NHB eNewsletter - May 2011
"Better, sooner and more convenient care from a unified and sustainable public health system."
- From the Chair
- From the Director's Desk
- Improving integration between enhanced primary care and hospital sectors
- DHB Success Story: Waikato cardiac service blitzes annual target
- The NHB and Primary Care
- Pleasing uptake of flu jabs this year
- Patients' experience a focus of NZ Health Survey
- Figures continue to increase for BreastScreen Aotearoa
- Disability: 100% accessible society for all New Zealanders
- Regional Service Plans update
- DHB Annual Plan update
- interRAI extension will support continuum of care - Dr Brigette Meehan
- IT Health Board: Electronic Prescription Service trial
- Health Workforce New Zealand: GP Training Programme
- About this Newsletter
Each year the Minister of Health highlights a new priority area in his letter of expectations to DHBs. He started with hospital care, then primary care and this coming year the focus is on aged care.
We are enlisting the help of the representatives of consumers and carers who want to make it easier for the elderly to keep themselves healthier for longer; to choose to be cared for at home; and to be confident that they will have access to affordable, quality residential care if that becomes necessary.
This should also help us to ease the pressure that the demands of an aging population would otherwise place on our public hospitals.
Providing better, sooner and more convenient health care for the elderly will require action on three fronts:
- Improving older people's underlying health and wellbeing - particularly in the areas of mental health, dementia and preventing disease and injury.
- Improving the quality of care by improving the ability to identify individual need and for the elderly and their families to choose those providers best placed to help meet that need. Regulating provider quality and enforcing quality standards have a place but will only ever ensure compliance with minimum standards, even when done well. Better informed consumer choice creates an incentive on providers to distinguish themselves on the quality of care and support they provide.
- Strengthening the workforce by developing workforce skills, better matching those skills with the type of care required and improving the opportunities for career and professional development will be needed to meet increased demands for higher quality care within available resources. Increasing workforce productivity is the only way to create a higher skilled - and higher paid - workforce without creating unsustainable cost pressures.
In his letter of expectations, the Minister asked DHBs to focus on a number of areas that will help us advance on all three fronts, including building better systems, providing new and expanded services, supporting families (respite care, day programmes and social support), and engaging in the next steps of the 2010 aged residential care review.
At the national level, work is underway on a number of complementary initiatives: encouraging better integration of care across care settings; strengthening training (including in aged care facilities); encouraging adoption of Comprehensive Clinical Assessments (via interRAI) in residential care and for older people living in the community; and improving the consistency of home care services across DHBs.
This work is vital to help us meet increased demands for affordable, high quality care with the public funding likely to be available.
I am certain that this focus on aged care will increase confidence in the quality of the services provided to older people as well as helping to create a more robust platform for meeting the future health needs of an aging population.
Dr Murray Horn, Chair
A great deal of work is required to support the health and disability sector to continue to deliver high quality services to the people of Canterbury following the Canterbury Earthquake.
The Capital Investment Committee's (CIC)first priority following the earthquake is to work alongside the Canterbury District Health Board (CDHB) to ensure adequate facilities are available to meet their short term needs.
There is immediate work which needs to get underway while the larger process around the DHB's capital project is carried out.
As part of this, the CIC commissioned an independent review of the Christchurch Hospital Riverside Block to help assess its safety.
Members of the Committee have also met with members of the CDHB Board and management this week to look at the DHB's capital project in light of the earthquake, and map out a timeline for its consideration. The CIC and CDHB have set up a joint working party to progress assessment of Canterbury's proposal in a timely way.
I am certain that during this time the sector will continue to support the CDHB in any way that it can. In the meantime, we will continue to keep you up to date as we help work through the many issues facing Canterbury.
Chai Chuah, National Director
National Health Board Member Dr Tom Marshall has been a general practitioner in Auckland since 1966 and is a Fellow of the New Zealand Medical Association, the Royal New Zealand College of General Practitioners and the Institute of Directors (NZ). Here he discusses the importance of strong links between primary and secondary health care and using advances in information technology (IT) to improve communication between the two.
The best health outcomes occur when there is a robust primary health care sector with strong links between patients and general practice, and where doctors, nurses and allied health care workers come together as general practice teams (such as in an integrated family health centre) but also in many existing well organised group practices throughout the country. The current framework enables us to ensure that this approach is strengthened and cemented.
We know that around 80 percent of New Zealanders consult a general practice at least once every two years and that around 95 percent of the issues patients consult general practices about are resolved at the time, without referral.
My particular objective is for more cohesive integration between an enhanced primary care sector and the hospital sector. This is particularly important as health care improves and so much more is able to be done for people with long-term conditions.
Advances in IT mean the opportunities to communicate with, and link to, different areas of the health sector are almost limitless. Although New Zealand was at the forefront of much IT development in the early 1990s, it has tended to stagnate in recent years.
We need to ensure the primary sector has the appropriate incentives and partnership arrangements to allow the development of communication between it and the other parts of the health service, and I know the National Health IT Board has already made great progress in this area.
The fact that everyone in New Zealand has a unique National Health Index number is a huge benefit that ought to enable a great deal to happen in this area, so I'll be looking to advance that.
One of the great strengths of our health sector is that it's populated with talented and innovative people who want to see the best outcomes for those they are caring for. I have confidence that they'll recognise and take advantage of these opportunities for better communication and integration to help them do just that.
I know many health professionals have felt there's been a swing away from clinical influence in key decision making over the last 10 to 15 years. That balance is now being redressed with the establishment of the National Health Board and other initiatives that endorse frontline decision-making.
Dr Tom Marshall, NHB Board Member
The cardiac surgery service at Waikato Hospital has not only met its surgical target for 2010, it has exceeded it.
The service was working toward a target of 500 operations but actually did 617. That's the highest number ever recorded by the hospital and a 57 per cent increase on the previous year.
This is just one of the statistics contained in the department's recently-released annual report. It's the first time Waikato has publicly released cardiac surgical results and Jan Adams, Waikato District Health Board's Chief Operating Officer, says the knowledge that better figures equate to better patient outcomes is especially satisfying.
"These statistics represent personal stories of lives saved, outcomes improved and patients waiting less time for surgery. Making that sort of impact on people's lives is immensely rewarding for every member of our team."
In the past two years Waikato has made sweeping changes to its cardiac surgical services. The hospital had been under-performing in cardiac surgery and an internal review in 2007 identified the need to improve systems and processes particularly related to the patient journey. Mrs Adams says the drive for efficiencies has been rigorous.
"We worked with both clinical and clerical staff across all disciplines and challenged them to their core to strive for ways to improve our service to our patients."
Improvements, driven through Health Waikato's Programme Management Office, include developing a better referral process, using Clinical Nurse Specialists to manage both elective and acute patients and making better use of available theatre time.
Last year the Service also employed internationally-renowned cardio thoracic surgeon Mr Adam El Gamel as Clinical Director. Mrs Adams says Mr El Gamel's appointment has not only boosted clinical capacity, "there is little doubt his international reputation, skills expertise and experience has had a tremendous impact on both the cardiac surgical services at Waikato Hospital as well as the colleagues that work with him."
In addition to increasing the number of operations by over half, the hospital has reduced operating times by almost two hours and ICU stays by 30 per cent.
Mrs Adams says the impressive results documented in the annual report are the result of a team effort, involving junior medical staff, nurses, perfusionists, anesthetists, management and clerical staff, as well as senior clinicians.
"This is a testament to the dedication of every member of our staff whose flexibility and tenacity has enabled us to serve the needs of our populations in an equitable and timely way."
The National Health Board is 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.
The next four stories look at recent developments in the area of Primary Care.
There's been a pleasing uptake of flu jabs this year, with more than 886,000 doses distributed by mid-May.
"We are very pleased that the uptake is almost as high as at the same time last year when there was a lot of media coverage of the pandemic," says David Wansbrough, Manager, National Immunisation Programme.
"We wanted to respond to the pandemic in a way that strengthened our existing immunisation programmes. Hopefully people who decided to get immunised last year because of the pandemic are returning this year to get their annual flu vaccine.
"Our goal this year is to reach one million doses - so we still have a lot of work to do before the end of July when the free flu immunisation offer ends."
He says influenza is a serious illness for many people who are at risk from complications, yet many thousands of New Zealanders who are eligible for free flu immunisation have not yet taken it up.
It's also hoped that health care workers, a group that traditionally has low uptake of influenza immunisation, take advantage of employer-subsidised free flu immunisation.
"One of the surprising things we found in the H1N1 seroprevalence survey was that 45 percent of people who had the antibodies for H1N1 reported that they had had no flu symptoms in 2009. In other words, many people who had had pandemic influenza didn't know they had had it. In a health care setting this could put patients at risk, even when people aren't feeling sick."
Unusually, the three strains of flu covered by the vaccine this year are the same as in 2010 - the Pandemic H1N1 (swine flu) and seasonal H3N2 and B viruses, which are all expected to circulate in New Zealand this season.
Mr Wansbrough says National Immunisation Week in late April was a great success, with DHBs, immunisation providers and supporters finding creative ways to promote immunisation in communities throughout New Zealand.
One of the key messages this year was encouraging parents to get children immunised on time. Raising immunisation rates to 95 percent in under-two-year-olds by 2012 is one of the Government's Health Targets.
"Right now about 88 percent of our two-year-olds are fully immunised but we really need to get to 95 percent to protect our children and our communities from diseases like measles."
Mr Wansbrough says Immunisation Week was also an opportunity for parents who have questions or concerns about immunisation to talk to their family doctor or health professional.
"Immunisation has proven to be one of the most effective medical breakthroughs in protecting children against serious diseases that can make them extremely sick and that used to take an enormous toll on communities.
"But just because we don't see epidemics of diseases like diphtheria anymore, it doesn't mean that they have disappeared. Over the past couple of years more than 200 children and adults have caught measles in outbreaks throughout New Zealand. Some were so sick they had to be hospitalised.
"Immunisation against measles is free and is the best way to prevent the disease. Although we've made a lot of progress over the past five years, our immunisation rates are still too low to prevent these kinds of outbreaks."
The experience of patients is a particular focus of the New Zealand Health Survey which is currently being carried out. About 14,000 households will be invited to take part in the survey over the next 12 months.
The survey is coordinated by the Ministry of Health's Health and Disability Intelligence (HDI) Unit, which is part of the Policy Business Unit. HDI designs the survey, analyses the data and reports the findings.
The survey started in the Auckland, Northland and Waikato regions in April and is now being rolled out to the rest of New Zealand.
Survey information provides an important picture of our health, and how we use services such as GPs, hospitals and specialists. It also enables us to develop better health programmes and services for all New Zealanders.
People are asked about a range of health-related issues and behaviours, from whether they have diabetes, arthritis, or high blood pressure, to how much physical activity they do and whether they smoke or drink alcohol.
In the past New Zealand undertook a general health survey about every three years, with a number of specialist surveys done at different times. From this year all these surveys have been integrated into a single survey that will be carried out on a rolling basis.
The Ministry of Health's Acting Chief Medical Officer, Dr Mark Jacobs, says this change is a more efficient and flexible way to collect information. A number of core questions will always be asked, with additional questions or modules on different topics changing every six or twelve months.
The first module has a focus on health service utilisation and patient experience in relation to primary care, after-hours care, the emergency department and specialists.
"Measures of patient experience are increasingly being used as an indicator of the performance of the health system internationally and in New Zealand," he says.
"They give us information that helps health professionals provide person-centred care. Experiences of care can be measured by looking at such things as whether people believe they are treated with respect and dignity and how well they think health professionals listen to them."
He says the survey measures New Zealanders' access to health services such as GPs and after-hours services. It looks at barriers to care (such as cost) and whether people can get appointments when they need them.
"Participants are asked questions such as whether they would usually see the same GP when they go to their medical centre and how often they have visited their own medical centre, after-hours service or hospital emergency department over the previous 12 months."
"Monitoring New Zealanders' health using a national survey is the best way to measure the size of potential problems, identify which groups are most affected and what is changing over time."
The National Health Board's National Screening Unit, General Manager Jacqui Akuhata-Brown is welcoming figures that show a big increase in the number of women who have taken part in the BreastScreen Aotearoa programme.
Figures to the 24 months to December 2010 show nearly 42,000 more women aged 50 to 69 took part in BreastScreen Aotearoa than in the previous period.
"BSA is very well supported by New Zealand women, with latest figures showing that 331,131 women aged 50 to 69 have been screened in the 24 months to December 2010. This is 41,833 more women than in the previous 24 month period, to December 2008.
"Women with breast cancer that is found early have the best chance of successful treatment, and going on to live full lives. For some women, their decision to join the programme will be lifesaving."
She says the percentage of Maori and Pacific women having breast screening has had the greatest increase.
"A further 5,486 Maori women and 2,898 Pacific women aged 50 to 69 took part in the programme over the 24 month period to December 2010, meaning over 45,600 Maori women and over 17,900 Pacific women in that age group were screened.
"Reducing inequalities is a major focus for the programme, as Maori and Pacific women are less likely to have breast screening, and have an increased likelihood of dying of breast cancer, so this result is very pleasing."
BreastScreen Aotearoa checks eligible women between the ages of 45 and 69 for signs of early breast cancer by using mammograms - the only proven way for finding breast cancers early enough to reduce the risk of dying.
Two-yearly breast screening reduces the chances of dying from breast cancer for women under 50 by about 20 percent, by about 30 percent for women between 50 and 65, and by about 45 percent for women aged 65-69.
Early May saw the launch of a nationwide disability enterprise aimed at changing how people and companies think and feel about disabled people and the role they can play as contributors to and leaders of our society.
The Be. Institute was jointly founded by Auckland DHB, Auckland University of Technology and the Auckland Council.
The aim of Be. Institute is to improve the accessibility of the physical environment, enable better access to information, promote the inclusion and leadership of disabled people in employment and the community, and change social attitudes and behaviours.
The Be. Institute looks at the needs of what it calls the "Access Customer". This could include older people, parents with strollers, people with a hearing or vision impairment, people with a mental health impairment as well as people who use wheelchairs.
The first two initiatives that were launched are Be. Leadership and Be. Accessible.
The Be. Leadership programme is the first leadership programme in New Zealand dedicated to developing disabled leaders of the future. The programme invites 20 emerging leaders to participate in a 12-month journey on which they will be challenged, inspired and supported to become the best leader they can possibly be.
"We are committed to fostering leadership in the disability community", says the National Health Board's Anne O'Connell, Group Manager Disability Support Services. "Leadership by disabled people is essential for service and sector development and will help improve the quality of support available for people with disabilities."
The launch of the Be. Accessible programme is timely. From a long-term perspective as we focus on rebuilding our second-largest city, Be. Accessible, aims to improve the accessibility of the physical environment.
Secondly the Be. Test Match project will be rolled out to the 12 New Zealand cities hosting Rugby World Cup 2011. Be. Assessors will visit key locations in each of the 12 cities and assess stadia, fan zones, i-SITES and other relevant locations such as hotels for physical access, website accessibility, customer service and accessibility of marketing material.
Minnie Baragwanath, Chief Executive Be. Institute, says, "In launching the Be. Institute we are mindful of the importance of recognising what is already being done. We have made great progress as a nation however, there is more we need to do to create a 100 percent accessible country. New Zealanders are by nature inclusive and socially aware, and we are seeking to build on this through specific practices in our two programmes. Our view is that if we get it right for disabled people, we get it right for all people."
The Be. Institute receives funding through the Changing Attitudes Fund launched last year and managed through the Ministry of Social Development and the Ministry of Health's disability Consumer Training and Leadership Fund.
For more information go to http://www.beaccessible.org.nz
Progress on Regional Service Plans (RSP) continues to go well with the draft RSPs from the Northern, Midland and Central regions' having been through the NHB review and feedback process.
The South Island draft RSP has also been received and is undergoing a similar review and feedback process. The South Island draft RSP also takes into account actions that will help the recovery effort in Canterbury.
All four regions are now focussed on revising their draft RSPs, and in particular their detailed implementation plans.
NHB Acting Director Planning and Analysis, Michael Johnson, says "The next step is to work closely with the DHBs to ensure progress is made on the actions that they have identified in their plans, with the expectation that regions will make measurable progress in their identified priority areas in 2011/12."
Michael says in addition, "To showcase the intended benefits of regional collaboration and RSPs, we have started an e-booklet which we hope will be ready for release in July.
"We are also now doing some early thinking on the next steps for next year's RSPs. This has come up already in discussions with DHBs, and we will work closely with them over the coming months to further develop and enhance the collaborative agenda."
This year represents a new way of doing things for the health sector in relation to District Health Board (DHB) service planning and accountability for 2011/12.
Since the establishment of DHBs, each has had a statutory responsibility to prepare:
- an Annual Plan for approval by the Minister of Health (Section 38 of the New Zealand Public Health and Disability Act 2000) - providing accountability to the Minister of Health
- a Statement of Intent (Section 139 of the Crown Entities Act 2004) - providing accountability to Parliament, and the public
However, in 2010 Cabinet agreed to combine the purpose of both documents into a single DHB Annual Plan with Statement of Intent (the AP). This was a challenging task as the two documents have historically had very different audiences and have been used for differing purposes by individual DHBs.
National Health Board deputy national director, Michael Hundleby, says "To help smooth the transition to this new unified document, a reference group with representatives from DHBs and the National Health Board (NHB) worked to create a standard template structure for all APs. This template was developed in consultation with The Treasury and the Office of the Auditor General to take account of the various needs of these stakeholders too.
"The intent of merging the two documents into one was to reduce bureaucracy and the reporting burden on DHBs, provide a more streamlined accountability framework that would complement the new DHB Regional Service Plans (developed to replace individual District Strategic Plans) and to present a coherent performance story in one place."
To support the DHBs to produce an AP that satisfies legislative requirements and Government expectations, the NHB conducts a review of draft APs and provides feedback to the DHBs for further development. At the time of writing the NHB has had the opportunity to view draft APs and overall, the documents are of a higher standard and show an improved performance story than previous years.
"Importantly, the APs generally reflect a greater emphasis on concrete actions to achieve national, regional and local priorities. It is also clear that DHBs are actively working with each other to achieve common goals regionally and sub-regionally," says Michael.
The decision to extend the use of the interRAI assessment tool for older people living at home to older people in over 700 residential aged care facilities will help support a continuum of care, says the home care implementation project's clinical leader.
The National Health IT Board is working closely with interRAI, as part of its National Health IT Plan objective towards national sharing of health information.
InterRAI is a comprehensive clinical assessment tool that looks at all of an older person's medical and social conditions, focusing on how they function, including their strengths and preferences. When used in the community, it helps identify the need for publicly funded support services for people aged over 65 so that they can remain in their homes, or clarify their need to go into residential care.
The Ministry of Health's interRAI Senior Project Manager, Dr Brigette Meehan, says the assessment of risks and opportunities is just as relevant for older people in residential care as it is for those who are in their own homes.
"It's important that the same quality framework for assessment travels with people who move from their homes to residential care. InterRAI allows better integration and care planning for older people and, because it highlights areas of concern, it can help reduce unexpected admissions to emergency departments."
She says the tool is used by a range of health sector workers from those in home health care to practice and district nurses and soon some nurses in residential care will get the opportunity to use it.
Assessors synchronise the assessment and care plan with a national system, so health professionals with the appropriate security clearance can see a person's assessment and the care plan that has been developed from it. Depending on their level of security, they may also be able to add to the care plan at any point of the patient's care.
"Essentially it means that opinion-based assessment decisions are backed up by a validated tool."
Dr Meehan has a Masters in Education and had recently completed a PhD in Speech Pathology looking at functional communication assessment when, back in 2004, she saw a two-year role to lead the Canterbury District Health Board interRAI implementation pilot as an interesting project, assuming she would return to clinical work when the pilot ended.
But she says she was 'absolutely captured' by what interRAI could achieve and wanted to stay involved when it was implemented nationally, first undertaking additional training from health organisations in the US and Canada that were already using interRAI.
"It's a very satisfying assessment process to be involved with because you're looking into the client's future as well as their current status, and because the assessment leads directly into the care plan, interRAI assessment findings focus on opportunities that exist to modify the client's function and the risks they may have. It's standardised and supports the clinical logic."
Dr Meehan says it's broadened her assessment experience to be much more holistic. "Sometimes there's an assumption that because you have one health condition it somehow protects you from getting another. But what happens if you have arthritis and then have a stroke? interRAI is designed to look less at a person's conditions and is much more about how they manage in their daily life.
"And if you focus on a quality care plan for one individual, then you're going to get general quality improvement."
All DHBs will be using interRAI for their community clients by mid 2012, and the implementation project is on time and on budget. The residential care implementation of interRAI is in the early stages of planning and will get underway this year.
Dr Meehan says the different versions of interRAI that have been developed mean it could be used to assess and develop care plans for other sectors of the population in the future.
"How valuable would it be for palliative care or younger people with mental health issues, for example. And into the future, wouldn't it be great if we had an assessment and care plan that followed a person at every point of care?"
The trial of the New Zealand Electronic Prescription Service (community ePrescribing), which allows doctors to send prescriptions to pharmacists digitally, began in late March in Auckland.
The trial of the New Zealand Electronic Prescription Service (community ePrescribing), which allows doctors to send prescriptions to pharmacists digitally, began in late March in Auckland.
Medicines are an essential part of managing a patient's health and medication errors can contribute to poor outcomes and potential harm. Electronic prescribing has been identified as important to improving safety and efficiency in the health system and is a priority in the 2010 National Health IT Plan.
Community e-prescribing is part of an umbrella larger programme known as the National eMedicines Programme. The programme contributes to the safe, effective and appropriate use of medicines. It ensures a person's medication information is accurate, up-to-date, and accessible across the continuum of care for a patient by all health care providers, pharmacists and the patient themselves.
The community ePrescribing service will introduce a number of benefits for patients, doctors and pharmacists. Patient safety will be improved by making prescriptions more accurate; by reducing manual data entry and therefore transcription errors; and by the ability to send status updates to the prescriber if requested.
The project has support of key stakeholders from across the health and disability sector including GPNZ, PHARMAC, the Pharmaceutical Society, the Pharmacy Guild, the Royal NZ College of GPs, Radius Pharmacies, and Pharmacy Brands.
Pharmacist Sanjeet Goundar, says, "My pharmacy is extremely pleased to have the opportunity to trial the initial phase of this programme. ePrescribing saves time and leads to more accurate dispensing." Other pharmacies are also keen to take part in trials and achieve the benefits available to them from improved workflow processes.
The experience of patients as consumers of the new service is also an important part of the trial. Consumer representative, Jean Park says, "I think [ePrescribing] is a great idea. The experience of consumers has already been positive".
The trial will take 12 to 18 months and will consist of three phases. In the first phase of the trial, a GP and a pharmacy system - My Practice and Healthsoft - commenced testing the initial version of the service. The testing will involve a barcode feature, which acts as a secure identification number for the prescription. The barcode will make it easy for the pharmacist to download the correct script for dispensing. "Testing has been successful, the communications links are working and all the indications are good", says Andre Bredenkamp, ePrescribing Project Manager, Patients First.
In the next phase, planned for June, the trial will be extended by adding features, another region and two new vendors. The final phase, planned for October, will include a further two regions. The trial will be evaluated before the system is rolled out nationally.
Health Workforce New Zealand, together with the Royal New Zealand College of General Practitioners and the Medical Council of New Zealand, released a discussion paper proposing changes to the GP training programme.
We believe the proposals will build on the strengths of the existing GP education programme, while introducing new opportunities and support that will benefit both current and future GPs and GP registrars.
The key themes of the paper include ensuring that the first stage of vocational training continues to be centred on practice in GP settings; introducing options for building specific specialist skills and competencies; moving towards greater equity between GP and DHB employed registrar terms and conditions and supporting greater exposure of GP trainees to some hospital-based practice.
You can read the discussion paper and details of opportunities for providing feedback online and at regional face-to-face meetings.
Workforce Service Reviews
The first five workforce service reviews in palliative care, eye health, anaesthesia, musculoskeletal, and aged care have reported their recommendations to the HWNZ board. Detailed summaries of these reviews are available on the HWNZ website.
Each of the reviews has identified ways in which the existing workforce can be better used to meet increasing demand for services and have focused on the range of skills available across a multidisciplinary team.
The outputs of the reviews are now being tested with colleagues and subjected to financial modelling. Business cases are also being be scoped for the establishment of demonstration sites to test new workforce scenarios.
We are encouraging feedback on the reviews, particularly regarding relevant local innovations that can feed into the next phase. If you would like to provide feedback please email email@example.com
Brenda Wraight, Director, Health Workforce New Zealand
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