NHB eNewsletter - July 2011
"Better, sooner and more convenient care from a unified and sustainable public health system."
- From the Chair
- From the Director's Desk
- Supporting health professionals to do good clinical work - Dr Jeff Brown
- Clinical Leader Profile: Dr Peter Foley
- Emergency preparation and plans in place for World Cup
- Radiotherapy Health Target met, but improvements continue
- First Air Ambulance to be accredited against new standard
- First World Report on Disability
- Sharing information between Healthline and GPs means more effective consultations
- Increased efficiencies for Primary Health Organisations
- Health Workforce New Zealand Update
- National Health IT Board: Telehealth changing the face of health care
- Regional Service Plans Update
- About this Newsletter
A much stronger regional approach to the planning and delivery of health services by DHBs is essential if we are going to meet increasing demands for health services within a funding track the economy can afford.
Regionalisation was one of the key "missing links" that the Ministerial Review Group (MRG) identified in the public health system.
The MRG found that the delivery of public health and disability services was too fragmented, with too much duplication. In response it recommended changes to make the current DHB model work better and to increase collaboration between DHBs at the regional level.
Legislation has now shifted the focus towards regionalisation and the Minister of Health's Letter of Expectations to DHBs for the 2011/12 year has made it clear that regional collaboration is a priority and an essential part of our future direction to maximise the use of our clinical and financial resources.
Under the Public Health & Disability Amendment Act 2010 DHBs are required to start planning at a regional level - co-operating, sharing resources and jointly planning to develop affordable and clinically sustainable regional health service arrangements. The first of these Regional Service Plans (RSPs) are now being approved.
In his letter the Minister expected to see DHBs develop RSPs which:
- Focus on a small number of high priorities and the most vulnerable services in each region, with implementation plans to quickly place these services on a more secure and sustainable footing;
- Development of shared back office functions across DHBs; and
- Regionalisation of IT platforms, IT support and workforce development.
Heath Benefits Limited is tasked with helping DHBs deliver quality healthcare through the development of shared back office functions across DHBs.
Meanwhile, the National Health Board is looking at both service delivery and capacity (capital, workforce and IT) and supporting DHBs through their regional planning processes.
While we have made a good start, and some regions are more advanced than others, we need to substantially pick up the pace if we are to ensure we drive real benefits through regionalisation.
In the coming weeks I will be writing to DHB Chairs to outline our views of their regions relative progress across four key areas:
- Service planning and implementation;
- Development of regional training hubs;
- Development of regional IT priorities and decision making; and
- Effectiveness of regional capital committees in setting regional investment priorities.
Dr Murray Horn, Chair
I would like to acknowledge District Health Boards (DHBs) for their financial management throughout the year.
The DHB sector has ended the year with a provisional result which is much better than planned.
In addition, early elective surgery information indicates that the sector had delivered more cases than the elective surgery volume target.
It is great to see DHBs collectively managing finances within budgets while increasing their delivery of elective services to New Zealanders.
I would also like to touch on change management and ask DHBs to ensure that they not only focus on the professional and technical side of change management processes but also ensure that they build the confidence of those affected by changes, especially clinicians and the community.
As we begin to think about the 20012/13 year, we will be engaging with DHBs about how we can use annual plans to better capture delivery plans, particularly around workforce, aged care and mental health.
The sector is continuing to support Canterbury following the June earthquake and a very cold July. I would like to thank the health and disability sector in Canterbury for its continued dedication in very trying times and am certain that we will all continue to support them in anyway we can.
Chai Chuah, National Director
National Health Board Member Dr Jeff Brown has been a paediatrician at Palmerston North Hospital for 19 years. He is President of the Association of Salaried Medical Specialists and Chair of Advanced Paediatric Life Support NZ (which delivers education programmes to improve the early management of critically ill and injured children). Here he discusses the importance of a centralised approach to planning and implementing change in order to free up health professionals to spend more time caring for patients.
New Zealand has made some world-leading health advances in past and recent years. Parts of our health system perform highly for a smaller dollar input and a smaller ratio of health professionals compared with many OECD countries. But care has often been fragmented and we still have quite variable rates of access to health services, depending on where you live, or whether you might be lucky enough to have an expert living close to you. We have often had a very localised approach to planning and implementing change.
It has been gratifying to be part of the National Health Board's drive to create national services and national networks where services are vulnerable, either because expertise is spread very thinly, or isn't evenly distributed around the country. These national services will help reduce variations in access to care and will support health professionals, who are often so busy working within the constraints of their own resources they haven't had the chance to share best practice with their colleagues.
The NHB's role is to cut through multiple blockages around the country and enable clinicians to get on and do good clinical work. Initiatives such as centralising purchasing and procurement and shared electronic records will make the daily working life of health professionals so much more productive and will mean they can spend much more time with their patients.
Health cannot be constrained by contracts trying to second guess every eventuality, so there has to be trust, and where there's trust, we also get innovation and quickly scalable innovations. The challenge is that innovation and improvement often comes down to small groups of the same clinicians being asked to spend time away from patients designing better ways to look after patients.
We know that a lot of clinicians feel frazzled and overworked and that, in many cases, their previous efforts and energies and enthusiasm have been stymied. They're weary and wary, and hesitant to step up. Grounded by the babies, children and families I encounter in my daily vocation as a paediatrician, I'm happy to take this opportunity to step up and be part of the reformation of clinical leadership for a better New Zealand public health system.
Dr Jeff Brown, NHB Board Member
Dr Peter Foley has been involved in medical politics for over 30 years, beginning with presidency of the Medical Students' Association when he was at the University of Otago, and moving through to recent respected clinical and political leadership across General Practice.
Dr Foley is the Deputy Chair of the Health Quality & Safety Commission, and recently completed two terms as Chairman of the New Zealand Medical Association. Last year he was appointed Hawke's Bay District Health Board's Chief Medical Officer (CMO) Primary Care. He is a busy Napier GP and a senior medic for the New Zealand Police. Most recently, Dr Foley was asked to lead the Wakatipu Health Services Expert Panel appointed by the National Health Board (NHB) to make a recommendation on the best structure for primary and secondary health services for the Wakatipu area.
A third generation doctor, he says he entered the medical profession despite seeing how hard it was for his parents' and grandparents' generations.
"I realised the only way you can really change things was by getting involved in the political interface.
"I've been a strong campaigner for better integration between hospital and non-hospital health services for years, which is why I've taken on the CMO role in Hawke's Bay, working in partnership with my hospital CMO colleague. It's the first DHB to give this position complete equality with the hospital CMO.
"One of my most important roles is to help the DHB deliver the message that it's not a hospital board, something some DHBs have taken a long time to realise."
Dr Foley says he believes strongly that all DHBs should deliver the same health outcomes, even though that might require different inputs.
"Health solutions aren't just about health spending. They're also about education and other socio economic factors, so it's important for agencies to work together, particularly at the ministerial level, to deliver the right solutions."
He says he can't imagine giving up being a GP. 'I like the interaction with my patients. By taking on these other roles, I'm able to treat the acute illness, and try and make things better for the future as well, especially as we now have encouragement to better integrate hospital and non-hospital services.'
The Wakatipu Expert Panel is holding a series of community and health sector meetings and workshops, and will make its recommendation in early August.
Dr Foley says the panel has much to consider, including whether the uniqueness of Queenstown means there is a justifiable case for treating it differently from other populations of a similar size.
"It is probably one of the largest - and still growing - populations in New Zealand so far from a base hospital. It's also a major tourist destination and a focal point for New Zealand's tourism image, and that needs to be considered.
"The process is very transparent and very fair. People are aware that this is their big chance to help us get it right, as we aim to solve the protracted uncertainty in the community.
"That's meant some people who might be perceived to have diametrically opposed views realising that they can work together. We're getting community support because we're making sure that every possible group gets a chance to talk to us, and I think the Southern DHB has a high level of comfort about the process.
"Everyone understands that the outcome may not be what they want, but it will have been fairly reached and, I would hope, will ensure the community has a safe and high quality health service that is both viable and geared to expand to meet future growth needs."
The National Health Board (NHB) Emergency Management Team was part of a mass casualty emergency simulation to help District Health Boards and emergency services test their preparedness ahead of Rugby World Cup 2011.
Exercise 'Fan Zone' brought together three Auckland DHBs, emergency services and private health services to train together to deal with a mass casualty emergency. The training used the Emergo Train Simulation (ETS) which is designed to test the emergency services and District Health Boards (DHBs) response to a disaster. It also provides learning and networking opportunities for health services in preparation of real emergencies. Exercise 'Fan Zone' also helped to test revised procedures developed after a similar exercise last year.
Director of Emergency Management, Charles Blanch says, "It's an opportunity for them to get into a room and see how they work together, and work with St John and White Cross* from the private sector. This reflects the importance of testing or reviewing emergency procedures ahead of any big event that attracts significant numbers of people.
"The simulation tool lets ambulance providers and receiving hospitals exercise patient treatment and transport based on their actual staffing and resources, without putting real people or patients at risk."
The exercise involved Auckland, Counties Manukau and Waitemata DHBs, and St John, and for the first time White Cross from the private sector. The Auckland Council Major Events Operation Centre also met and discussed their response as the simulation unfolded. On the DHB teams were clinical representatives from Intensive Care Units (ICUs), Emergency Departments (ED) and DHB emergency management teams.
Lucy Adams, St John Emergency Planning Advisor and ETS Project Manger, says "Recent events have shown how important it is to be prepared for an emergency response to mass casualties. This exercise using the ETS is about educating people to be familiar with their own and others' emergency systems when the unexpected happens.
"Our aim is to have the right people in the right place at the right time making the right decisions. The ETS has been used nationally to test DHBs' emergency plans. After the exercise the DHBs are able to go back and analyse their response to identify any further training needs and any gaps in communication between agencies."
Twenty-four exercises have now been run in New Zealand and the lessons learned helped enhance readiness with West Coast DHB prior to the response to the Pike River Mine Disaster. It was also an essential element to Canterbury DHB's response to the Canterbury Earthquake - Canterbury DHB had undertaken the ETS exercise twice before the February Earthquake.
* White Cross is a primary care service provider in the private sector.
The Auckland DHB's Oncology Service's response to the Shorter waits for cancer treatment Health Target to reduce radiotherapy waiting times has been a catalyst for a process of continuous improvement in the delivery of treatment.
Oncologist, Dr Andrew Macann, says staff took up the 'Project 28 days' challenge, and at one stage there were about 20 sub projects underway to streamline processes and increase productivity to make sure the Service was in a good position to be compliant.
"One of the main projects was reconfiguring how we undertook the whole radiotherapy treatment planning process," says Dr Macann. "It's quite a complicated process involving input from clinicians, radiation therapists and physicists, and used to take about 15 working days or longer for patients to get their treatment plans, so we knew that was going to be an issue."
The Service redesigned how planning was structured, and developed the concept of clinicians, radiation therapists and physicists working in 'tumour stream' teams.
"It was a major reconfiguration of the whole department and helped a lot with preventing the planning process from being too much of a bottleneck. As a result, we were able to reduce the planning time to a maximum of around eight working days, and for some patients it's more like two or three days."
He says the tumour stream model will continue to be developed. "We've already seen the benefits that result from the interactions between clinicians, therapists and physicists, but we still feel there's quite a lot of work ahead to achieve a more comprehensive tumour stream model."
Dr Macann also says the Service didn't have a good way of modelling the future capacity on the linear accelerator (Linac) treatment machines.
"It's difficult to model because some patients only have a single fraction of radiotherapy in their course of treatment, some might have five fractions and some might have 35 or more treatments over seven weeks.
"So quite a lot of work went into developing a model that can project the capacity of the linear accelerators based on the work coming through the door in real time, and it shows us if we're going to struggle to meet the four week target."
He says two or three years ago when the Service's waiting lists weren't under control, patients could be sent as far as Australia for treatment.
"But we've been meeting the Target now for well over a year. To meet occasional peaks in demand, we outsource the service for some patients to the private sector, but no one is travelling outside Auckland anymore."
The Service is also moving towards a full electronic record of treatment requests and wait-list management.
"We're hoping to have that completed within the next six months, and that will streamline the whole process further and make it even more efficient. It's about continuous improvement. There are always more things we can do."
Dr Macann says everyone is happy the Service is meeting the Target.
"Historically we had really long waiting lists and it was just demoralising for everyone. It's great to be able to treat people in a timely manner because it gives patients and their families confidence in the public health system. That's a very powerful message."
Hawkes Bay Rescue Helicopter Trust is the first Air Ambulance service in the country to achieve the new standard for 'front of aircraft' - NZ Air Ambulance/Air Rescue Service 2011.
The goal of this new standard is to ensure that the service provided by air ambulance/air rescue services in New Zealand promotes safety, consistency and is patient focused. It was developed jointly by Ambulance New Zealand and the Aviation Industry Association (AIA), and came into operation on 01 July.
The new standard has been developed by a working group including chief pilots, Ministry of Defence, Civil Aviation Authority, ambulance sector representatives and National Ambulance Sector Office (NASO) (a joint ACC/Ministry of Health group based in the National Health Board).
The new standard aims to get greater alignment with existing ambulance standards and ensure services are provided to meet the needs of the patient in a way that reflects current international best practice. It will also define quality parameters around pilot performance, skills and equipment and ensure consistent standards and service collaboration.
Joy Cooper, Group Manager NASO, says that the new accreditation will raise the safety bar for air rescue/air ambulance services throughout New Zealand.
The new standards will eventually replace the current ones developed in 2003, and are designed to complement the existing Ambulance and Paramedical Service standard that covers the 'back of aircraft'. ('Front of aircraft' standards cover the people operating the actual aircraft, while 'back of aircraft' standards cover clinical flying staff).
Along with achieving accreditation in the new standard, Hawkes Bay Rescue Helicopter Trust has also achieved the Ambulance and Paramedical Service standard and ISO 9001, making it the first air ambulance provider in the country to do so.
"The people of Hawke's Bay can be assured that they have a local Air Ambulance service that meets the highest standards", says Joy.
Being audited under the new standard is currently voluntary. Air Ambulance providers can choose whether to be audited under the existing or new standards while the transition between the two occurs.
The first ever World Report on Disability, produced jointly by the World Health Organisation (WHO) and the World Bank, suggests that more than a billion people in the world today experience disability. The report gives an extensive picture of the lives of people with disabilities, their needs and unmet needs, and the barriers they face to participating fully in their societies.
The Report was compiled from data from over 74 countries including New Zealand and found that:
- Disability prevalence is high and growing. There are over one billion people with disabilities in the world. This corresponds to about 15 percent of the world's population and is higher than previous WHO estimates
- Disability disproportionately affects vulnerable populations
- People with disabilities are a diverse group
- People with disabilities face widespread barriers in accessing services (health, education, employment, transport as well as information)
- People with disabilities have worse health and socioeconomic outcomes.
Kylie Clode, Acting Group Manager Populations Policy, contributed to the development of the Report. "New Zealand has been internationally recognised for our New Zealand Disability Strategy. We also were one of the first countries to sign the UN Declaration on the Rights of People with Disabilities. It was therefore really important that we participated in this World Report and that our information was included."
The Report provides the best available evidence about what works to overcome barriers to health care, rehabilitation, education, employment and support services, and to create the environments which will enable people with disabilities to flourish. The main recommendations are:
- Enable access to all mainstream policies, systems and services.
- Invest in programmes and services for people with disabilities.
- Adopt a national disability strategy and plan of action.
- Involve people with disabilities in formulating and implementing policies, laws and services.
- Improve human resource capacity through the attitude and knowledge of people working in areas such as health care and education.
- Provide adequate funding of public services and improve affordability.
- Increase public awareness and understanding about disability.
- Improve the availability and quality of data on disability.
- Strengthen and support research on disability.
Anne O'Connell, Group Manager Disability Support Services, National Health Board, says, "Many of these recommendations are not new to us. People with disabilities and their families have identified a number of these issues and over the last few years we have been working towards addressing them. A number of initiatives are already underway and it will be valuable for us to see how we can incorporate the best practice from the Report into our work practices
New Zealand's free telephone health advice service - Healthline - just got better with the introduction of a system which ensures callers can share important information with their General Practitioner (GP).
Healthline, a Ministry of Health service, is funded by the National Health Board and delivered by a contracted provider, Medibank Health Solutions. It is a free service available 24 hours a day, nationwide. Registered nurses answer each phone call, assess the caller's health needs and provide advice and information on what the caller should do next.
The service answers more than a thousand calls a day, nearly 80 percent of which involve adults and children who are feeling unwell and need advice on what they should do next, and in what timeframe.
Each day around one-quarter of all callers need to see their GP within 24 hours or less.
Anna Redican, Acting Group Manager Public Health, says the latest enhancement to the Healthline service will see those recommendations shared with GPs - enabling the GP to incorporate that information or incident into the patient's file, and to give the patient priority if they seek an appointment.
"GPs around the country are now being sent these summary reports which record when the patient called Healthline, what their symptoms and level of discomfort were, and noting that Healthline recommended the patient see their GP quickly", says Anna.
Patient consent is sought before information is shared and patients can opt out if for any reason they do not want their GP to know this information. The reports are transmitted electronically via a secure and encrypted service directly to the GP.
Waitakere doctor Jann Singer is one of many GPs who have welcomed the additional information. "These patients often turn up for consultations the next day and these summary reports help with those consultations," she says.
"What I really like is that it's a very concise report, which lets us see exactly what the patient told Healthline.
"I'm really pleased we're now getting these reports. Anything that allows us to use our consultation time more effectively is a welcome move," Dr Singer says.
This extra service has been rolled out nationally by the service provider at no additional cost to the National Health Board.
Primary Health Organisations (PHOs) are funded by District Health Boards (DHBs) to support the provision of essential primary health care services through general practices. The aim of PHOs is to ensure GP services are better linked with other primary health services (such as allied health services) to ensure a seamless continuum of care (in particular, to better manage long term conditions).
In 2009 (in line with Better, Sooner, More Convenient Health Care) DHBs and PHOs were asked to look at opportunities for consolidating PHOs in their region.
Consolidating PHOs can have a number of benefits says Justine Thorpe, CEO of Well Health Trust.
"Amalgamation means that PHOs increasing in size and therefore capability, can take on new responsibilities and make appropriate strategic investments. It also provides opportunities for achieving efficiencies through infrastructure, IT systems and administration. However, the challenge moving forward is to ensure that the sector continues to maintain the flexibility to respond to unique local needs that many of the previous smaller PHOs were able to do - in particular in areas where there are clusters of high needs populations."
From a starting point of 82 PHOs around the country, this had decreased to 78 by April 2010, to 44 by April 2011 and has reduced further to 32 from July 2011 (although this does not include South Canterbury DHB's Primary and Community Services Unit). As of May 2010, South Canterbury DHB took over the functions of the region's PHO through its Primary and Community Services Unit.
ProCare Health Limited is now the largest PHO in the country, with an enrolled population of about 850,000. "With the combined expertise and shared infrastructure, efficiencies can be made and redirected into frontline patient care," says Ron Hooton, CEO of ProCare Health Limited.
There has also been an increase in the number of 'cross-boundary' PHOs which receive funding from different DHBs. Five PHOs now have general practice membership sourced from up to five different DHB regions.
According to Ron "All of this means that PHOs are starting to enjoy the benefits of economies of scale and the flow on effects for patients are the services they need, when and where they need them."
GP Training Review
Consultation on the paper 'Workforce Requirements for New Models of Service Delivery: Proposed Changes to the General Practice Education Programme' has now closed.
Thoughtful and constructive comment was received from a number of organisations, vocationally registered GPs (including GP educators), doctors considering entering GPEP, current GPEP registrars and doctors from other vocational scopes.
There has been general support for the concept of advanced competency modules and the vision of an expanded role for primary care in the future. A number of respondents raised questions and made suggestions about the nature and duration of hospital-based experience.
The feedback has been analysed and is being presented to HWNZ, the Royal New Zealand College of General Practitioners and the Medical Council of New Zealand for decision making and development of an implementation plan during July and August.
A summary report of the feedback will be issued on the discussion paper website http://gpepproposals.hiirc.org.nz/ in the next few weeks.
We have developed a prioritisation criteria for determining HWNZ's investment in post-graduate training for 2011/12 onwards, to ensure that our investment is targeted at those training programmes and health workforce areas that will deliver the best outcomes in terms of a fit-for-purpose health sector workforce.
The HWNZ prioritisation criteria and a draft funding formula for medical trainees was sent to sector stakeholders in June for initial discussion and feedback, and we received a number of submissions on this. As a result of this feedback we are now meeting with a small group from the sector to further refine the funding formula.
The final draft of the prioritisation criteria and funding formula will then be provided to stakeholders for wider consultation in September and will be implemented from October.
Regional Training Hubs
The Northern and Midlands regional training hubs are operational and the Central hub is about to commence.
The South Island hub is progressing well and we expect this to be operational by the end of year. The hubs will report through the National Health Board reporting framework with HWNZ providing a strategic direction and maintaining a monitoring and oversight role.
Telehealth is the collective term for the use of information and communication technologies to deliver health care in situations where patients and care providers are separated by distance. It is bringing health care 'closer to home', enabling remote diagnosis, treatment and prevention of disease and injuries, as well as health care-related education, research and evaluation.
Telehealth has the potential to reduce demand for high-cost services and facilitate the delivery of Better, Sooner, More Convenient Health Care. Its delivery is underpinned by better, faster broadband services.
The New Zealand Telehealth Forum has been established to promote the use of telehealth, and maximise the benefits of the Government's broadband programme. The National Health IT Board has funded the establishment of the forum because it recognises telehealth is an important component of an integrated model of healthcare.
Sadhana Maraj, forum member, and the Health IT Board's Manager of Health IT Engagement, says telehealth is especially useful in areas that experience greater workforce shortages and limited exposure to speciality services.
"Telehealth will also have a positive impact on how we manage health going forward - such as helping improve equity of access to services."
Dr Michael Sullivan, Paediatric Oncologist and Telehealth Clinical Leader for Canterbury and West Coast DHBs, says increased specialisation in health care delivery makes it increasingly difficult for rural and smaller regional centres to meet the health care needs of their population alone.
"To address these issues, new collaborative models of care will need to be developed based on regional and national clinical networks. The networks should provide access to continuing medical and nursing education, clinical supervision and professional development programmes.
"We see telehealth as the enabling technology to support health care delivery across geographic regions and ensure the success of clinical network-based care."
Several initiatives are underway using telehealth. In Northland, it enables renal specialists at Whangarei Hospital to better manage the care of renal patients who live rurally, via videoconference, and also to talk directly to renal specialists at Auckland City Hospital. This ensures patients get the best possible treatment, and saves them a trip to Whangarei or Auckland.
"Before the use of videoconferencing with Auckland, we mainly relied on email and written correspondence with the hospital's vascular and radiology teams," says Northland DHB Nephrologist Dr Walaa Saweirs.
"The videoconferencing lets us have 'real time' discussions with the teams at Auckland City Hospital - meaning there is far less risk of information being lost in translation."
"We can jointly plan the best care for the patient and clarify any clinical issues. And patients no longer have to face hours of travelling just to talk to a specialist."
Videoconferencing also enables doctors at Whangarei Hospital to regularly communicate with Northland's two dialysis 'satellite' units at Kaitaia and Kawakawa.
The Northern, Midland and Central regions 2011/12 Regional Service Plans (RSPs) have been signed off by the Minister of Health. The South Island RSP has been delayed due to the ongoing aftershocks, but it is expected to be with the Minister soon. The National Health Board (NHB) is working closely with the South Island region to finalise their RSP.
The NHB's Acting Director, Planning and Analysis Michael Johnson, says "I am very pleased that the Minister of Health has now signed off three of the four RSPs. The next steps are for the District Health Board (DHB) regions to make measured progress against their agreed priority areas over the next financial year."
The NHB will meet regularly with each regional governance body to monitor progress against their agreed actions. Importantly, the meetings also provide an opportunity to discuss specific regional issues and next steps. The first of these regional meetings with the four DHB regions will commence in early August.
"Over the last year we sought to work collaboratively with the DHB regions in order to progress the regional service planning agenda. It has been a transition year in respect to service planning, accountability arrangements and planning documentation as the sector moves to greater collaboration, and new ways of thinking about how we coordinate the delivery of health services," Michael says.
As well as focussing on delivery of 2011/12 actions, the NHB is giving early thought to 2012/13 RSPs and the next steps for enhanced regional collaborative activity. The NHB shall be engaging and working closely with the health and disability sector over coming months on the 2012/13 RSP requirements.
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