Statement of Intent 2008-11 Operating Intentions: A. Taking public and primary health care to the next level On this page A1 Getting ahead of the chronic disease burden A2 Driving forward the Primary Health Care Strategy A3 Investing in the early years and youth potential A4 Caring for older New Zealanders Back to Operating Intentions page A1 Getting ahead of the chronic disease burden What are we seeking to achieve? Chronic conditions and their social determinants are a major cause of poor health and mortality in New Zealand. They are also a significant driver of inequalities in health outcomes. In particular, a higher proportion of illness and mortality among Maori, Pacific peoples, and people with low incomes is attributable to chronic conditions. The Ministry aims to contribute to a reduction in the incidence and impact of chronic conditions by: providing leadership and direction in policy development on the issue of chronic conditions supporting initiatives and programmes that address the determinants of chronic conditions, particularly for people at greater risk supporting the development of services that meet the needs of people with chronic conditions, particularly among those populations that experience inequalities in outcome fostering an environment of collaboration, innovation, and evaluation in the health sector in the area of chronic conditions. What will we do to achieve this outcome? Better prevention and management of chronic diseases and their social determinants at a population level, and in primary health care and community settings among groups at greatest risk, will contribute directly to reducing inequalities in outcomes. To achieve this, the Ministry needs to do a range of activities that are on a continuum from reducing risk to managing disease. Over the medium term, the Ministry will focus on supporting and leading the development and implementation of action plans; encouraging the development of networks; and funding the development and evaluation of new initiatives. A particular focus will continue to be applied to the public health needs of Maori and Pacific peoples. New migrant populations also have specific health needs that require specific focus. Supporting and leading action plans National and international research shows that action plans collaboratively developed, prioritised and agreed have increased buy-in and a greater chance of achieving successful outcomes. The Ministry’s work programme includes a number of initiatives focused around action plans. Support and monitor the delivery of newly developed DHB tobacco control plans from 2008/09. The DHB plans focus on decreasing the rate of smoking, in particular in the primary care setting. Increasing quitting will reduce smoking-related illness and deaths. Review and widen the scope of the existing Healthy Eating – Healthy Action (HEHA) implementation plan (Ministry of Health 2004), in response to the recent Health Select Committee Inquiry into Obesity and Type 2 Diabetes. The HEHA Strategy and its associated implementation plan aim to decrease the risk factors for a range of diseases including cancer, cardiovascular disease and diabetes (Health Committee 2007). Fund DHBs to develop breastfeeding action plans. The plans will reflect the population needs and identify activities to increase the breastfeeding rates in their districts. Evidence indicates that breastfeeding has short- and long-term health benefits for the infant and mother. Longerterm benefits include a reduction in some chronic diseases. Lead the Long-Term Conditions Programme (LTCP) to establish a 10-year pathway for a ‘wholeof- system’ response to long-term conditions. The LTCP, which began in 2007, aims to galvanise action for effective long-term conditions management in the health sector and intersectorally, and create suitable structures within the Ministry for working on long-term conditions. Continue implementation of Te Kokiri: The Mental Health and Addiction Action Plan 2006–2015 (Minister of Health 2006). Continue to implement projects which support the implementation of the Cancer Control Strategy Action Plan 2005–2010 (Cancer Control Taskforce 2005). Encouraging the development of networks A report on innovation in the heath sector, commissioned by the Ministry last year, identified the establishment of networks as an important way of assisting to create innovation and build relationships (Lomas 2008). The Ministry’s work programme includes two initiatives focused on encouraging the development of networks: further development of regional cancer networks the national HEHA network will improve leadership, communication, learning and development within the HEHA sector to support implementation of the HEHA Strategy. Funding the development and evaluation of new initiatives The Ministry’s work programme includes two initiatives focused on funding the development and evaluation of new initiatives. Fund and support implementation of a mass vaccination programme for Human Papillomavirus (HPV). Cervical cancer is caused by persistent infection with HPV, which is a common sexually transmitted infection – 70 percent of women are infected in their lifetime. HPV vaccination alongside the cervical screening programme is expected to reduce the incidence of cervical cancer in the vaccinated population. Work with the Law Commission to review the Misuse of Drugs Act 1975 by December 2008. This review will consider the principle of harm minimisation and the most suitable model for controlling drugs, and New Zealand’s international obligations under United Nations conventions. The report is expected to be considered by the Government in 2009. Why is this outcome a priority? Chronic diseases are a priority because they impose a significant burden on disadvantaged populations. Nutrition, physical activity and healthy weight play a critical role in maintaining health, reducing premature deaths and preventing chronic diseases, such as cardiovascular disease, diabetes and cancer. Tobacco smoking will result in the deaths of about 5000 people this year, about 1500 of whom will be in middle age. Diabetes affects about 200,000 people in New Zealand, but only half of these have been diagnosed. The prevalence of diabetes in the Maori and Pacific populations is more than twice as high as among other New Zealanders. Cardiovascular disease is the leading cause of death for New Zealanders, accounting for around 40 percent of all deaths each year. The burden of cardiovascular disease is greatest among Maori and Pacific peoples. Cancer is the second leading cause of death in New Zealand, accounting for 29 percent of all deaths each year. There are about 17,000 new registrations of cancer each year, with the highest rates in the middle and older age groups. There are significant inequalities in cancer outcomes for Maori and Pacific peoples, and cancer incidence is increasing. Nearly 47 percent of the population are predicted to meet criteria for a mental disorder at some time in their lives, 39.5 percent have already done so, and 20.7 percent have had a disorder in the past 12 months. Maori and Pacific peoples have a greater burden due to mental health problems, when adjusted for age and socioeconomic disadvantage. In any year, 8 percent of the New Zealand population will experience a depressive disorder. Twenty percent of the population will experience a depressive disorder at some stage in their lifetime. About 500 people die by suicide each year, and there are 5000 hospitalisations for suicide attempts. Maori, male young people and people living in deprived areas are overrepresented in suicide mortality statistics. Achieving changes in risk factor profiles such as decreasing smoking, obesity and physical inactivity requires approaches that modify the social and health environments so they support individuals to make and sustain healthy life choices. The ways in which the health and disability sector makes its services accessible, the quality of the services it provides, and how easy it is for people to traverse the care pathway, also influence health inequalities. All of these factors can be improved. There are also opportunities to minimise the impact of disability and illness. How will we demonstrate success? Table 1 shows how we will measure the success of the health and disability sector in, and the Ministry’s contribution to, reducing chronic disease. Table 1: Measuring the success of the health and disability sector in, and the Ministry’s contribution to, reducing chronic disease Level Indicators/measures Health and disability sector The following 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. Ministry of Health’s contribution The following initiatives, delivered in accordance with agreed measures and standards: tobacco control Health Eating – Health Action implementation of Cancer Control Strategy Action Plan Long-Term Conditions Programme implementation of the Diabetes and Cardiovascular Disease Quality Improvement Plan implementation of Te Kokiri: The Mental Health and Addiction Action Plan. How will we demonstrate cost-effectiveness? It is estimated that smoking kills around 5000 people in New Zealand every year (including deaths due to exposure to second-hand smoke). 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 the Ministry funds for this purpose. An analysis of the Quitline service gives very favourable cost-effectiveness ratios. The value of investing in HEHA interventions is supported by a number of economic analyses. Modelling work has indicated that HEHA-type interventions could save up to 1000 lives a year by 2011 (Ministry of Health and University of Auckland 2003). Preliminary estimates suggest cost-effectiveness ratios in the order of $3000 to $10,000 per year of life saved, and a net health benefit of 1500–3000 deaths avoided in the first six years of intervention. Estimates of the direct health care costs of obesity alone are in the order of $460 million for the year 2004. Given that the Maori and Pacific populations have higher rates of obesity than the rest of the population, a small reduction in obesity rates is likely to reduce the health care costs. Value for money is a key component of the overall evaluation of HEHA, so further information regarding the cost-effectiveness of the implementation of HEHA will become available as the evaluation gets under way. Long-term conditions are a major driver of health sector costs, within both primary and secondary care. More than 70 percent of health care funding is spent on managing long-term conditions. When combined with the burden of disease, this also has social and economic costs through loss of work, support payments, and the physical and emotional toll on families, caregivers and the community. The Ministry’s focus on supporting the sector, through initiatives such as the Long-Term Conditions Programme and Cancer Control Strategy Action Plan, will be significant in helping the system to provide care that results in a sustainable reduction in this economic burden. Data from a New Zealand health economic analysis of HPV vaccine estimates that administration of HPV vaccine to girls at age 11, with a catch-up programme for 11–17-year-olds would result in 3584 cases of cervical cancer being avoided over 90 years, and a cost offset of $200 million (with no changes to the National Cervical Screening Programme). Back to top A2 Driving forward the Primary Health Care Strategy What are we seeking to achieve? The fiscal year 2008/09 year will be the seventh year in a 10-year implementation pathway for the Primary Health Care Strategy (Minister of Health 2001). The infrastructure to support implementation of the strategy is now in place, including the final capitation funding formulae rollout for Very Low Cost Access and under 6s. DHBs are working with their local primary health care sectors, including 82 PHOs and 94 percent of the population are covered by a PHO. The 2008/09 year will be marked by the consolidation of the current policy and implementation settings, and a sharper focus on health gains and outcomes that are influenced by the primary care sector, using tools such as Health Targets and the PHO Performance Management Programme. This will be achieved through the review of current clinical programmes (eg, Careplus) and improving the way we work with health professional and clinical leaders to realise the full potential of the Strategy. The Ministry’s aim is to work with DHBs to strengthen the effectiveness of the primary health care sector, which will strengthen the ability of primary health care services to improve health outcomes for New Zealand’s population. What will we do to achieve this outcome? Almost full enrolment of New Zealand’s population in the PHOs provides an important platform for a focus on health gains and outcomes. As at 1 April 2008, the 82 PHOs have a combined enrolment population of 3.9 million New Zealanders. The Ministry, consistent with the intentions of the Strategy and the current policy and implementation settings, and working with DHBs, will do the following. Review the key policy parameters and funding formulae underpinning the Strategy (informed by implementation experience) to ensure that the policy intentions of the Strategy are fully realised. Integrate existing funding streams and clinical and service programmes that are delivered in primary care settings through PHOs. Integration will support greater flexibility for DHBs, PHOs and their providers to better co-ordinate care for their enrolled populations within agreed national service and health gain priorities and performance management programme.. Integration includes: transforming Careplus into a long-term conditions fund supporting after hours services in line with DHB acute demand management approaches in the primary health care setting implementing the findings of a review of Services to Improve Access funding to better link with local and regional care programmes expanding coverage of primary care-based mental health services, including services for suicide and depression management, and targeting youth health services implementing a framework for the integration of complementary and alternative medicine into primary care. Improve access and coverage for populations who are most vulnerable but can benefit from primary care services including Maori, Pacific peoples, young people and people in low socioeconomic groups, to ensure they receive the full benefit of the Primary Health Care Strategy. Invest in infrastructure and processes that support shared learning, promote the quick diffusion and spread of improvements and innovations across primary health care sector. This includes the dissemination of the findings from the evaluations of the Strategy, support for research capacity and capability in the primary care sector and nationally agreed information standards (Key Directions). Improve national processes for PHO, health professional and clinical leadership groups to engage and participate in the development and implementation of the Primary Health Care Strategy. This comprises refining the joint DHB/Ministry work programme to ensure joined up decision making at a national level, establish a new national primary health care council with mandated membership to inform and provide sector leadership on implementation. This includes membership in key groups, such as general practice, primary health care nursing, pharmacists, allied health groups and linkages with the NGO sector both locally and nationally, community and consumers. Through these forums, the primary health care sector will participate in how further implementation planning is progressed. Why is this outcome a priority? Primary health care, for most of the population, is the first point of contact for the prevention, diagnosis, treatment and ongoing management of many conditions that are a burden on the national health system and New Zealand society. Primary health care plays an influential role in managing acute demand, supporting access to specialist and other referred services (pharmaceuticals, laboratory and other diagnostics) that are accessed in other parts of the health system, such as hospitals. The New Zealand health system values the role that the primary health care sector can play, in particular, in preventing chronic disease, identifying people at risk of developing long-term conditions and providing ongoing treatment, management and co-ordination of services for those groups. The primary health care sector is an important component of improving access to services for the Government’s strategies in other health areas (eg, Cancer Control, Tobacco Control Action Plan, Health Eating – Health Action, Mental Health Strategy). Many vulnerable groups, such as Maori, young people, Pacific peoples, and people from low-income groups, are more likely to access services in primary health care settings. These groups are over-represented as having high health needs. Despite high population enrolment overall, only 83 percent of Maori were enrolled as at 1 January 2008. Young people are-over represented in mortality and morbidity statistics and have high rates of preventable disease, suicide, unintended pregnancies, sexually transmitted diseases, injuries and mental illnesses. How will we demonstrate success? Table 2 shows how we will measure the success of the health and disability sector in, and the Ministry’s contribution to, improving primary health care. Table 2: Measuring success of health and disability sector in, and the Ministry’s contribution to, improving primary health care Level Indicators/measures Health and disability sector The following health sector targets: improved immunisation coverage reduced ambulatory-sensitive hospital admissions improved diabetes services reduced harm caused by tobacco. Ministry of Health’s contribution The Ministry will work with DHBs and PHOs, in accordance with agreed measures and standards, to: achieve targets in Clinical Performance Indicators in the PHO Performance Management Programme (led by DHBNZ on behalf of DHBs) deliver the joint DHB/Ministry primary health care work programme that implements the Primary Health Care Strategy, including: implementation, planning and delivery realising the potential of the Primary Health Care Strategy a Framework for Integrative Primary Care. How will we demonstrate cost-effectiveness? The final evaluation of Primary Health Care Strategy implementation will be completed in 2009, providing further evidence of outcomes, including cost-effectiveness and access. Interim evaluation reports will inform the impact of the Strategy on the Maori and Pacific populations, and on workforce participation. The ‘Realising the potential of the Primary Health Care Strategy’ initiative will include a review of funding formulae and the blend of funding and how to maximise health outcomes from PHC funding. Integrative care has the potential to enhance the earlier detection and treatment of certain conditions, reducing the need for specialist or hospital referrals at a later stage. The PHO Performance Management Programme (that includes clinical performance indicators) is one lever of a wider performance assessment and management system that will be developed over the 2008/09 year. It will help to align PHO performance with the health gains and outcomes sought from the primary health care sector. Back to top A3 Investing in the early years and youth potential What are we seeking to achieve? Children and young people make up about a quarter of New Zealand’s current population, but 100 percent of our future. Child and youth services aim to ensure that: children and young people receive the best possible care and support from the health and disability sector, within existing budgets the approach used in child and youth services recognises the developmental needs of children and young people, related to critical events and developmental processes. What will we do to achieve this outcome? The Ministry’s focus for child and youth services over the medium term is on prevention, early intervention and improved access to health services. This will contribute to a decrease in the demand for secondary and tertiary services in the long term. Prevention The Ministry will help to improve prevention by providing leadership on the following initiatives. The development of an action plan to reduce the incidence of fetal alcohol spectrum disorder (FASD) and maternal drug use, and improve the lives of those affected by that disorder and drug use. The development of an immunisation strategy to provide direction for the National Immunisation Programme over the next 3 to 5 years. The strategy will form the basis of the National Immunisation Programme’s annual plans and work programme with the health sector. A key component of the strategy will be the implementation of improvements to the current arrangements for decision-making about the funding and procurement of, new vaccines. The scientific consensus is that immunisation is one of the most cost-effective means of preventing disease and improving health. Early intervention Early intervention is a key strategy in the provision of health care. It ensures that potential problems are identified and treated early, to lessen the likelihood and impact of long-term illness and disability where possible. The implementation of the recommendations from the review of the Well Child Framework will take place from 2008/09. This will involve several initiatives, including the development of a needs assessment tool, the introduction of a screening programme, support for mothers with postnatal depression, a review of resources, and the development of a quality framework and child health indicators. The implementation of a comprehensive and universal health check for all four-year-olds, for which new funding has been allocated. DHBs will roll out the B4 School Check service nationally during 2008. This service is an opportunity for health-promoting, wellness-enhancing contact between parents and a child health nurse. It provides an opportunity for parents and the nurse to identify any issues with health, development or behaviour that may affect the child’s ability to learn at school. Appropriate and timely referrals can be made to support the child and their family, improve the child’s health and maximise their chance of doing well at school. Improved access The Ministry will provide leadership in two improved access initiatives. A continued focus on the reorientation of child and adolescent oral health services, and funding to support a second round of oral health research projects. The Ministry will work with DHBs to substantially upgrade community-based oral health facilities, support enhanced delivery of child and adolescent oral health services, and complete a review of the hospital dental services service specification. This initiative’s impact on oral health status and outcomes will be better access to dental services, supported by better facilities and modern equipment, enhanced information and better models of care. The consideration of expanding comprehensive school-based health and social services that are similar to the services provided under the Achievements in Multicultural High Schools Programme in nine decile 1 schools, to other low decile schools. This will meet the needs of a larger group of high-needs youth. Why is this outcome a priority? Good progress has been made towards improving the health status of children in New Zealand. However, there are still disparities and New Zealand has a long way to go before it can be ranked in the top half of OECD counties. Within New Zealand there are large disparities in health status between population groups. Tamariki Maori, Pacific children and children from low-income families and whanau are experiencing comparatively poorer health outcomes than the overall child population. Good health in childhood and adolescence is important for children and families, and is vital for good health in adulthood. A number of the risk factors for many adult diseases – such as diabetes, heart disease, and certain mental health conditions such as depression – arise in childhood. Poor child health and development also have an adverse impact on broader social outcomes, including family violence, crime and unemployment. Many of these conditions are intergenerational, in that unrecognised and untreated, many child victims will go on to repeat the cycles of disadvantage and illness in their own lives and those of their children. The statistics below give an indication of the child and youth health landscape. The proportion of children fully immunised at age two years has improved from less than 60 percent in 1992 to 77.4 percent in 2005 (Ministry of Health 2007b), but there is still a long way to go. Maori are significantly less likely to be fully immunised at age two years (69 percent) than are European/other children (80.1 percent). Internationally, the prevalence of mental health problems with clinical impairment in children and young people has been found to be around 15 percent (Ramage et al 2005). The World Health Organization has identified alcohol-related harm as one of the leading causes of preventable morbidity, mortality and disability in the Western Pacific Region and the third largest risk factor in developed countries such as New Zealand. Alcohol-related harm also increases health inequalities by affecting Maori and Pacific peoples, youth and people from low socioeconomic groups more significantly than it affects other population groups. Unintentional injury is the cause of 36 percent of deaths in children aged under four years. Dental decay is slowly increasing in prevalence and severity in five-year-olds, and there are significant disparities exist between ethnic groups. In 2006, 52 percent of all five-year-olds in New Zealand were caries free, but the rates for Maori five-year-olds the rates were significantly lower at approximately 30 percent (Ministry of Health 2008). The 2002 New Zealand Children’s Nutrition Survey (of children aged 5 to 14) found that 16 percent of five- and six-year-old boys and 22 percent of five- and six-year-old girls were overweight, and 9 percent of five- and six-year-old boys and 7 percent of five- and six-year-old girls were obese (Ministry of Health 2003). The declining trend in ambulatory-sensitive admissions (primary health care avoidable hospitalisations) for children aged under five is statistically significant. However, admission rates are higher for Maori and Pacific children than for other children. How will we demonstrate success? Table 3 shows how we will measure the success of the health and disability sector in, and the Ministry’s contribution to, improving child and youth services. Table 3: Measuring the success of the health and disability sector in, and the Ministry’s contribution to, improving child and youth services Level Indicators/measures Health and disability sector The following health sector targets: improved immunisation coverage improved oral health reduced ambulatory-sensitive hospital admissions improved nutrition increased physical activity reduced obesity reduced harm caused by tobacco improved mental health. Ministry of Health The Ministry, in accordance with agreed measures and standards, will deliver: the National Alcohol Action Plan and FASD Action Plan Good Oral Health For All, For Life the Well Child Review recommendations the Maternity Services Strategic Plan the National Immunisation Programme. Back to top A4 Caring for older New Zealanders What are we seeking to achieve? The Ministry is seeking to improve the quality of life and increase the participation and independence of older people, today and in the future, by providing services that are affordable, targeted, integrated and responsive to the needs and preferences of older people. What will we do to achieve this outcome? In line with the Minister’s priorities, and the Government’s commitment to both the Positive Ageing Strategy (Minister for Senior Citizens 2001) and the Health of Older People Strategy, (Associate Minister of Health and Minister for Disability Issues 2002) the Ministry has a multi-year work programme focused on improving services targeted at older people by: supporting the stability of services (eg, ongoing access to safe and reliable services) facilitating improvements in the quality of services (eg, improvements to existing services that allow purchasers to require higher service standards, such as training) encouraging the service development (incentives to restructure services and change policy settings to better meet future needs, such as improving integration for users and rebalancing services towards home and community services) achieving sustainability (mechanisms capable of responding to growth in demand from population growth and to meet the Health of Older People Strategy objectives, such as increased use of technology). In recent years the focus has been on supporting stability in the sector, particularly the workforce in the home based sector. In 2008/09 the Ministry will be working with DHBs on new service development including assessment services and improving the clarity of service coverage requirements for DHBs. Why is this outcome a priority? New Zealand’s population is ageing. By 2020 the population’s age distribution will have a significantly larger proportion of older people including a significant number over the age of 85. This part of the population is projected to continue to relatively increase until 2040. New Zealand’s life expectancy compares well internationally, but independent life expectancy is about 13 years less than life expectancy. According to the 2006 Census of Population and Dwellings, the proportion of the Maori population aged 65 years and over has increased from 3.4 percent in 2001 to 4.1 percent in 2006. The priority placed on this work programme acknowledges the importance of the health needs of this part of the population today and in the future. Figure 3: New Zealand population, by age group, 1940–2100 (projected) View this figure at full size and text description. How will we demonstrate success? Table 4 shows how we will measure the success of the health and disability sector in, and the Ministry’s contribution to, caring for older New Zealanders. Table 4: Success of health and disability sector in, and the Ministry’s contribution to, caring for older New Zealanders Level Indicators/measures Health and disability sector The following health sector target: proportion of people in subsidised aged residential care* percentage of people aged 85 years and over living in private dwellings.+ Ministry of Health The Ministry, in accordance with agreed measures and standards, will: finalise proposed health of older people service cover requirements advise on Health of Older People Strategy developments in the areas of new services in the community, assessment, information collection and workforce. * Recorded in five year age groups, starting from age 65. + This is measured five-yearly as part of the census. How will we demonstrate cost-effectiveness? An objective of the overall programme of work is to contain future cost pressures arising from an increasing ageing population. The Ministry aims to do this through early intervention and introducing programmes that not only improve older people’s quality of life, by allowing them to remain at home longer, but are less costly than residential and hospital care alternatives. Back to top

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