensure the law no longer differentiates between people in committed, exclusive and stable relationships on the basis of their marital status or sexual orientation. The Ministry of Justice is working with other government agencies, including the Ministry of Health, to identify legislative provisions that are potentially discriminatory towards same-sex couples and opposite-sex de facto couples and to determine how these should be amended.
7.7 Information management and technologyPolicy context
The ability to exchange high-quality information between partners in health care processes is vital for a health system focused on achieving better health outcomes. Better access to timely and relevant clinical information can improve clinical decision-making and, therefore, health outcomes for individual patients.
Progress in 2003
This year information management has concentrated on the continuing implementation of the WAVE Strategy (Working to Add Value through E-information) recommendations. WAVE outlines the direction of Health Sector information management development. The Ministry continues to successfully work and engage with DHBs and other partner organisations ranging from Practitioner registration authorities, professional bodies, and Primary Health Organisations to IT software developers, hardware suppliers, and telecommunications companies.
The implementation of the Primary Health Care Strategy and the development of Primary Health Organisations (PHOs) have emphasised the need for information management systems and structures to remain flexible enough to meet the sector’s changing needs. New structures such as PHOs require new information systems. The Ministry has implemented the Capitated Based Funding system, which will allow more accurate and timely allocation of funding for a PHO’s enrolled population.
Ways to share developed excellence are also needed. The ‘Sharing Excellence in Health and Disability Information Management’ awards were initiated to recognise and support those working in the sector and developing innovative technology that improves patient care. The Otago electronic prescribing project (profiled later in this chapter) was one of the six projects recognised as innovative in this years awards (Ministry of Health 2003h). The other projects that were recognised follow.
- Counties Manukau DHB improved the co-ordination of health care between the community and its providers by launching two projects in conjunction with the Ministry of Health -
Kidslink and the Diabetes Integrated Care System. These projects have both now proved their worth to the community to which they provide care.
Kidslink can identify children who have missed their scheduled immunisations or wellchild checks. Local services find these children and link them with a health provider. Kidslink is now implemented throughout the Counties Manukau DHB district and in part of the Waitemata DHB district. Immunisation rates of over 95 percent have been achieved across its wide population base. Kidslink will be linked to the developing National Immunisation Register.
The Counties Manukau DHB Diabetes Integrated Care system provides disease management programmes for individuals and co-ordinates their free monthly reviews. At the first review after three months on the project, only 7 percent of patients had not had improved their management of their diabetes.
The Integrated Care System contributed to reduced hospitalisation rates. In 1999 the growth in acute medical admissions to Middlemore Hospital was 9 percent per year. By 2002 the growth rate was reduced to nearly zero.
- Prompt is a cardiovascular risk assessment tool implemented by ProCare, an Auckland PHO. It links data on patient profiles, risks, management and outcomes, and provides feedback and support planning. It also provides for information to be collected for statistical purposes to enable New Zealand to build its own risk model for cardiovascular disease, particularly for Maori and Pacific patients.
- Hutt Valley DHB has developed a Regional Health Surveillance System, which is an integrated database for use by the DHB’s Regional Public Health Service. The Regional Health Surveillance System supports analysis and reporting, and includes reference information, activity information, and public health management information.
- Auckland DHB’s A+ ‘Network Centre for Best Patient Outcomes’ developed the Clinically Integrated System model. Previously, data was spread between departments, and was often incomplete or insufficient to give clinicians the information they needed to set up the best care regimes for patients. The model links three concepts of patient management into a single framework: evidence-based practice, clinical redesign and outcome management.
As well as providing clinical information, the model addresses the specific clinical problems of adverse outcomes. For example, there have been considerable developments in implementing at-risk assessments, such as for falls, pressure areas and pain scores. Risk assessments are implemented on the patient’s admission to the hospital and continue until their condition improves. Assessment summaries also allow clinicians to review large amounts of patient data quickly, which helps to reduce post-operative complications.
- Electronic Medical Internet Technologies Ltd. has developed an internationally accessible online patient management system. This eliminates waiting for patients’ files to be sent by other health providers. Health providers with patients who are seen by a specialist or hospital will have the specialist’s opinion and care plan available immediately. The software will also alert clinicians to allergies and drug interactions. Doctors will not be reliant on patient’s memories for problems like allergies to drugs or chronic medical conditions, and the result will be a reduction in medical errors from prescribing.
Taking the New Zealand Health Strategy forward
The decision by the New Zealand Government ‘to invest in, and promote, key items of health information management infrastructure has been described as positioning the country as a world leader in the field, particularly in the primary health care sector. The infrastructure includes the National Health Index, the Medical Warning System, a national clinical coding system for primary health care as well as for hospitals, the early adoption of a standard for
health messaging, and a national health intranet and the attendant security apparatus in the form of Public Key Infrastructure’ (Commonwealth Department of Health and Ageing 2003).
The Ministry is further developing these building blocks and developing other capability to provide the infrastructure necessary to support the goals of the New Zealand Health Strategy.
Building IT capability
The National Health Index (NHI) system is a national system which is used to assign a unique identifier, an NHI ‘number’, to each health care user for the purposes of health care service delivery and recording. The NHI Programme includes improving the quality of data held in the collection and improved access for primary health care providers. The programme has been developed to maintain and strengthen existing uses of the NHI that health and disability support services make with regard to individually focused care, treatment and support. The work being undertaken will also provide a more robust collection for population based initiatives.
The Ministry is working with ACC and with the sector to develop a Health Practitioner Index. The index will assist to protect privacy of patient information, reduce compliance costs for practitioners who have multiple identifiers, and improve information quality. The proof of concept for the Health Practitioner Index has been successfully completed. A Privacy Impact Assessment is in progress and data access agreements with registration authorities are being
developed.
Sharing information
- Affordable network capability including an appropriate security and privacy context is an emerging requirement. Access to Broadband for rural providers will support telehealth initiatives such as ongoing electronic education and access to specialist advice via services such as video conferencing. Health is recognised as being advanced in developing protocols to ensure interoperability in New Zealand.
- The secure Health Network continues to provide a secure exchange environment for the safe transfer of health information. Access to the Health Network has been made more available by the provision of free digital certificates to PHOs.
- The involvement of Ministry of Health staff in the PROBE (Provincial Broadband Extension) project to provide Broadband (high speed Internet) access to rural areas means the needs of the health and disability sector are considered in the project rollout.
- Access to services such as specialist consultation for mental health patients is to be improved through a national project to promote the use of Telepsychiatry. This entails the provision of follow up specialist appointments via video conferencing.
- Online access to hospital waiting lists for GPs in the Counties Manukau DHB region is now available and provides them with information on care options for patients.
- Hospital electronic discharges and referrals, which improve co-ordination between tertiary/secondary and primary health care providers, is being progressively implemented across the country. GPs are more able to provide seamless care once the patient has been discharged from hospital.
- The Special Authority process will be improved considerably by the provision of online applications for subsidies. This system will enable decisions to be made in ‘real time’ so providers will be able to tell patients the results of requests immediately.
- HealthLine is a nurse triage service with a comprehensive decision support tool to provide accurate and consistent advice from experienced nurses as to where and if the patient should seek help for their health care need. This will provide more extensive coverage of health information for the whole country, regardless of how remote. HealthLine is discussed further in Chapter 6.
Managing standards
- Greater exchange of data requires a greater use of common standards for data and messaging and appropriate security and privacy measures. The newly formed ministerial committee, called the Health Information Standards Organisation, will help connectivity in the sector by identifying, developing and endorsing health information standards. This will make it more efficient for providers to appropriately exchange health information and software developers to develop quality software that can be used nationally.
- A draft Standards Plan for New Zealand has been developed by the Ministry to identify and develop the standards that are need exchange information can be appropriately exchanged. The Health Information Standards Organisation has endorsed the plan.
- The Privacy, Authentication and Security project is a joint project between the Ministry of Health and ACC and builds on existing foundations to standardise practice for a connected health care system. The project will enable consistent privacy and security practice across the sector. The project is now in the sector consultation phase and aligns with current e-government initiatives.
Aligning investment
- To better manage IT investment within the sector, a common format for DHB Information Systems Strategic Plans has been agreed with DHBs. This Ministry-based initiative will encourage a standard approach to common information management challenges among DHBs, allow DHBs to compare plans in a collaborative way, and allow the Ministry to fairly evaluate differing initiatives.
- This is supported by the Guidelines for Capital Investment, which provide the context and criteria for IT investment. A template to enable DHB IT business cases to be developed in a standard format is being finalised. A survey has been sent to all DHB Chief Information Officers to assess the level of current IT infrastructure and future plans. The survey will inform the development of business process guidelines for IT investment in DHBs.
Improving information
- Further developments undertaken by the Ministry of Health are targeted towards improve the quality of data available to improve decision-making. A Data Quality Evaluation Framework project is under way. This will allow clear and consistent assessment of the level of data quality for national health data collections and will provide information for the development of a wider Data Quality Improvement Strategy.
- To improve the quality of ethnicity data collected and used in the sector, the Ministry of Health has led the development of Ethnicity Data Protocols. Based on a whole-of- Government approach, the protocols provide guidance for the consistent application in the health and disability sector of the Statistics New Zealand census ethnicity collection standards. The implementation of the protocols will contribute towards reducing inequalities by enabling the better identification of need and the consequent development of more appropriately targeted services.
- The Ministry of Health has implemented the General Medical Subsidy data store to complement the Laboratory data and Pharmacy data stores. The building of the General Medical Subsidy warehouse will help support the implementation of the Primary Health Care Strategy.
- The ongoing development of the Mental Health Workforce Information System will improve our ability to target workforce issues. This project is now in the build phase following discussions with the mental health service providers and wider health sector.
- The Ministry of Health website has been improved to provide easier access to information about the Ministry and its services and who to contact for assistance. This is also in line with e-government requirements.
- The Ministry of Health has implemented ProClaim to replace outdated claims processing systems. This will enable a faster turnaround of claims and establishes a flexible e-commerce platform. The development also allows activity to occur 24 hours a day, seven days a week.
| Electronic prescribing system provides support for clinicians
An electronic prescribing system, trialed by Dunedin Hospital in 2003, has led to an improvement in the quality of patient care.
Otago DHB Information Group Project Leader John Lucas says while the majority of GPs regularly use computers to generate prescriptions, there is an increasing awareness of mistakes made when medication is prescribed in hospitals.
‘It is fast becoming a priority to introduce similar prescribing tools into wards.’
He says medication management in a hospital is a team effort involving doctors, pharmacists and nurses who prescribe, carry out pharmacy reviews, dispense and administer medication. International studies suggest medication mistakes make up at least 20 percent of all hospital errors that affect patients. This implies about 800 medication mistakes are likely to occur at Dunedin Hospital each year.
Factors contributing to these mistakes include poor handwriting, drug interaction and use of the wrong drug name, dose or form.
In response to this issue Otago DHB trialed MedChart, an electronic medication system developed by Australian company HATRIX, which includes full decision support for clinicians by providing detailed drug information.
The three-month trial began in April and was preceded by a one-month assessment and orientation period.
Laptop computers connected to the hospital network are wheeled around ward areas allowing doctors ready access to the system as they attend to patients.
‘An unexpected benefit was the organisation-wide introduction of MedChart, the electronic drug reference views which contains information on about 2100 commonly used medicines.’
John says computer literate junior doctors who were willing to make changes to their work practices and carried out the electronic prescribing were key to the project’s success.
The original software was updated during the trial improving speed of prescribing from four to six minutes (more than twice the time for a written prescription) to two to three minutes.
‘Within just a few weeks the benefits were obvious.’
‘Prescriptions are clear, accurate and complete, drug information is readily accessible for correct decision making and prescribing is linked to medication policies to alert doctors to limitations on drug use.’
He says although electronic prescribing is slightly slower than the traditional handwritten method, there are great benefits for patients.
‘If even one patient benefits from the prevention of a serious outcome due to a medication error, it is worthwhile. If 800 mistakes are possible at Dunedin Hospital each year and a medication mistake increases a patient’s length of stay by four to seven days, that’s an unnecessary cost of $0.3 million a year.’
‘This pilot programme cost less than $30,000 and the extension of the system to the whole hospital will cost considerably less than the potential savings in the first year alone.’ |
Chapter 8: Active Involvement of Consumers and Communities at all Levels
The New Zealand Health Strategy recognises that consumers and communities need to be involved in the decisions that affect them. Involvement in the governance of health sector structures and providing input into, and being informed of, DHBs’ decisions contribute to a health system New Zealanders trust. Involvement of consumers and communities should also ensure services at all levels of the health sector reflect the needs of individuals and communities, which in turn will maximise health gains within available resources.
This chapter discusses the DHB requirement to involve consumers and communities in governance and decision-making and to develop consultation processes. Consumer and community involvement in PHOs is also discussed.
Policy context
Consumers and communities have a direct involvement in DHB governance by being able to vote or stand as a candidate in DHB elections. The community elects the majority of DHB members; this ensures DHBs are accountable to the community and are aware of the region’s needs. Community involvement in DHB governance is also facilitated with board meetings being open to the public.
Under the New Zealand Public Health and Disability Act 2000, DHBs are required to have a Community and Public Health Advisory Committee and a Disability Support Advisory Committee. These committees advise the board on the health and disability support needs of the region’s population and the priorities and funding required to address those needs. Committee meetings are open to the public.
As well as providing for consumers and communities to participate in governance structures, DHBs are required to foster community participation in health improvement and involve communities in planning and decision-making, so they develop policies and services that will best meet their communities’ needs. DHBs also have a responsibility to ensure Maori are able to participate in decisions that will affect them.
Although formal consultation is usually necessary on only a few issues, DHBs also need methods that allow individuals and groups to provide informal feedback on issues that may affect them. One aspect of this is ensuring that timely information on the board’s decisions is available to the public. Consultation also helps the accountability and acceptability of DHBs, and helps ensure the rights of consumers are upheld. As a process that allows DHBs to gain the full picture on issues, it leads to better and sustainable decisions, which in turn saves time and money.
Progress in 2003
Further development of DHBs’ formal and informal consultation processes occurred in 2003. Methods of consultation included advisory and focus groups, hui, fono, public meetings, workshops and surveys, informal communications with individuals and groups, and distribution of written information for comments and submissions. DHB newsletters and websites also provide opportunities for community input into DHB decision-making.
Engagement with tangata whenua by DHBs during the last year has resulted in the development of DHB partnership agreements with Maori. Sixteen DHBs have signed memoranda of understanding with Maori, and several DHBs are close to signing. In addition, DHBs are finalising Maori Health Plans, which align closely with He Korowai Oranga (the Maori Health Strategy) and Whakatataka (the Maori Health Action Plan). Most DHBs have submitted their Maori Health Plans to the Ministry of Health for review.
Consultations have been undertaken by DHBs to promote and encourage the provision of information to the community about specific activities or service proposals. Examples include consultation on Nelson-Marlborough rural hospital services and the Waikato Community Health Forums.
- Nelson-Marlborough DHB engaged in consultation about the Nelson-Marlborough rural hospital services as part of a review of health and disability services available to the minor urban and rural communities throughout the region. The consultation process followed up on concerns raised during previous consultation on the DHB’s District Strategic Plan. The consultation process included public meetings and written submissions.
- Waikato DHB has established seven Community Health Forums (CHFs) throughout the region, with up to 80 people regularly involved in CHF/DHB activity. The chair of each forum (a local resident) meets regularly with DHB staff, and has access to the DHB chief executive to discuss issues of local importance. CHFs are a vital part of Waikato DHB’s consultation strategy: local people provide input on health issues that affect them. Community Health Forum members have also been active in the establishment of PHOs, and are involved in local management groups and PHO governance. These forums are examples of how DHBs can formalise consultation processes on local issues and general strategic direction in their areas.
Taking the New Zealand Health Strategy forward
The establishment of PHOs has required considerable consultation to ensure communities, iwi and consumers are involved in their governing processes and that the organisations are responsive to the community.
PHOs are required to involve communities, iwi and individuals in governance processes, and be responsive to community needs. PHOs take various forms, so use various processes to ensure community involvement in PHO governance. These include boards that are elected by the community, community input into the PHO’s business plan, and the inclusion of community representatives on PHO management committees.
Many methods are being used to involve the wider community in PHO policy setting. An important part of this is informing the community about PHO services and processes, and organisations are using newsletters, meetings (including hui and fono) and reports to achieve this. Providing opportunities for the community to respond to this information is equally important. Consumer surveys, satisfaction questionnaires and suggestion and complaint
processes provide these opportunities. (PHOs are discussed in more detail in chapter 6.)
The Intersectoral Community Action for Health (ICAH) projects (one of which is profiled in this chapter) are good examples of strong community involvement in health and disability needs identification, local advocacy and planning. (The ICAH is covered in more detail in chapter 5.)
| Pilot improves access to primary health care in Porirua
A collaborative approach to health involving local communities has provided a boost to health services in Porirua.
The Porirua Improving Access to Primary Care Pilot Project, managed by Capital and Coast DHB, demonstrates the value of community involvement in the development of primary care services to meet the needs of Maori, Pacific peoples and those on low incomes whose needs are poorly met by traditional services.
The initiative is based on recommendations made by Porirua Healthlinks, developed with extensive involvement from the community, providers, iwi, Pacific peoples and local and central government representatives.
Six providers – Te Runanga o Toa Rangatira Inc (Ora Toa), Maraeroa Marae Health Clinic, the Greater Wellington Health Trust (Wellington Independent Practitioners Association general practices), Porirua Healthlinks (for the Porirua Health Information and Communications System), Pacific Health Service Porirua Inc and Porirua Union and Community Health Services – collaborate to provide a package of services under an agreement signed in October 2002.
These developments include a health information and communication system, 16 additional full-time equivalent positions providing extended community and practice based nursing services, community health workers, increased access to general practitioner services, and other innovative community projects such as the community garden project.
Maraeroa Marae Health Clinic Tamariki Ora Nurse Lianne Ormsby says her clinic, which has an enrolled population of about 1,500, focuses on home visits, which support the whole whanau. ‘If I go to see a baby I also see the whole whanau.
‘If nanny has a cough or grandpa is diabetic we can keep an eye on them.
‘We know a lot of them won’t get to the doctor so we advocate with the group to make sure they get the services they need.’
Ora Toa Practice Manager Ana Apatu says the initiative has provided funding for two extra fulltime equivalent primary care nurses to work with Ora Toa.
The practice, which looks after 10,000 patients, 97 percent of whom are Maori or Pacific peoples or from areas of high deprivation, places a strong emphasis on timely, accessible care.
‘The extra nursing staff allow us to have a triage system, which helps facilitate patients to the correct health provider, whether it be a doctor visit, primary nurse visit, a home visit or another community health provider, so appointments can be booked in a more efficient way.’
She says in some situations health problems can be managed by giving appropriate advice over the phone.
‘Phone contact and creating relationships with patients is proving to be really important for people.
‘If people are anxious about their health problems it is vital that they are able to speak to a health provider and feel like they have had their health concerns sorted out promptly.’
She says extra funding under the access scheme has allowed the clinic to subsidise medications for some clients who are otherwise unable to afford them.
Extra nursing staff has also allowed Ora Toa to offer extra care in the community including health assessments for work placements, a primary care nurse providing a weekly clinic to students and more home visits.
‘Overall the fostering of relationships with clients and the community is the most important factor in improving our delivery of care.’ |
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