"Better, sooner and more convenient care from a unified and sustainable public health system."

• From the Chair
• From the Director's Desk
• From the Director-General of Health
• Management of patients with complex health needs
• Success Story: A new approach at Timaru Emergency Department
• Success Story: Releasing time to care
• Regional Planning Update
• Health Workforce Update
• IT Health Board Update
• About this Newsletter

From the Chair

Progress is being made in the integration of primary and secondary care in many parts of the country and in order to accelerate improvements in patient care and deliver sustainable cost growth this integration needs more pace and momentum.

The National Health Board is now responsible for overseeing the Ministry of Health's work in implementing the Government's primary care policy. The aim is to encourage a more patient-centred health system with care better integrated across existing institutional and professional boundaries.

We will focus on ensuring hospital and non-hospital based services work together more seamlessly.

We are looking to District Health Boards (DHBs) to make much more active use of services provided outside the hospital to improve quality, contain cost and move care closer to home: to help people to keep themselves well, reduce avoidable hospital admissions (and re-admissions) and reduce unnecessary prescriptions, tests and referrals.

The whole system has to work together to deliver better integrated patient-centric care. Managers and clinicians should be encouraged to be proactive and to work together with a real sense of urgency and common purpose.

In his recent letter of expectations to Board Chairs, the Minister of Health talked about the growing range of services provided outside the hospital and noted that work is well underway on establishing the first phase of Integrated Family Health Centres (IFHC), Community Health Hubs and Whanau Ora Centres.

The Minister expects DHBs to re-focus resources towards delivering frontline services in local community settings where it makes clinical and financial sense to do so. This work needs to include:

• Consolidating Primary Health Organisations (PHOs)
• Establishing efficient and effective IFHCs
• A growing range of services provided closer to home
• Front line teams within primary care improving quality and productivity

A number of important initiatives are planned by the Ministry for the 2011/12 year including "Kickstart", an initiative that provides one-off funding to support the development of IFHCs.  "Kickstart" is a promising step towards integrating services that New Zealanders will look for in a healthcare system centred on their needs.

The National Health Board is keen to ensure that the approved nine Better Sooner More Convenient (BSMC) business cases (covering 60% of New Zealanders) make substantive and timely progress.

These initiatives range from comprehensive Whanau Ora assessments, Mama and Pepi / Tamariki initiatives within the National Maori PHO coalition, to acute demand initiatives led out of the metro-Auckland Greater Auckland Integrated Health Network (GAIHN) business case. 

The progress made by each business case will be highlighted on the NHB website to enable colleagues to learn from these experiences.

We will work with DHBs and PHOs not already involved in business case development and implementation to ensure that the conditions are right to expand coverage of the BSMC environment to the remaining 40% of New Zealanders.

These DHBs and PHOs must demonstrate the same conditions currently developing inside the BSMC business cases, which includes:

• primary and secondary clinical leadership at alliance decision making forums to jointly prioritise funding and service developments that best meet population health needs;
• investment in primary and community based capacity (facility, workforce, information systems) through IFHC developments;
• shifting of services where it makes sense to increase access for enrolled populations and their families; and
• real investment in the clinical pathways processes that support integrated care for patients.

In the meantime, we are also focusing on building on existing work in primary care including:

• Health Workforce NZ's joint project with the New Zealand College of General Practitioners to review the way GPs in training can develop better understanding of future models of care;
• The National Health IT Board's primary care based information system developments that facilitate integrated care: e.g. GP2GP, expansion of e-referral initiatives and e-prescribing.

We expect primary and community based service developments to be as core to how DHBs plan, fund and work with their communities as hospital services are. And we will work to ensure that these initiatives provide a collective platform to progress the integration of services that New Zealanders will look for in a modern and responsive patient-centric health system.

If you would like to comment on ways in which hospital and non-hospital services can be better integrated please visit our Facebook page and feel free to leave a message.

Dr Murray Horn, Chair

The National Health Board is now responsible for oversight of the Ministry of Health's work in implementing primary health care policy and integrating that into its existing roles. The Ministry will continue to develop primary health care policy and the Deputy Director-General, Sector Capability and Implementation (Margie Apa) continues to lead  primary health care programme and will work closely with NHB Business Unit National Director (Chai Chuah) to support PHOs and DHBs collectively.

From the Director's Desk

During the Christmas New Year break I had the opportunity to reflect on the progress the health and disability sector has made throughout the year and on the challenges of the year ahead.

Excellent progress has been made on a number of fronts including the number of elective surgical discharges and emergency department shorter stays. We are starting to see a sustained improvement in clinical and financial performance and a greater emphasis on moving resources from the back office to the front line.

The Minister of Health's Letter of Expectations was sent to DHB Chairs in January highlighting five key areas of focus for DHBs:

• Improving service and reducing waiting times
• Clinical leadership
• Services closer to home
• Health of older people
• Regional collaboration

The next few months will also see DHBs submitting their inaugural Regional Service Plans.

We look forward to working with DHBs to deliver plans that while having a strategic component, heavily focus on actions to advance selected clinical services on a regional basis.

The early advice to DHBs in November 2010 on the next financial year's funding package was to provide a longer timeframe for DHBs to complete their 2011/12 budget.

Half way through the current year, the DHB sector as a whole is doing well in managing its financial results. For the 2011/12 year DHBs will need to continue to find efficiency and productivity gains to maintain their positive track record.

We have increased our communication efforts with the sector over recent months and we intend to continue to enhance our relationships with the sector and to work with you and be responsive to your needs.

I look forward to the challenges ahead and to working with you all throughout the year.

Chai Chuah, National Director

From the Director-General of Health

Kevin Woods took up the role as Director-General of Health earlier this year.

In the last month I've had the pleasure of visiting both the Hutt Valley and Canterbury District Health Boards which has reinforced for me the obvious passion and commitment people have to a strong public health and disability system.

The visits are my first to DHBs since arriving and I hope to spend as much time as my schedule allows in the sector engaging with clinicians, medical staff, health workers and administrators.

One of my other priorities is getting to meet as many people as possible to help me understand the detail of how the sector works and to better understand the finer points and interrelationships.

I know there will be questions about my view of the wider system, the role of the Ministry and any specific plans I may have.

It's a little too soon for me to be definitive, but what I can say is that the challenges we face are common to all health jurisdictions.  At the same time, New Zealand has an enviable reputation and record of performance internationally that would not be possible without dedicated and committed health professionals across all roles in the sector.

Sustainability in financial management and the health and disability workforce are critical areas for our health system - they were Government priorities for 2010 and remain so this year. 

The role of the Ministry is to deliver these priorities which will be our organisational focus for the year ahead.

 Kevin Woods, Director-General of Health

Management of patients with complex health needs

National Health Board member Dr Margaret Wilsher is the Chief Medical Officer for Auckland District Health Board, and a practicing respiratory physician with a special interest in interstitial lung disease. Here she discusses the management of patients with complex health needs.

I am privileged to work in a large teaching hospital with access to diagnostic expertise which supports the management of patients with rare lung disorders. However such expertise is not readily available to many of my specialist colleagues working in smaller hospitals in New Zealand. This situation is really no different for doctors working in the community health care setting where timely access to diagnostics or specialist opinion can be difficult. Thus, I have a particular interest in reorganisation of the care pathway for patients with complex health needs or rare disorders.

There are many examples of health delivery models that are designed for local health systems, putting the patient and family at the centre of the care pathway, and enabling clinicians to access specialist, diagnostic or allied health support.

In New Zealand patients with cystic fibrosis have been managed by a partnership of local hospital and multidisciplinary specialist centre for years, with proven benefit in terms of patient survival. Similarly in Canada (in the Greater Toronto area) patients with lung cancer are managed in an integrated regional and community services model, supported by a non-hierarchical clinical network.

Clinical networks can draw together a multi-disciplinary team of community and hospital clinicians which can enable the delivery of patient-centred, individualised care packages allowing access to a range of services from diagnostic to treatment in a variety of care settings. Telemedicine is a great enabler of such services, allowing virtual outpatient appointments with the specialist able to view clinical information online using email, telephone or video conferencing for communication. Patients do not always need to travel - instead their locally obtained images and physiologic measurements can, via the internet!

New Zealand is a small country and needs to make best use of expensive diagnostic modalities and scarce clinical expertise in areas of complex disease management. Clinical networks and telemedicine allow greater sharing of that clinical support, and importantly, allow local clinicians to manage their patients without the patient having to travel to another facility or even area. If we are to improve access to healthcare services and reduce health status disparities, clinicians need to work collaboratively, utilising networks and modern communication technology to enable better, sooner  and more convenient care.

Dr Margaret Wilsher, NHB Board Member 

The NHB eNewsletter now includes success stories showcasing the improvements being made by the sector at the coalface.  

Success story: A new approach at Timaru Emergency Department

While some hospital emergency departments reported being overloaded during the Christmas holiday period, Timaru Hospital's emergency department was meeting its targets and living within its budget thanks to a closer working relationship between the South Canterbury District Health Board (SCDHB) and local GPs.

In late 2009, SCDHB and GPs worked in partnership to address a number of issues around access to health care, including appropriate use of the emergency department, the importance of patients maintaining a direct relationship with their GP, and management of overnight GP care.

General Manager Secondary Services, Christine Nolan, says the emergency department was in and out of crisis almost weekly because there were too many patients for the number of nursing staff. GPs in Timaru were also looking for a sustainable way to provide overnight after-hours care.

In a Memorandum of Understanding, urban GPs agreed to treat patients redirected to them who presented to the emergency department but were assessed as not needing emergency care. The DHB and GPs also agreed to introduce a 24-hour telephone service staffed by registered nurses to help people connect with their own GP, or the duty GP. Local GPs can divert their phones to this service after hours.

All patients arriving at the emergency department are seen first by the triage nurse who uses clinical guidelines to assess the urgency of their condition. Those who are assessed as not needing emergency treatment are redirected to their GP, or the duty GP.

The result has been a 25 percent reduction in the number of patients treated in the emergency department over the last year. The department now sees around 45 patients a day instead of 60 plus which, Christine says, is a "comfortable number".

"Nursing staff file a report if they feel the department is under resourced and I used to get reports almost every day. However since November 2009 I've only had two and the reduction in stress levels in the department has been amazing. It's made a huge difference."

There have also been savings in overtime payments, the level of sick leave has dropped considerably and the department is now living within its budget.

Christine says the new policy represented "quite a cultural shift" for the people of Timaru.

"Many people saw the emergency department as the place to go to get any medical attention. In fact, research showed that South Canterbury people were more likely to use the hospital's emergency department for minor health problems than people anywhere else in New Zealand."

She says good communication was key to the success of the policy change, which has been well accepted.

''One of our key messages was 'Your GP knows you best' and that seems to be the one that has really hit home with people.

"We started out redirecting about 90 patients a month and now we're averaging about 60, so the message has definitely got through."

The change has also given the department the time to better manage its large number of 'over utilisers'.

"Every emergency department in the country knows who their top 50 patients are; the ones who will phone for an ambulance or front up on a regular basis. We knew we had to manage this group of people better because they were taking up a considerable amount of time and weren't making improvements in their overall health and wellbeing between visits to the emergency department and their GPs.

"Now when a patient presents to us over a certain number of times in a three-month period, we send their GP a letter advising them of that, along with what the patient presented for."

She says some GPs have been surprised at how often some of their patients are going to the emergency department.

"GPs have found that report really valuable because they've got a better picture of what's happening with their patients."

When high users continue to present at the department for non-emergencies, the GP meets with the department's staff to draw up a treatment plan for the patient.

"Patients get a copy too, so we're all working from the same page. They know that if they continue to go to the department for non-emergencies they will be referred back to their GP."

She says most people in Timaru are enrolled with a GP, but those who aren't are given assistance to enrol.

"I believe emergency department patients are now getting a better standard of care. They're better observed and they're getting the nursing and medical input they need - care we were sometimes struggling to provide before."

Success story: Releasing time to care

 By Katherine Rock, Communications Advisor, Nelson Marlborough DHB

How often have you wished there were more hours in a day?  A recent study by Nelson Theatre and Day Stay Unit (DSU) staff has uncovered a way of returning an additional 17.5 days per year of nursing time without reducing the level of patient care.

It might not sound much, but according to Service Improvement Facilitator Peter Twamley it's a significant reduction of waste in the system. Peter says during a recent 'process mapping' session, staff from the DSU and theatre highlighted an issue involving the handover of DSU patients to orderlies.

"When an orderly collected a patient, they had to find the nurse associated with that patient, which meant interrupting the nurse, just to hand a patient over to be taken to theatre," explains Peter.

"The staff have set up a better process so when a patient is signed off as ready to go, the orderly doesn't need to waste time tracking a nurse down - they follow a checklist and take the patient - this change also releases 17.5 days of orderly time per year." 

Win/Win For All

Charge Nurse Manager Lynne Mercer says although some patients still require a nurse handover, the system is working well and involves a more streamlined process for the patients to theatre.

"It's a good example of how challenging the status quo can effect positive changes," Lynne says. "In this case it's a win-win situation for the nurses, patients and the orderlies."

Theatre Orderlies Give New Process The Big Tick

The change in handover procedure has also meant greater responsibility for the theatre orderlies.  Feedback from orderlies has been positive. Comments included: "It's a great idea." "It helps get patients to theatre on time, therefore theatre staff can get through their lists on time." "It saves a lot of time and frustration looking for a nurse - and anything that removes frustration from your work has got to be a good thing." "It's great recognition that we are capable of the role and the responsibility." 

Regional Planning Update

Work on the Regional Service Plans (RSPs) continues with progress well on-track to meet expected deadlines.  DHBs are now working through the second phase of the planning process with their initial draft plans undergoing further development over the next few months. 

Acting Director of Planning and Analysis, NHB, Michael Johnson, says all of the DHB regions have now been provided with verbal and written feedback on their draft plans for 2011/12.  "We wanted them to focus on three to five high priority areas where they can take tangible actions to address clinical and financial sustainability or equity of access," he said.  "At the crux of this process is our desire that RSPs address these issues and produce hard actions that will make a difference."

"We also want to ensure that clinical leaders and clinical groups are supportive of these actions, and have buy-in to the process right from the outset."

"It is important that RSPs are aligned with DHB Annual Plans," continued Johnson.  "We also need to ensure that RSPs are aligned with regional IT plans and that any workforce implications are addressed.  The RSPs need to come together as integrated documents for each region.   It is about consistency and ensuring that we don't duplicate things."

"Finally we asked that each region provide details on their regional governance and decision making arrangements including how they would resolve any differences that may arise as they collaboratively work together."

"In terms of next steps, DHBs (as regions) are all really busy pulling together the next iteration of their RSPs, based on the recent feedback provided, and building on the work that they have done already."

"The process to-date has allowed us to provide specific detail for each region in terms of where they have reached with development of their RSP. The NHB is working closely with each region to provide help and support where possible."

"We have asked for RSPs to be submitted by late March/early April.  Between now and then DHBs (as regions) will provide us with updates on their progress so we can support them and provide feedback as they move forward."

"Over the course of 2011 we will look to meet with DHBs, as regions, on a quarterly basis to discuss their Plans and to support DHBs with any issues that they may be having.  We see this as being a really useful forum to work through the process together."

"It is also worth noting that, whilst we are working on 2011-12 Plans, we are also doing some very early thinking about 2012-13 RSPs and will be working closely with DHBs on what this will look like."

"I would like to acknowledge the considerable work completed to-date by DHBs.  We are making good progress and are well on track to meet timelines and expectations.  We recognise that this process is challenging, and the timelines are extremely tight, particularly as DHBs are developing their Annual Plans at the same time."

Health Workforce Update

2011 will undoubtedly be a very busy year for Health Workforce New Zealand (HWNZ).

We look to consolidate the work commenced in key areas including, the outputs of the workforce service reviews, consulting on the outcome of the GP training review and the first programmes emerging from the Institute of Health Leadership.

A more strategic and integrated approach to career planning will be a major focus, as will the development of and support for the regional training hubs.

We also expect to move to a new level in our overall approach to workforce planning and development; crucially that means ensuring we have better information to make informed decisions and that we are training for the needs of the sector, which will contribute to genuine alignment between service delivery and workforce.

Our March Board meeting will focus on the priorities and strategic direction for the 2011/2012 business year.

We look forward to working closely with you throughout year and hearing your views.

Brenda Wraight, Director, Health Workforce New Zealand

IT Health Board Update

The IT Health Board brought a new approach to the investment in health IT solutions in 2010 based on a 'whole of sector' viewpoint.

Key aspects of the approach included greater clinical leadership in IT investment decisions, clear priorities for national and regional solutions (that have already shown proven benefits), and strengthened relationships with health IT vendors. The Board described this new approach in the National Health IT Plan, released in September 2010. The Plan has gained strong support from clinicians, executives and health organisations throughout the sector and will be the basis for engagement and accelerated progress in 2011 and beyond.

Over the past year a considerable amount of time has been invested in establishing governance and laying the groundwork to ensure we achieve phase one of the Plan: increasing health care organisations' use of health IT solutions to a consistent level of capability. This includes laying foundations for a consistent regional and national infrastructure and consolidating many systems into common platforms.

Late last year we reached an important milestone with all DHBs agreeing to use a single clinical work station solution in all hospitals. This will result in a common way for clinicians to access patient information, improvements in productivity and patient safety, and a simpler, more cost-effective IT environment.

Phase two of the Plan - the design and development of a shared care record - is now underway with trials for maternity and long-term conditions being run by sector governance groups in partnership with the IT Health Board.

A shared care record is a tool to help share and coordinate information and care between healthcare practitioners from primary, secondary and community settings, and also with the patients themselves, authorised family members and other support people, enabling a collaborative, multidisciplinary style of care.

The trials aim to demonstrate that seamless care delivery for long-term and maternity patients improves quality of care, removes duplication and reduces costs. I will keep you updated as the trials report progress throughout the year.

As part of the NHB, the IT Health Board will continue to coordinate with Health Workforce New Zealand, the Capital Investment Committee, as well as with DHBs, primary care and the wider Ministry of Health to support their requirements for information and ensure a strategic approach to health IT investments.

With the development of the Plan, the IT Health Board has become the 'go to resource' for progressing sector projects and advising on IT investments, which meant a busy end to last year and an even busier start to this one. Our focus this year will be on maintaining the momentum created by the response to the Plan, and continuing to share examples of good practice across the country. For regular updates on our progress, please visit our website www.ithealthboard.health.nz.

Graeme Osborne, Director, National Health IT Board

About this Newsletter

This newsletter is published by the National Health Board. To join or unsubscribe from the mailing list please email enquiries@nationalhealthboard.govt.nz

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