NHB eNewsletter - December 2011

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

• From the Chair
• From the Director's Desk
• Working with and not just for patients and families - Margaret Wilsher
• DHB Success Story: Elective surgery patient education programmes paying off
• Central region patient information management system will improve care
• Consumers playing a key role in disability services delivery
• More integration of care a major focus for Better, Sooner, More Convenient
• Health Workforce New Zealand update
• National Health IT Board update: Clinicians' Challenge winners 2011
• The Green Paper
• About this eNewsletter 

From the Chair

It is two years since the inception of the National Health Board and while there is still much to do to improve the sustainability and performance of the health and disability sector I feel that we are making real progress.

The Ministerial Review Group talked about the importance of New Zealanders continuing to have affordable access to a strong public health and disability system and the National Health Board (NHB) is tasked with helping lead the sector towards that goal.

One of the more notable trends under the guidance of the NHB has been a marked and sustained improvement in the deficit track of District Health Boards (DHBs).  We are expecting a net deficit of DHBs for the year ended June 2011 of $20.1m, an improvement of $56.4m against the planned deficit for DHBs and an improvement of $81.8m on the previous year.

Within that improved financial result there have been improvements in service delivery.

The number of elective discharges has increased from 138,521 in 2009/10 to 145,414 in 2010/11, well in excess of targets.  At the same time there has been a downward trend in numbers of patients waiting more than six months for first specialist assessments or for surgery.

New Zealanders can now be more assured of timely access to cardiac surgery thanks to the work of the New Zealand Cardiac Network. Improved access to cardiac surgery has reduced patient waiting times to levels never achieved before.  This network provides a best practice model for clinical leadership driving improvements in the delivery of health services in New Zealand.

Regional collaboration was one of the key "missing links" that the Ministerial Review Group identified in the public health system.

Legislation has now shifted focus towards collaboration and the Minister of Health made it clear in his Letter of Expectations to DHBs for the 2011/12 year that regional collaboration to maximise the use of our clinical and financial resources is an essential part of our future direction.

During the past year we have introduced Regional Service Plans and the emphasis on collaborative planning will continue to strengthen.

The NHB has also begun developing national services and national service improvement programmes to protect the most vulnerable services.

These initiatives all help to make sure that we are configuring the sector - nationally, regionally, and locally - to best meet the needs of New Zealanders by putting the right services in the right place.

Under the NHB's direction the sector is seeing greater alignment in Capital, Workforce and IT planning and real progress on mid to longer term planning for the sector.

As a board the NHB has taken a role in primary care and we are now seeing some excellent examples around the country of models of care which focus on greater integration of primary and secondary care.

During the year the NHB has also been involved in leading the sector in a number of issues.  Of particular note was the panel to determine the future shape of South Island Neurosurgery Services, the joint assessment of Dunedin Hospital, and the independent expert panel review of the shape of Wakatipu basin health services. I would like to thank everybody who helped us with these important projects.

We have made a good start. The changes underway have solid momentum behind them. We need to build on that success by picking up the pace on regionalisation and on delivering more integrated and patient-centric care. We need to ensure that successful pilots are spread quickly across the whole health system. We also need to give more attention to finding ways of encouraging greater involvement of patients and their families in staying healthy and in delivering care at home. 

Wishing you all a merry Christmas and an enjoyable holiday. Looking forward to working with you in 2012.

Dr Murray Horn, Chair 

From the Director's desk

As the dawning of 2012 draws near what can we, as a sector, expect from the next 12 months?

While the new year is traditionally a time for new hope and aspiration, as a sector we must also keep a focus on how we can continue to perform well within the confines of this increasingly challenging economic climate.

As the global economic slow down continues to impact every area of the health sector, we can expect to see the next 12 months having a much greater focus on the way we work, not just what we work on.

I believe we will all be asked to do more and find more efficient, effective and productive solutions to achieving outcomes. To deliver more, our response needs to be about greater alignment and teamwork. It's about working more collaboratively across multiple parts of the sector (departments, agencies and organisations) to find increasing ways of improving our outcomes whilst being efficient with the resources available to us.

It will be a time when we'll need to not just focus on the momentum of our change and response, but also the speed of our responses. More than ever it will be about working efficiently as a wider team to advance outcomes at a national, regional and local level.

In 2011 such a collaborative approach brought us good returns in many areas, for example our response to the Canterbury earthquake and in the number of elective surgeries we were able to deliver, which well exceeded targets. Looking ahead it's going to be about building on these successes to find new and different ways to keep on improving on our outcomes.

In the meantime, I hope that this coming month brings you a chance to take a well-earned break, to relax, recharge and come back refreshed and ready to embrace the new year.

Wishing you a safe and happy holiday.

Chai Chuah, National Director 

Working with and not just for patients and families - Margaret Wilsher

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 importance of working with patients and their families to achieve good health outcomes.

In the past, we have tended to regard patients and families as passive recipients of health care delivery, yet the inclusion of the patient and family voice in clinical decision-making can improve outcomes. Not only can patients and families contribute to an agreed management pathway, but their opinions can and should shape how we develop health policy and design our services and facilities.

Working in partnership with patients and families is respectful and restores dignity and control. Such partnerships also contribute to patient safety - family members at the bedside may notice small changes in the patient's condition ahead of any physiological measurement. They can also assist with medicines reconciliation and help protect the patient from falls. Hospitals which embrace family-centred care have been shown to have greater patient satisfaction, reduced nursing turnover and lower hospital-acquired infection rates. So why do we not engage patients and families in this way more consistently?

All too often discussions with families are reserved for difficult situations such as the communication of bad news; things like a difficult diagnosis, a poor prognosis, or when things have gone wrong.

Many clinicians find open disclosure difficult, and fear criticism and blame. Yet the early establishment of a partnership with the patient and family can make it much easier to communicate bad news or admit to failings. In my experience, most patients and their families want to work with and not against clinicians to ensure omissions of care or harmful events do not impact on future patients. Their voices can help influence system changes and act as key learning catalysts. Patient stories powerfully illustrate the impact of not only what happens when things go wrong, but also when things go well. We should listen to a lot more of them.

It is time that we stopped regarding families as visitors. As part of the health team, families not only comfort and support patients but also act as guardians for their safety. That is a resource we cannot afford to pass up.

Dr Margaret Wilsher, NHB Board Member 

DHB Success Story: Elective surgery patient education programmes paying off

Two District Health Board (DHB) education programmes for patients undergoing knee and hip replacements are achieving the hoped for benefits of less anxious and better informed patients able to be discharged earlier from hospital.

More than 900 patients have attended Northland DHB's 'joint camp' since it began in April 2009. Patients begin the programme as soon as they're accepted by the surgeon onto the waiting list, and a series of booklets keep them informed about what to expect in the lead up to and post surgery.

They also receive a personalised 'joint journey' booklet that they fill in at key steps in the process. 'We use the traffic light concept to explain what happens at every stage, and why there might be delays,' says Project Manager Dee Telfer. 'Patients carry it everywhere, always have it to refer to and it's resulted in a big reduction in the number of phone queries from patients about their pending surgery. It also demonstrates transparency between patients and the DHB as the service provider.'

A week before surgery the patients attend a three-hour education session in Whangarei. Patients' supporters are also encouraged to attend the session, which includes interactive presentations on all aspects of their surgery from admission through to discharge and recovery.

'It's very interactive and visual,' says Mrs Telfer. 'They can try out the crutches, there's a mannequin set up with all the drips and drains patients can expect to see post op, and everything is explained and demonstrated to the patients and their whanau. They get to listen to and understand what the alarms mean, the clinic nurse goes through all the procedures, medications, pain management and hospital routines to ensure all aspects of hospitalisation are covered. Patients also get to meet other people about to undergo the same surgery.

'A Takawaenga service talks about spiritual and cultural support, a social worker ensures any necessary referrals are in place for things like personal care and meals on wheels once they're discharged, and a physiotherapist and an occupational therapist talk separately to the knee and hip groups. At the end of the session the patients go home with all the equipment they'll need post surgery so that they're all set up when they're discharged.'

She says the feedback from patients about the programme has been excellent. 'And the difference it makes is clear when they come onto the ward. Patients and their families are more knowledgeable and less anxious. Patients spend less time in hospital, are having fewer complications and readmission rates are also much lower.'

Palmerston North Hospital has been operating a joint care clinic for hip and knee replacement surgery patients for the past three months. It also covers everything the patient needs to know from the first clinic appointment through to a safe discharge home.

Maria Shaw, Lead Clinical Nurse specialist in orthopaedics says 103 patients have been through the joint clinic which, like Northland's programme, has had a 100 percent attendance rate.

'We're able to identify issues such as wound infections which might prevent the patient having their surgery. By giving us more time to assess and make these decisions early, we reduce day-of-surgery cancellations and are able to use our operating theatres to the maximum.'

She says patients attending the joint clinics are spending between one and two days less in hospital, which frees up bed space for other patients. Staff are also reporting a marked improvement in how patients are prepared for their surgery and discharge.

'Knowledge and understanding of their surgery and recovery helps to reduce patients' fear of the unknown.'

Clare Perry, National Health Board Manager Elective Services, says it's very encouraging to see the benefits that both these initiatives are producing.

"'Patient education programmes are recognised as important aspects of enhanced recovery, enabling patients to recover faster from joint surgery and return to normal activities. A range of expertise is brought together to achieve these improvements, and they require dedicated focus and co-ordination from across the multi-disciplinary team. Such initiatives support DHBs' performance against one of the key priority health targets - Improved access to elective surgery." 

Central region patient information management system will improve care

The six Central Region DHBs have committed to invest $38 million in a regional IT system for managing patient information which, the project's clinical leader says, will deliver tremendous advances in patient care.

Central Region Information Systems Plan (CRISP) will deliver 'one portal, one password, one patient record for every clinician at every facility across the central region'.

Approval to proceed with CRISP has been received from Capital & Coast, Hawke's Bay, Hutt Valley, MidCentral, Wairarapa and Whanganui DHBs, the National Health Board, the National Health IT Board, the Capital Investment Committee and the Minister of Health.

Central region DHBs are the first to commit to sharing the same systems. CRISP is the beginning of a regional platform, an important component of the Central Regional Service Plan and aligns with phase one of the National Health IT Plan, which is to consolidate and rationalise existing clinical systems.

Central region clinical leader Dr Ken Clark says CRISP will be incredibly important to the way clinicians work and the safety of the services they provide.

He says clinicians are looking forward to working with technology systems that 'talk' to each other and not wasting time using several different systems or transferring hard copy notes between sites.

'Clinicians will be able to access all of a patient's up-to-date clinical information in a consistent form - not just for a patient in front of them, but also for a patient they might have seen a day ago in a different part of the region.

'Patients sometimes need to move around the region, depending on the type or level of care they need. This will mean any clinician looking after them can access information about them from wherever it originated, whether it's from their home DHB, another DHB or somewhere else.

'It will avoid duplication and be a major factor in our ability to deliver more efficient and more effective care - including transferring care - and will reduce risks to patients. It will also be very useful in training health professionals.'

Dr Clark says CRISP will also improve the privacy and safety of patient information. 'We'll be able to audit who has been accessing information and how it has been used in ways we can't at the moment.'

He says he's entirely comfortable with the cost of the project because it will directly benefit patients by giving clinicians timely access to information, helping them deliver new models of care, and allowing innovations in care to be more easily shared across the region's DHBs.  'It's very exciting and I'm delighted to have been able to supply a clinical perspective to this project.'

CRISP will be implemented in the Central region in project phases over the next three to four years. 

Consumers playing a key role in disability services delivery

The Disability Support Services Group (within the National Health Board) has just wrapped up the most recent Consumer Consortium gathering. 

The Consumer Consortium is a group of representatives from different disability consumer groups that come together twice a year to have input into how disability support services are planned, funded and purchased.

Group Manager Disability, Anne O'Connell, says the constant theme in the work of the Disability Support Services Group is 'Nothing about us without us'.

'That means disabled people and their families, whanau and carers should be involved in any decision that affects them.

'With an exciting and ambitious work programme underway, we need to check back regularly with those who are the experts in their particular area of disability to make sure we are on the right track. It ensures the improvements we are making and the support services we are providing represent value for money and meet the needs of disabled people.'

Ms O'Connell says the Consortium has a rotating membership that ensures different people from the consumer groups represented get a chance to be involved.

'We also involve consumers in projects and in decisions about the purchase of new disability support services outside of the bi-annual meetings.'

The Ministry of Health has also recently convened a Maori Leadership Group and organised a series of focus groups to develop Whaia te ao marama (the Maori Disability Strategy).

'A Pacific Leadership Group also meets regularly to advise the Ministry on how to improve access to disability support services for Pacific peoples. Many of the members of this group were involved in the development of Faiva Ora (the Pasifika Disability Plan) and the Leadership Group is playing a critical role in supporting its implementation.'

She says, there is also a Local Working Group and a National Reference Group involved in the introduction of the new model for disability support services, which supports disabled people to have more choice and control over the support they receive. 'The members of these groups ensure disabled people and their families, whanau and carers have a voice in these far-reaching changes.'

The new model is having a limited introduction in the Western Bay of Plenty and Local Working Group members supported the Ministry's appointment of the first four local area coordinators. 

More integration of care a major focus for Better, Sooner, More Convenient

Further integration of primary, community and hospital-based services will be a major focus of the next phase of implementation of the Better, Sooner, More Convenient (BSMC) initiative.

BSMC is a policy the National Health Board works towards. It aims to deliver a more sustainable health system with services closer to where people live, and that are more timely, of a higher quality and affordable.

Sam Cliffe, who has been appointed to the new role of Director BSMC Implementation at the Ministry of Health, says accelerating the integration of primary and secondary care is the overall theme of BSMC for the next 12 months.

'There's been a huge amount of work undertaken to get structural and governance issues in place, including merging and consolidating primary health care organisations and establishing alliances so that primary care can help reduce pressure on hospitals by better managing chronic conditions and proactively supporting high-needs populations.

'There are great things happening. It's being clinically driven, staff are engaged, and it's starting to pay dividends.'

Ms Cliffe says further service improvements will include the development of multiple integrated family health centres, care coordination models for patients with chronic conditions, providing a wider range of care and support for patients, and shifting some secondary care services to primary and community settings.

'Alliance leadership teams have been established that are made up of clinical and senior managers from across primary and secondary care. They are focused on initiatives for patients who are most in need, such as frequent attendees at emergency departments and GPs, the elderly and those who have chronic and complex conditions.'

She says these patients need to be supported through the health system and there are already some very good initiatives underway.

'For example, there's been some excellent work in care coordination models for older people, with the aim of keeping people well and at home. There has also been a growing focus on child health issues, and the development of alternative facilities, such as integrated family health centres.

'Across the primary sector GP teams are working with other GP teams under the same clinical governance structures and using the same clinical pathways so patients get a consistent approach when they're referred to secondary services or diagnostics.'

The Ministry of Health is supporting GPs in partnership with DHBs and local communities to develop the infrastructure, workforce and information technology needed to provide a much greater range of services much closer to home and delivered in a way that's much more convenient for patients, says Ms Cliffe.

'That means looking at new models of care and service coordination that sit within primary care, such as supporting people when they are discharged from hospital.

'This may mean secondary care clinicians operating out of different locations, nurses taking different roles, or GPs being able to access secondary services more quickly and conveniently in a setting that makes it easier for their patients to benefit from them.'

She says the Ministry has a central role in supporting DHBs through their planning processes, building robust performance frameworks, and looking at things like how contracts are set and how funding streams can be better aligned. 

Health Workforce New Zealand update

2011 has undoubtedly been a busy year for Health Workforce New Zealand. Work has progressed in several key areas:

Service forecasts

Nine service forecasts (formerly known as the workforce service reviews) were completed in 2011 from across a number of service areas including aged care, anaesthesia, diabetes, eye health, gastroenterology, mental health and addictions, musculoskeletal, palliative care and youth health. The forecasts provide the platform for stronger integration between workforce and service planning, and the next phase of the project will include demonstration site testing of forecast recommendations.

Review of GP training

Work continued in 2011 on the review of GP training and during May and June we consulted on a discussion paper outlining proposals for changes to the GP Education Programme. The revised training programme (to be introduced from next year) is likely to include some training under supervision of a hospital-based consultant, a modular approach to assessment and an academic component.

Regional training hubs

In 2011 significant progress was made with the regional training hubs.  The hubs developed their local governance arrangements which are integrated into regional decision-making systems. While the integration and coordination of pre-vocational medical training was identified as a priority for the hubs, they all took the opportunity to develop a multi-disciplinary approach. HWNZ expects the hubs to be fully operational by 1 January 2012, whilst further developments will continue to ensure national integration. 

Workforce innovations programme

Our workforce innovations programme introduced a number of new demonstrations in 2011 including the primary care practice assistant, non-surgical orthopaedic physician, and the Wairoa integrated health services and workforce reconfiguration demonstrations.

A number of demonstrations established in 2010 also came to completion including the diabetes nurse specialist prescribing, specialist gerontology nurse, physician assistant (PA), and community pharmacy anti-coagulation management services demonstrations. We are now seeking to demonstrate the utility of the PA role in other health settings as well as undertaking essential work around the regulation of PAs so they are able to practise to their full scope. The Minister of Health also recently announced the nationwide rollout of community pharmacy anti-coagulation management services.

In 2011 we also commenced work to develop more robust processes to underpin our core business and ensure we are as efficient and effective as possible. This includes the development of our investment prioritisation criteria, starting with medicine, but subsequently to be applied to our investment in all training and wider workforce development. The prioritisation criteria for the funding of medical disciplines will be finalised in the new year and will be applied from the 2012/13 year onwards.

Recruitment and retention

The strategies established to support recruitment and retention including the Voluntary Bonding Scheme (VBS) and Advanced Trainee Fellowship (ATF) continue to be popular initiatives. In 2011 the Minister confirmed all 429 applications of interest received for the VBS. The 2011 intake is comprised of 41 doctors, 39 midwives and 349 nurses, who will receive payments (to go toward their student loans in the first instance) in exchange for working in hard-to-staff areas for a minimum of three years. 

We accepted 12 advanced medical trainees onto the ATF in 2011 in the specialty areas of:

• Anatomic Pathology - Perinatal Pathology
• Anatomic Pathology - Perinatal and Paediatric
• Endometriosis and Gynaecology Oncology Surgery
• General Surgery - Laparascopic Colorectal Surgery
• General Surgery - Breast and Endocrine Surgery
• General Surgery - Rural
• Obstetrics and Gynaecology - Reproductive Endocrinology and Infertility
• Obstetrics and Gynaecology - Maternal Foetal Medicine
• Paediatric Dentistry
• Psychiatry - Psycho Geriatrics
• Respiratory Physician - Thoracic Malignancy and Interventional Bronchoscopy
• Transplantation Anaesthesia (liver).

These trainees have to have a guaranteed job on completion of their advanced training and support from their specialty college.

Looking ahead to 2012

Our investment in clinical training will focus particularly on mental health, rehabilitation and aged care, as well as supporting expanded roles and support for nursing, primary care, in particular general practice, the unregulated workforce, and the home support and self-care 'workforce'.

Our work in boosting the Māori and Pacific workforce and ensuring the health workforce meets the needs of Māori and Pacific communities will continue, incorporating our partnerships with Te Rau Matatini, Te ORA and the Pasifika Medical Association.

In addition, HWNZ is also undertaking Service Forecasts for Cancer, Māori, Family/Women and Baby, Pacific and Rehabilitation. We anticipate these being released throughout 2012.

The hubs have been set an ambitious programme for 2012 and tasked with ensuring that by the end of March 2012, all trainees in receipt of HWNZ funding have a personal career plan. Systematic career planning will ensure that training has a clear purpose and will benefit the trainee through discussion and support for career development.  Employers will be able to plan their workforce more effectively in line with service needs.

We will continue to engage and communicate with the sector in 2012 to ensure that stakeholders are consulted with and involved in shaping the future health workforce and the systems that support it.

We wish you a wonderful Christmas and happy New Year and look forward to working with you in 2012. 

National Health IT Board update: Clinicians' Challenge winners 2011

From measles to whooping cough, disease outbreaks have hit the headlines this year.

Behind the scenes, doctors are busy reporting patients with these conditions, and the other 50 or so notifiable diseases, to public health services. If this year's winning Clinicians' Challenge vendors have their way, this reporting process will be electronic in future.

Corinne Gower of Maxsys worked with Healthlink and Kinross Group to come up with a way to electronically notify legally reportable conditions, following a Clinicians' Challenge entry from public health physicians including Hawke's Bay Medical Officer of Health, Nicholas Jones.

"In our case the solution is a kitset.  Our solution is about showing the sector how to create the solution they want with some base materials." 

Clinicians entered the challenge by outlining a work-related problem the innovative use of information technology could help solve. Health IT vendors were then asked to come up with a solution to the three cases chosen as finalists. There were 56 entries from clinicians this year.

Corinne Gower says while there is no guarantee the work will go ahead, the opportunity to collaborate and make a real difference was appealing.

"Earlier notification and smarter interconnectivity between systems would make a real difference to this important area of health. Let's hope the time to meet this challenge has come!"

Meanwhile, the plight of seriously ill patients who don't speak English spurred Waitemata DHB intensive care specialist Janet Liang to enter -- and eventually win -- the clinicians' category.

"Communicating to different ethnicities and across cultures can be challenging enough at the best of times. The situation can be particularly difficult when the patient is in the emergency department and so sick we need information faster than we can get hold of an interpreter."

Dr Liang highlighted the need for a portable language interpreter system that can deal with both clinical and colloquial terms.

So far no vendor has come up with a solution, although Dr Liang is having conversations with several developers.

An electronic early warning scoring system to alert staff to patients who are deteriorating -- entered by Capital and Coast DHB Intensive Care Specialist Alex Psirides and presented by Nurse Specialist Anne Pedersen -- was also a finalist in the Clinicians' Challenge.

The challenge is run by the National Health IT Board (NHITB), Health Informatics New Zealand (HINZ), and the New Zealand Health IT Cluster. The Ministry of Science and Innovation also provided sponsorship towards the vendor prize.

Over the next year, clinicians and vendors will be working together to research solutions to these real-life challenges. 

The Green Paper

The Government is looking for feedback on the Green Paper looking at better ways to protect abused, neglected and disadvantaged children.

The Green Paper was launched by the Government in July, and sets out some ideas on how to improve the lives of vulnerable children

A number of resources have been prepared to help groups and individuals put forward their ideas and let the Government know what they think.

Resources including a freepost form are available here. 

About this eNewsletter

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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