Statement of Intent 2007–2010

Part 6: The Ministry’s Strategy: ‘Better Health for All’

Table of Contents:

From the Minister

Part 1: Introduction and Health Context

Part 2: The Government’s Priorities

Part 3: The Ministry’s Vision and Outcomes Framework

Part 4: What the Ministry Does

Part 5: Measuring the Ministry’s Progress

Part 6: The Ministry’s Strategy: ‘Better Health for All’

Part 7: Financial Information

References

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In this section:

• Introduction
• Chronic disease
• Child and youth services
• Elective services
• Primary health care
• Health of older people
• Infrastructure
• Value for money
• Improving Māori health
• Reducing inequalities
• Developing a long-term health sector strategic plan

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The Ministry’s Strategy: ‘BetterHealth for All ’The Ministry’s strategy is to:

• shift emphasis to performance improvement focusing on the Minister’s priorities,improvements in Māori health, and reducing inequalities
• better prioritisation of resources
• service reviews to ensure the best use of available resources.

Chronic disease

Both national and international literature and research show that action plans developed,prioritised and agreed collaboratively have increased buy-in and a greater chance of successful outcomes. The Ministry is intervening to reduce the incidence and impact of chronic disease by:

• screening for some chronic diseases to provide timely early intervention
• addressing the risk and behaviour factors that lead to chronic disease
• addressing some of the further impacts of chronic disease.

The Diabetes and Cardiovascular Disease Quality Improvement Programme (QIP) is a key component of chronic disease management. The development of the QIP involves working closely with DHBs, primary health care and NGOs. The continuation of Get Checked provides the information necessary to monitor CVD and diabetes outcomes while also providing focused primary health care interventions for those with diabetes.

In the Cancer Control Strategy: Action plan 2005–2010 (Cancer Control Taskforce 2005) the Minister sets out a series of action to reduce the incidence and impact of cancer and current inequalities in outcomes for cancer.

By screening 70 percent of eligible women (aged 45–69 years), BreastScreen Aotearoa aims to reduce breast cancer mortality in this population by 30 percent. By increasing the three-year coverage of women to 80 percent by 2011, the National Cervical Screening Programme aims to reduce incidence and mortality from squamous cell carcinoma of the cervix to 7.5 and 2.0 cases/year (age-standardised rates) respectively.

In Te Kokiri: The Mental Health and Addiction Action Plan 2006–2015, the Minister sets out actions to address the leading challenges identified for mental health and addiction in New Zealand(Minister of Health 2006b). The benefits outlined in Te Kokiri are based on the best available evidence, are clear and obtainable, and have been jointly developed with DHBs in collaboration with non-governmental organisations, Māori and Pacific peoples, service users, other government agencies and other key stakeholders.

Table 5: Measuring our progress in reducing chronic disease

Level	Indicators/measures
Relevant headline indicators	Healthy New Zealanders – better health, reduced inequalities A fair and functional health system – equity and access, quality, efficiency and value for money, effectiveness, intersectoral focus
Relevant health sector targets	Reduced cancer waiting times Reduced ambulatory-sensitive admissions Improved diabetes services Improved mental health services Improved nutrition Increased physical activity Reduced obesity Reduced harm caused by tobacco
Performance measures	The Healthy Eating – Healthy Action (HEHA) social marketing campaign will be in place by 31 August 2007 to facilitate progress on promoting the key messages from the HEHA strategy HEHA strategy evaluation will be in place by 31 December 2007 to determine the effectiveness of HEHA implementation and to inform the future direction for the HEHA strategy The first phase of the project to assess national capacity and capability required to meet future demand for cancer services, and address geographic and ethnic inequalities in access (including for Māori), will be completed by 30 September 2007 (Whakatataka Tuarua) Four regional cancer control networks will be established, with reporting frameworks, by 31 October 2007 Intensive tobacco control programmes will be implemented in four high-needs DHBs (Whanganui, Tairawhiti, Lakes and Northland) by 31 December 2007 DHB co-ordination pilots on suicide prevention that include contributing to the reduction of Māori suicidal behaviour, will be established by 31 March 2008 (Whakatataka Tuarua) An update of the framework for the provision of forensic mental health services will be completed by 30 November 2007 A breastfeeding social marketing campaign will be in place by 31 March 2008 to facilitate progress on the breastfeeding health target All BreastScreen Aotearoa lead providers will migrate to one software system,the Orion Soprano BreastScreening system, by 30 June 2008 in order to address performance issues with other existing information systems, and to meet the accreditation requirements of the BSA Data Management Manual version 4.0 National Screening Unit Reducing Inequalities Action Plan actions will be completed by 30 June 2008 The focus of screening will be strengthened in DHB district strategic plans and district annual plans The first year of the three-year joint work programme (with DHBs) for Te Kokiri: The Mental Health and Addiction Plan will be implemented by the 30 June 2008. The review and update of the Opioid Treatment Guidelines will be completed by 30 June 2007.

Child and youth services

The review of the well child framework and implementation of the Ready for School check are based on growing evidence that health and wellbeing in the antenatal, infancy and childhood stages can have significant and lasting effects on health and wellbeing throughout life. Effective health promotion, prevention, early detection and intervention are important strategies for reducing the impact of disease and disability in childhood and throughout the life span. A life course approach to child health and wellbeing is now well accepted.

Pregnancy, infancy and childhood are also the best times to act to prevent the development of many of the long-term chronic adult diseases, and to prevent the perpetuation of intergenerational disparities.

Screening is not useful in predicting child abuse and neglect, but there is considerable evidence to demonstrate that well-trained professionals can identify vulnerable families and offer assistance in a non-stigmatising and child-centred fashion. Screening for behaviour problems is likely to be a useful part of the Ready for School check.

The community-based child and adolescent oral health service is strongly focused on prevention and early intervention, particularly during the pre-school years. Improving the oral health of younger children in this way will positively influence the oral health of children and adults over the long term.

The injection of capital funding will ensure that oral health services can be built in areas where a larger proportion of the population can access them. It is anticipated that larger, more modern facilities open for longer hours throughout the whole year will become a more visible and accessible part of the community. A more skilled workforce employed at these facilities – including community dentists – will allow more complex conditions to be treated at the primary health care level.

The newborn hearing screening intervention is intended to identify hearing impairments at an early stage, thereby allowing more effective early intervention and a reduction in the burden of disability for each child with hearing impairment than is currently possible without screening.

Table 6: Measuring our progress in child and youth services

Level	Indicators/measures
Relevant headline indicators	Healthy New Zealanders – better health, reduced inequalities A fair and functional health system – equity and access, quality, efficiency and value for money, effectiveness, intersectoral focus
Relevant health targets	Improved immunisation coverage Improved oral health Reduced ambulatory-sensitive admissions Improved nutrition Increased physical activity Reduced obesity Reduced harm caused by tobacco
Performance measures	The Ready for School pilot will be in place by 31 August 2007, with the Ready for School check national implementation phased in from 29 February 2008 The well child service review which will promote whanau ora and improve the delivery of well child services to tamariki Māori will be completed by 29 February 2008 (Whakatataka Tuarua) Guidelines for targeted chlamydia testing will be completed by 29 February 2008 Public health education and a media campaign on safe sex will be under way by 31 May 2008 to follow up the Hubba campaign of 2004/05 Implementation of a family violence death review process will be completed by 30 June 2008 The policy environment for maternity services in a devolved DHB context will be completed by 30 June 2008 The review and update of the child and youth mental health and addiction policy and service delivery framework will be completed by 30 June 2008 The National Immunisation Schedule, including the pneumococcal vaccine, will be implemented by 30 June 2008.

Elective services

The key interventions aim to achieve:

• clarity – patients know if they will receive publicly funded services or not
• timeliness – where access to services can be delivered within the available capacity, patients receive it in a timely manner
• fairness – the resources available are directed to those most in need
• delivery – the maximum volume of elective services is delivered, in the most effective and efficient manner.

The Ministry will provide advice and tools – such as information on relative intervention rates, and the use of prioritisation tools to understand the level of need below access thresholds – to DHBs to help enable a more consistent level of access to elective services across New Zealand. In addition,there will be a significant (10 percent) increase in the number of people receiving elective services.

Improvements in decisions will be made on prioritising people to receive elective services by providing tools and advice to clinicians and DHBs that support the people with the greatest level of need and ability to benefit from accessing elective services. The management of elective services patient flow processes will be maintained and improved by providing support to DHBs and developing the internal capability of DHBs to better manage elective services.

There will also be a greater emphasis on development at the primary/secondary interface, by working with GP liaisons to support alternative models of care, and an increased role for primary health care in the provision of elective services.

Table 7: Measuring our progress in elective services

Level	Indicators/measures
Relevant headline indicators	• Healthy New Zealanders – better health, reduced inequalities, trust and security • A fair and functional health system – equity and access, quality,efficiency and value for money, effectiveness, intersectoral focus
Relevant health targets	• Improving elective services
Performance measures	• A formal Monitoring Intervention Framework response will occur within 8 weeks of confirmed material deterioration in performance • Contracts for new initiative money will be monitored throughout the financial year

Primary health care

In considering how financial barriers to access can be addressed, the Ministry intends to work with DHBs to encourage the sector to balance the present focus on per visit co-payments with approaches that promote the advantages of applying capitation funding to the PHO population.In this way the funding formulas should be better aligned with health need.

The work on PHO capability will:

• help sustain smaller PHOs, especially those serving high-needs populations
• clarify changes needed in PHOs and their relationships if they are to successfully implement the Primary Health Care Strategy
• enable PHOs to act collaboratively to optimise their resources and improve outcomes
• help develop a shared understanding of accountabilities (ie, who is responsible for what in implementing the Strategy)
• assist with strategic planning for the Ministry of Health, DHBs and PHOs so that activities are congruent with outcomes
• reduce the likelihood that policies are implemented with perverse incentives, or that are contrary to the aims of the Strategy
• enable better identification of those capabilities likely to make the greatest gain in reducing health inequalities.

Due to the fact that some PHOs only began to form in 2002, there are still some remaining tasks held by the Ministry. In addition, issues relating to implementation of the Primary Health Care Strategy, which are affecting the ability to deliver services effectively, are often raised through different forums. The Ministry needs to understand and respond accordingly, with appropriate changes to its policy work programme. We also need to ensure that performance management systems are in place to be able to measure the success of DHBs and PHOs in reducing health inequalities and improving health outcomes.

In response to the unmet need for treatment for people with mental health disorders, the Ministry will develop a primary mental health and addiction strategic policy, and will implement a programme to develop the capability of primary mental health and addiction service delivery.

Table 8: Measuring our progress in primary health care Level Indicators/measures

Level	Indicators/measures
Relevant headline indicators	Healthy New Zealanders – better health, reduced inequalities, trust and security A fair and functional health system – equity and access, quality, efficiency and value for money, effectiveness, intersectoral focus
Relevant health targets	Improved immunisation coverage Reduced ambulatory-sensitive admissions Improved diabetes services Improved nutrition Increased physical activity Reduced obesity Reduced harm caused by tobacco
Performance measures	Stronger PHOs as evidenced by: production of a good governance guide by 30 September 2007 participation in governance workshops and training by PHO board members so that they better understand their roles and obligations (at least four courses/sessions during the 2007/08 year) a description of the key capabilities required of PHOs to assist DHBs and PHOs with their planning and capability development by 30 June 2008.
	A chronic disease focus in primary health care, as evidenced by: findings from the evaluation of the mental health initiatives completed by 30 June 2008 by 30 December 2007, completion of a review of best practice guidelines for the management of depression in primary health care settings a reviewed scope for the Care Plus Programme by December 2007. Better alignment of accountabilities and funding, as evidenced by the next stage of the funding formula review completed by 30 December 2007.

Health of older people

In line with the Minister’s priorities, and the Government’s commitment to both the Positive Ageing Strategy and the Health of Older People Strategy, the Ministry is shifting its focus from income and asset testing to supporting people to remain living in the community. This shift requires the Ministry to demonstrate leadership in identifying new models of care (restorative/promoting independence), and developing national information and age-specific guidelines to support DHBs develop new service models and implementing assessment tools. The growth in demand for both existing and new services, and the outstanding workforce, funding and quality issues are to be addressed if the desired spectrum of services is to be available to New Zealanders in an equitable and sustainable manner. A focus will be to look at national consistency in outcomes for older New Zealanders.

Table 9: Measuring our progress in the health of older people

Level	Indicators/measures
Relevant headline indicators	Healthy New Zealanders – better health, reduced inequalities, better participation and independence, trust and security A fair and functional health system – equity and access, quality, efficiency and value for money, effectiveness, intersectoral focus
Performance measures	A Cabinet paper updating progress and advising on the next steps on community-based aged care and funding of aged care services in support of the Minister’s priority for the health of older people will be completed by 10 December 2007 A report on gaps in services supporting the continuum of care for older people will be completed by 30 May 2008

Infrastructure

Workforce

As well as being part of the Minister’s sixth priority, workforce will also be critical to achieving the first five priorities. The Ministry must take the lead in ensuring the appropriate environment for innovation, increased recruitment, improved retention and an appropriate health workforce. For these reasons, the Ministry has developed workforce plans in collaboration with the health sector,and the focus now is on their implementation.

The Ministry of Health’s role in workforce development is to ensure that the policy and regulatory environments support the Government’s strategic objectives, and to provide leadership and support to the sector on workforce development. The key elements of the Ministry’s planned interventions are:

• leading change in health workforce development
• health workforce regulation
• co-ordinating workforce activities
• workforce development in specific areas.

This priority is supported by the delivery of the core operating functions, particularly the administration of funding and purchasing of health and disability services, where the Ministry is focusing on service development for targeted groups, such as home-based support service workers and needs assessment and service co-ordination, mental health workforce development and clinical training services.

Information systems Improved information systems will:

• support better decision-making and service delivery
• provide faster dissemination of best practice through well-developed information systems
• reduce costs associated with poor decision-making.

The National Systems Development Programme is a four-year initiative expected to deliver improved and sustainable national payment, information and connectivity systems that interact more efficiently in the health and disability sector.

The Programme seeks to consolidate,rationalise and optimise a range of core payment, information and connectivity systems.The Programme will build foundations that can be used by future sector systems. These foundations will be developed partly through the stabilisation of infrastructure, standardisation of information and integration of business processes. Improvements in health payments, information and connectivity will produce many benefits to the health and disability sector in the medium to long term.

Investment in new information technology capability needs to be supported by analytical capacity,otherwise the sector may not benefit as much as it should. Information services are a core operating function of the Ministry as depicted within the Statement of Service Performance.

Implementing the National Non Admitted Patients Collection (NNPAC) will increase monitoring DHB throughput by at least 10 percent. This information will lead to a better understanding of performance.

Measuring progress on infrastructure improvements

Health is a labour-intensive industry. Achieving the health targets is critically dependent on the quality and distribution of the health workforce, which will be influenced by the Ministry’s key interventions. Also, we will only know if we are achieving progress if the information systems and analyses are effective. Positive improvements in the health targets over their current baseline levels are indirect indicators that the relevant infrastructure is in place.

The National Systems Development Programme will deliver six major workstreams that will provide the foundation capability for enhancing sector-wide health information, connectivity and systems.Therefore success will be measured by achieving the outcomes from each of the individual workstreams.

The performance measures are as follows.

New Zealand’s Health Career framework, in partnership with District Health Boards New Zealand,will be published and distributed by 31 October 2007 to map health and disability careers to support staff retention and innovation in workforce planning and development.

A Cabinet paper to implement the Workforce Taskforce (an advisory body to the Minister of Health)recommendations on streamlining medical education and training to produce medical practitioners who are fit for purpose and for practice in the minimum time period will be completed by 29 February 2008.

Under the Health Practitioners Competence Assurance Act 2003, the Ministry is required to commence a review of the operation of the Act. This review will start by 30 November 2007 with a view to completion by December 2008.

The development of a Mental Health and Addiction Core Competencies Framework will be completed by 30 June 2008.

The development of a National Training Plan for mental health and addiction workers will be completed by 30 June 2008.

A Public Health Workforce Development Implementation Plan will be completed by 30 June 2008.

A national body to co-ordinate public health workforce development will be established by 30 June 2008.

The National Systems Development Programme has been implemented as agreed between the Minister and Ministry. The programme consists of six workstreams and 28 portfolios, and within these portfolios there are 129 projects by June 2008. This progressive programme will have completed some key stabilisation and standards projects that will provide foundation capability for enhancing sector-wide health information, connectivity and systems. The programme will monitor,on a weekly basis, all programme costs against forecasts and report monthly as per its governance framework. Timeliness performance will be measured by measuring the percentage of on-time deliverables against the plan.

Value for money

The Director-General’s programme of development and change within the Ministry has been established in response to the findings of the Ministry review (Gaudin and Wong 2006). There view identified the need to go ‘harder and faster’ on the Minister’s priorities while streamlining the delivery of the core operating functions to achieve increased responsiveness and a proactive management approach.

A key focus in implementing the review will be developing the Ministry’s role in strengthening the connections between research, research uptake into innovation, and spreading innovation through shared learning and best practice.

Many of the interventions to deliver the core operating functions and the other priorities also contribute to improved value for money. For example, the Ministry/DHB joint funding work programme that leads to a successful DHB funding round means a single agreed process for interdistrict flows, national pricing, common costing and counting and maintenance of the Nationwide Service Framework rather than 400 separate negotiations, thereby ensuring unnecessary duplication of effort.

DHB reviews identify savings and/or service enhancements. Reviews are part of business as usual and are intended to identify efficiencies and savings.

Rationalised accountability arrangements will result in reduced transaction costs for DHBs and reduced processing and monitoring costs for the Ministry.

The Service Planning and New Health Intervention Assessment (SPNIA) Framework is intended to help DHBs and the Ministry of Health with health service changes (including the reconfiguration of a service or the introduction of new health interventions) that require a collective decision.

It also seeks to ensure that individual DHBs are not inappropriately compromised by the decisions of other DHBs. The SPNIA Framework ensures decisions at all levels (local, regional and national)are made in a structured, consistent and robust manner.

The Government’s Quality Improvement Strategy (Minister of Health 2003b) defines quality as the degree to which the services for individuals or populations increase the likelihood of desired health outcomes and/or increase the participation and independence of people with a disability,and are consistent with current professional knowledge. Quality improvement systems support consistency of service delivery standards and provide a more focused use of resources in areas of work deemed most likely to improve outcomes. Quality improvement is a critical component of value for money.

The Public Health Advisory Committee has reported that international experience shows that without an explicit process, such as Health Impact Assessment (HIA), the availability of technical information on the expected health impacts is unlikely to be sufficient to influence decision making to any significant degree (Public Health Advisory Committee 2006). If policies from other sectors are to have a positive impact on health and avoid unintended consequences,consideration of health, wellbeing and health inequalities needs to be embedded into the policy development processes.

Table 10: Measuring our progress in achieving value for money

Level	Indicators/measures
Relevant headline indicators	Healthy New Zealanders – better health, reduced inequalities, trust and security A fair and functional health system – equity and access, quality, efficiency and value for money, effectiveness, intersectoral focus
Relevant health sector targets	A reduced percentage of the health budget spent on the Ministry of Health
Performance measures	Depending on the output of the health sector survey about multiple audits in the health and disability sector (June 2007), a Cabinet paper on implementing specific feasible solutions to improve efficiency in health provider audits will be completed by 31 August 2007 The National Service and Technology Review Advisory Committee (NSTR) will analyse,review, rank and makes recommendations on business cases, and submit these by 30 September 2007 The review of the mental health sector service standards will be completed by 30 November 2007 A health impact assessment unit will be established within the Ministry of Health by 31 May 2008 Develop and deliver training in the use of the whanau ora health impact assessment tool (Whakatataka Tuarua) Key DHB mental health performance indicators will be developed by 30 June 2008 Two DHB reviews will be undertaken by 30 June 2008

Improving Māori health

Enhancing the effectiveness of mainstream services in delivering and positively contributing towards improving Māori health outcomes remains an important priority for the Ministry of Health.To date, the Ministry of Health has put considerable effort into supporting Māori capacity building within the sector.

The focus has shifted in recent years from increasing the number of Māori providers to building,strengthening and sustaining the quality of the services provided.

Alongside the work with Māori providers, an ongoing focus will remain on DHBs and mainstream providers to ensure greater effectiveness of the resources and initiatives aimed at improving Māori health outcomes. A high proportion of Māori continue to access mainstream services,and an overwhelming proportion of health and disability funding goes to mainstream providers.Therefore, these providers have a critical role in improving Māori health, and it is essential that mainstream services respond effectively to improve the health status of Māori.

As part of Whakatataka Tuarua, the Ministry of Health has identified the following areas for priority attention:

• building quality data and monitoring Māori health
• developing whānau-ora-based models
• ensuring Māori participation: workforce development and governance
• improving primary health care.

Table 11: Measuring our progress in improving Māori health

Measuring progress	Indicators/measures
Relevant headline indicators	Healthy New Zealanders – better health, reduced inequalities
Relevant health targets	Improving immunisation coverage Improving oral health Reducing ambulatory sensitive admissions Improving diabetes services Improve nutrition Increase physical activity Reduce obesity Reduce the harm caused by tobacco
Performance measures	Key Whakatataka Tuarua measures: see relevant priority area The first year of the three-year joint work programme (with DHBs) for Te Kokiri:The Mental Health and Addiction Plan will be implemented by 30 June 2008,including review of Te Puawaitanga: Māori Mental Health National Strategic framework Administration of the Māori Provider Development Scheme in line with guidelines and stated timeframes

Reducing inequalities

To address inequalities we need action that focuses on the causes of inequalities, which are complex. Much of what influences health outcomes, for example, lies outside of the control of the health and disability sector. Nevertheless, we know that health sector policy, planning and delivery can either decrease or increase inequalities.

Research tells us that specific one-off projects to reduce inequalities are less successful than a co-ordinated approach that makes reducing inequalities ‘business as usual’ across all the priorities. The first step in this co-ordinated approach is raising awareness, which is the primary aim of the workshops and includes providing tools such as the Health Equity Assessment Tool (HEAT). The second step is to implement co-ordinated actions to reduce inequalities, on an ongoing basis.

The Ministry’s interventions will have an impact on all participants in the health and disability sector, but due to its intersectoral focus will also involve working with other government agencies to see where action to reduce inequalities can be jointly beneficial.

Table 12: Measuring our progress in reducing inequalities

Level	Indicators/measures
Relevant headline indicators	Healthy New Zealanders – reduced inequalities
Relevant health targets	Improved immunisation coverage Improved oral health Reduced ambulatory-sensitive admissions Improved diabetes services Improved nutrition Increased physical activity Reduced obesity Reduced harm caused by tobacco
Performance measures	Four workshops, with a particular focus on the four regional cancer networks,will be conducted by 30 June 2008 to raise awareness of the need to reduce inequalities The Health Equity Assessment Tool will be reviewed by 30 June 2008 and a guide to its use will be developed to improve its uptake The Pacific Health and Disability Action Plan will be reviewed by 29 February 2008, and implementation of the action plan for the next period will commence to improve Pacific health and to reduce inequalities

Developing a long-term health sector strategic plan

There are more than 30 strategies that provide guidance to the sector on achieving progress on a specific disease, disability or service. At a national level, the many strategies provide useful signals to the community on how the health system will achieve progress in specific areas of need, but prioritising the implementation of the many actions involved can be difficult at a local level.

In this planning period, a long-term plan that brings together these many strategies will be developed within a sector sustainability context. The long-term plan will respond to the risks and opportunities signalled in the health context, such as reducing inequalities. The plan will be developed collaboratively with the health sector.

Interventions will include:

• long-term strategy development
• long-term demand modelling
• high-level advice on the budget process and the level of Vote Health
• advice on further devolution of funding responsibilities to DHBs
• advice on funding levels for specific service areas, clarifying boundary issues such as disability support for individuals with chronic conditions, and cross-sectoral funding issues
• advice on the population-based funding of DHBs
• a strategy on the public-private interface.

Intersectoral and interagency activities and initiatives

Many of the things that most affect the health of New Zealanders are heavily influenced by factors outside the direct control of the health and disability sector. These include education, housing,transport, urban and rural environments, employment and wealth distribution, all of which affect health outcomes.

In order to maximise the health of New Zealanders the Ministry needs to work collaboratively with other government agencies, local government and communities across a number of sectors.Obesity, inactivity and poor nutrition affect health, but the causes and solutions range across a number of sectors, including health, physical activity, education, active transport, local government and the food and beverage industry.

Healthy Eating – Healthy Action is a cross-sectoral initiative led by the Ministry of Health, which engages and works collaboratively with all these sectors in its actions to achieve the goal of healthy New Zealanders, and to reduce health inequalities through encouraging healthy nutritionand physical activity.

Examples of other intersectoral and interagency activities the Ministry either leads or contributes to are set out in Table 13.

Table 13: Intersectoral and interagency activities aimed at improving the health of New Zealanders and reducing inequalities

Activity	Agencies involved
Aim Hi Schools, Family Violence, wellchild review	Ministry of Social Development (MSD) and the Ministry of Education (Aim Hi is MSD led from 1 July 2007)
The Review of Long-term Disability Supports	Office for Disability Issues (ODI)
Boundary and workforce issues	Tertiary Education Commission, DHBNZ and DHBs, ODI, MSD (including Child, Youth and Family), Ministry of Education, Pacific Island Affairs
Work with MSD and ACC on the Working NZ initiative is being led by MSD	MSD, ACC
Forming initiatives to reduce the impact of sexually transmissible diseases	Ministry of Women’s Affairs and Ministry of Youth Development
Leading the whole-of-government initiative to plan for a pandemic	Ministry of Agriculture and Forestry and the Department of Prime Minister and Cabinet
Reduce the incidence of tuberculosis in New Zealand, particularly among new arrivals	New Zealand Immigration Service
Source and deliver vaccines for vaccination programmes	PHARMAC and DHBs
Build and share knowledge and information in relation to communicable diseases	Environmental Science and Research, DHBs, and academic institutions
Work on issues relating to alcohol,illicit and other drug use under the interagency framework of the National Drug Policy	Police, Customs, the Ministry of Justice, Department of Corrections,ALAC
Suicide prevention strategies	Ministries of Social and Youth Development and Te Puni Ko¯kiri
Monitor and address health issues in the physical and social environment	Territorial local authorities and the Department of Internal Affairs
Address chemical injury in the workplace	Occupational Safety and Health
Address health impacts of biosecurity risks	Ministry of Agriculture and Forestry and the Environmental Risk Management Agency
Develop knowledge and understanding	Academic organisations, including the National Poisons Centre
Develop and administer the legislative framework	DHBs, territorial local authorities and other government departments
Health of Older People	ACC, MSD
International obligations	Ministry of Foreign Affairs and Trade, NZAID, World Health Organization
Value for money – reducing the cost of regulatory requirements	Ministry of Economic Development
Mission On initiatives – getting young New Zealanders healthy	Ministry of Education, SPARC, Ministry of Youth Development, DHBs
Monitoring wha¯nau outcomes	TPK, MoE, Department of Labour, Housing Corporation NZ, Justice
Healthy Housing Programme	Housing Corporation NZ, DHBs

Measuring the cost effectiveness of priorities and interventions

This section provides some examples of the cost effectiveness of the Ministry’s interventions in this planning period.The Ministry’s approach to cost effectiveness is to:

• constantly review its baseline and reprioritise and redirect funding to areas of need
• undertake economic appraisals of new initiatives
• include economic appraisals in the evaluation of existing interventions, where possible and appropriate
• participate and undertake benchmarking exercises on cost effectiveness, where possible and appropriate
• monitor the domestic and international literature for the cost effectiveness of interventions
• monitor a set of cost effectiveness measures that illustrate the cost effectiveness of the Ministry’s interventions.

The Ministry constantly reviews its baseline funding so that it can reprioritise and redirect resources as new issues arise, or if interventions prove to be more complex than planned. Taking 2006/07 as an example, the Ministry has redirected around $14 million of its baseline funding to interventions such as:

• elective services
• the National Non-Admitted Patient Database
• chronic health conditions
• the Nurse Practitioner Employment and Development Working Party report
• the establishment of a rural desk
• Service Planning and New Health Intervention Assessment
• DHB elections support
• DHB reviews
• the evaluation and audit of a group of providers
• nursing policy
• the Mortality Database for the Child and Youth Mortality Review Committee.

It is anticipated that the Ministry will continue this approach during the planning period.

Using approaches 2 to 5 (above), the following provides some examples of the cost effectiveness of the Ministry’s interventions in this planning period.

• Previous modelling work has indicated that Healthy Eating – Healthy Action (HEHA)-type interventions could save up to 1000 lives a year by 2011 (Ministry of Health and the University of Auckland 2003). Based on this level of benefit, and a cost of $28 million a year for the interventions, preliminary estimates suggest cost-effectiveness ratios in the order of $3,000 to$10,000 per year of life saved, and a net health benefit of 1500 to 3000 deaths avoided in the first six years of intervention.
• Based on conservative estimates and assumptions, an economic appraisal of the introduction of a Universal Newborn Hearing Screening Programme would lead to at least 74 more early diagnoses, and lifetime cost savings in excess of $23 million.² The cost of providing screening services is $70 per baby screened.
• According to several conservative estimates, every dollar invested in opioid dependence treatment programmes may yield a return of between $4 and $7 in reduced drug-related crime,criminal justice costs and theft. When savings related to health care are included, total savings can exceed costs by a ratio of 12:1 (Godfrey et al 2004).
• From HealthPAC’s audits and investigations to reduce fraud, there are demonstrated recoveries of $4.6 million per annum, savings³ of $3.8 million and a deterrent⁴ of $150 million per annum from an investment of $1 million per annum. No other health shared-service agency in New Zealand has ever achieved a prosecution.
• Benefits assessed for the National Systems Development Programme were forecast to reach$54.3 million per annum from 2013/14. This amount includes benefits accruing to the wider health sector (estimated at 65 percent of total benefits) as well as those accruing to the Ministry (estimated at 35 percent of the total). The Programme is forecast to cost $147.4 million over four years ($105.8 million capital, $41.6 million project operating expenses).
• In 2006 the Ministry’s Knowledge Management activity was benchmarked against similar activities in the Ministry of Social Development, Department of Labour, and the Ministry of Education. The Ministry of Health was in the mid-range for the ratio of library staff to total staff numbers, and expended a similar mid-range budget (Algar 2006).

Studies of this nature will continue throughout the planning period.

In addition, the Ministry will monitor the following measures of cost effectiveness. The measures chosen aim to combine measures of impacts, outcomes or objectives with the cost of producing these results. Some of the measures chosen do not achieve this level of specificity, but are based on evidence that the impacts are of improved quality and lower cost than the alternatives as a result of the Ministry’s interventions, or sector interventions that the Ministry influences.

Cost effectiveness measure: value for money: deviations from GDP based predictions of life expectancy at birth and of total health expenditure, OECD countries

Why are these indicators important?

International comparisons are one way of monitoring our performance in relation to the efficiency and value for money outcome. Across the OECD, there is an association between national wealth(as measured by GDP) and life expectancy, and between GDP and the proportion of GDP spent on health. Deviations from expected life expectancy and expected expenditure are measures of the cost effectiveness of the health system. As the Government’s primary advisor on health and disability support services, the Ministry’s advice contributes to New Zealand’s performance against this outcome.

What does the data show?

The data shows that New Zealand has a somewhat better life expectancy than expected for its GDP expenditure, and that spending on health is slightly lower than would be expected. This suggests that New Zealand’s health and disability support system is relatively effective and efficient in comparison with many other OECD countries.

Figure 17: Deviation from GDP-based predictions of life expectancy at birth and of total health expenditure, OECD countries (except Luxembourg), 2002

Cost effectiveness measure: smoking cessation: the cost effectiveness of Quitline

Why is this measure important?

It is estimated that smoking kills around 5000 people in New Zealand every year (including deaths due to second-hand smoke exposure). A key area of tobacco control is supporting New Zealanders to quit smoking and therefore prevent adverse health outcomes. Quitline is a smoking cessation service funded by the Ministry of Health for this purpose.

What does the data show?

An analysis of the Quitline service gives very favourable cost-effectiveness ratios. Data presented here is for the ‘post-NRT’ Quitline programme; that is, after the inclusion of subsidised nicotine replacement therapy (NRT) in late 2000. The cost per quality-adjusted life year (QALY)⁵ gained was estimated to be between about $2,000 and $3,000 ($2,449 to $3,339, using a range of cost data).The cost per 12-months quitter was estimated to be just over $2,000 ($2,099).

Some comparison with other interventions is given in Figure 18. Note that overseas results cannot be directly compared given different cost drivers and structures, although they may give some general indication of relative value for money.

Figure 18: Cost per quality-adjusted life years (QALYs) gained, for selected secondary prevention interventions for chronic disease (cardiovascular disease and cancer)

Notes:
Solberg et al 2006: result converted from US$1,100 per QALY. Discount rate 3%. Data for one-time intervention.
Parrott et al 2006: analysis for NICE Public Health Intervention Guidance (No.1). Result converted from UK£3,248.50 perQALY. Mid-point of range £1664–£4833. Discount rate 3.5%. Data used for GP Brief Intervention (5 minutes) plus NRT.
Dalziel et al 2006: base case result $2,053 per QALY (range $827–$37,516). 90% of cost-effectiveness ratios under$7,500. Discount rate 5%.
Milne and Gamble 2003: middle result $5,043 per QALY (range $3,295–$10,532). Discount rate 5%.
Stout et al 2006: result converted from US$37,000 per QALY. Discount rate 3%.

Cost effectiveness measure: ownership and performance of DHBs and Crown entities: mechanisms to encourage DHBs to do things once rather than 21 times

The indicator is the Ministry–DHB joint funding work programme leading to a successful DHB funding round. The joint process covers the interdistrict flow (IDF) project, the National Pricing Project, the common costing and counting projects and the maintenance of the Nationwide Service Framework.

Why is this indicator important?

Increasing efficiency and effectiveness, and reduced costs through joint Ministry of Health/DHB collaboration on pricing and funding activities.

What does the data show?

One agreed process versus 400 separate negotiations. Without a nationally co-ordinated process,each DHB would have to negotiate with every other DHB on IDF pricing/volumes, definitions for purchase units, service specifications, etc.

Cost effectiveness measure: payment services: administration costs per claim

Why is this indicator important?

HealthPAC processes 90 million claims, 11,000 agreements and 16,000 contract monitoring returns every year. This volume of activity ensures the health system works for New Zealanders.The total dollar value of the activity is $4.15 billion.

What does the data show?

Costs estimated by KLA in 2003 were 10c per electronic payment (EFTPOS comparable comparison10–15c). There are no real comparisons available, because the systems around the world are very different, and there is no comparable public sector system in New Zealand. The Accident Compensation Corporation (ACC) operating costs (the majority of which relate to the payment of claims) have increased in recent years, but remain at about 12 percent of claim costs (ACC 2006).

Cost effectiveness measure: administration of legislation and regulations and meeting legislative requirements: certification and audit costs under the HDSS Act 2001 with no calls for changes to the Ministry’s administration of the Act

Why is this indicator important?

The Health and Disability Services (Safety) Act 2001 (HDSS Act) regulates the facilities in which residents are cared for when admitted to a facility, and has an important impact on promoting continuous improvement in the provision of safe and quality focused health and disability services.Regulatory scrutiny has been shown to lead to improvements in the quality of care, particularly in long-term care (Wunderlich and Kohler 2000). To date the Health and Disability Commissioner is unaware of any complaints under the Code that could be associated with inadequate regulation under the Act (personal communication, 8 January 2007).

What does the data show?

Over the last three-year period there were 2045 certified facilities with 61,524 beds, an average of30 beds per facility. The beds comprise 8457 rest home beds, 25317 hospital beds, and 27750 residential disability beds. Facilities are certified for an average of 32 months. The average cost of a certification audit is $3,600. The costs of certification and audit are given in Table 14.

Table 14: Costs of certification and audit

	Per bed$	Per bed average certification period(months) $	Per bed average certification period(years) $
Average cost of certification audit	119.66	3.73	44.74
Operational costs	15.13	0.47	5.66
Total cost	134.79	4.2	50.4

Note: All costs are GST inclusive.

These costs may be compared with the licensing fees of local authorities. For example, Wellington City Council charges $240 to $700 for an annual licence for registered food premises with a good grade. The fee for licensing a hairdresser is $100.⁶

Review of the current state of the Ministry of Health 2006

Recognising the size and significance of the Government’s agenda, and the major change in the health sector settings, in 2006 the Director-General undertook a review of the current state of the Ministry of Health (Gaudin and Wong 2006). The findings of the review highlighted a number of things the Ministry does well, but also identified a number of areas for development and change that will be addressed in the planning period. These include the need to:

• confirm the shared sector vision and intended outcomes consistent with the Government's priorities, and to clarify the roles of the Ministry in supporting that vision
• significantly increase our emphasis and focus on a number of core roles, particularly those that contribute to system-wide performance
• organise ourselves in a way that enables us to focus on key priorities in a planned way
• improve our internal performance management arrangements to ensure they are aligned with sector accountabilities, and therefore enable us to see whether we are making progress against planned goals.

The review also recommended that the following roles should receive increased emphasis:

• performing a sector leadership role, including confirmation of a shared sector vision and focus on intended outcomes (this role should be undertaken within a collaborative and shared learning environment)
• long-term strategic development for the health sector, as part of long-term whole-of-sector strategic planning (including long-term needs analysis, service planning, workforce planning and capital planning) to promote ongoing sector sustainability
• providing performance improvement assistance and best practice advice, separate from the Ministry's monitoring function, across the health sector.

• In response to these findings, and the wider strategic context in which we operate, during the planning period the Ministry intends to focus its interventions and outputs to achieve measurable outcomes by:
• developing a long-term health sector strategic plan that includes the Ministry of Health
• focusing on the Minister’s priorities for concerted action for the health sector
• developing the Ministry of Health by clarifying the Ministry’s core roles and strengthening our capacity to deliver on them. We will also streamline how we work with the wider sector to ensure the health system delivers on the Government’s themes and priorities for health now,while at the same time developing our capability and focus to implement the long-term health sector strategic plan in collaboration with the sector.

Developing the Ministry of Health

The Ministry of Health’s roles, as listed earlier, were last reviewed as part of the planning undertaken for the Statement of Intent 2003–2004 (Ministry of Health 2003b). In the current health settings, many of these roles are complex, and some often have the potential to conflict with each other. Each of these roles requires varying skill sets, carries different risks and, more importantly,sets a framework for a different range of relationships and types of engagement with the wider sector. There is also growing recognition of the Ministry’s wider role in supporting the performance of the system that is distinct from performance monitoring.

The Ministry review in 2006 picked up on many of these issues (Gaudin and Wong 2006). In particular the review identified the need to go ‘harder and faster’ on the Minister’s priorities while streamlining delivery of the core operating functions to achieve increased responsiveness and a proactive management approach. To implement the findings of this review over the planning period, the Director-General will establish, lead and implement a programme of development and change within the organisation.

The programme will focus on ensuring that the:

• Ministry’s roles are appropriate, with particular reference to the Ministry’s role as planner and funder of selected services, and as manager of a range of national operations functions
• Ministry’s structure accommodates streamlined core operating functions and potentially revised roles, while ensuring appropriate emphasis on the delivery of the Minister's priorities and the Government’s themes in this period
• existing performance management frameworks and processes are strengthened to ensure that the delivery of work programmes are on track against priorities
• existing leadership capability is strengthened in its various forms necessary to adequately fulfil the Ministry’s potentially revised roles in the sector
• Ministry effectively manages these functions within a changeable operating environment.

Developing and maintaining our capability

This section outlines the initiatives we intend to use in 2007/08 to maintain and improve our capability and capacity. These initiatives build on our 2006/07 work programme and are informed by the Government’s strategic priority areas, the Ministry’s health targets (which are aligned to strategic priorities) and the 2006 review of the Ministry.

The ability of the Ministry to undertake the key functions defined by these documents depends on identifying and addressing its future capacity and capability requirements.

These initiatives have been mapped to two of the six State Services Commission’s development goals which the Ministry will focus on, in particular for the coming period. Goals one and two specifically to strategies to develop people capability across the state sector. The Ministry’s four levers for capability development (attraction and commitment, learning and development, healthy workplaces and human resources information capability) are aligned to the streams of State Services Commission (SSC) work that sit beneath the goals (attracting and hiring the best, positive workplaces and developing for excellence).

SSC Development Goal 1 Employer of choice: ensure the state services is an employer of choice attractive to high achievers with a commitment to service

Effective attraction and commitment

The labour market is becoming increasingly complex and competitive and the Ministry needs to be able to improve its ability to recruit and retain competent and capable staff to deliver the Ministry’swork programme. An indicator of organisation health is the staff turnover rate, which in recent years has been as high as 20.7 percent (30 June 2006). There is currently a downwards trend(17.8 percent as of 30 September 2006), and our initiatives are designed to ensure we continue this trend to be more aligned to the sector average of 13 percent (as at the year to 30 June 2006).

The key milestones in 2007/08 are to have:

• developed a new employee attraction strategy that ensures consistent recruitment practice in the Ministry and provides the context for future initiatives – this will include consultation within the Ministry and external agencies, as required
• implemented actions from the staff commitment (retention) stocktake completed last year – this has highlighted some key actions that can be taken to extend the length of stay of our staff
• implemented two initiatives that support more effective remuneration and reward policies– these will build on a review of Ministry remuneration policy, and will ensure we meet the State Sector Retirement Savings Scheme (SSRSS)/Kiwisaver requirements and extend implementation of a team reward and performance process.

Relevant and timely information

The ability to provide relevant and timely information from our Human Resource Information System (HRIS) is essential for us to measure progress towards being an employer of choice,and managing the attraction and staff commitment issues mentioned above. We also need to monitor and address our people’s individual development by having accurate data on the range of development and training options people are using.

The key milestones in 2007/08 are to have:

• a monitoring plan in place to ensure we have improved reporting functions from our new HRIS
• initiated a process for a staff survey aligned to the change and development programme signalled in the Ministry review of 2006, and the Ministry’s Employment and Pay Equity Audit.

Healthy workplaces

Modelling the way forward in supporting healthy lifestyles and providing healthy workplaces are key strategies to ensure we maintain our people capability. For example, employees were asked in an exit survey whether they were leaving due to the impact work has on family life. They responded with a 4.1/5 average, which is between agree and strongly agree.

The key milestones in 2007/08 are to have:

• increased staff awareness of our smoking cessation policy, and to have made available some Healthy Eating – Healthy Action (HEHA) options for staff
• implemented an interactive session to promote valuing difference as a way of working, aimed at achieving attitudinal awareness of the importance of a diverse workplace
• raised awareness of the range of flexible working arrangements available to staff – this will support staff commitment to the Ministry and be measured by the increase in staff taking up these options. It is an essential action for ensuring we are an employer of choice.

The success of all these interventions will be measured through monitoring, using the following tools:

• an initial three-monthly survey of staff for feedback on the efficacy of advertising media
• an initial three-monthly survey of staff for feedback on awareness of healthy workplace initiatives
• quarterly reports on the use of unplanned leave (ie, domestic and special leave)
• quarterly reports on the use of flexible workplace arrangements.

SSC Development Goal 2 Excellent state servants: developing a strong culture of constant learning in the pursuit of excellence

Developing leadership capability

The Ministry review in 2006 highlighted the need to ensure that leadership capability is strengthened to adequately fulfil the Ministry’s potentially revised roles in the sector. There is a need to develop a shared, organisation-wide vision and achieve an outcomes-based culture which will require capable leadership. Our initiatives build on last year’s work plan as well as ensuring we work towards addressing future needs.

The key milestones in 2007/08 are to have:

• implemented actions from the review of management delegations completed last year
• reviewed our management competencies to ensure they are relevant and aligned to the Change and Development programme signalled in the Ministry review.

Effective and relevant training

To support the development of both leadership and management capability we need to provide training opportunities that are outcomes based and aligned to the strategic direction of the organisation. This training will incorporate reducing inequalities training into the internal training programme available to all employees.

By 30 June 2008 we will have completed a training needs analysis for the current internal‘Managing in the Ministry’ training programme to ensure that it is effective and relevant, and that we have capable and competent managers.

Measuring the success of all these interventions will be through monitoring, using the following tools:

• quarterly reports on participation in the performance appraisal process
• quarterly reports on attendance in the Managing in the Ministry programme.

Carbon neutrality in the public service

The Prime Minister’s Statement to Parliament speech on 13 February 2007 announced that the Ministry of Health is one of six public service departments will take the lead on achieving carbon neutrality.

The three aspects to achieving carbon neutrality that will challenge each of the six departments are to:

• measure emissions
• reduce emissions
• offset unavoidable emissions.

By early 2008, the six lead agencies will have plans in place to reduce their emissions further and offset unavoidable emissions. This may be:

• energy efficiency measures, which might include energy use audits, educating staff on using less electricity, low-energy lighting systems, more efficient heating and cooling systems, and purchase of equipment that uses less electricity
• travel measures, which might include workplace travel plans to eliminate unnecessary journeys, purchasing more fuel-efficient vehicles, and transport alternatives such as video conferencing facilities
• waste reduction and recycling systems.

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Footnotes
2 Internal report prepared for the Ministry of Health.

3 Funds that would have continued to be paid out in a year had the fraud not been stopped. This definition is widely used internationally (eg, National Health Service = Counter Fraud Service, European Healthcare Fraud and Corruption Network).

4 The estimated difference in claiming if the HealthPAC Audit and Compliance unit did not operate. It represents an estimated 3 percent of the funds paid out by HealthPAC on behalf of DHBs and the Ministry of Health. A 3 percent deterrence effect is conservative in international terms, with health organisations in Australia, the US and the UK providing estimates ranging around 5 to 10 percent.

5 A QALY is a measure of the outcome of actions (either individual or treatment interventions) in terms of their health impact. If an action gives a person an extra year of healthy life expectancy, that counts as one QALY. If an action gives a person an extra year of unhealthy life expectancy (partly disabled or in some distress), it has a value of less than one. Death is rated at zero.

6 http://www.wellington.govt.nz/services/foodsafety/fees/fees.html, accessed 23 February 2007