Health and Independence Report 2007
2 Progress on Headline Indicators
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
In this section:
2.1 Introduction
Presenting a comprehensive picture of progress in a diverse and complicated sector such as health is difficult. No single measure summarises health sector performance. Our snapshot of progress is organised around the goals outlined in the Ministry of Health outcomes framework (see Figure 1.1). Against each goal, specific indicators tell us how the health sector is doing.
Table 2.1 summarises each headline indicator’s progress. Sections 2.2–2.10 provide more detail. Note that the symbols used in the table are also used in each section heading to indicate progress, and are defined in the notes under Table 2.1.
The progress symbols allocated to each headline indicator are an overall judgement of performance based on the following three elements (where such comparative information is available): i. the overall trend of performance; ii. reduced inequalities between ethics groups; iii. how our performance compares internationally.
Table 2.1 Summary of progress against headline indicators, 2006/07
| Outcome | Headline Indicators | Progress* | Page |
| Better health | Life expectancy†
Healthy life expectancy†
Infant mortality†
Mental health status† | YY
YY
YY
± | 14
14
15
15 |
| Reduced Inequalities | Life expectancy by ethnicity†
Healthy life expectancy by ethnicity†
Mortality disparity by ethnicity†
Infant mortality by ethnicity† | Y
Y
Y
Y | 16
17
19
21 |
| Better participation and independence | Disability requiring assistance†
Unmet need for disability support services | =
± | 22
23 |
| Trust and security | Views of the health care system
Confidence in obtaining high-quality and safe medical care when needed
Cost of medical care
Access to medical care | YY
=
=
Y | 25
25
26
26 |
| Equity and access | Primary health care utilisation‡
Elective surgery discharges
Radiotherapy waiting times
Matching of health workforce to population characteristics
Rate of new admissions to general acute inpatient mental health services
Secondary mental health services utilisation | =
Y
Y
X
YY
= | 27
28
30
30
31
32 |
| Quality | Patient satisfaction
Emergency department triage times
Hospital readmission rate
Hospital mortality rate
Cancer screening coverage
Immunisation coverage
Proportion of health records with a National Health Index number | YY
Y
YY
YY
X
X
YY | 33
33
34
35
36
40
41 |
| Effectiveness | Ambulatory-sensitive hospital admissions
Cardiovascular disease mortality
Cancer survival
Diabetes management
Smoking prevalence and consumption | =
YY
Y
Y
YY | 43
44
45
47
47 |
| Efficiency and value for money | Day-case procedures
Older people living independently
Efficiency of primary health care
Costs and outputs of public hospital services | YY
Y
Y
= | 48
49
50
51 |
| Intersectoral focus | Obesity†
Alcohol available for consumption
De-stigmatisation of people with mental illness | X
X
YY | 53
56
57 |
Notes:
* Symbols:
YY progressing well
Y some progress
= neutral or little progress
X needs improvement
± no trend or comparative data reported.
† Data available for analysis by ethnicity.
‡ Incorporates ethnicity in that it measures the ratio of high-need visits (ie, from Māori, Pacific peoples, and people living in areas of high deprivation) to non-high-need visits.
Societal outcomes
2.2 Better health
Outcome goal The best possible improvement in New Zealanders’ health status and quality of life over time, within the resources available.
2.2.1 Life expectancy YY
Life expectancy has been steadily increasing. According to the New Zealand abridged life table for 2004–06 (see Figure 2.1), a newborn female can expect to live, on average, 81.9 years, and a newborn male, 77.9 years.
These levels represent longevity gains since 1995–97 of 2.2 years for females and 3.5 years for males. These gains were due largely to the reduction in mortality rates at late-working and retirement ages (50–89 years).
Newborn females can expect to outlive males by four years, down from a peak of 6.4 years in1975–77.
Figure 2.1 Life expectancy at birth, by gender, 1950–52 to 2004–06
Source: Statistics New Zealand
2.2.2 Healthy life expectancy YY
Similar to life expectancy, healthy life expectancy (that is, a life free of functional limitation requiring assistance) also shows a steady improvement. The most recent data (from 2001) shows that males had a healthy life expectancy of 64.8 years and females a healthy life expectancy of 68.5 years.
Females gained one extra year of healthy life expectancy between 1996 and 2001, but males gained only 0.1 of an extra year over this time.
2.2.3 Infant mortality YY
Infant mortality fluctuates annually, but has continued to decline steadily (see Figure 2.2).
In the year ended 31 March 2007, the infant mortality rate was 5.1 per 1000 live births, down from 7.1 per 1000 live births in 1997 and 14.2 per 1000 in 1977.
Figure 2.2 Infant mortality rate (deaths per 1000 live births), 1961–2007 (year ended 31 March)
Source: Statistics New Zealand
2.2.4 Mental health status ±
Data from the 2002/03 New Zealand Health Survey indicates that New Zealanders overall have a high self-rated mental health status (Ministry of Health 2004b). On a 0–100 scale, females rate their mental health at 81.6 and males at 84.4.
Te Rau Hinengaro (New Zealand’s mental health survey as part of the World Health Organization World Mental Health Survey Consortium) found a mental disorder prevalence rate of 20.7 percent in the total population in the past 12 months (Oakley Browne et al 2006).
Younger people have a higher prevalence of disorder in the past 12 months, and are more likely to report ever having a disorder by any particular age.
Females have a higher prevalence of anxiety disorder, major depression and eating disorders than males have (which correlates with the 2002/03 New Zealand Health Survey finding that females tend to rate their mental health as lower than males). Males have a substantially higher prevalence for substance use disorders than females have.
The prevalence of disorder in any period is higher for Māori and Pacific peoples than for Others (a composite ethnic group of non-Māori non-Pacific peoples). For disorder in the past 12 months, the prevalence rates are 29.5 percent for Māori, 24.4 percent for Pacific peoples and 19.3 percent for Others. This indicates that Māori and Pacific peoples have a greater burden due to mental health problems. Much of this burden appears to be due to the youthfulness of the Māori and Pacific populations and their relative socioeconomic disadvantage (Oakley Browne et al 2006).
2.3 Reduced inequalities
Outcome goal An improvement in the health status of those currently disadvantaged, particularly Māori, Pacific peoples and people living in areas of high deprivation.
2.3.1 Life expectancy by ethnicity Y
Māori life expectancy is significantly lower than the life expectancy for non-Māori. In 2000–02 (the most recent years for which data is available) Māori female life expectancy was 73.2 years, 8.7 years below that of non-Māori females (81.9 years), and Māori male life expectancy was 69.0 years,8.2 years below that of non-Māori males (77.2 years). (See Figure 2.3.)
After some years of a widening life expectancy gap between Māori and non-Māori, the gap narrowed slightly between 1995–97 and 2000–02.
Life expectancy for Pacific peoples in 2000–02 was 4.8 years less than the New Zealand average life expectancy for males (71.5 and 76.3 years respectively) and 4.4 years less than the New Zealand average for females (76.7 and 81.1 respectively).
Socioeconomic differences are also apparent, with people from more deprived areas experiencing lower life expectancies than people from less deprived areas experience (Ministry of Health and University of Otago 2006).
Figure 2.3 Life expectancy, by ethnicity, 1950–52 to 2000–02
Source: Statistics New Zealand
2.3.2 Healthy life expectancy by ethnicity Y
Inequalities in the probability of living a long and healthy life are most apparent for Māori females, who have a partial (0–85 years) independent life expectancy 9.2 years less than non-Māori females have (as at 2001). Māori males have a partial (0–85 years) independent life expectancy 7.2 years less than non-Māori males have (Table 2.2).
From 1996 to 2001, Māori males gained 1.2 years of healthy life expectancy (substantially more than non-Māori males gained). However, Māori females’ healthy life expectancy remained at 59 years, with no change in the five years from 1996 to 2001.
Table 2.2 Part al (0–85 years) Independent life expectancy at birth in years, by ethnicity and gender, 1996 and 2001
 | 1996 | 2001 |
| Gender | Māori | Non-Māori | Māori | Non-Māori |
| Females | 59.0 | 67.7 | 59.0 | 68.2 |
| Males | 56.8 | 65.3 | 58.0 | 65.2 |
Source: Ministry of Health
In 2000–02, Pacific peoples had an independent life expectancy lower than the New Zealand average: 2.7 years lower for males (Pacific male 61.8 years, total New Zealand male 64.5 years) and 4.5 years lower for females (Pacific female 63.1, total New Zealand female 67.6) (Ministry of Health and Ministry of Pacific Island Affairs 2004).
Tongan community-driven health services
Langimalie, a community-owned Pacific PHO, is the embodiment of the local Tongan community’s commitment to improving its own health. The Langimalie waiting room in Onehunga is busy with people attending the PHO’s numerous clinics and services: a diabetics centre, asthma nurse support, Well Child nursing services, mobile nurses working with youth at risk, immunisations and doctors by appointment. The services are open to all New Zealanders, but cater particularly for Tongans in New Zealand.
Since Langimalie became a PHO in 2003, it has built a patient base of nearly 7,000 people. Chief Executive Paul Lavulo says the PHO now runs two medical centres, one in Onehunga and another in Glen Innes. He estimated Langimalie’s 38 staff see as many as 32,000 people each year.
Paul says the need for Langimalie was evident from the beginning.‘Communication was a big problem for Tongan people. Even if they didn’t understand what the doctor was saying, our people would just say ‘yes’.That meant prescriptions weren’t always relevant. So there was a big need and community leaders decided to set up a Tongan clinic. That’s how it started – it was a community driven initiative from the beginning.’
The affordability of services was also a key issue for the Tongan community. ‘Maintaining our fees, which are among the lowest in the country, means our people can afford access to doctors. But it also means we need support from government. That’s why the government’s recent low cost initiative has helped tremendously.’
However, it is the holistic community-driven approach that holds the key to improving Pacific peoples’ health outcomes, according to Lee Ahokovi, Langimalie's clinical nurse advisor. ‘We speak their language and understand their culture. We bring an approach that makes a difference. For example, we are running a diabetes clinic here, and we are offering a full range of services such as cervical smears, mammograms and triage services. It’s like a “one-stop-shop”. This means people don’t have to travel all over Auckland to access these services.’
Every patient seeing a doctor at the clinic for the first time is given a finger-prick blood sample that is tested for diabetes. If the blood sugar level is high, the clinic does further blood tests. Then a management plan is drawn up according to the patient’s needs. This early intervention combined with the clinic’s computerised recall system enables Langimalie to identify patients much earlier for appointments, blood testing, education and the subsequent management of their condition.
Taniela Lutui, the public health manager, says Langimalie also runs a wide range of health promotion activities: from Well Child, asthma and youth-at risk services to mobile school-based nursing. ‘These types of programmes are reaching people who wouldn’t have been reached otherwise. Working through churches is an example of engaging with our people. We work with their local church, talk to the minister, organise a time to talk to the whole congregation and arrange for our public health team to weigh people, and check for diabetes and hypertension. We do a health profile of people attending the church and tell them the data.’
Taniela says the two major health problems facing the community are diabetes and obesity. ‘Now most churches are running two aerobic classes a week. Taking the clinic to the people is helping to keep people healthy, or, if they have health problems, preventing them from getting worse. It’s a very preventative approach.’
Paul is determined Langimalie will have a lasting impact on the health of the community. ‘For me, the future is about the health of our people. According to the statistics we are among the worst – diabetes, life expectancy, infant mortality. I think through a concentrated effort, we are hoping to make a difference to the lives of our members. The statistics will tell us whether we are catching up in 15 or 20 years. The health of our community is about reaching out to them every day. Giving them the skills and knowledge that will make a difference to their lives.’
2.3.3 Mortality disparity by ethnicity Y
Between 1996–99 and 2001–04 absolute inequality1 in all-cause mortality decreased, more so for Māori than for Pacific ethnic groups. (See Figures 2.4 and 2.5.)
The decline in mortality for all ethnic groups over the period can be attributed to a progressive reduction in the incidence and case fatality of cardiovascular disease (CVD), ischaemic heart disease and stroke in particular. The contribution of CVD to the total mortality ethnic inequality has been replaced by an increasing contribution from cancer.
Figure 2.4 All-cause mortality rates per 100,000 for males, by ethnicity, age standardised within the group aged 1–74 years, 1981–84 to 2001–04
Source: Public Health Intelligence, 2007 (see Blakely et al 2007)
Figure 2.5 All-cause mortality rates per 100,000 for females, by ethnicity, age standardised within the group aged 1–74 years, 1981–84 to 2001–04
Source: Public Health Intelligence, 2007 (see Blakely et al 2007)
Disparities in mortality between the Māori and European/Other group persist within all income groups. For males and females aged 25–74 years, the mortality rates for Māori in the high-income group were similar to or greater than the mortality rates for European/Other in the low-income group in each period.
Among the European/Other group, mortality declined from 1981–84 to 2001–04 within all income groups (overall and among middle-aged and older adults in particular). However, among Māori, declines in mortality rates in the 1980s and 1990s tended to be more evident among the high and medium-income groups, but not the low-income group.
Statistical modelling suggests that socioeconomic differences mediate about half of the inequality in mortality between the Māori and European/Other groups, although this is probably an underestimate, because socioeconomic position cannot completely account for the mortality disparity. (See Figure 2.6.)
Figure 2.6 Estimated trends in absolute and relative inequality in all-cause mortality, all ages and both sexes combined, 1981–84 to 2001–04
Source: Public Health Intelligence, 2007 (see Blakely et al 2007)
2.3.4 Infant mortality by ethnicity Y
Māori have a consistently higher infant mortality rate than the total New Zealand population has. However, there is some evidence the gap is closing: in 2005, the rates had declined to 6.6 per 1000 live births for Māori and 5.1 per 1000 for the total population, compared with 11.5 per 1000 live births for Māori and 7.1 per 1000 for the total population in 1996. (See Figure 2.7.)
In year ended 31 March 2007, the total population infant mortality rate has remained at 5.1 per 1000, but the Māori rate has further reduced to 6.5 per 1000 live births.
The infant mortality rate for Pacific peoples is also higher than that for the total population. The most recent data is for 2002/03 when the rate was 6.9 per 1000 for Pacific peoples compared with the 5.5 per 1000 for the total population (Ministry of Health 2007b).
Infant mortality rates are, overall, higher in areas of highest deprivation and lower in areas of least deprivation.
Figure 2.7 Infant mortality rate, Māor and total population, 1996–2005
Source: Statistics New Zealand
2.4 Better participation and independence
Outcome goal The health and disability sector contributes constructively to having a society that fully values the lives of people with disability.
2.4.1 Disability requiring assistance =
Approximately 10 percent of New Zealanders had a disability requiring assistance in 2001 (the most recent year for which data is available), a similar proportion to 1996. (See Table 2.3.)
The health and disability sector has a responsibility to make a positive difference through the support services it provides and by promoting inclusive attitudes, so the lives of people with disabilities are fully valued by society.
Table 2.3 Prevalence of disability requiring assistance, by ethnicity and sex, 2001
| Māori (%) | Non-Māori (%) | Total (%) |
| Males | 13.5 | 9.9 | 10.7 |
| Females | 14.4 | 8.9 | 9.7 |
Source: 2001 Household Disability Survey; 2001 Disability Survey of Residential Facilities; 1996/97 Disability Survey
2.4.2 Unmet need for disability support services ±
In 2001, only small percentages (2–5 percent) of adults with disabilities or parents or caregivers of children with disabilities reported an unmet need2 in relation to everyday activities (such as personal care or household tasks). (See Figure 2.8.)
Twelve percent of adults with disabilities and 6 percent of parents or caregivers of children with disabilities reported an unmet need in relation to equipment or technology (such as hearing or mobility equipment).
Fifteen percent of adults with disabilities and 17 percent of parents or caregivers of children with disabilities reported an unmet need in relation to health services (such as therapists).
Figure 2.8 Unmet need reported by adults with disabilities or parents or carers of children with disabilities, 2001
Source: 2001 Household Disability Survey; 2001 Disability Survey of Residential Facilities
Opening a new world for the hearing impaired
In 2001, a new world opened up for 10-year-old Matthew Pakura when he received a government-funded cochlear implant. Matthew’s family has a history of hearing problems. His older sister and younger brother have hearing impairments, and his mother, grandfather and uncles all have partial hearing loss. Matthew’s hearing was tested from the time he was a baby, gradually his hearing deteriorated and by the time he was 2½ years old he was profoundly deaf.
Matthew’s mother, Esther Pakura, says, ‘Deciding to go ahead with the cochlear implant was a huge decision to make, but it was the right decision, it’s given him the opportunity to hear and has opened up a new world.’
The procedure involved surgically implanting a device in Matthew’s ear under general anaesthetic. Matthew spent the night in hospital. Six weeks later the external part of the device, the speech processor, was switched on. The speech processor, which usually sits behind the ear like a hearing aid, converts sound to a digital signal, sending this to the implant and this activates sensory hearing cells in the cochlea.
Esther says the implant has had a huge impact on Matthew’s life. ‘He used to wear a hearing aid, which didn’t really work for him, and he had delayed speech. At kindergarten he had a teacher aid and resource teacher helping him. He’s always been a very outgoing social child and would happily play alongside his peers, but his language skills were way behind.’
‘In a teaching environment he used to get very frustrated at not being able to communicate properly. On occasion, this led to behavioural problems where he’d throw things or lash out, out of sheer frustration. He’s a changed boy since he had the implant. He’s going to a mainstream school, which I don’t think he would have been able to do had he not had the implant. And he’s doing well; he’s no longer lagging behind academically. He likes reading now too.’
More profoundly deaf New Zealanders are set to benefit from cochlear implants over the next four years with the Government committing an extra $8 million for the procedure.
In addition, the government-funded Universal Newborn Hearing Screening Programme is set to be phased in across the country over the next three years, beginning in July 2007. The joint initiative between the Ministries of Health and Education will see Waikato, Tairawhiti and Hawke’s Bay DHBs participating in the initial implementation phase. These three DHBs all have experience in newborn hearing screening and have good links with education services.
Having a hearing screening programme for newborns will make sure those who have a hearing loss will be identified much earlier, and so offered help much earlier. Without screening, hearing loss is not picked up in some children until they are nearly four years old.
2.5 Trust and security
Outcome goal New Zealanders are able to feel secure that the system will protect them from substantial financial costs due to ill health and will trust the system because it performs to high standards, reflects their needs and provides opportunities for community participation.
2.5.1 Views of the health care system YY
Commonwealth Fund surveys for 1998, 2001 and 2004 show a positive change in New Zealanders’views about their health care system. The proportion of respondents who felt the system required only minor changes increased from 9 percent in 1998 to 19 percent in 2004, and the proportion of respondents who indicated the health care system should be rebuilt completely decreased from 31 percent in 1998 to 19 percent in 2004.
The 2006 Commonwealth Fund survey of primary care doctors’ views of their health care system in seven countries found New Zealand compared favourably, 34 percent of primary care doctors in New Zealand reported that the health care system worked well on the whole and only minor changes were needed, compared with only 4 percent in Germany and 23 percent in Canada. (See Figure 2.9.)
Figure 2.9 Primary care doctors’ views of their health care system in seven countries, 2006
Source: Commonwealth Fund International Survey of Primary Care Doctors, 2006
2.5.2 Confidence in obtaining high-quality and safe medical care when needed =
When asked about their confidence in obtaining high-quality and safe medical care when needed, New Zealanders’ ratings in the 2004 Commonwealth Fund survey were similar to those of respondents from the other participating countries. In all countries, only a minority were ‘very confident’ of obtaining high-quality care when needed. Twenty-five percent of New Zealanders were ‘not very or not at all confident’ and similar proportions were reported in Australia, the United States and the United Kingdom.
Data from the 2006 Commonwealth Fund survey of primary care doctors in seven countries shows that 37 percent of New Zealand primary care doctors reported an improvement in their ability to provide quality medical care to their patients in the past five years. While this proportion was not as high as in the United Kingdom (48 percent) or Australia (45 percent) it was much higher than in the United States (21 percent) and Germany (5 percent).
A very high proportion of New Zealand primary care doctors (78 percent) had participated in collaborative quality improvement efforts with other practices, hospitals, government agencies or professional associations. This compared favourably with Australia and the United Kingdom (58 percent reported participating) and the United States (49 percent reported participating).
2.5.3 Cost of medical care =
Data from the 2006 Commonwealth Fund survey of primary care doctors shows that 39 percent of doctors in New Zealand reported that patients ‘often’ experience difficulty paying for out-of-pocket costs of care (other than prescriptions) and 54 percent reported patients ‘sometimes’ have difficulty paying. Figure 2.10 shows that cost barriers remain for many New Zealanders.
Figure 2.10 Difficulty paying for out-of-pocket medical costs, other than prescriptions, in seven countries, 2006
Source: Commonwealth Fund International Survey of Primary Care Doctors, 2006
2.5.4 Access to medical care Y
The 2006 Commonwealth Fund survey found New Zealand performed relatively well internationally in terms of access to medical care. Of the primary care doctors surveyed, 69 percent reported that almost all of their patients (more than 80 percent) could obtain a same-day or next-day appointment when they needed one. Only 52 percent of Australian and 23 percent of Canadian primary care doctors reported providing similar access to the majority of their patients.
System outcomes
2.6 Equity and access
Outcome goal New Zealanders in similar need of services have an equitable opportunity to access equivalent services, and resources are allocated in a way that reduces inequity of outcomes.
2.6.1 Primary health care utilisation =
‘High-need’ groups are defined as people living in a deprived area3 or people of Māori or Pacific ethnicity. These groups are defined as high need because analyses of morbidity and mortality statistics show that they experience higher levels of illness and die younger than the rest of the population. Given this higher level of need, higher utilisation of primary health care (as measured by GP visits) by high-need groups is important for reducing inequalities and is an important indicator of equity and access.
The under-utilisation of primary health care is an indicator of unmet health needs Figure 2.11 shows the distribution of PHOs based on the ratio of their high-need enrollees level of GP visits to their non–high-needs enrollees level of GP visits. If the ratio is above 1, the people enrolled with PHOs from high-need groups have a higher level of utilisation than people enrolled from non–high need groups have. If the ratio is below 1, high need enrollees have a lower level of utilisation than non–high need enrollees have. The expectation is that PHOs will aim to achieve a ratio of 1 or higher.
As at 31 March 2007, of the 81 participating PHOs, 55 were serving high-need enrollees at the same or higher level than non–high-need enrollees.
Figure 2.11 Distribution of Primary Health Organisations (PHOs) by ratio of general practitioner visits for high need enrollees to non-high need enrolees, June 2006 and March 2007
Source: Ministry of Health PHO utilisation database
Note: LT = less than, GT = greater than. Visits standardised by age.
2.6.2 Elective surgery discharges Y
The elective services policy seeks to ensure that patients with the greatest clinical need and ability to benefit are seen first.
Although discharge volumes fluctuate over time, the number of case-weighted discharges increased 12.6 percent between 2001/02 and 2006/07. (See Table 2.4.)
Table 2.4 Number of elective surgery discharges, 2001/02 to 2006/07
| Financial year | Number of discharges | Number of case-weighted discharges* |
| 2001/02 | 106,663 | 122,555 |
| 2002/03 | 104,985 | 121,866 |
| 2003/04 | 106,150 | 123,492 |
| 2004/05 | 107,159 | 129,349 |
| 2005/06 | 105,784 | 130,796 |
| 2006/07 | 112,583 | 137,955 |
Source: Data extracted from the National Minimum Data Set, Ministry of Health, September 2007
* The number of case-weighted discharges are calculated using WIEs 11 for all years. Case-weighting adjusts the numbers of discharges for the relative resources used (eg, theatre time) for those discharges. For example, a more complex operation such as a hip replacement uses more resources than a cataract surgery and therefore has a higher case-weighted discharge value.
Pre-admission changes lead to improved patient flow
A nurse-led pre-admissions clinic has reduced the number of cancelled elective gynaecology operations in six months at Waikato Hospital. This has improved the overall efficiency of the service, so more women can be seen.
Debi Whitham, clinical nurse specialist pre-admission, developed the programme. She describes it as an improved service for women where the nurse co-ordinates the pathway for the patient from pre-admission to post-operation.
‘Previously clerical staff would decide which patients should attend the pre-admission clinic. Women would turn up to their pre-admission appointment, the house surgeon would be held up on the wards and women were left waiting for hours. Inevitably, they’d leave without having the assessment. They would then turn up for surgery, which would be cancelled due to a lack of pre-admission planning. It was an ineffectual system for all involved’, says Debi.
Under the nurse-led pre-admissions programme, a clinical nurse specialist reviews a health questionnaire completed by patients and asks only those with a high anaesthetic risk to attend the pre-admission clinic. Clinical staff interview low-risk patients over the telephone, give them appropriate information and send them forms for blood tests. The system has freed up the hospital’s six gynaecology house surgeons to focus on theatre and their ward rounds.
The hospital runs 16 pre-admission clinics a week, with two of those being gynaecology. A nurse takes patients’ histories, orders pre-operative investigations, plans and implements discharge requirements, delivers education and reviews blood test results. The number of women needing to attend a clinic has been reduced by 40 percent since the programme was put in place in 2005.
The programme is patient centred, which means the focus for pre-admission requirements is on the individual’s history and support needs. In this way, they are better prepared for surgery before they arrive and supports are in place before they’re discharged, thereby minimising the chance of re-admission and a longer length of stay in hospital.
Debi says, ‘I have a weekly meeting with the gynaecology charge nurse, social workers and physiotherapists where we discuss patients’ needs. This approach means we’re able to arrange support for people once they’re back home, particularly when they don’t have family members who can look after them while they recover from their procedure. This has led to a reduction in the length of stay at hospital for many women.The meeting also ensures that the health care team is incorporated in the patient’s operative journey.
‘For example, if a patient smokes, a referral is sent to a smoking cessation practitioner. They can then make contact with the patient before they arrive for surgery and help them to stop smoking before their operation.’ Debi also liaises closely with the gynaecology surgeons and the anaesthetists who complete the team.
Debi would like to extend the programme to other elective procedures at Waikato Hospital. The Nurse-Led Pre-admission Gynaecology Programme has attracted interest from other DHBs wanting to roll out similar programmes. ‘There are many pre-admission clinics running all with different definitions of ‘nurse-led’. However, Waikato DHB seems to be the only one that is using senior nurses to ‘clerk patients’ in and plan their surgical pathway holistically, says Debi.
The programme is a finalist in the 2007 New Zealand Health Innovation Awards.
2.6.3 Radiotherapy waiting times Y
Delays to radiotherapy for cancer patients are likely to lead to poorer outcomes of treatment. Patients are divided into priority categories: A urgent, B curative, C palliative and other treatment, D combined chemotherapy and radiation treatment. National waiting times for priority C patients provide the best trend information to determine whether there are emerging problems, because priority C patients are most affected by any delays.
Analysis by national trend from March 2003 to June 2007 shows an overall increase in the proportion of priority C patients receiving radiotherapy treatment within eight weeks of their first specialist assessment. For June 2007, 96.72 percent of people whose treatment had started in the current month waited less than eight weeks. One of the health targets is to progress toward all priority A, B and C patients receiving radiation treatment within eight weeks of their first specialist assessment.
Figure 2.12 National waiting times for megavoltage radiation treatment: the percentage of priority C patients waiting less than eight weeks between first specialist assessment and radiation treatment
Source: Aggregated Cancer Centre data, Ministry of Health, 2007
Note: Data for October to December 2006 excludes Otago cancer treatment centre.
2.6.4 Matching of health workforce to population characteristics X
Māori and Pacific peoples are under-represented in the New Zealand health workforce in almost all areas of health.
Data from the Medical Council of New Zealand shows that in 2005, of all medical practitioners (eg,general practitioners, specialists and registrars) 2.6 percent were Māori and 1.5 percent were Pacific. In contrast, Māori comprise 14.6 percent and Pacific people comprise 6.9 percent of the New Zealand population. Additionally, 7.5 percent of registered nurses and midwives working in New Zealand were Māori and 2.7 percent were Pacific.
Very few Māori and Pacific peoples work in other health professions (eg, optometry or physiotherapy).
Despite the low overall numbers of Māori and Pacific peoples employed in health, the numbers have been increasing in some areas. For example, the number of Māori medical radiation technologists increased from 12 in 2005 to 40 in 2006 and the number of Māori midwives increased from 110 in 2005 to 157 in 2006 (Ministry of Health 2007c).
While progress has been made in the monitoring of numbers of Māori and Pacific peoples in the health workforce, gaps remain in our ability to monitor those working in the non-regulated workforce.
The percentage of medical practitioners who trained overseas has been increasing since 1985 and reached just under 38 percent in 2005.
2.6.5 Rate of new admissions to general acute inpatient mental health services YY
A proxy measure for the effectiveness of community mental health services with regard to early detection and service responsiveness is whether a person’s first contact with mental health services coincides with an inpatient psychiatric admission.
Access to a recovery-focused mental health service that is effective, efficient, responsive and timely minimises the impact of mental illness on a person.
The rate of new admissions directly to acute mental health services decreased between 2002/03and 2005/06 (Figure 2.13), indicating that mental health services are becoming more responsive. Admissions to acute mental health services vary considerably between DHBs, but this variation decreased between 2004/05 and 2005/06.
Given that the total number of people seen by mental health services has increased by 10,000 over the past year, a decrease in the number of clients seen as acute for the first time indicates that mental health services are becoming more responsive.
Figure 2.13 Mental health clients seen as acute and for the first time as a percentage of total clients seen, 2002/03 to 2005/06
Source: New Zealand Health Information Service
Note: DHB minimum is the lowest individual DHB figure; DHB maximum is the highest individual DHB figure; New Zealand is the national mean. The DHB minimum for 2004/05 and 2005/06 is 0.0 percent.
2.6.6 Secondary mental health services utilisation =
Measuring access rates to secondary mental health services estimates service responsiveness. Te Rau Hinengaro (New Zealand’s mental health survey as part of the World Health Organization World Mental Health Survey Consortium, Oakley Browne et al 2006) reported the prevalence of a mental disorder requiring secondary mental health services was closer to 4.7 percent than the previously estimated 3 percent. Prevalence of mental disorder is estimated to be higher in Māori (8.4 percent) than in the Pacific (5.9 percent) and Other (4.0 percent) groups.
Access rates remained stable at approximately 2.2 percent between 2001/02 and 2004/05. Concordant with an elevated prevalence of mental disorder, access rates were higher for Māori at 3.0 percent. (See Figure 2.14.)
Data from the Mental Health Information National Collection4 shows secondary mental health services saw more (92,389) clients in 2005/06 (an increase of 2813 on last year’s 89,576 individuals). However, access rates to secondary mental health services remain below the estimated prevalence of mental health need.
Te Rau Hinengaro reports that of the New Zealand population with a serious mental disorder, 35.3 percent made contact with a secondary mental health service; this compares with 28.6 percent of Māori and 15.7 percent of Pacific peoples with a serious mental illness.
Figure 2.14 Access to secondary mental health care services by ethnicity, 2002/03 to 2005/06
Source: New Zealand Health Information Service
2.7 Quality
Outcome goal Health and disability support services are clinically sound, culturally competent and well co-ordinated, and ongoing service quality improvement processes are in place.
Progress on implementing the national strategy for quality improvement is discussed in section 3.
2.7.1 Patient satisfaction YY
Satisfaction ratings indicate how well services meet consumer expectations. Because expectations change over time, satisfaction-rating trends indicate the match between changing quality and changing expectations.
Survey results of consumer satisfaction with DHB services show that in the past three years since the December 2002 quarter the combined patient satisfaction rate for all DHBs has varied very little. The most recent rating was 88.6 percent in the March 2007 quarter (ratings between 75 percent and 100 percent indicate a patient satisfaction rating of ‘very good’).
2.7.2 Emergency department triage times Y
Emergency departments are the main points of entry for acute patients. The length of time from presentation at the emergency department to treatment by a health professional affects patient outcomes. Benchmarks describe the percentage of patients who should be seen within the ideal time. A triage code indicates the urgency with which patients need to receive treatment for the best possible outcome: 100 percent of triage code 1 patients (the most urgent) should be seen on arrival,80 percent of triage code 2 should be seen within 10 minutes and 75 percent of triage code 3 within 30 minutes.
Emergency department staff maintained a stable and high proportion of triage code 1 patients seen within the recommended time: in the June 2007 quarter, 96.4 percent of these patients were seen on arrival. (See Figure 2.15.)
The proportion of less acute patients (triage codes 2 and 3) seen within the recommended times could be improved. Triage times have remained stable for code 3 patients since December 2004,but are below the target level. It is important to note that the percentage of triage code 2 patients seen within the target time of 10 minutes is showing an improving trend: the proportion seen in time during the March 2007 quarter reached the highest level (67 percent) since December 2003.
Figure 2.15 Proportion of patients seen in recommended triage times, quarterly December 2003–June 2007
Source: Hospital benchmark information, quarterly data
2.7.3 Hospital re-admissions rate YY
The hospital readmissions rate5 is a quality check on pressures to reduce the length of stay in publicly funded hospitals and to encourage the maintenance of high quality services generally.The desired direction of change is a decrease over time. International experience suggests that the indicator is related to the length of stay in hospital and, that where the length of stay decreases overtime, there can be increases in re-admissions rates.
The New Zealand experience indicates that over the past five years there has been little movement in the re-admissions rate, while the average length of stay for inpatients has been declining. This indicates the quality of services has improved.
Re-admissions rates fluctuated between 8314 and 8647 per 100,000 discharges since 2000/01.Although 2005/06 had a higher rate of re-admissions than 2004/05, it was only a 0.3 percent difference and was not statistically significant. (See Figure 2.16.)
Figure 2.16 Readmission rate* per 100,000 discharges (all District Health Boards), 2000/01–2005/06
Source: New Zealand Health Information Service
2.7.4 Hospital mortality rate YY
Hospital mortality rates are monitored to flag patterns of mortality in publicly funded hospitals that are higher than expected, in order to focus on the quality of care. The desired direction of change is a decrease over time.
Trend analysis of hospital mortality rates shows that rates have been declining over the past four years, with the 2005/06 hospital mortality rate at just under 1300 deaths per 100,000 discharges.This follows a peak in 2001/02 of 1650 deaths per 100,000 discharges and represents nearly 2000 fewer in-hospital deaths annually. (See Figure 2.17.)
Figure 2.17 Hospital mortality rate per 100,000 discharges (all District Health Boards), by age group, 2000/01–2005/06
Source: New Zealand Health Information Service
2.7.5 Cancer screening coverage X
The National Cervical Screening Programme’s coverage goal is 75 percent of eligible women aged 20–69 years receiving a cervical smear in the past three years. The 2006 national coverage rate(69.7 percent) fell short of this goal, although it represents a slight increase on the previous year. (See Figure 2.18.)
Coverage of the target population is a broad indicator of whether sufficient numbers of eligible women are being regularly screened to effectively reduce the incidence of and mortality due to cervical cancer. Regular screening aids the early detection and treatment of pre-cancerous squamous cell changes of the cervix.
Age-group analyses show that the apparent decline in coverage may be driven by low coverage of younger women (20–49 years). While coverage of women aged over 50 years is increasing, this is obscured by the falling coverage of younger women.
The National Cervical Screening Programme’s resources may be better directed away from screening very young women (who are at lower risk) to women who are under-screened or never screened: specifically, Māori, Pacific and Asian women. Analyses by ethnicity reveal the coverage of Māori,Pacific and Asian women is dramatically lower than for Other women over the years 2001 to 2006 (see Figure 2.19).
Figure 2.18 National Cervical Screening Programme coverage of women aged 20–69 years,2001–2006
Source: National Cervical Screening Programme Register, 2007
Note: Figures are hysterectomy adjusted.
Figure 2.19 National Cervical Screening Programme coverage rates for women aged 20–69 years,by ethnicity, 2006
Source: National Cervical Screening Programme Register, 2006
Note: Figures are hysterectomy adjusted.
BreastScreen Aotearoa’s coverage goal is 70 percent (or greater) of eligible women aged 45–69 years receiving a breast screen within a two-year screening period. As at 31 December 2006, coverage was 60.1 percent. (See Figure 2.20.)
Although the early screening and detection programmes are approaching coverage targets, noticeable inequalities remain: Māori and Pacific women are less likely to access screening services and have poorer rates of five-year cancer survival relative to non-Māori non-Pacific women.
Figure 2.20 BreastScreen Aotearoa coverage rates for women, by ethnicity, quarterly December 2001–December 2006
Source: BreastScreen Aotearoa database, 2007
Note: The sharp decline in the graph reflects the policy change to extend breast screening coverage from women aged 50–64 to 45–69 years
Marae-based breast screening boosts coverage of Māori women
Traditionally, breast screening activities have not been as successful with Māori and Pacific women, with coverage rates falling below that of non-Māori non-Pacific. In BreastScreen South Limited’s (BSL’s) region, which covers an expansive geographical area including Canterbury, Nelson, Marlborough and the West Coast, the situation in 2000 was much the same. In 2005, it achieved what is believed to be a world first for a population based breast-screening programme: 70 percent coverage for ethnic minority women (ie, Māori and Pacific women).
Joan Miles, BSL’s programme manager, says marae-based screening is one of the key contributors to that improvement. BSL has an agreement with general practitioners, whereby GPs are paid an annual fee to enrol eligible women to the programme. Ninety percent of Māori women are enrolled with a general practitioner. As a result of this agreement, 67 percent of Māori women and 76 percent of Pacific women have been recruited into the screening programme. This is above the national rate of 60 percent coverage.
The idea for marae-based screening came from a hui in 2001 that was organised to discuss how to improve breast-screening coverage rates for Māori and Pacific women.
‘It was decided to take the mobile breast-screening unit onto Nga Hau E Wha Marae and Rehua Marae, both in Christchurch. A prominent and respected local Māori woman, Hine Te Ao Tau, was appointed to assist the health promotion team in promoting breast screening to Māori wāhine.
‘It wasn’t instantly successful. In the first year we screened 30 women on the marae from a target of 100. It wasn’t cost effective and we didn’t think it was sustainable. However, we didn’t want to lose face with the Māori community and returned the following year. In September last year we screened 210 women at Rehua Marae over a 10-day period and in July this year we screened 157 women at Nga Hau E Wha Marae over an 8-day period.’
Joan Miles says a lot of groundwork goes into preparing for breast screening on the marae. ‘Two months prior to the screening time on the marae, BSL’s two health promoters work closely with their contacts in the community, trying to ensure word is out about the mobile unit’s presence there.
‘Volunteers also run a “pamper day”, previously held on the marae, but this year held in the community. The idea is Māori women can have lunch with an emphasis on healthy eating, have a massage, manicure, or pedicureor get their hair trimmed. At the same time, we discuss the importance of having a mammogram. Thirty women attended the last pamper day. While that’s not a big number, they help to spread the word around the community about the upcoming breast screening on the marae. They also give us feedback on how we can do things better for Māori. We also run pamper days for Pacific women.’
Joan believes taking the mobile breast-screening unit onto the marae has had other positive spin-offs for Māori health. ‘The marae has a strong whānau focus with children running around. By taking the mobile breast screening unit there, the children get to see Māori health workers taking care of their loved ones. It is an experience that they might not have been exposed to had we not gone to the marae, and it may inspire them to pursue a career in health in the future.’
Despite the mobile unit being at the marae only for two weeks of the year, 17.5 percent of Māori women registered with BSL are screened during that time.
2.7.6 Immunisation coverage X
The national and international scientific consensus is that immunisation is one of the most cost effective means of preventing disease and improving health. Immunisations offer individual protection against vaccine-preventable diseases and protection for the community against recurring epidemics.
In March 2005, based on a national survey, 77.4 percent of two-year-olds were fully immunised.The Ministry of Health’s goal, which was adopted from the World Health Organization, of having 95 percent of two-year-olds fully immunised was not achieved. However, coverage had improved since the last immunisation coverage survey in 1992, rising from less than 60 percent.
The National Immunisation Register captures detailed information on immunisation, including the percentage of children who are fully immunised at certain ‘milestones’, such as ages 6, 12, 18 and 24 months.
For the three-months ended 30 June 2006, 81 percent of 12-month-old children were fully immunised.
Immunisation coverage in the Māori and Pacific populations is lower than the coverage of other New Zealand children. Improving immunisation rates in these groups would help to reduce health inequalities (see Figure 2.21). Outreach immunisation services and well child services promote immunisation in areas with low coverage (see also Health Target section p 65).
In general, immunisation coverage decreases proportionally with increasing levels of socioeconomic deprivation (see Figure 2.22).
Figure 2.21 National immunisation coverage at the 12-month milestone age, by ethnicity, quarterly comparison, 2007
Source: National Immunisation Register
Figure 2.22 National immunisation coverage at the 12-month milestone age, by level of deprivation, quarterly comparison, 2007
Source: National Immunisation Register
Note: The level of deprivation scale (NZDep2001) ranges from 1 to 10; 1 indicates areas of low deprivation , 9 and 10 indicates areas of high deprivation.
2.7.7 Proportion of health records with a National Health Index number YY
Having National Health Index (NHI) numbers on administrative records facilitates a better understanding of the health services received by individuals and can lead to improved health service delivery for populations and communities.
Figure 2.23 shows the capture of NHI numbers on records of PHO enrolment, laboratory tests ordered, and pharmaceutical items dispensed. As can be seen in Figure 2.23, capture is at 92 percent or greater and tracking upwards. Hospital discharges (not shown) have 100 percent or near 100 percent NHI recording.
Linking databases by NHI (with appropriate measures to protect privacy) leads to richer information about the health services delivered. It also facilitates monitoring, evaluation and improved service delivery. For example, by linking databases we can get information about:
- whether the uptake of statins by patients discharged with myocardial infarction is in accordance with clinical guidelines
- the estimated number of people with known diabetes, which facilitates outreach services
- the estimated number of people likely to experience an ambulatory-sensitive hospital admission,which enables primary care interventions to be better targeted
- the number and type of laboratory tests ordered and pharmaceuticals prescribed by PHO practitioners, which assists in measuring primary care efficiency and effectiveness.
Figure 2.23 Proportion of health records with a National Health Index number
Source: NZHIS data warehouses, 2007
The capture of NHI numbers on records of PHO enrolment for Māori enrollees is the highest at more than 98 percent. Additionally, the capture of NHI numbers for Pacific enrollees has improved since 2003. (See Figure 2.24.)
Figure 2.24 Capture of National Health Index on Primary Health Organisation registers,1 October 2003–31 March 2007
Source: PHO enrolment database, 2007
2.8 Effectiveness
Outcome goal The system as a whole and the services provided within the system are effective incontributing to the end outcome of healthy New Zealanders.
2.8.1 Ambulatory-sensitive hospital admissions =
Ambulatory-sensitive hospital admissions are admissions that might have been prevented if services had been delivered effectively in the community.
From 2000/01 to 2005/06, ambulatory-sensitive hospital admission rates have declined for non-Māori non-Pacific (ie, ‘Other’) people. However, rates for Māori and Pacific people have remained the same or increased slightly during this period. The ambulatory-sensitive hospital admission rate for Pacific people is 1.9 times and for Māori 1.67 times that for Others. (See Figure 2.2.5.)
DHBs and the Ministry of Health are collaborating to reduce overall rates of ambulatory-sensitive hospital admissions and to concentrate on decreasing the associated ethnic disparities. Reducing these admissions is one of the 10 health targets that will provide greater focus for action and lifting performance.
Figure 2.25 Ambulatory-sensitive hospital admissions for people aged 0–74 years, age-standardised rate per 100,000, by ethnicity and sex, 2000/01–2005/06
Source: Ministry of Health, 2007
2.8.2 Cardiovascular disease mortality YY
For the total population, deaths from cardiovascular disease (CVD) have decreased steadily since the early 1990s. This is consistent with trends in other developed countries during this period.
Males have a significantly higher CVD mortality rate than females have, although this gender difference has reduced to almost half what it was in 1990. (See Figure 2.26.)
There are significant ethnic differences in the CVD mortality rate, with Māori and Pacific people having higher rates than the total population. (See Figure 2.27.)
The Healthy Eating – Healthy Action Strategy to improve nutrition, increase physical exercise and reduce obesity focuses on reducing the impact of chronic conditions such as CVD. Care Plus and the Green Prescription (see p 55) are primary care initiatives aimed at reducing the risk of CVD. It has also been proposed that a health target around cardiovascular disease mortality be developed.
Figure 2.26 Cardiovascular disease mortality, all ages, age-standardised rate per 100,000, by sex, 1990–2004
Source: New Zealand Health Information Service, 2007
Note: The data for 2004 is provisional.
Figure 2.27 Cardiovascular disease mortality, all ages, age-standardised rate per 100,000, by ethnicity, 1996–2004
Source: New Zealand Health Information Service, 2007
Note: The data for 2004 is provisional.
2.8.3 Cancer survival Y
Cancer survival is a key outcome measure of cancer control and provides useful insights into the effectiveness of health care in detecting and treating cancer.
The five-year relative survival rate has increased for all five major cancer sites featured in Figure 2.28. This increase was in the region of 5–6 percent for colorectal, breast and cervical cancers. The five-year relative survival rate has increased by 12.8 percentage points for prostate cancer in the seven years since 1997/98.
The survival rate at five years for lung cancer was 9.8 percent for patients diagnosed in the most recent two-year time interval. This is significantly less than other for cancer at other sites and has improved the least.
Figure 2.28 Five-year relative survival rates in two-year periods, by major cancer sites, 1997–2006
Source: New Zealand Health Information Service, 2007
Note: Trends were estimated by examining survival for patients diagnosed in successive two-year intervals by using the period analysis approach.
For all cancers diagnosed between 1994 and 2006, five-year relative survival rates show Māori at a marked disadvantage compared with other ethnic groups for five selected cancer sites: colorectum, lung, female breast, cervix and prostate. (See Figure 2.29.)
Pacific people show the lowest relative survival rates for female breast and cervical cancers of all ethnic groups. Efforts to increase the number of Pacific women being screened through cancer screening programmes should help to identify greater numbers of women in need of cancer treatment in the future.
Figure 2.29 Five-year relative survival rates, by major cancer site and ethnicity, 1994–2006
Source: New Zealand Health Information Service, 2007
2.8.4 Diabetes management Y
The proportion of people who access free annual diabetes checks (the Get Checked programme)recording satisfactory (or better) diabetes management (as indicated by the HbA1c blood test, which measures average blood glucose over the past 4–6 weeks) is an indicator of the effectiveness of care for people with diabetes and a more general marker of the effectiveness of primary health care and chronic disease management.
In 2006, 73 percent of people in Get Checked had good diabetes control. This overall rate has not changed substantially since 2001.
The proportion of Māori (60 percent) and Pacific peoples (56 percent) with good diabetes control remains lower than the proportion in the Other ethnic group (78 percent). Although there has been a significant increase of Pacific people with well-controlled diabetes (8 percent in five years), there has not been an equivalent increase among Māori.
The Care Plus and Get Checked programmes are part of the diabetes target programme, which has a significant focus on Māori participation.
Figure 2.30 Percentage of people enrolled in Get Checked with satisfactory or better diabetes control (HbA1c less than or equal to 8), by ethnicity, 2001–06
Source: Ministry of Health, 2007
Note: HbA1c blood test measures blood glucose level.
2.8.5 Smoking prevalence and consumption YY
Cigarette smoking is a leading cause of preventable death in New Zealand. An estimated 25 percent of adult New Zealand males (ie, aged 15 and over) and 29 percent of adult New Zealand females smoke. (See Figure 2.31.)
The prevalence of smoking remains high among Māori (45.2 percent) and Pacific peoples (37.4 percent), compared with the prevalence among European/Other (20.6 percent) and Asian people (12.3 percent) (Ministry of Health 2006).
According to the Year 10 Smoking Survey, the daily smoking prevalence in Year 10 students (14- and 15-years-old) declined approximately 42 percent (from 17.1 percent to 10.1 percent) in girls and 56 percent (from 14.1 percent to 6.2 percent) in boys over 1999–2006 (Scragg 2007).
Since the relative decrease of almost 16 percent in tobacco consumption per capita in New Zealand from 2002 to 2004, tobacco consumption rose 5 percent in 2005 but fell again by 1 percent in 2006.
Smoking is a major contributor to inequalities in health. People living in more deprived areas have higher rates of smoking than do people living in less deprived areas:6 34.2 percent in NZDep2001 quintile 5 (most deprived) compared with 14.3 percent in NZDep2001 quintile 1 (least deprived) (Ministry of Health 2007d).
Reducing the harm caused by tobacco is a health target. The target aims to increase the proportion of smokefree homes and increase the number of young people who never start to smoke.
Figure 2.31 Prevalence of tobacco smoking, total population, 1983–2006
Source: AC Neilson (NZ) Ltd and the New Zealand Tobacco Use Survey
2.9 Efficiency and value for money
Outcome goal The system operates efficiently and services deliver relatively large gains in health status for each unit of resource.
2.9.1 Day-case procedures YY
When surgical procedures can be undertaken on a day-case basis (ie, the patient is admitted and discharged on the same day), the hospital visit results in less disruption for the patient and fewer resources are used.
Day-case rates increased by 9 percent for ophthalmology from 2000/01 to 2005/06 (from 78 percent to 85 percent). There were minor decreases in ear, nose and throat, urology and gynaecology day case surgeries from 2006 despite showing an increasing trend from 2000.
Although the rate of day-case procedures performed fluctuates quarterly, the average across the four quarters shows an increasing trend. The four-quarter average to 30 June 2007 is 52.2 percent (measuring day-case procedures as a proportion of all electives, as opposed to all surgeries above). This indicates that more than half of the procedures performed allow the patient to be admitted and discharged on the same day.
The variance in the day-case procedure rate across the 21 DHBs is more than 20 percent. Tairawhiti DHB has the lowest day-case procedure rate, with 44.2 percent of elective surgeries being same day admissions and discharges. South Canterbury DHB manages to treat 65 percent of its elective surgeries on a day-case basis. (See Figure 2.32.)
Figure 2.32 Day-case procedures, all DHBs, quarterly March 2001 – March 2007
Source: Hospital Benchmark Information, 2007
2.9.2 Older people living independently Y
A key objective of the Ministry of Health is to support older people to remain in their home rather than enter residential care prematurely. Even late in life, most older people prefer to live in their own home. As well as being relatively less expensive then residential care, there is some evidence to suggest that people who continue to live in their own home, with personal care and home management support, experience greater wellbeing.
In the absence of direct measures of levels of community-based support, the high proportion of people in the very oldest age group living in private dwellings indicates that people are likely to be receiving support to stay at home rather than enter residential care.
At the 1996 census 67 percent of people aged 85 years and over (25,974 people) were living in a private dwelling. This increased to 70
percent (56,673 people) at the 2006 census.
Another indirect measure is the extent to which older people are admitted to residential care.The proportion of people in subsidised residential care in each five-year age group from 65 years(65–69 years, 70–74 years etc) remained relatively constant between December 2003 and 31 December 2006.
Table 2.5 Proportion of the population in subsidised aged residential care, by age group, 2003–06
| Age group | December 2003 (%) | December 2004 (%) | December 2005 (%) | December 2006 (%) |
| 65–69 | 0.6 | 0.5 | 0.5 | 0.5 |
| 70–74 | 1.4 | 1.4 | 1.5 | 1.4 |
| 75–79 | 3.1 | 3.0 | 3.3 | 3.2 |
| 80–84 | 6.7 | 6.9 | 7.5 | 7.3 |
| 85+ | 18.1 | 18.9 | 21.7 | 20.0 |
Source: Ministry of Health, Client Claims Payment System, 2007
Note: The reported figures are for people in subsidised residential care, not the total number of people in residential care.
2.9.3 Efficiency of primary care Y
Monitoring PHO pharmaceutical and laboratory actual expenditure against needs-based expected expenditure is one way of tracking whether value for money is being achieved.
Laboratory test ordering and pharmaceutical prescribing vary considerably. For example, high need groups (Māori, Pacific people and people living in high-deprivation areas) tend to under-use pharmaceutical and laboratory tests compared with their level of need. Additionally, DHBs (which have a fixed annual needs-based budget for pharmaceuticals and laboratory test ordering based on the age, gender, ethnicity, and deprivation level of their enrolled population) are concerned about the potential for demand-driven cost increases. For these two reasons, reducing variation and aligning actual expenditure with needs-based expected expenditure (ie, in a ratio of 1) is desirable.
Figure 2.33 shows the distribution of PHOs by the ratio of actual expenditure to needs-based expected expenditure for pharmaceuticals and laboratory test ordering. A ratio greater than 1 indicates actual expenditure exceeds expected expenditure and a ratio less than 1 indicates actual expenditure is less than expected expenditure.
For pharmaceutical expenditure, the distribution of PHOs by ratio of actual expenditure to needs based expected expenditure is not as dispersed as for laboratory expenditure, and a large proportion of PHOs are close to achieving the desirable alignment between actual and expected pharmaceutical expenditures. There has been an improvement (ie, a decrease in variation) with respect to pharmaceutical expenditure from previous years.
For laboratory expenditure there is a great deal of variability among PHOs and lower overall laboratory expenditures than expected. Reducing this variability and achieving greater alignment between actual and expected laboratory expenditure is important.
Figure 2.33 Primary care efficiency based on laboratory expenditure ratio and pharmaceutical expenditure ratio, July 2006 – March 2007
Source: PHO Performance Management Programme, DHBNZ
Note: LT = less than, GT = greater than.
2.9.4 Costs and outputs of public hospital services (medical and surgical) =
Figure 2.34 shows the overall change in output per full-time equivalent employee (ie, labour productivity) from 2000/01 to 2005/06 for doctors and nurses combined in medical and surgical units (indexed to 2002/2003 as the base year). An output is measured as a case-weighted discharge equivalent (outpatient and inpatient combined).
While there was a 7.4 percent decline in outputs per doctor and nurse during 2000/01 to 2005/06,most of this decline occurred between 2000/01 and 2002/03; outputs per doctor and nurse rose almost 1 percent between 2003/04 and 2005/06. The levels of outputs per doctor and nurse in 2002/03 and 2005/06 are about the same.
Figure 2.34 Output per doctor and nurse in District Health Board provider arms (medical and surgical), 2000/01–2005/06
Source: Ministry of Health, 2007
Note: Labour inputs are full-time equivalent employees, labour outputs are case-weighted discharge equivalents(outpatient and inpatient combined), labour productivity is calculated as outputs over inputs.
Figure 2.35 shows that costs per output, a measure of efficiency, increased steadily during 2000/01–2005/06. When adjusted for the consumer price index (ie, inflation), medical and nursing costs per output increased 22.2 percent during this period or at a 4.1 percent average annual rate.
During 2000/01–2005/06 there were wage settlements for senior doctors and resident medical officers (both in 2003/04) and nurses (in 2004/05). These cost increases reflect that New Zealand competes in an international market for doctors and nurses.
Figure 2.35 Doctor and nurse cost per output in District Health Board provider arms(medical and surgical), 2000/01–2005/06
2.10 Intersectoral focus
Outcome goal Social, environmental, economic and cultural factors are influenced to reduce their negative impacts and increase their positive impacts on outcomes for the health and disability system.
2.10.1 Obesity X
The prevalence of obesity in adults7 doubled from 1977 to 2003, increasing from 9 percent to 20 percent in males and from 11 percent to 22 percent in females. In 2003, an additional 41 percent of males and 28 percent of females were overweight; this equates to 1 in 3 being overweight and 1 in 5 being obese. (See Figure 2.36.)
New Zealand joins nine other countries in the Organisation for Economic Co-operation and Development (OECD) in which more than 50 percent of adults are defined as overweight, including those who are categorised as obese (the United States, the United Kingdom, Mexico, Australia, Canada, Greece, Luxembourg, Hungary and the Czech Republic).
In 2003, Pacific adults in New Zealand were the group most likely to be obese (43.0 percent),followed by Māori (28.3 percent), European/Others (18.9 percent) and Asian people (5.7 percent).
Adults living in the most deprived areas (NZDep2001 quintile 5) were twice as likely as adults living in the least deprived areas (NZDep2001 quintile 1) to be obese. A similar pattern of findings is noted for overweight and obese children (see Figure 2.37).
Figure 2.36 Prevalence of overweight and obese adults, by sex, 1977–2003
Source: Ministry of Health, 2004
New Zealand’s strategy to address obesity is Healthy Eating – Healthy Action (Minister of Health2003a), which incorporates a comprehensive approach to achieving sustainable lifestyle changes.
Two out of every five deaths each year (about 11,000 deaths annually) are due to nutrition-related risk factors such as:
- high cholesterol (reflecting mainly saturated fat intake)
- high blood pressure (reflecting a range of factors most notably high sodium intake)
- higher-than-optimal body mass index.8
Figure 2.37 Prevalence of overweight and obese children, by deprivation quintile and sex, 2002/03
Source: New Zealand Health Survey, 2003
Note: Deprivation quintile 1 = least deprived, deprivation quintile 5 = most deprived.
The 2002 National Children’s Nutrition Survey (Ministry of Health 2003) showed only about two out of five children ate the recommended number of fruit servings (at least two) a day, while around three out of five children ate the recommended number of vegetable servings (three or more) a day.Increasing those proportions is the basis for the Fruit in Schools initiative, funded by the Cancer Control Strategy.
Prescription for Healthy Eating – Healthy Action
Four months ago, 68-year-old Ken Mua woke up one night and could hardly breathe. The next morning he visited his doctor. At 1.8 metres and weighing 104 kg, with a body mass index of 32 he was obese: something had to change. His general practitioner wrote him a Green Prescription. He’s since lost about 11 kg and feels great.
Sport Gisborne Tairawhiti co-ordinates the Green Prescription programme in the region. Green Prescription Manager Toni Hoskin describes a Green Prescription as a health professional’s written advice to a patient to be physically active, as part of the patient’s overall health management plan. The Green Prescription team’s role is to set goals with the client, and to support, encourage and motivate them into making positive lifestyle changes.
‘We listen to the individual and work out the best way they can achieve a better healthy lifestyle, in most cases using other health care services in the region. For Ken, this meant joining the local Turanga Health Men’s Group,’ says Toni. Turanga Health is a limited liability health company with charitable trust status. The three iwi of Turanganui-a-Kiwa are the principal shareholders of the company. It has a range of health services aimed at improving the health status of Māori.
As part of the Turanga Health Men’s Group, Ken is picked up and taken to the gym three times a week. ‘There are about a hundred of us, all different shapes and sizes and ages. It’s really motivating working out together and I’ve made new friends as well.’
On top of that, Ken walks about 16 km daily. He’s also swimming or doing aqua exercises twice a week.
‘My diet has also undergone a massive change.Gone is the fatty food and white bread. Surprisingly I don’t miss it. My wife and I are eating good healthy food and we’re enjoying it,’ says Ken.
Ken says his weight started piling on when he was working behind a desk in Wellington and with little exercise in his lifestyle. He moved to Gisborne when he retired. His weight and heart problems meant he couldn’t enjoy his retirement as much as he would have liked to. Golf became too hard because he was getting to the stage where it was a strain to walk very far.
Under the Green Prescription programme, Ken’s progress is monitored and he has a regular health check up that includes recording his weight and checking his fitness.
He says he looks and feels much better. ‘My doctor can’t get over the change in my appearance. If I’d carried on the way I was heading I would have developed diabetes, on top of my heart problems. Now I hardly need to see my general practitioner.’
Latest figures show there are more than 20 thousand people on the Green Prescription programme in New Zealand.
Results of a recent patient survey carried out by Sport and Recreation New Zealand, the lead agency for the Green Prescription programme, shows 74 percent of respondents noticed a change in health after following the prescription. The main improvements were feeling better generally (52 percent), losing weight (46 percent), feeling stronger or fitter (49 percent) and having more energy (42 percent). In addition, 59 percent of respondents had improved their diet, with 15 percent cutting down on fats and 21 percent eating fewer or smaller meals.
2.10.2 Alcohol available for consumption X
While alcohol available for consumption9 per adult (over 15 years of age) decreased from 11.3 litres per head in 1987 to 8.7 litres in 1998, the number of litres available for consumption per person has been increasing, rising to 9.4 litres per adult in 2006, an increase of 0.5 percent on the previous year. This is 16.4 percent lower than the 11.3 litres per head recorded in 1986, when the current series began, but has been on the rise since the lowest level recorded in 1998 (8.7 litres per head). (See Figure 2.38.)
Among New Zealanders (aged 12 to 65 years) who had consumed alcohol in the past 12 months,14.7 percent consumed large amounts10 on at least a weekly basis (Ministry of Health 2007a).
Over half of youth (55.7 percent) aged 12–17 years had consumed alcohol in the last 12 months, and 12.4 percent of these youth drinkers said they had consumed large amounts of alcohol at least once a week (Ministry of Health 2007a).
Although Māori are more likely to abstain from drinking than the total population, Māori drinkers were significantly more likely (50.3 percent) than non-Māori drinkers (23.3 percent) to consume a large amount of alcohol on a typical drinking occasion (Ministry of Health 2007a).
Figure 2.38 Alcohol available for consumption, litres per head of population aged 15 and over, year ended 31 December 1986–2006
Source: Statistics New Zealand
2.10.3 Destigmatisation of people with experience of mental illness YY
Seven surveys have tracked public attitudes to people with experience of mental illness since the inception of Like Minds, Like Mine, the campaign funded to counter the stigma and discrimination associated with mental illness.
The surveys have shown significant improvements in attitudes and behaviours towards people with experience of mental illness, as indicated by the greater acceptance of people with mental illness indifferent social roles.
Research attributes the increased public awareness and understanding of mental illness to the effectiveness of the mass media advertising.
However, negative attitudes and discrimination persist in many areas of community life, including employment, housing and education, and in families and access to goods and services.Reducing stigma and discrimination is complex, and a long-term view to achieving success needs to be taken. However, there are hopeful signs: in less than a decade, an additional 17 percent of the responding population would accept a person with a mental illness as their neighbour. (See Table 2.6.)
Table 2.6 Percentage of respondents willing to accept people with mental illness, 1997 and 2006
| Situation | 1997 % | 2006 % | Increase (percentage points) |
| As a workmate | 69 | 84 | 15 |
| As a resident in a halfway house in your street | 56 | 67 | 11 |
| As a babysitter for your children | 12 | 23 | 11 |
| As a next-door neighbour | 55 | 72 | 17 |
Source: Attitude tracking surveys performed by Phoenix Research and BRC Marketing and Social Research, 2006
Benefit of employment for people with experience of mental illness
New research from the Mental Health Foundation of New Zealand shows that people who experience mental illness can and should be actively encouraged to undertake paid work.
Darryl Bishop, the Like Minds, Like Mine programme leader at the Ministry of Health says, ‘Gaining employment is an important step for people living with a mental illness. Work gives us all a sense of purpose, and for people with experience of mental illness it is one of the key components of the road to recovery.’
It was a year before Geraldine Bryant sought help for her mental illness.‘It started when I was 25 years old. Trying to get to sleep at night was impossible; I just kept hearing voices and wouldn’t get any sleep.’ Eventually, she told her mother and sought help. She was later diagnosed with schizophrenia.
Geraldine says, ‘I think I’ve seen about 10 psychiatrists. I also suffered from anxiety attacks, at its worst sometimes twice a week. I’d feel scared and panic, I’d feel like I was trembling on the inside, but on the outside I wouldn’t be moving. It took a while to get the right medication for me.’
Now Geraldine sleeps well, which she says puts her in good spirits.
Last year she found a job with the help of Workbridge. Workbridge is the government-funded employment agency that assists people with disabilities into employment.
‘I work part time at a motel in Palmerston North as a cleaner. Having the job has made me feel positive about myself and since I’ve been working I’ve had fewer anxiety attacks. In the past I felt like I couldn’t do anything. Going to work makes me feel happy. My mind is thinking constructive thoughts, like what the next task is, rather than negative stuff,’ says Geraldine.
‘People at work don’t treat me any differently. I told my boss I’m on prescribed medication because I have a chemical imbalance. We’re busy cleaning rooms, we just get on with the job and that’s the way it should be.’
‘I’ve set myself new challenges at work; I want to get faster at doing the tasks. The motel is expanding and I hope to increase my hours there,’says Geraldine.
Geraldine would like to encourage other people with schizophrenia to find a job they enjoy doing. ‘If you’re well enough to understand your illness, and know that they’re just voices, then getting a job is a positive move.’
Long-term mental health clients are supported in their pursuit of staying psychologically healthy by having relapse prevention plans. Increasing the number of patients with strategies in place for managing the challenges of a mental illness is a health target.
The Ministry of Health funds the Like Minds, Like Mine programme, which is in its tenth year. Like Minds, Like Mine includes a television campaign challenging friends, whānau, families and employers to be more inclusive and less discriminatory towards people with experience of mental illness. In 2006, the annual attitude tracking survey revealed that 84 percent of respondents would willingly accept somebody with mental health illness as a workmate, a significant increase from previous years.
‘Employment is a big focus of our work, and we feel we can make areal difference to the lives of people with mental illness by removing the biggest barrier to gaining employment, and that is discrimination,’says Darryl.
Footnotes
- Absolute inequality is a measure of actual standardised rate difference.
- Unmet need describes self-reported access to support equipment and services that adults with disabilities, or parents or caregivers of children with disabilities, felt they needed but were unable to obtain.
- A ‘deprived’ area is one where the New Zealand Deprivation Index 2001 score is 9 or 10.
- The Mental Health Information National Collection is a database that records what has been reported to the New Zealand Health Information Service. Data may change over time as more information is received.
- The re-admission rate is calculated by dividing the number of acute readmissions (to the same or another hospital)within 30 days of the original discharge by the number of total discharges, and then multiplying by 100,000.Various exclusions apply, notably: transfers, deaths, planned and unavoidable readmissions, AIDS cases, palliative care cases and long-stay cases.
- NZDep2001 refers to the 2001 New Zealand Deprivation Index based on the 2001 Census.
NZDep2001 quintile 1 = least deprived, quintile 5 = most deprived.
- Aged 20–64 years from 1977 to 1988, and 15–74 years from 1989.
- The body mass index is a measure of weight adjusted for height. It is calculated by dividing weight in kilograms by height in metres squared (kg/m2).
- Alcohol available for consumption is the quantity of alcoholic beverages released to the market each year.
- ‘Large amounts’ is at least six standard drinks for males and four standard drinks for females. A standard drink is about the equivalent of one can of beer or 100ml of wine.