Health and Independence Report 2007

1 Introduction

Date of publication: October 2007

Table of Contents:

From the Minister of Health

From the Director-General of Health

1 Introduction

2 Progress on Headline Indicators

3 Improving Quality

4 Health Targets

5 References

Appendix: Additional input, output and outcome data

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In this section:

• 1.1 Overview and Outcomes Framework
• 1.2 Structure of the report
• 1.3 Māori health
• 1.4 Pacific peoples’ health
• 1.5 New Zealand health system
• 1.6 Implementing the New Zealand Health Strategy

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1.1 Overview and Outcomes Framework

The health system is broad and diverse, touching the lives of many New Zealanders in a variety of ways. For example, in the past year, 2006/07:

• 17.3 million visits were made to general practitioners and nurses in Primary Health Organisations (PHOs)
• 46.4 million prescription items were dispensed
• 23.2 million laboratory tests were performed
• 681,102 hospital discharges for medical and surgical services occurred
• 91,092 people accessed mental health services
• 418,332 cervical smears were taken
• 440,392 free influenza vaccinations were given
• 74,902 free annual checks for people with diabetes were undertaken
• 1.69 million personal care and home management hours were provided for older people
• 20,211 ‘green prescriptions’ (advice on exercise or nutrition) were dispensed.

Have these services improved the health of New Zealanders? Have the people most in need of health services received the services they require? Have these services been provided in the most efficient and effective manner possible? Have these services been provided to the highest standards of quality and safety?

This report summarises the answers to these questions at a high level, and maps the health sector’s progress toward achieving its high-level outcomes. This report is aligned with the Ministry of Health’s outcomes framework from the Ministry’s Statement of Intent (Ministry of Health 2007e). (See Figure 1.1.) The outcomes framework includes societal outcomes (such as better health and reduced inequalities), which are influenced by the activities of the health system as well as initiatives of the wider government and society as a whole, and system outcomes (such as effectiveness and equity and access), which relate to a fair and functional health system. Progress towards societal and system outcomes is measured using a suite of headline indicators (detailed in Table 2.1).

In addition, this report outlines the Minister of Health’s priority areas for health improvement, for 2007 and beyond, and the 10 health targets that aim to ensure progress in these priority areas. Along with addressing inequalities across population groups, improving Māori health, improving Pacific peoples’ health and improving access for people living with disabilities, the Minister’s priority areas are:

• getting ahead of the chronic disease burden
• child and youth services
• primary health care
• health of older people
• elective services
• infrastructure
• value for money.

The selection of the specific targets within these priority areas was based on the principle that achieving the targets will make a significant contribution to improving health outcomes in these areas. (See Section 4.)

Table 1.1 outlines which indicators are used to measure progress towards the high-level aims of the New Zealand health sector as reflected in the Ministry of Health’s outcomes framework and the Minister of Health’s priority areas.

Table 1.1 Measuring health sector progress

Measuring progress towards	Measures
Ministry of Health’s outcomes framework (Figure 1.1)	Headline indicators (Table 2.1)
Minister of Health’s priority areas (section 4)	Health targets (Table 4.1)

The outcomes framework and the Minister of Health’s priority areas reflect the directions established by the two overarching strategies of the New Zealand health and disability sector: the New Zealand Health Strategy (Minister of Health 2000) and New Zealand Disability Strategy (Minister for Disability Issues 2001). Section 1.6 summarises the major actions to implement the New Zealand Health Strategy.

This report fulfils the Minister of Health’s responsibilities under the New Zealand Public Health and Disability Act 2000 to report annually on the implementation of the New Zealand Health Strategy and on progress in implementing the Quality Improvement Strategy (Minister of Health 2003b). In addition, it fulfils the Director-General of Health’s obligation under the Health Act 1956 to report on the state of public health.

This Health and Independence Report sits alongside the Ministry of Health’s Annual Report for the year ended 30 June 2007. The Ministry of Health’s Annual Report details the Ministry’s financial and non-financial performance in the priority areas agreed with the Minister of Health and in delivering outputs purchased by the Minister.

Figure 1.1 Ministry of Health outcomes framework

Better health The best possible improvement in New Zealanders’ health status and quality of life over time,within the resources available.	Reduced inequalities An improvement in the health status of those currently disadvantaged, particularly Māori, Pacific peoples and people with low socioeconomic status.	Better participation The health and disability support sector contributes constructively to having a society that fully values the lives of people with disabilities.	Trust and security New Zealanders feel secure that they are protected by the system from substantial financial costs due to ill health, and trust it because it performs to high standards, reflects their needs and provides opportunities for community participation.
Healthy New Zealanders
Equity and access New Zealanders in similar need of services have an equitable opportunity to access equivalent services and resources are allocated in a manner that reduces inequity of outcomes.	Quality Health and disability support services are clinically sound, culturally competent and well co-ordinated and ongoing service quality improvement processes are in place.	Efficiency and value for money The system operates efficiently and services deliver relatively large gains in health status for each unit of resource.	Effectiveness The system as a whole and the services provided within the system are effective in contributing to the end outcome of healthy New Zealanders. Intersectoral focus Social,environmental,economic and cultural factors are influenced to reduce their negative impacts and increase their positive impacts on end outcomes for the health and disability system.
A fair and functional health system

Source: Ministry of Health (2007d, p 27)

1.2 Structure of the report

1.2.1 Content of the four sections

Section 1 introduces the Ministry of Health’s outcomes framework and Minister of Health’s priorities, Māori and Pacific peoples’ health, the structure of the New Zealand health and disability sector, and progress towards implementing the New Zealand Health Strategy.

Section 2 updates progress against 39 headline indicators. The headline indicators, which are aligned with the nine goals in the outcomes framework, were agreed by the Director-General of Health’s Performance Assessment and Management Steering Group as the high-level indicators of health system performance. Where possible, the report assesses whether the health sector is making progress in each indicator area.

Woven through these indicators are six stories that bring the statistics to life. These stories describe the improvements in health and health service delivery occurring throughout New Zealand. The stories cover a range of topics, including:

• a person experiencing mental illness who has found sustainable work as the result of a relapse prevention plan and a government-funded employment agency
• Tongan community-driven health services
• a profoundly deaf child whose opportunity to participate fully in society has been enhanced by a cochlear implant
• an innovative pre-admission programme in the Waikato that has halved the number of operations cancelled as a result of incomplete pre-operative care
• mobile breast-screening services that have boosted coverage rates for Māori women by bringing the service to marae in the South Island.

Section 3 describes how the health sector is co-ordinating its activities to improve quality and safety. This section fulfils the Minister of Health’s responsibility under the New Zealand Public Health and Disability Act 2000 to report on progress on implementing the Quality Improvement Strategy.

Section 4 describes the health targets introduced in 2007. Making progress towards these targets, which cover the Minister of Health’s priority areas for the health sector for 2007 and beyond, is an overarching goal for the health system.

1.2.2 Importance of data by ethnicity and deprivation level

One of the four societal goals in the Ministry of Health’s outcomes framework is reducing inequalities in health. While expressed as a distinct goal, reducing health inequalities must be incorporated into the fabric of health service delivery and planning to be effective. In this report, where information is available, we have described health system progress by ethnicity, deprivation level or income. Additionally, in describing health system performance, we have applied a reducing inequality lens wherever possible.

1.2.3 Data and analysis

This report uses the most recent and robust data available from a range of sources. Where possible, trends are provided and information is analysed by ethnicity or high-need groups (eg, Māori, Pacific peoples or people living in areas of high deprivation).

Data collection and audit processes sometimes mean 2007 data is only provisional, so cannot be published yet. This means sometimes the ‘most recent’ data is earlier than 2007 (eg, the most recent robust mortality disparity data is for 2004).

For views of the health care system, data has been used from the Commonwealth Fund International Health Policy Surveys. These surveys of the general population and primary care doctors have been conducted annually since 1998.

1.3 Māori health

The health and disability sector has a focus on improving Māori health and reducing health inequalities for Māori. Health inequalities for Māori are complex and require system-wide approaches. The Ministry of Health and District Health Boards (DHBs) will be working over the coming years to identify successful approaches to reducing health inequalities, improving Māori health, and to support the adaptation and implementation of these approaches throughout the country as appropriate.

The New Zealand health system is concerned with building on the considerable gains already made in Māori health. Major gains in Māori provider development and Māori workforce development have begun, and will continue, to strengthen Māori infrastructure and leadership.

Activities in 2006/07 included the following.

• The platform for action, Whakatātaka Tuarua: Māori Health Action Plan 2006–2011, was launched (Minister of Health and Associate Minister of Health 2006). This plan sets objectives for Māori health over the next five years, building on Whakatātaka: The Māori Health Action Plan 2002–2005 (Minister of Health and Associate Minister of Health 2002).
  
  
• Three Ministry of Health-led governance training sessions (Te Matawhānui) were held for Māori DHB board members. Te Manu Whakahiāto, the Māori governance training programme for DHB Māori Relationship Boards was implemented and these governance training sessions will be adapted for PHO governance boards in 2007/08.
  
  
• Taonga Tuku Iho, the rongoā development plan, was implemented. (The next step is the establishment of a national rongoā body.)
  
  
• The Ministry has been working with the DHB Chief Executives and/or senior managers of Tairawhiti, Northland, Whanganui and Lakes DHBs on the Four DHBs Inequalities Project. The project aims to address the inequalities identified in the report Monitoring Neighbourhood Inequality through Neighbourhood Life Expectancy: Public Health Intelligence occasional bulletin no. 28 by working closely with these DHBs to improve their respective average levels of health and distribution of health through a suite of targeted interventions.
  
  
• The Ministry continued to facilitate communication and information sharing through its newsletter Ngā Korero and through a variety of presentations and workshops held with, health and disability sector organisations, DHB boards and management teams, and iwi and Māori providers on Whakatātaka Tuarua, Māori health research, and other Māori health and disability issues.
  
  
• A portfolio of research, evaluation and statistical information, including a new web resource that is an easy to use and accessible source of Māori health statistical information, and the Māori Health Review, an online monthly publication for disseminating Māori research findings, were launched.
  
  
• The Ministry has been negotiating with the WAI 692 – Napier Hospital and Health Services claimants to resolve issues related to the health needs of Māori in the Napier (Ahuriri) area.
  
  
• The Ministry of Health has been working with WAI 1315 – Primary Health Organisations claimants to address issues around the constraints for small practices participating in the very low cost access scheme, while serving Māori populations and other populations with high health needs.
  
  
• The Whānau Ora Awards (held every two years) were held in Wellington in November 2006 to showcase Māori health provider excellence and innovation. The Māori Provider Development Scheme continued to be administered with more than 500 scholarships granted to assist students studying in relevant Māori health fields. An evaluation of the Hauora Māori Scholarship Programme (part of the Māori Provider Development Scheme) found that the scholarships made a substantial contribution to developing and expanding the Māori health and disability workforce.
  
  
• A portfolio of research, evaluation and statistical information, including a new web resource that is an easy to use and accessible source of Māori health statistical information, and the Māori Health Review, an online monthly publication for disseminating Māori research findings, continued to be managed. The Ministry of Health will be working with DHBs to ensure the targets agreed for addressing equity are met; particularly, how DHBs will work to not only improve the health of Māori in their districts but also to ensure Māori have equitable health outcomes.

Fundamental to reducing inequalities is having a solid evidence base. More activity will occur to improve the quality and collection of ethnicity data and to understand more about the nature and extent of inequalities in the target areas. The Ministry of Health will continue to develop and support Māori providers and to develop the Māori health workforce.

1.4 Pacific peoples’ health

The increased focus by the Ministry of Health and the broader health sector on the health of Pacific peoples over the last few years has produced positive results in some areas, such as the success of the Meningococcal B immunisation programme, improved access for Pacific peoples to primary health care services and the strengthening of Pacific health service providers. However, significant health inequalities remain for Pacific peoples in New Zealand.

In 2006/07, the Ministry of Health’s work focused on:

• building a Pacific health knowledge and information base
• building capacity and capability in Pacific providers and the Pacific workforce to support them to lead service innovation and to implement the Pacific Health and Disability Workforce Development Plan (Ministry of Health 2004a)
• supporting mainstream health services, including DHBs and PHOs, to deliver high-quality,culturally competent services for Pacific peoples by monitoring DHB activity and providing policy advice
• facilitating communication and information sharing within the Pacific health sector and with the wider health sector with publications such as Voyages magazine and the Pacific Health Research Review.

A review of the Pacific Health and Disability Action Plan (Minister of Health 2002) identified child health and chronic disease as key clinical priority areas. Addressing these priorities requires the health sector to provide effective, culturally competent health services and leadership from the Pacific community to support lifestyle changes.

1.5 New Zealand health system

The New Zealand Public Health and Disability Act 2000 directed the development of DHBs. Governed by boards of directors that include locally elected members and ministerial appointees, the 21 DHBs are responsible for planning, funding and delivering most publicly funded health services to New Zealanders. DHB provider arms offer most secondary and tertiary hospital services, including for all acute and most elective cases. Private hospitals offer elective services on contract to DHBs and on a private basis, generally for those cases who do not meet the need thresholds established by DHBs.

The first PHOs were introduced in 2002 as the cornerstone of the implementation of the Primary Health Care Strategy (Minister of Health 2001a). There are now 82 PHOs with more than 3.9 million enrollees (more than 95 percent of the New Zealand public) involving the vast majority of general practitioners and practice nurses. Governed by non-profit boards of directors, PHOs contract with DHBs to offer a range of preventive and curative services as well as an increasing array of population health services. From 1 July 2007, all New Zealanders enrolled with PHOs can avail themselves of low or reduced cost primary care services.

Much health care in New Zealand is delivered by non-government organisations (NGOs). These include providers with national contracts such as the Royal New Zealand Plunket Society and providers who contract with their regional DHBs such as community-based NGOs providing services to people with experience of mental illness.

Overall, 77 percent of health expenditures are funded by the public through taxes; 5 percent are funded by private health insurance premiums; less than 1 percent by non-profit organisations; and the remainder (17 percent) is paid directly by those receiving the service.

The Ministry of Health is a policy advisor to the Minister of Health, an agent of the Minister for monitoring and overseeing DHBs, a funder of DHBs and national services such as national screening services, and a provider of regulatory and other functions (eg, public health).

The Director-General of Health reviewed the Ministry of Health in December 2006. The review identified that the Ministry needed to go ‘harder and faster’ on the Minister of Health’s priorities while streamlining the delivery of its core operating functions. Based on this review, the Director-General is implementing a programme of development and change within the organisation.

The programme of change is focusing on the:

• Ministry’s role as the planner and funder of selected services and the manager of a range of national operations functions
• Ministry’s structure, including streamlining core operating functions and, potentially, revising roles
• strengthening of existing performance management frameworks and processes to ensure the delivery of work programmes against priorities
• strengthening of existing leadership capability to better fulfil the Minister’s priorities and face the challenges to the health sector in the next three to five years.

In 2007/08, the Ministry is focusing on long-term sector planning to ensure the sustainability of the health system, set the scene for allocating resources and planning services, and aid prioritisation of services and investments locally.

1.6 Implementing the New Zealand Health Strategy

The New Zealand Health Strategy (Minister of Health 2000) was released in December 2000 and it provides a robust, overarching vision for improving the health and wellbeing of all New Zealanders. It sits alongside the New Zealand Disability Strategy (Minister for Disability Issues 2001), and together they set New Zealand’s overall health and independence goals. Consultation on the Strategy was extensive, including 466 written submissions and almost 60 meetings involving approximately 1500 people.

An expert advisory group developed draft goals and objectives aimed at improving the population’s health, reducing health inequalities and improving social inclusion. Out of a total of 10 goals and 61 objectives, the Government highlighted 13 population health objectives for the Ministry of Health and DHBs to focus on for action in the short to medium term.

These 13 population health objectives are to:

• reduce smoking
• improve nutrition
• reduce obesity
• increase the level of physical activity
• reduce the rate of suicides and suicide attempts
• minimise harm caused by alcohol and illicit and other drug use to both individuals and the community
• reduce the incidence and impact of cancer
• reduce the incidence and impact of cardiovascular disease
• reduce the incidence and impact of diabetes
• improve oral health
• reduce violence in interpersonal relationships, families, schools and communities
• improve the health status of people with severe mental illness
• ensure access to appropriate child health-care services, including Well Child and family health care and immunisation.

The centrality of the New Zealand Health Strategy to action on health is recognised across the entire sector. Work is underway at all levels of the health system to implement the Strategy and considerable progress has been made so far. The sector is committed to building on what has already been achieved in reducing inequalities, delivering high quality health care, and providing timely and equitable access to health services for all.

A major development in the New Zealand health sector since the launch of the New Zealand Health Strategy has been the implementation of the Primary Health Care Strategy (Minister of Health 2001a). PHOs have been rolled out nationwide and access to primary care has been improved progressively through lower fees and initiatives to reduce non-financial barriers to access.

Advancing tobacco control is one of the most effective ways to improve health status and reduce health inequalities and New Zealand has made substantial progress with tobacco control since the launch of the New Zealand Health Strategy. In January 2004, the buildings and grounds of schools and early childhood centres became smokefree and from December 2004 all indoor workplaces including restaurants and bars became smokefree under the Smoke-free Environments Amendment Act 2003. Prior to enactment of the smokefree legislation amendment, approximately 350 New Zealanders died each year because of exposure to second-hand smoke. The legislation is also expected to further reduce tobacco consumption and smoking prevalence.

Recent achievements include the March 2007 launch of the new National Drug Policy 2007–2012 (Ministerial Committee on Drug Policy 2007) with a goal to prevent and reduce the health, social and economic harms that are linked to tobacco, alcohol, illegal and other drug use. In August 2007, new guidelines for the Violence Intervention Programme were launched to ensure that victims of violence using health services receive the support they require, and ensure that staff are trained and competent to screen health service users who may be victims of child and partner abuse. To date, more than 4500 health professionals have been trained in family violence intervention; the Royal New Zealand Plunket Society has screened 29,200 new mothers for violence and made 600 referrals; and, in the past year, 500 general practitioners and midwives have been trained in family violence prevention.

Table 1.2 summarises the major actions and achievements from the launch of the New Zealand Health Strategy in 2000 to the ongoing implementation of the Strategy seven years on.

Table 1.2 Summary of major actions to implement the New Zealand Health Strategy

New Zealand Health Strategy objective	Headline Indicator	Health Target	Major actions to implement the New Zealand Health Strategy
			2000	2001 - 2007
			New Zealand Health Strategy launched	2001 - 2007	Toolkits developed for the 13 population health objectives
Reduce smoking	2.8.5	4.9		2003 - 2007	Smoke-free Environments Amendment Act passed
				2004 - 2007	Smoking banned in schools and early childhood centres
				2004 - 2007	Clearing the smoke five-year plan released
				2004 - 2007	All indoor workplaces became smokefree
				2005 - 2007	WHO Framework Convention on Tobacco control came into effect
Improve nutrition Reduce obesity Increase the level of physical activity	2.9.1	4.8		2003 - 2007	Healthy Eating – Healthy Action launched
				2003 - 2007	Health Eating – Healthy Action Implementation Plan released
				2005 - 2007	Fruit in Schools programme rolled out
				2006 - 207	Health Select Committee inquiry into obesity
				2006 - 2007	Review of food and nutrition guidelines
Reduce the rate of suicides and suicide attempts				2006 - 2007	New, all-ages suicide prevention strategy (2006–2016) launched
				2007	First five-year action plan released
Minimise harm caused by alcohol and illicit and other drugs to both individuals and the community	2.9.2			2005 - 2007	Misuse of Drugs Amendment Act passed
				2005 - 2007	Community Action on Youth and Drugs (CAYAD) projects under way
				2007	New National Drug Policy 2007–2012 released
Reduce the incidence and impact of cancer	2.6.5 2.8.3	4.4 4.9		2003 - 2007	New Zealand Cancer Control Strategy launched
				2005 - 2007	Cancer Control Action Plan 2005–2010 released
				2005 - 2007	National Cervical Screening Programme Amendment Act came into effect
				2005 - 2007	Cancer Control Council and regional networks established
				2006 - 2007	Late Effects (into childhood cancer survivors) Assessment Programme (LEAP) pilot began
Reduce the incidence and impact of cardiovascular disease and diabetes	2.8.2 2.8.4	4.8 4.9 4.6		20030 - 2007	Cardiovascular Action Plan released
				2003 - 2007	Cardiovascular risk, stroke, and diabetes management guidelines released
				2007	CVD and diabetes services review
				2003 - 2007	Healthy Eating – Healthy Action launched
				2004 - 2007	Health Eating – Healthy Action Implementation Plan released
Improve oral health		4.2		2004 - 207	Review of school dental services by DHBs
				2006 - 2007	Good Oral Health for All, for Life launched
Reduce violence in interpersonal relationships, families, schools and communities				2002 - 2007	Family Violence Intervention Guidelines released
				2007	Violence Intervention Programme launched
Improve the health status of people with severe mental illness	2.5.5 2.5.6 2.9.3	4.7		2000 - 2007	Mental Health Information National Collection established
				2002 - 2007	Mental Health Workforce Development Framework released
				2005 - 2007	Te Tāhuhu, the second mental health and addiction plan 2005–2015 released
				2006 - 2007	Action plan to implement Te Tāhuhu released
Ensure access to appropriate childhealth care services including well child and family health care and immunisation	2.1.4 2.2.3 2.6.6	4.1		2002 - 2007	Well Child/Tamariki Ora Framework and service specifications introduced
				2002 - 2007	Child and Youth Mortality Review Committee established
				2005 - 207	Meningococcal B Immunisation Programme national rollout starts
				2005 - 2007	Perinatal and Maternal Mortality Review Committee
				2005 - 2007	National Immunisation Register implemented nationwide
				2007	Review of Well Child/Tamariki Ora services begins

* Refers to section of this report where related Headline Indicator or Health Target can be found.