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2020 04 28 Wairarapa Board Meeting PUBLIC - Agenda

Meeting Date: 28th April 2020

Meeting Time: 09:30am

Venue: Zoom

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Wairarapa District Health Board

Government Priorities 2019/20 “Improving the wellbeing of New Zealanders and their families“

Improving child wellbeing Improving mental wellbeing

Better population health outcomes Improving wellbeing through prevention supported by a strong and equitable public health and disability system

Better population health outcomes Strong fiscal management supported by primary health care

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AGENDA Held on 28 April 2020

Zoom video conference

Commencing at 9:30am – 11:30am

BOARD PUBLIC SESSION Item Action Lead Minute Allocation 1. Procedural Business 1.1 Karakia 1.2 Apologies Accept 1.3 Interest/Conflict register 1.4 Previous Minutes Accept Chair 25 9:55am 1.5 Previous Actions Confirm 1.6 Draft 2020 Board Work Plan 1.7 Chairperson Report Verbal 1.8 Chief Executive Report Note D Oliff 2. Patient Story Verbal C Matthews 15 10:10am 3. Presentation: Allied Health Verbal N Rivers 20 10:25am 4. Decision 4.1 Youth Health Service Development Approve S Williams 10 10:45am 4.2 Strategic Direction Decline 5. Information 5.1 Planning & Funding Report S Williams 5 10:55am 5.2 Finance Report F vanHam 5 11:00am 5.3 Hospital & Community Services Report K McCann 5 11:05am 5.4 People & Capability Report Receive S McKay 5 11:10am 5.5 Information Communication Report T Voice 5 11:15am 5.6 Quality, Risk & Innovation Report C Stewart 5 11:20am 5.7 Chief Medical Officer Report S Sturland 5 11:25am 6. Other 6.1 General Business 5 11:30am 6.2 Resolution to Exclude the Public Agree Morning Tea Date of next meeting: 25th May 2020

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Karakia Tuia ki runga, Tuia ki raro Tuia ki roto, Tuia ki waho Ka rongo te ao, Ka rongo te pō Haumi e, Hui e Taiki e ------Unite above Unite below Unite without Unite within Listen to the night Listen to the world Now we come together As one.

Wairarapa District Hutt Board

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Wairarapa Board INTEREST REGISTER Name Interest Sir Paul Collins ∑ Director of: Active Equity Holdings Limited (Chair) Chair Hurricanes GP Limited Ides Limited Shott Beverages Limited Technical Advisory Services Limited ∑ Director and shareholder of: AEL Managers Limited Beverage Holdings Limited Cohiba Traders Limited Ecopoint Limited Tofino Trustee Limited ∑ Member of shareholders Review Group for New Zealand Health Partnerships Limited ∑ Trustee of the Malaghan Institute of Medical Research ∑ Member to Governance Board for Health Finance, Procurement & information Management System Programme (FPIM) Dr Tony Becker ∑ Shareholder and Director (Clinical) Masterton Medical Limited Deputy Chair ∑ Shareholder and Director Wairarapa Skin Clinic ∑ Wife contracts to Wairarapa District Health Board ∑ Trustee, Hau Kainga ∑ Member Alliance Leadership Team Mrs Leanne Southey ∑ Chair, Wairarapa District Health Board, Finance Risk & Audit Committee Member ∑ Chair of Lands Trust Masterton (15 February 2016) ∑ Director, Southey Sayer Limited ∑ Chartered Accountant to Health Professionals including Selina Sutherland Hospital and Selina Sutherland Trust ∑ Trustee, Wairarapa Community Health Trust ∑ Shareholder of Mangan Graphics Ltd ∑ Member of UCOL Council Mr Ronald Karaitiana ∑ Member, Wairarapa District Health Board Member ∑ Member, Wairarapa Te Iwi Kainga Committee ∑ Member, Wairarapa District Health Board, Finance Risk & Audit Committee ∑ Akura Lands Trust Chairman ∑ Extended family members work in varying roles at DHB ∑ Chair of WrDHB Hospital Advisory Committee ∑ CE Te Hauora Runanga o Wairarapa ∑ RK Consulting Ltd, Business owner ∑ Whanau ora Collective Member Te Hauora and Whaiora via Te Pou Matakana Helen Pocknall ∑ Contractor with Ministry of Health Member Ryan Soriano ∑ Community Coordinator for FOCUS, Disability Support Services at Wairarapa DHB Member ∑ Member, Board Trustee for Saint Patrick School Board, Masterton ∑ Wife Employed as Senior Caregiver at Lansdowne Park Aged Care Facility Joy Cooper ∑ Chairperson Wharekaka Trust Board Incorporated Member

Updated: 2020-04-16 1

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Norman Gray ∑ Association of Salaried Medical Specialists (ASMS) Branch Representative for Wairarapa Member ∑ Emergency Consultant and Clinical Lead, Wairarapa DHB ∑ Member, Mid Central DHB Jill Stringer ∑ Director, Touchwood Services Limited Member ∑ Husband employed by Rigg-Zschokke Ltd Yvette Grace ∑ General Manager, Rangitāne Tu Mai Rā Treaty Settlement Trust Member ∑ Member, Hutt Valley District Health Board ∑ Husband is a Family Violence Intervention Coordinator at Wairarapa District Health Board ∑ Sister-in-law is a Nurse at Hutt Hospital ∑ Sister-in-law is a Private Physiotherapist in Upper Hutt Jill Pettis ∑ Nil Interests declared Member

Updated: 2020-04-16 2

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Minutes: Kadeen Williams , Board Secretary

Held on 30th March 2020 Zoom, virtual meeting Wairarapa Hospital, Masterton

Board Meeting Public Board Members Present Sir Paul Collins Board Chair Dr Tony Becker Deputy Chair Leanne Southey Member Ron Karaitiana Member Joy Cooper Member Helen Pocknall Member Ryan Soriano Member Jill Stringer Member Yvette Grace Member Sign in at 11:00am Jill Pettis Member Executive Leadership Team Present Dale Oliff CEO WrDHB 1. Procedural Business

Note to extend a thank you to all the Health professionals in the current difficult circumstances. Now is the time to show leadership

1.2 Apologies As noted above

1.3 Minutes from previous meeting

∑ The Board RESOLVED to approve the minutes of the Members’ Minutes from the previous meeting as a true and accurate record of the meeting ∑ The Board NOTED Minutes were updated with minor spelling and wording updates with Chairperson and administrator prior to the meeting

Moved R.Karaitiana Seconded R.Soriano Carried

Action Items Register

∑ The Board NOTED and CONFIRMED no previous actions to be followed up

Work plan 2020

∑ The Board NOTED that business as usual will be continued as required but there will need to be changes as required due to current circumstances

Interest/Conflict Register

∑ The Board NOTED that there are no changes to the interest register to be declared in the meeting ∑ The Board CONFIRMED current conflicts prior to discussion on each item of the agenda are accurate with one Board Member (R.Karaititana) having a conflict with the Funder Commitments 2020/21 paper under Public Excluded

Wairarapa DHB Board Meeting Page 1 of 5

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Chairperson reports

∑ The Board received a VERBAL update which has been NOTED ∑ NOTED Weekly Friday Ministerial meetings coordinated by Michelle Arrowsmith ∑ NOTED Meetings discuss working relationships across Health and importance of good Leadership at all levels. DHBs are receiving regular updates on funding, guidance, planning and reporting with a focus on vulnerable communities ∑ NOTED Ministry has asked to try keep business as usual where possible as there is still a need for healthcare

Chief Executive Reports

The report was taken as READ, NOTED and this paper and discussed The Board: ∑ NOTED COVID-19 updates: ∑ COVID-19 works are changing daily so the latest advise will be presented verbally ∑ Minister requested DHBs to set up local testing assessment centres and have Community Based Assessment Centres (CBACs)) ready to be available when called for (within 24hr notice) ∑ The Primary Health Organisation (PHO) and Masterton Medical Limited (MML) set up the COVID assessment centre on Columbo Rd, Masterton ∑ The DHB set up the Emergency Operation Centre (EOC) on Sunday 21st March 2020 ∑ The Hospital set up a single point of entry with testing and is adhering to the latest visitor policy/guidance for social distancing ∑ David Mates and Dale Oliff are working with the Ministry to develop National policy and community responses. For Hospital Operations ∑ Monday 22nd March Local General Practices have set up testing sites outside practices and a mobile unit is being progressed for rural areas with Wellington Free Ambulance (WFA) ∑ There are constraints with Personal Protective Equipment (PPE) and protocols and guidance on the use of PPE is being developed to help mitigate ∑ Essential services encompasses orderlies, cleaners etc. Further education for staff and their families through the Workforce/Welfare streams is being organised to assist with anxiety levels ∑ NOTED Boarders being closed has caused delays with Clinical staff entering the Country (14day stand down) which have been appropriately mitigated to ensure continued clinical cover ∑ NOTED Messages for general population to be reminded to access healthcare when they are unwell. Our communications have been updated to show “If you need care, we are here” ∑ NOTED More ventilators have been ordered for a total of seven (7) to be available. Staff are receiving training for these ∑ NOTED Waitlists are being reviewed and updated for those in high need to receive treatment and those whom can be delayed after best practice and conversations with patients ∑ NOTED Community and Public Health Advisory Committee (CPHAC) delayed, next meeting April 2020 ∑ NOTED Healthcare workers who enter people’s homes will be provided with appropriate PPE. There will be further guidance provided from a National level

ACTION Follow up with PPE training and supplies for community workers to be included at next meeting

Wairarapa DHB Board Meeting Page 2 of 5

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2 Patient Story Maori Health The Board received a VERBAL update which has been NOTED ∑ NOTED due to technical difficulties the verbal report was interrupted and an electronic version of the patient story will be sent through to the Board for there information

3 Presentation Primary Health Organisation The Board received a VERBAL update which has been NOTED ∑ NOTED Testing Assessment Centre set up on Colombo Road, Masterton; good access and space ∑ NOTED Wairarapa is a large area with a high needs population. Working with the five (5) practices throughout the community. The Masterton Assessment Centre is open seven days a week, referral only with easy scale up options. Afterhours are through normal processes Emergency Department (ED) and other community services ∑ NOTED There are good infection control systems in place similar to international processes to keep staff and patients safe and to minimise spread. The PHO are taking infection control very secure for all zones ∑ NOTED Virtual health at medical centres are in use across the Wairarapa ∑ NOTED The DHB, Maori Health team has been an invaluable resource. We are one team Kotahitanga – teamwork. ∑ NOTED Currently working on establishing mobile units with WFA, support Maori and pacific plans, follow through with vaccinations (Flu stock can be distributed as needed). Watching closely on the costs but doing what is needed ∑ NOTED All the CEs supported the GPs to get further assistance and to keep the workforce functional at the primary care level Nationally ∑ NOTED PHOs have locums to assist and provide information to get more Clinical staff on-site

4 Visit Allied Health The Board received a VERBAL update which has been NOTED ∑ NOTED Due to technical issues we have not been able to receive the full verbal presentation for Allied Health and this will be re-presented to the Board at the April Meeting

5 Information Finance Report The report was taken as READ, and the Board NOTED ∑ NOTED budget is $15K positive but further work to identify costs for further improvements ∑ NOTED high cost for staff, to be recalculated ∑ NOTE Forecasted deficit is in an early stage due to financial commitments not visible at the moment, further reporting to be done ∑ NOTE The Financial, Risk and Audit Committee (FRAC) emphasised that the financial team will capture COVID-19 costs separately through year end. FRAC Chair advised very good numbers at this stage

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Planning & Funding Report The report was taken as READ, and the Board NOTED ∑ NOTED Flu vaccinations, Further distributions to be received ∑ NOTED Providers will be paid. New ways to provide services to be looked into due to the National state of emergency ∑ NOTED Youth Health Services, good direction but further work to be done ∑ NOTED April 2020, strategic direction to have priorities and details on reporting expectations ∑ NOTED Mental Health in the community, Welfare options are being worked through with all the DHBs in conjunction with Addictions, Family Violence etc. across a number of different service providers including local police Hospital & Community Services Report The report was taken as READ, and NOTED ∑ NOTED Orthopaedics vacancy being recruited for. Capital Coast and Locums supporting WrDHB ∑ NOTED Anaesthetists working 1:1, while we wait for further staff who are in stand-down for 14days; we will then have five staff ∑ NOTED ED wait times are just under the target. Currently lower numbers than expected are coming through; on mark to meet the target going forwards ∑ NOTED C-Section rate has increased 34%, Maternity are looking to to audit this procedure to get more information. At this stage they are higher needs for births

6 Other General Business

∑ What technology is available to be used to ensure social distancing and to keep Patients involved with Health. Resolution to Exclude the Public SUBJECT REASON REFERENCE Public Excluded Minutes For the reasons set out in the public Board agenda Section 9(2)(f)(iv) Information contained in the paper may be subject to change as the information has not yet been reviewed by the FRAC Chief Executive’s report Section 9(2)(j) Paper contains information and advice that is likely to prejudice or disadvantage negotiations Clinical Board Minutes Draft Minutes from sub-committees. Papers contain Section 9(2)(b) March information and advice that is likely to prejudice or disadvantage negotiations. Remuneration Minutes February Lease agreement for room Any department or organisation holding information to carry Section 9(2)(j) in new Featherston out prejudice or disadvantage, negotiations (including Medical Centre commercial and industrial negotiations Section 9 (ba)(i) Quality, Risk & Innovation Would be likely to prejudice the supply of similar information, Quarterly Report, February or information from the same source, and it is in the public 2020 interest that such information should continue to be supplied Clinical Board Update Correspondence Commercially sensitive information Section9(2)(i) Moved P.Collins Seconded J.Cooper Carried

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Meeting Closed: 11:32am

CONFIRMED that these minutes constitute a true and accurate record dated Tuesday 28th April 2020

Sir Paul Collins Chair, Wairarapa District Health Board

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PUBLIC WrDHB MEETING ACTION

Wairarapa DHB Public Action Register Opened Completed # Lead Action How Dealt with Owner Due date date Date Details provided Further information on PPE training and supplies for 1. D Oliff through the COVID- D Oliff 30/03/20 28/04/20 28/04/20 community workers 19 report

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Wairarapa DHB Work Plan 2020

Regular public monthly items: Chair report CEO report Hospital & Community Services Finance Resolution to exclude the public People & Capability Quality & Risk Patient Story Planning & Funding

Financial Quarter 3 Financial Quarter 4 Financial Quarter 1 Financial Quarter 2 27th 27th 30th 28th 25th 26th 27th 31st 28th 27th 30th 14th January February March April May June July August September October November December Draft AP and Funder Policies/Procedures Budget Commitments Legislation H&S Planning 3D Sub Regional Pacific Health & National National Draft 2019/20 Final Annual Plan Wellbeing Agreements & Agreements & Delegation MH Report 2019/20 Solutions Ltd & Te Strategic Plan Negotiations Negotiations Hauora Runanga o 2020/25 Wairarapa Inc n o

i MHAIDs s

i Food and Catering Final Financial

c Consultation Seismic Updates

e Contract (Defered) Plan 2019/20

D Document Youth Health Development Services (CPHAC) 3D Sub Regional Pacific Health & Wellbeing Strategic Plan 2020/25 (Deferred May) Update on VIP Draft Annual Plan Clinical Board ICT Reporting Māori Health Pacifica Health ICT Reporting Pacifica Health ICT Reporting Māori Health unit 2020/21

Clinical Board Consumer Consumer Draft Financial n Māori Health Iwi Kainga Clinical Board Māori Health Clinical Board Iwi Kainga o i (Defered July) Council Council Plan 2020/21 s s u c s

i “5” Equities Strategic Direction Strategic

D Iwi Kainga Pacifica Health Update (Deferred May) Direction

Consumer Council n o

i Regional Public Regional Public Regional Public Regional Public t Primary Health Allied Health “5” Equities Public Health Midwifery Public Health Family Violence a

t Health Health Health Health

n Care Services Update Organisation Liz Darling Organisation & Partner Abuse

e Population Population Population Population s Justine Thorpe Nicky Rivers ELT Justine Thorpe Leila Sparrow Justine Thorpe Jennifer Milne e

r Peter Gush Peter Gush Peter Gush Peter Gush P

Mental Health Palliative Care &

s Older Persons’ Allied Health Acute Respite & Selina Sutherland t

i Hospice Maternity & Taku Wahi WrDHB s

i Services Services N/A Marae Community Marae Hospital Carter Court Pediatric Services Jason Kerehi Executives V Lyndale Care Nicky Rivers Services Cate Tyrer Lynley Batson Nigel Fairley

Updated: 20/04/2020 11:00 p.m.

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PUBLIC

BOARD INFORMATION PAPER

Date: April 2020

Author Dale Oliff, Chief Executive Wairarapa District Health Board

Subject Chief Executive Public Report to the Board

RECOMMENDATION It is recommended that the Board: a. Notes this paper and discusses as appropriate APPENDICIES 1. Communications update March 2020 2. Kia Ora Hauora Central Region Quarter two Report October – December 2019

1 PURPOSE

The purpose of this paper is to provide the Board with updates from across the hospital and wider Wairarapa Health Community. It highlights work that is occurring at the Wairarapa District Health Board (WrDHB).

2 COMMUNICATION

We have provided a brief outline of the media coverage of interest through appendix 1. Please note due to current COVID-19 status the media of interest specific for the Wairarapa District Health (WrDHB) Board is very minimal. Media Interest has been related to COVID-19 which we will update separate to this report.

3 CORONAVIRUS

Following the state of emergency declaration on 25th March 2020 due to COVID-19 the Wairarapa District Health Board and wider Health Community has successfully pulled together in response. As of the 20th April 2020, the Wairarapa has a total of six (6) confirmed and two (2) probable. All the Wairarapa people have recovered and the region is shown as having no positive coronavirus people at the moment Despite this testing is ongoing through the Wairarapa by all practises. The MOH website showed that 755 people had been tested at a rate of 16.3% (per 1000 population) which in one of the highest in NZ. Our Primary Health Teams are working with local practices for assessment centres in the communities while also manning a larger drive through swabbing station in Masterton, Colombo Road. The COVID-19 environment is changing daily and having a significant impact on all aspects of all New Zealanders lives. Coronavirus has been a challenging time for all of the community and I wish to acknowledge the leadership and actions of our PHO and medical practices also the aged residential in meeting the challenges. The secondary and hospital services have also responded in an excellent way in preparation to meet the challenges and many hour of work has gone into the planning and execution of the plans in line with the national hospital response guidelines.

Wairarapa District Health Board Page 1 of 3

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PUBLIC

4 INFORMATION

DHB Staff News Donations for Masterton Foodbank, Our social work team had been collecting donations and to date has donated 108 tins of spaghetti, baked beans and 108 jars of jam. While these are high numbers there are an average of 40 food parcels delivered a day so continued support would be appreciated. Thank you to the team for their hard work. Kia Ora Hauora Quarterly Report October – December 2019 In New Zealand and specifically the Wairarapa a key workforce priority is the recruitment and retention of Maori into the health sector workforce. Kia Ora Hauora (KOH) is a National programme to support Maori into Health which the WrDHB is proud to be able to lead and support for the Central Region. WrDHB saw the first Champions programme member Tama Paku, a year 13 Wairarapa College student finish in December, 2019 after a full calendar year with us. Having spent time with Physiotherapy, Pharmacy, Occupational Therapy, Theatre, Urology, Kaupapa Maori community health and the Violence Intervention team. Tama has since been accepted to study health sciences at Otago University during 2020. While the WrDHB has had 12.28% of the total 57 Maori registered in this quarter for the central region we have staff passionate and working to expand on this programme for the Wairarapa. The full report has been attached as appendix 2.

Thank you to Staff I have received a phone call from a patient who has been a health professional for many years acknowledging her experience in our hospital from emergency services through to the medical and surgical work. The Caller cannot speak highly enough of the attitudes and the care and for the way in which she was treated at all times in our hospital. She is unable to communicate through the written form and has asked that I let both the Board and staff know of her experience.

5 NURSING ACTIVITY

Main focus for nursing activity has been to prepare for advent of COVID-19: ∑ Scheduled education and training has been suspended and clinical nurse educator time re-focused into upskilling nurses with regard to Infection, Prevention and Control (IPC) practices including use of Personal Protective Equipment (PPE), ventilator training, orientation of staff to different areas to enable redeployment as required. Nurse Entry to Practice The new Nurse Entry to Practice (NETP) Clinical Coach commenced at the WrDHB at the end of March 2020 and in addition to operationalising the NETP support role has been active in supporting other areas of COVID-19 preparation e.g. with Welfare and Workforce and Planning and Performance teams.

Wairarapa District Health Board Page 2 of 3

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PUBLIC

Care Capacity Demand Management There is no doubt that the Care Capacity Demand Management (CCDM) programme will be impacted by COVID-19, however at this point just what this will be is unclear. The programme itself is on track for completion as required by end of June 2021: ∑ The Full-Time Equivalent (FTE) calculations for 2021 year have been completed. How these will be operationalised given the changes to services that are occurring as a result of COVID-19 will need to be considered. It is my recommendation that the FTE calculations for Acute Services be implemented as the workload due to COVID-19 is more likely to increase rather than decrease. ∑ Implementation of TrendCare into Maternity Services is currently on track with different solutions for training Maternity staff being investigated. ∑ Variance Response Management component is ready to be rolled out when appropriate although much of the foundational work is already being undertaken given the need to be able to redeploy staff as part of our COVID-19 response. NB: this is being worked through from a WrDHB-wide perspective, not just from a provider arm perspective. 2020 Year of the Nurse It is ironic that the effects of COVID-19 should strike in this World Health Organisation (WHO) ‘Year of the Nurse’. Nurses in the Wairarapa DHB are responding positively and well to the challenges that this has presented. International Nurses Day (12th May 2020) this year will require some re-thinking as the annual quiz night will not be able to go ahead.

Wairarapa District Health Board Page 3 of 3

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Patient experience of ED and staff reflection

Presented by: Viv Petersen, Quality Facilitator Acutes Clare Matthews, Patient Experience Coordinator

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Meet Mrs S

• Married for 63 years • Lived in Masterton for 40 years • Mother, Grandmother & Great Grandmother • Lead a fit and active life • Varied jobs over the years • Loved to garden and maintains a passion for horses

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Presentation to ED via Ambulance

• Ambulance called to Mrs S 16.50 by husband due to suspected stroke

• Admitted to ED 17.35hrs • Triaged 17.45hrs • Seen By Dr 23.15hrs • Discharged home 23.45hrs

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ED situation

17.35pm Mrs S arrives by ambulance

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What caused the long waiting times in ED • Number of presentations • AM shift admission numbers • AM shift presentations waiting to be seen overflowed into PM shift • Bed block • Complexity of patients • Availability of Drs

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• Demand on the Emergency Department has been increasing steadily over the last 6 years with presentation complexity increasing in keeping with a growing and aging population.

• Steady rate of presentations over the day from 0800-2200 but staffing levels drop around 1700 which extends waiting times for those patients presenting in the evening.

• The increased demand on the evening and nightshift within the emergency department needs to be reviewed with the increased demands taken into account.

• The current situation presents significant risks.

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Allied Health Services

The current picture - who, what and how? and Future opportunities

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Who are we?

• The allied health team at Wairarapa DHB represents a diverse group of health professionals and assistants who work together with medical and nursing staff to deliver care that supports people to 'live well, stay well and get well' (NZ Health Strategy 2016).

• Each professional group within the allied health team has distinct and specialist body of knowledge and skills, which they apply when working with people accessing health and disability services across a range of inpatient, outpatient and community settings. https://www.health.govt.nz/about-ministry/leadership-ministry/allied-health

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Who are we – WrDHB profile

The allied health team at WrDHB includes the following professions together with our allied health Assistants: • Dietetics • Occupational Therapy • Physiotherapy • Social Work • Speech-language Therapy

+ Child Development Service.

Others are stand alone services or fall under the scientific and technical professions group.

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What do we do?

The allied health team provides services and works together with clients in the areas of: • Prevention • Assessment / evaluation • Identification / diagnosis • Treatment • Rehabilitation • Advocacy • Promotion of health and wellbeing • Education

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WrDHB Allied Health staffing

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AHST staffing – national view

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Dietitian service

Evaluate scientific evidence about food and nutrition, and translate it into practical strategies.

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The Figures

O/p Referrals Dietetics 2018/ 19 36% Obesity / Bariatric / Overweight ↑↑

Electrolyte Abnormalities Eating Disorder 15% Post ward follow up ↓ Chronic Renal Failure Pregnancy Enteral Nutrition 12.80% Diabetes ↑↑ Chronic Liver Disease Healthy Eating Dyslipidaemia 10.77% Unintentional weight loss ( CA often ) ↑ Feeding Problems Constipation Congestive Heart Failure Diverticular Disease Bowel Disease Other Faltering Growth Underweight Coeliac Disease 1.6 FTE Allergy / Intolerance Irritable Bowel Syndrome Acute + OP / Community Unintentional Weight Loss ↑ Increasing population Diabetes Post ward Follow Up ↑ Complex patients Obesity / Bariatric / Overweight 0 20 40 60 80 100 120 140 160 180 “ Generalist”

Number Referrals +/- Inpatient demand seasonal

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Dietetics

• Aim to support our patients better - right service, right time, right place • Better integration of GPs / PHO and DHB services • Community dietitians? to support patient transition • Obesity – better outcomes? • Group sessions , non DHB services • Support our people with Diabetes appropriately

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Occupational Therapy

Occupational therapy is a client-centred health profession concerned with promoting health and well being through engagement in occupation.

The primary goal is to enable people to participate in their activities of daily life.

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Occupational Therapy

Occupational Therapists help people of all ages and work in a variety of settings to support people to: • Learn new ways of doing things following illness or injury • Develop new skills, abilities or interests • Access support available in the community • Provide adaptive equipment and home modifications • Make changes in work environments • Enable social participation • Regulate emotions • Achieve goals • And much more!

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Physiotherapy

• Physiotherapy uses proven techniques to help restore movement and function to anyone affected by an injury, disability or health condition.

• A Physiotherapist uses their in-depth knowledge of how the body works and hands on clinical skills to assess, diagnose and treat or manage symptoms.

• Acute services, Rehabilitation, Outpatients, Community and Selina Sutherland Hospital.

• 6.0FTE Physiotherapists.

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Social Work

• 4.8FTE, 7 Social Workers • 3 with community caseloads. • 3 hospital based, but all have community cases as well. • Plus Team Leader – hospital based.

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What do we do?

All sorts of roles within the DHB:

• Support people while in hospital and at home to make changes that empower them. • Support patients experiencing family harm. • Social work input to Termination of Pregnancy Service. • Support whanau / families during traumatic events. • Debriefs and support for staff. • Court applications for welfare guardianship. • Child abuse – suspected and known. • Liaison with community supports.

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Speech-language Therapy (SLT)

• 2.1FTE Speech-language Therapists in Allied Health, • Provide full range of secondary SLT services with valued input from trained AH assistants. • Relatively high inpatient component (ED through to Rehab including Paeds). • Hospital and primary care based outpatient clinics and community visits to peoples homes and ARC facilities. Joint clinics with Dietitians, ENT, Paediatricians.

• Core business: assessment and treatment of paediatric swallowing disorders, adult swallowing problems in mouth and throat (oropharynx), voice and upper airway disorders, acquired speech and language disorders. Aetiologies: stroke/ neurological, head and neck cancer, COPD/respiratory, prematurity, cleft, syndromes, other.

• Need access to objective testing: videofluoroscopy and FEES/ fibreoptic endoscopic evaluation of swallowing. New fluoroscopy unit with TIMS software will improve diagnostic imaging for swallowing disorders and offer possibility of CRT (cough reflex testing). Limited access to FEES and ENT/nasendoscopy. Videostroboscopy via Sub Regional Voice Clinic.

•

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Primary/Secondary Care challenges

• Swallowing disorders/dysphagia associated with morbidity/mortality • Multiple referral routes for dysphagia: SLT, ENT, General Surgery, Gastroenterology, Imaging • Health Pathways assume knowledge of appropriate referral route • Direct referral to Imaging bypasses clinical pre-assessment by SLT • Results in unnecessary radiation, delay, and expense • Frequently standard Barium Swallow requested when Modified Barium Swallow aka Videofluoroscopic Swallow Study VFSS needed • COPD exacerbations and dysphagia closely linked by research • Paediatric dysphagia in premature babies, and children who’ve undergone aversive experiences as a baby: tube feeding, intubation, syringe feeding, tongue tie revision, reflux, challenge the limited Paediatric SLT service, paediatricians, nurses, WCP, GPs, families.

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Child Development Service

Multidisciplinary Clinical coordinator 0.2 FTE, Occupational Therapy 0.4 FTE, Physiotherapy 0.5 FTE, Visiting Neurodevelopmental Therapy 0.5 FTE, Clinical Psychologist 0.4 FTE, Speech and Language Therapy 0.2 FTE.

Assessment and treatment of children aged 0-16 with a diagnosed disability or at risk of a developmental disorder.

Provision of specialist equipment.

Extremely long waitlists for assessment service, both cognitive and multidisciplinary. Funding for CDS is directly from MOH. Some extra funding in budget 2019 for the next four years – total $8000,000.00 for the country’s CDS’. Central region received $615,000.00. Wairarapa CDS received $34,501.00. Need to think innovatively about how to spend this to make an impact on waitlists, which is the focus for MOH.

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CDS – Challenges going forward

• MOH working towards equity across the country. They have signalled that they do not want to contract with 33 separate CDS providers. What will that mean for us? • Current waitlists cannot be addressed by the current level of funding and staffing.

• Autism Spectrum Disorders (ASD) assessment referrals exploded a few years ago. Foetal Alcohol and Foetal Drug Spectrum Disorders will be the next wave. It is anticipated that these will come through CDS.

• Issues with service provision are both financial, but also one of workforce availability.

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CDS – Positive Strengths

• We do have a very cohesive group of agencies in the Wairarapa who work together well and meet monthly.

• We are already community focused – a MOH driver for service delivery going forward.

• Having to find different ways of service provision during the Covid 19 crisis may prove to be positive. This is especially true working in a rural area, where travel can be a significant part of the service provision.

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Current and future direction

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Current and future initiatives

• Community response teams – admission avoidance, Hospital At Home.

• Increased ED engagement to support sustainable discharge planning and reduction in admissions for social reasons.

• Community rehabilitation – stroke, ACC Non Acute Rehabilitation.

• Musculoskeletal initiatives – working with orthopaedics at point of referral to implement evidence based assessment and interventions to maximize function and minimize / delay surgery, plus optimize pre-op function.

• Increased multi and interdisciplinary models of working.

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Current and future initiatives

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PUBLIC

BOARD DECISION PAPER

Date: April 2020

From Sandra Williams, Executive Leader Planning and Performance

Author Lisa Burch, Service Development Manager, Planning and Performance

Endorsed By Dale Oliff, Chief Executive Officer, Wairarapa District Health Board

Subject Youth Health Service Development

RECOMMENDATION

It is recommended that CPHAC: a. Note the DHB and Tū Ora Compass Health have received a report: Feasibility Study. The Effective delivery of Youth Health Services in the Wairarapa. b. Notes the report found that, while there are individuals and services providing invaluable healthcare to young people, services are not connected to each other, and for many young people there are multiple barriers to care. c. Notes in 2019/20 Wairarapa DHB has invested $500k in localproviders (excludes community AOD and mental health services) of youth health services. d. Notes the DHBs current investment in youth health services has not been reviewed for some years, and there are expected to be reinvestment opportunities, and a small additional investment may be needed, post 2020/21, in the next three to four years. e. Notes This paper has been approved through the Community and Public Health Advisory Committee. f. Agrees to recommend that the Board accept the feasibility study, and endorse the development of a youth health service development programme of work that addresses the recommendations. g. Agrees to recommend to the Board that the 2006 Wairarapa Youth Health Strategy be refreshed to guide the service development programme.

APPENDICES

1. McKenzie, Feasibility Study. The Effective Delivery of Youth Health Services in the Wairarapa, December 2019. 2. Wairarapa DHB, Life 2 Go! Youth Health Strategy 2006 – 2009.

1. PURPOSE The purpose of this paper is to advise the Committee of the findings of a recent review of youth health services in Wairarapa. The paper is seeking endorsement of a proposed process for addressing the findings of the review. 2. BACKGROUND In 2019 the DHB and Tū Ora Compass Health were approached to consider options for relocating the Youth Kinnex Clinic which operates out of premises in Masterton. Currently this clinic is funded jointly by Tū Ora (rental, via Connecting Communities) and Masterton Medical (personnel costs).

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PUBLIC The venue is no longer fit for purpose. Due to its size it is unable to support more than one clinician at a time and is unsuitable for many consults, e.g. sexual health. Masterton Medical Limited (MML), Tū Ora Compass Health (Tū Ora) and Wairarapa DHB (the DHB) jointly agreed that any decisions about the future of Youth Kinnex should be considered within the context of all funded youth health services. The organisations commissioned a review which was conducted by Maria McKenzie, with a final report received in December 2019. The report, which is attached as Appendix 1, makes a variety of recommendations on ways in which services could be delivered so as to improve accessibility of services and thus health outcomes for our young people. 3. CURRENT DHB YOUTH INVESTMENT The range of services available to youth in Wairarapa is detailed in the McKenzie report. These service arrangements have largely resulted from new Ministry of Health funding which has subsequently been absorbed into the DHB’s baseline. DHB discretionary spending which is funded outside of the Service Coverage Schedule, e.g. free sexual health, and the Kuranui College Clinic, has not been reviewed for over ten years. The DHB’s current investment in youth specific services is outlined in table 1 below. This excludes capitation funding paid to each practice based on the number of young people enrolled. Table 1: DHB funded youth services SERVICE PROVIDER 2019/20 FUNDING COMMENTS Free sexual Tū Ora $75,740 This funding is allocated to practices, with low health for utilisation in some practices. The new MOH under 21 year contraception funding rolled out in 2019 should olds reduce the demand for this funding Youth primary Tū Ora $74,328 Counselling provided under the To Be Heard service. mental health This service, and funding level has not been reviewed service since the inception of the service. Youth alcohol Tū Ora $2,222 Funding available to practices to fund brief brief interventions in primary care. intervention School based Tū Ora $119,317 Historic MOH funding for nurse clinics in decile 1 – 3 health services schools (Makoura, Kura, Teen Parent Unit, Alternative Education). DHB has provided additional funding for clinic at Kuranui. DHB and Tū Ora have agreed that funding would be used for GP and nurse clinics. School based Tū Ora $34,992 Additional funding made available 2019/20 for nurse health services clinics in decile 5 schools. Implementation in Chanel College underway. Youth Multi- Emerge $186,942 3DHB service based in Wellington. 1 FTE dedicated to Systemic Wairarapa. Payment through IDF to CCDHB. Therapy (MST) service Community Pathways Pathways: 2 FTE FTE working with young people with mental health mental health and Te clinical, 1 non- and addiction support needs. and addictions Hauora clinical services Te Hauora: 0.5 FTE approx

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PUBLIC Table 2: Services provided by other funders SERVICE PROVIDER COMMENT Youth Kinnex Clinic MML/Tū Ora Currently 2 sessions per week. Masterton based drop in clinic. Funded by MML and Tū Ora. Service demand is exceeding current provision. Piki Tū Ora MOH funded pilot mental health programme for 18-25 year olds.

Table 3: Proposed service Access and choice TBC A 3DHB response to the RFP was successful and the detail for primary mental health (awaiting Wairarapa is currently being agreed. initiatives – Youth contract) funding stream Youth Primary Mental TBA WrDHB has responded to a MOH RFP closing 9 March 2020. If Health successful Te Hauora Runanga will employ 2FTE Youth Kairarahi / navigators who will be attached to the school and youth clinics.

4. PROPOSED SERVICE DEVELOPMENT APPROACH As described above and in the McKenzie report, the current investment in youth health services reflects historic decisions rather than a strategic approach. We consider that the recommendations contained in the attached report provide a feasible pathway towards providing an accessible and appropriate range of services for young people. We propose that a detailed implementation plan is developed that enables rapid action where needed to address service gaps, alongside more detailed needs analysis, stakeholder consultation, and collaboration with other Government agencies and social service providers. The key immediate actions we propose include: 4.1 Establish Youth Service Implementation Group This group will be responsible for addressing the recommendations of the McKenzie report as they pertain to community based health services provided to the young people of Wairarapa. The group will include youth representation. 4.2 Develop process for youth participation In conjunction with the youth representative/s on the Implementation Group, a process for meaningful youth participation in health service development will be developed, Options might include youth ambassadors, a DHB Youth Reference Group, or tapping into the Youth Council. 4.3 Procure appropriate premises for the Youth Kinnex Clinic The youth mental health proposal submitted to the Ministry this month requires that the new youth workers are co-located with youth services to enable “warm-handover’ from other clinicians. This is not possible in the current premises. All the funding partners are committed to finding premises that will enable a holistic approach to youth needs. Some DHB funding may be required to facilitate this. 4.4 Refresh the 2006 Wairarapa DHB Youth Health Strategy The 2006 Youth Health Strategy was based on wide consultation and youth development principles. We consider we can relatively quickly “refresh” the document to provide on-going guidelines for service development. 4.4 Identify opportunities for rapid improvement initiatives and re-prioritisation Some opportunities for ‘quick-wins’ are already apparent. For example, the sexual health contract pre- dated the establishment of the Youth Kinnex Clinic, and is now supplemented by the low-cost contraception initiative.

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PUBLIC 5. CLOSING STATEMENT It is proposed that Management will provide the Board with a progress report and detailed implementation plan in October 2020. A small investment of new funding may be required to extend access to all young people across the valley in the outyears.

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PUBLIC

BOARD INFORMATION PAPER

Date: April 2020

Author Sandra Williams, Executive Leader, Planning & Performance

Endorsed By Dale Oliff, Chief Executive Office, Wairarapa District Health Board

Subject Planning and Performance Report for April 2020 RECOMMENDATION It is recommended that the Board: a. Notes this paper and discusses as appropriate.

1 PURPOSE

This paper provides an update to the Board on the work being progressed by Planning and Performance.

2 STRATEGIC DIRECTION FOR HEALTH SERVICES IN THE WAIRARAPA

The Community and Public Health Advisory Committee (CPHAC) considered the draft Strategic Direction Hauora Mō Tātou We are Wairarapa 2020-2030 at the April meeting. The version included in the Board’s agenda will incorporate the feedback from CPHAC. Work is beginning on the Clinical Services Plan and we will report next month on the scope and timelines for this work.

3 ACCOUNTABILITY

3.1 Annual Planning The Annual Plan, Statement of Service Performance and System Level Measures Improvement Plan 2020/21 first draft was submitted to the Ministry of Health (MOH) on the 2nd March 2020. We are still waiting for information on the funding envelope for 2020/21 and any new annual planning guidance. We understand from the Ministry of Health that they are reviewing their 2020/21 Annual Planning timelines and we can expect new guidance around the impact of COVID-19, and the future path to recovery. Feedback from MOH is now expected in mid-May 2020 with the revised Annual Plan due back to the Ministry mid-June 2020. 3.2 Quarterly Reporting The MOH has notified DHBs that a reduced level of reporting is required for quarter 3 2020.

4 YOUTH HEALTH

Recommendations of a recent review of youth health services are being considered by CPHAC at the April meeting for endorsement at the April Board meeting. In anticipation of Board approval, work is underway to refresh the DHB’s 2006 Youth Health Strategy. Work will also begin shortly on a reconfiguration of the current youth and school health services delivered by Tū Ora Compass Health and the seven practices. A proposal for the relocation of the Youth Kinnex clinic has been received from Connecting Communities. In collaboration with Masterton Medical and Tū Ora Compass Health, Management will consider options for supporting the clinic from reconfiguring existing investments.

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PUBLIC 5 NEW FUNDING

Suicide Postvention The 3DHBs have received funding for suicide prevention from the MOH for additional Full Time Equivalent (FTEs). The Wairarapa DHB’s (WrDHB) share is $17,814 for 17 months (April 2020 to September 2021). COVID-19 The Government has made available the first stage of a primary care response package to the COVID- 19 pandemic, to be available until 30 June 2020. This includes nationally: - $32 million for community-based assessment clinics; - $7.8 million for community-based assessments in General Practice (GP) ; - $15 million to be provided as a one-off primary care response payment and to support establishing telehealth/virtual consultations; and - $15 million for COVID-19 related costs in community pharmacy.

The table below lays out WrDHB share of the funding received to date.

Activity Amount General Practice Based COVID-19 Assessments $ 77, 309 General Practice Enhanced Primary Health Care $178,536 General Practice Sustainability Fund $252,946 Community Pharmacy $149,318 Community Based Assessment Clinics $316,264 Establishment [CBAC’s & Mobile Teams] Total funding $974,373 *all figures are GST exclusive

We are expecting funding to be made available for additional costs in Aged Residential Care facilities and for there is also likely to be further funding made available for primary care and community services.

6 FLU VAX FUNDED PROGRAMME 2020

Due to the Alert Level 4 situation the Ministry of Health has extended the timeframe for priority only flu vaccines, so we can ensure as many of those eligible people as possible get immunised. New stocks of vaccine began arriving in the first week of April. The Director General of Health requested a focus on equity and the WrDHB has responded by developing a targeted and tailored approach to the funded flu vaccination programme within the WrDHB area for 2020. The emphasis on getting high numbers of eligible Māori and Pasifika people protected. The DHB Māori Health Directorate and Tū Ora Compass are co-leading this response. Essentially this will be a three pronged approached: static influenza vaccination centres which are likely to be existing marquees located at General Practices but not existing COVID-19 swabbing stations; designated drive through areas as deemed appropriate; mobile clinic for home/community visits if required.

7 SUICIDE PREVENTION AND POSTVENTION

Peer support and counselling provider MOSAIC Tiaki Tāngata has been contracted by the WrDHB to deliver suicide prevention and postvention services in the region. MOSAIC provides services across the Wellington-Wairarapa region and local peer support worker Jared Renata will fill the role of suicide prevention and post-vention co-ordinator. The role has been increased to one full time equivalent to improve coverage and will be for six months.

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PUBLIC 8 HOME ASSESSMENTS WHAIORA WHĀNUI

In preparation for winter and the effects of a potential downturn we have contracted Whaiora Whānui to deliver home assessments with vulnerable whānau (when they can safely enter homes post lockdown) in our community and remedy some of the issues for whānau in terms of home dryness, warmth and water tightness. This programme is known as Kainga Ora “healthy homes” and will be complemented by existing local whānau ora services.

9 REFUGEES

We have been advised that the refugee settlement programme is on hold indefinitely due to the COVID-19 pandemic, with no families being settled into the new settlement areas. The families who arrived just prior to the borders being closed will move to existing settlement areas. The families who were due to settle in Masterton did not arrive in New Zealand.

10 3DHB COMMUNITY INCIDENT MANAGEMENT TEAM

We are continuing to work with Capital and Coast DHB (CCDHB) and Hutt Valley DHB (HVDHB) as part of a 3DHB Incident Management Team (IMT) which has a community response workstream. This work includes the response plan for primary and community services, older people services, mental health NGOs, modelling and logistics for supplies such as Personal Protective Equipment (PPE). Work is also underway with our local providers to ensure the Wairarapa response is well connected.

11 MENTAL HEALTH

All local mental health providers have activated their pandemic plans and services continue to be provided within social distancing protocols. This includes phone or video consults and doorstep visits for medication management. In some cases providers are taking a more active role in helping people with accessing food or essential requirements. Pathways have been able to close their social detox unit and redeploy staff elsewhere. The rollout of the new primary care access and choice initiative continues despite the current lockdown, with the Health Improvement Practitioner already employed at Masterton Medical working virtually. This has been working well. The Ministry response to COVID-19 has resulted in a delay in funding decisions about new youth primary mental health initiatives and we have not yet heard whether our Request for Proposal has been successful.

12 AGED RESIDENTIAL CARE

We have worked with our Aged Residential Care (ARC) providers over the last four weeks on the planning for COVID-19 readiness. Through site visits, facility contacts and virtual conversations, surveys and distance learning opportunities we have covered a wide range of aspects relating to managing residents and staff safely through the current stage of COVID-19. We continue to build on this work to ensure that our facilities are well prepared.

13 PRIMARY CARE

The Primary Health Organisation has been working with its practices to ensure we have good swabbing and assessment access in place across the Wairarapa. A Mobile team staffed by Community District Nursing has been set up to ensure that GPs can refer people who are unable to easily access the other sites.

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PUBLIC

14 PHARMACIES

All seven Wairarapa Pharmacies remain open during the lockdown period, with appropriate distancing measures in place. Measures are in place to ensure that vulnerable patients continue to access medications, including home delivery services where appropriate. All medications except oral contraceptives are now being dispensed on a monthly basis to prevent stockpiling. Prescribers are asked to pay particular attention to ensuring scripts are accurate and complete, to aid pharmacy workflow and ensure patients receive all medications they require. Community pharmacies have had a busy time from prior to the start of the COVID-19 lockdown through to the end of March when the load started to lighten and they were able to start to catch up. Wairarapa pharmacies have been provided with $149k in funding to use to enable them to manage COVID-19 related costs.

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Wairarapa District Health Board Financial Report

March 2020

Dale Oliff Frank van Ham Chief Executive Executive Leader Finance

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GENERAL NOTE Please also refer to the notes made in CFO FRAC briefing paper re March 2020 results. 1 FINANCIAL PERFORMANCE OVERVIEW

The month of March is unfavourable variance to budget of ($388k) and a favourable $1,509k year to date.

Month $000s Year to Date Annual Actual Budget Variance Actual Budget Variance Forecast Budget Variance (338) (201) (136) Funder (472) (1,993) 1,521 (1,303) (2,875) 1,571 (1) 8 (9) Governance 36 (27) 64 47 (0) 47 (681) (438) (243) Provider (4,248) (4,172) (76) (7,243) (6,666) (577) (1,019) (631) (388) Net Result (4,683) (6,193) 1,509 (8,499) (9,541) (1,042)

The key points March;  Community Pharmacy costs are up $99k due to increased costs as advised by the National Haemophilia Management Group.  Ongoing reliance on Locums to cover Medical vacancies net overspend ($160k) in March. With ($81k) relating to Mental Health for vacancies 2.6 FTE and sick leave cover 1FTE. Anaesthetics were ($64k) unfavourable due to higher than budgeted leave cover required and 1.6 FTE vacancies.  Higher Nursing costs in March, due to additional 4.1FTE ($31k), cost variance of ($11k), mostly due to the annual leave calculation, along with higher than budgeted health workforce and professional development costs ($18k).  Additional Allied workforce cost due to change in staffing mix with Mental Health Professionals, budgeted in Nursing paid, as Allied 3.1FTE and additional Imaging shifts required for Covid-19 readiness 1.6 FTE.  Covid-19 related funding $155k, offset by costs in External Provider Payments, nil impact to the bottom line. We have decreased the forecast deficit by $188k to ($8.50m) as a result of;  The MOH revenue has increased by $549k because of the new funding for Covid-19 pandemic. This is off-set by the higher costs in the Covid-19 expenditure lines, hence there is no bottom line impact.  A further increase in Locum costs to cover vacancies and sick leave specifically in Mental Health, partly offsetting the decrease in employed Senior Medical Officers and the additional locum costs incurred in March ($164k).  Allied workforce increase due to Mental Health staffing mix and Covid-19 requirements ($52k)  Reduction in forecast IDF Outflow $598k based on information to hand. The remaining IDF provision in the balance sheet is subject to ongoing review as we approach yearend.  Other movements in the forecast are reflections from the March month result. Potential financial risks;  Holidays Act provision and remediation process.  Oracle/stock issues now seem to have settled down, stocktake scheduled for May.  Budgeted leaves rate calculation, particularly in Nursing.  Ongoing Nursing FTE creep.  Medical vacancies particularly in Orthopaedics and Mental Health.

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COVID-19 estimated cost tracking to 5/4/20

COVID-19 Cost Tracking as at 05/4/20 $000 Labour related costs $246 Clinic Supplies and Equipment $30 Primary Care $155 Communications $12 Security $6 On-site Triage unit $38 Estimated Operational Expenses $487

Capital Commitments $150

Note: the costs at this stage are largely estimates and have been incurred across the DHB.

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Operating Report for the month of March 2020

Month $000s Year to Date Annual Actual Budget Variance Actual Budget Variance Forecast Budget Variance

Revenue 13,629 13,444 185 Devolved MoH Revenue 121,789 121,269 520 162,729 161,725 1,004 146 168 (22) Non Devolved MoH Revenue 1,319 1,515 (196) 1,774 1,970 (196) 200 196 4 ACC Revenue 1,753 1,766 (13) 2,317 2,355 (38) 377 372 5 Other Revenue 3,682 3,448 234 4,799 4,565 234 322 381 (59) IDF Inflow 3,125 3,429 (304) 4,194 4,572 (378) 98 80 18 Inter DHB Provider Revenue 903 760 143 1,142 999 143 14,773 14,641 131 Total Revenue 132,571 132,187 385 176,955 176,185 770

Expenditure Employee Expenses 909 1,094 186 Medical Employees 8,479 9,800 1,321 11,123 13,114 1,992 2,007 1,947 (60) Nursing Employees 17,890 17,349 (541) 23,891 23,143 (748) 585 530 (55) Allied Health Employees 4,762 4,704 (59) 6,340 6,272 (69) 94 90 (4) Support Employees 780 811 31 1,048 1,077 29 710 744 34 Management and Admin Employees 6,151 6,567 416 8,350 8,776 426 4,306 4,406 100 Total Employee Expenses 38,062 39,231 1,168 50,752 52,381 1,630

Outsourced Personnel Expenses 626 280 (346) Medical Personnel 4,027 2,521 (1,507) 5,542 3,361 (2,182) 5 16 11 Nursing Personnel 120 146 26 169 195 26 14 10 (4) Allied Health Personnel 49 92 43 80 123 43 0 0 0 Support Personnel 1 0 (1) 1 0 (1) 65 68 2 Management and Admin Personnel 528 611 83 797 807 10 710 374 (335) Total Outsourced Personnel Expenses 4,726 3,370 (1,356) 6,589 4,485 (2,104)

293 325 31 Outsourced Other Expenses 2,911 2,921 10 3,894 3,895 1 1,039 1,012 (27) Treatment Related Costs 9,527 9,218 (309) 12,655 12,296 (359) 819 800 (19) Non Treatment Related Costs 6,873 7,381 508 9,512 9,949 437 3,504 3,524 19 IDF Outflow 30,853 31,713 860 41,424 42,284 860 4,917 4,570 (346) Other External Provider Costs 41,476 41,556 80 56,037 55,636 (401) 205 262 58 Interest, Depreciation & Capital Charge 2,827 2,989 162 4,589 4,799 210

15,792 15,272 (519) Total Expenditure 137,255 138,379 1,125 185,453 185,726 273

(1,019) (631) (388) Net Result (4,683) (6,192) 1,509 (8,498) (9,541) 1,043

1.1 Revenue Revenue is favourable against budget by $131k for the month and favourable $385k year to date, this mainly relates to other revenue for donations, rental income from SSH. Increased Devolved MoH Revenue for Pharmaceuticals, Covid-19 primary funding and PHO Capitations services, yet an offset for Kia Ora Hauora and the decreased IDF inflows.

1.2 Workforce expenses Total employee and outsourced workforce expense is ($225k) unfavourable to budget for the month and ($188k) year to date. The Holiday Act Provision, the total provision is $4,988k. This includes the year to date addition of $519k. The Holiday Act provision is at risk and could be significantly understated. We will only know the true impact when we progress through to remediation. The variance by employee type is explained by: • Medical workforce costs are ($160k) unfavourable for the month and ($186k) year to date. Savings in employed personnel are off set with higher costs for locums and external staff. • Nursing costs are unfavourable to budget by ($49k) for the month and adverse ($515k) year to date;

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the areas which are experiencing higher nursing requirements are Acutes, MSW and Palliative Care and budgeted leave calculation underestimated, under review. • Allied Health costs are unfavourable ($51k) for the month and adverse $16k) year to date due to timing and staff mix in the budget. • Management and administration costs are $445k favourable year to date due to vacancies mainly in planning & funding and corporate services.

1.3 Outsourced Other Expenses Outsourced other costs are $10k favourable to budget year to date due to higher Radiology and Ophthalmology costs.

1.4 Treatment related costs Treatment related costs are ($309k) unfavourable year to date largely due to gastro-intestinal and malignant disease pharms and treatment disposables offset in implants and prostheses costs. We are currently forecasting ($359k) unfavourable, but there is potential risk around COVID-19 supplies which are not reflected in this forecast.

Non Treatment related costs Non-treatment related costs are $508k favourable to budget year to date due to a year to date favourable adjustments in stock accounting relating to Oracle processes, timing of the Kia Ora Hauora programme initiatives, IT costs due to Central TAS 18/19 wash up and other IT cost releases and in consultancy mainly due to the adjustment to the Nursing Advisory Board arrangement. We are forecasting the rest of the year to remain in line with budget.

IDF Outflows IDF outflows are $860k favourable to budget year to date and forecast to be $860k at year end. Please refer to the comments in the funder section.

1.5 Other External Provider costs These are $80k favourable year to date and forecast to be ($401k) unfavourable to budget, see funder section for more detail.

1.6 Interest, Capital Charge & Depreciation The year to date position is favourable against budget by $162k this is due to depreciation phasing and rate adjustment, offset by increased capital charge due to late change in building valuation after budgets set.

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2 STATEMENT OF FINANCIAL POSITION

Actual Variance to Previous Movement $000s Budget Explanation of Variances Between Actual and Budget 31-Mar Budget Year End from 30 June

Assets Current Assets Bank 3,257 568 2,689 9 3,248 Accounts Receivable 5,589 4,290 1,299 6,435 (846) Variance is because of higher accruals for funder revenue which was not factored into the phasing of the budget.

Stock 1,155 1,039 116 1,039 116 Prepayments 402 370 32 320 82 Total Current Assets 10,403 6,267 4,136 7,803 2,600 Fixed Assets Fixed Assets 47,252 48,809 (1,557) 50,588 (3,336) Work in Progress 7,916 7,964 (48) 6,490 1,426 Total Fixed Assets 55,169 56,773 (1,604) 57,078 (1,910) Investments Trust Funds Invested 189 185 4 185 4 Total Investments 189 185 4 185 4

Total Assets 65,760 63,225 2,535 65,067 694 Liabilities Current Liabilities Bank 0 0 0 1,799 (1,799)

Accounts Payable and Accruals 13,308 12,103 (1,205) 14,212 (904) Phasing of budgets for payroll accruals was incorrect and level of accrued costs is higher than expected. Income in Advance 7,946 0 (7,946) 240 7,706 Variance is because of $7m cash advance received not budgeted for. Crown Loans and Other Loans 0 71 71 85 (85) Current Employee Provisions 12,889 7,952 (4,937) 10,844 2,045 Higher accrued annual leave than expected - impacted by provision relating to Holiday Pay Act. Total Current Liabilities 34,143 20,126 (14,017) 27,179 6,965 Non Current Liabilities Other Loans 0 0 0 54 (54) Long Term Employee Provisions 639 639 (0) 639 0 Trust Funds 187 185 (2) 185 2 Total Non Current Liabilities 827 824 (3) 878 (51) Total Liabilities 34,970 20,950 (14,020) 28,057 6,913 Net Assets 30,791 42,275 (11,484) 37,010 (6,219)

Equity Crown Equity 90,575 103,869 (13,294) 90,573 2 $7m equity funding budgeted for September and $6m equity budgeted for January - $7m received as cash in advance instead.

Revaluation Reserve 11,234 11,234 0 13,012 (1,778)

Opening Retained Earnings (66,335) (66,632) 297 (51,937) (14,398)

Net Surplus / (Deficit) (4,683) (6,196) 1,513 (14,398) 9,715 Total Equity 30,791 42,275 (11,484) 37,250 (6,459)

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3 TREASURY MANAGEMENT

3.1 Cash Flow Statement & Forecast

Wairarapa District Health Board Cash Flow Forecast For period July 2019 to June 2020

Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Actual Actual Actual Actual Actual Forecast Forecast Forecast $'000 $'000 $'000 $'000 $'000 $'000 $'000 $'000 Cash flow from operating activities Operating receipts 16,728 17,939 15,883 16,670 18,692 16,626 15,902 8,394 Payment to suppliers (12,674) (11,691) (12,846) (11,855) (12,059) (14,770) (13,767) (13,298) Payments to employees (3,965) (5,216) (4,370) (3,853) (3,822) (3,967) (4,290) (4,185) Capital charge 0 (1,036) 0 0 0 0 0 (1,036) GST (net) (634) 0 (1,115) (491) (632) 0 (1,000) (500) Net cash flow from operating activities (545) (3) (2,448) 471 2,179 (2,111) (3,155) (10,624)

Cash flows from investing activities Purhase of property, plant & equipment (442) (125) (125) (298) (327) (631) (263) (259) Net cash flow from investing activities (442) (125) (125) (298) (327) (631) (263) (259)

Cash flows from financing activities Capital contribution from the Crown 0 0 0 0 0 0 0 13,000 Repayment of loan (7) (7) (86) 0 0 0 0 0 Net cash flow from financing activites (7) (7) (86) 0 0 0 0 13,000 Net Cash Flows (993) (135) (2,660) 173 1,852 (2,743) (3,418) 2,117 Opening cash balance 5,025 4,032 3,897 1,237 1,410 3,263 520 (2,898) Closing cash balance 4,032 3,897 1,237 1,410 3,263 520 (2,898) (781) Available Overdraft with NZHP (5,642) (5,642) (5,642) (5,642) (5,642) (5,642) (5,642) (5,642) Balance Available (9,674) (9,539) (6,879) (7,052) (8,905) (6,162) (2,744) (4,861) This table indicates the forecast position at the end of each month. This cashflow forecast includes funding in advance received in October of $7m and now assumes the Ministry will provide us with a $13m equity funding in June 2020 at which time the cash advance will be repaid.

3.2 Borrowing Schedule The following table shows the borrowing facilities currently available to the DHB and the amounts drawn against each facility.

Wairarapa DHB Borrowing Schedule as at 31 March 2020

Facility Limit Maturity Date Balance 31-Mar OCR Interest Rate Paid/Payable $000 $000 Working Capital - NZ Health Partnerships Sweep arrangement ( 5,642) - 1.00%

Selina Sutherland ( 700) $ - 7% Fixed Margin plus OCR

Total Borrowing ( 6,255) $ -

The bank account was not overdrawn during the month. The loan with Selina Sutherland was repaid in January saving $3K interest over 2020.

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3.3 Funding and Equity Changes There have been no changes during the month.

Wairarapa DHB Equity / Funding Changes as at 31 March 2020

Amount (excl GST) Expected Date of $000 Received Repayment MOH Income in Advance

- Cash Disbursement Funding $ 7,000 1-Oct-19 Jun-20

3.4 Foreign Exchange Transactions The following table shows the transactions involving foreign currencies, and is provided for the purposes of monitoring risk.

Wairarapa DHB Foreign Exchange Transactions as at 31 March 2020

Month Year to Date Foreign Foreign Currency Currency Range of Exchange Total No. of Amount NZD Cost Amount NZD Cost Rates Transactions Currency AUD $2,631 $2,682 $85,386 $89,695 0.9250 to 0.9808 21 USD $4,474 $7,128 $41,268 $62,490 0.6379 to 0.6689 7 GBP $0 $0 $1,816 $3,657 0.4964 to 0.4980 2 EUR $0 $0 $0 $0 0 Totals $9,810 $155,842 30

The above transactions are for normal operating and capex costs. These stand-alone transactions were all done at the spot rate on the day.

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4 CAPITAL EXPENDITURE The following table shows the capital expenditure for the year to date.

Wairarapa DHB Capital Expenditure Summary 2019/20

Budgeted Expenditure and Balances Actual Expenditure WIP Balances

Project description WIP Balance Committed Costs Budget for Expected Budgeted Closing Year to Date Year to Date Year to Date Amounts Current WIP Brought Forward from 2018/19 2019/20 Capitalisation Balance Costs Budget Variance Full Year Forecast Capitalised Balances ($000) ($000) ($000) ($000) ($000) ($000) ($000) ($000) ($000) ($000) ($000)

BASELINE CAPEX - WIP - INTANGIBLES Regional and 3DHB Regional - Central TAS - RDHS 4,416 - 324 (1,591) 3,149 137 243 106 324 - 4,553 Regional - Central TAS BAU 469 - 192 - 661 136 144 8 192 - 605 Local Oracle Project 800 243 - (1,043) - 581 243 (338) 518 - 1,381 Gynae Plus Project 17 - - - 17 - - - - (17) - NCAMP - 373 - 250 250 373 - - Webpas Project 538 - 250 (570) 218 252 189 (63) 250 - 790 Diagnostic Sign-offs (Radiology and Lab) - transferred to In Tune - - 67 - 67 52 52 - - - Software Licensing (Citrix, Microsoft) - Growth - - 50 - 38 38 50 - - Software - Cyclical Maintenance & Upgrade - - 25 - 18 18 25 - - Security Improvement Programme - - 25 - 18 18 25 - - Concerto Transition & Enhancements - $25K carried over to 20/21 - - 100 - 72 72 75 - - National Screening Solution - - 25 - 18 18 25 - - CostPro Upgrade - - 250 - 189 189 250 - - In Tune - MDM Implementation ------132 - - TOTAL WIP PROJECTS 6,240 616 1,308 (3,204) 4,112 1,106 1,474 368 2,239 (17) 7,329

BASELINE CAPEX - NON WIP Buildings - Capex < $100k 187 9 187 178 187 59 68 - Seismic Remediation - Front Canopy 250 104 250 146 320 26 130 - Seismic Remediation - Additional Prior Year Costs - 19 - (19) 19 - 19 Clinical Equipment - - Capex < $100k 266 95 150 55 100 (36) 59 - Theatre Lights (approved last year) - 33 - (33) 139 - 33 - DDR and Fluoroscopy (Total of 2) 1,300 - 900 900 1,200 - - - Lease Switching 200 - 80 80 - - - Other Equipment - - Capex < $100k 60 3 60 57 60 6 9 IT - Hardware - - IT Server Upgrade 250 - (250) - (21) - 21 - 21 250 - Capex < $100k 150 (16) 150 166 75 35 19 TOTAL NON-WIP CAPEX 250 2,413 (250) 226 1,777 1,551 2,100 111 587 TOTAL CAPITAL EXPENDITURE (excl GST) 6,490 616 3,721 (3,454) 4,112 1,332 3,251 1,919 4,339 94 7,916 Forecast Overspend 2

In preparation for the 2020/21 budgets a capex wish list has been started to help improve visibility, planning and governance of capex going forward.

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5 FUNDER FINANCIAL RESULT 5.1 Financial Statement of Performance

DHB Funder (Wai) (Wairarapa DHB) Financial Summary for the month of March 2020 Month $000s Year to Date Annual Actual Budget Variance Actual Budget Variance Forecast Budget Variance

Revenue

12,425 12,425 0 Base Funding 111,825 111,825 (0) 149,100 149,100 (0) 1,202 1,017 185 Other MOH Revenue 9,951 9,432 519 13,612 12,609 1,003 27 27 (0) Other Revenue 259 244 15 341 326 15 322 381 (59) IDF Inflows 3,125 3,429 (304) 4,194 4,572 (378) 13,977 13,851 126 Total Revenue 125,160 124,930 230 167,247 166,607 640

Expenditure 183 188 4 DHB Governance & Administration 1,673 1,691 18 2,225 2,255 30 5,710 5,770 60 DHB Provider Arm 51,631 51,963 333 68,864 69,306 442

External Provider Payments 1,124 1,026 (99) Pharmaceuticals 9,510 9,509 (1) 12,619 12,620 0 2 2 (0) Laboratory 13 15 2 20 20 0 1,006 973 (33) Capitation 9,149 8,909 (240) 12,226 11,890 (336) 586 591 5 ARC-Rest Home Level 4,920 5,241 321 6,635 6,957 321 433 467 33 ARC-Hospital Level 4,132 4,139 7 5,487 5,494 7 613 509 (105) Other HoP 4,587 4,635 47 6,138 6,185 47 265 265 0 Pay Equity 2,340 2,383 43 3,134 3,178 43 349 339 (10) Mental Health 2,925 3,028 103 3,972 4,038 66 18 18 0 Palliative Care / Fertility / Comm Radiology 177 176 (1) 232 231 (1) 155 0 (155) Covid-19 Primary Care payments 155 0 (155) 549 0 (549) 364 381 17 Other External Provider Payments 3,567 3,520 (47) 5,025 5,025 (0)

3,504 3,524 19 IDF Outflows 30,853 31,713 860 41,424 42,284 860 14,314 14,052 (263) Total Expenditure 125,633 126,924 1,291 168,550 169,482 931

(338) (201) (136) Net Result (472) (1,993) 1,521 (1,303) (2,875) 1,571

Overall, the result for Wairarapa DHB Funder for the month of March is ($136k) unfavourable to budget and $1,521k favourable for the year to date. The main reasons for the year to date favourable variance are favourable IDF Outflows, lower than expected utilisation in ARC services and Mental Health services for the 2018/19 financial year. We are forecasting a deficit of ($1,303k) which is $1,571k favourable to the budgeted deficit of ($2,875k). The year end forecast variance to budget has improved by $294k in March. The key changes in March month are as follows:  The MOH revenue has increased by $549k because of the new funding for Covid-19 pandemic. This is off-set by the higher costs in the Covid-19 expenditure line, hence there is no bottom line impact. In March, we have paid ($155k) to Tu Ora Compass for Primary Care response and virtual consultations on Ministry’s direction. The balance funding has been accounted as revenue received in advance from the Ministry.

 Community Pharmaceuticals costs were forecasted to be favourable to budget in February by $201k. However, now we have new information to suggests that National Haemophilia Management Group costs would be ($163k) higher than budget ($14m for the nation) for 2019/20 financial year as the result of increase in blood costs. In March, we are forecasting the community pharmaceuticals costs to be on budget for 2019/20 financial year. In February, the actual claims for community pharmaceuticals were significantly higher than any other months in 2019/20. On average, the claims for February month in the last five years were $934k, however in Feb-20 the actual claims were $1,206k which is ($272k) higher than average claims for Feb month. The reasons for these higher claims are being currently investigated.

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 In December 2019, Pharmac has introduced new high costs drugs on the list, for which the DHB has received additional funding from the Ministry. This could be one of the reasons for the high costs in February. A full data set for February is not yet available in the pharmacy data warehouse.

 We are currently forecasting the ARC costs to be favourable at least by the year to date variance of $328k to budget. However, due to the Covid-19 pandemic, it is highly likely that with loss of people’s savings & investments, the proportion of ARC residents who would qualify for a DHB subsidy will increase. The actual impact of this is unknown at this stage.

 The year end IDF Outflows expenses forecast reflects the year to date favourable variance of $860k. This is an improvement of $598k from February forecast. The latest information on IDF activities suggest that the Capital and Coast DHB is unlikely to catch up with its target for 2019/20 financial year. The planned care services were cancelled due to Covid-19 pandemic and possibly will have an impact during part of April-20.

 As at March-20, we are carrying a provision of $1m for IDF outflows wash-up with other DHBs for 2019/20 financial year. This includes $400k for 4 long stay patients in Wellington hospital and that we’ll review this over the next months to release as new information becomes available closer to year end.

 Other HOP expenses are community based demand driven services. These services include Home and Community Support Services, respite care services and day programmes for older peoples. In March, there have been higher utilisation in Home and Community Support Services. The detail breakdown of these costs are reported below.

Other MOH revenue is $185k favourable for the month and $519k favourable for the year to date. The Other MOH revenue is forecasted to be $1,003k favourable for the full year and the details are presented in the table below:

Mar-20

MOH Revenue Variance to budget $000s Month $ YTD $ Forecast $

Covid-19 Primary Care Funding 155 155 548 Additional Funding for Combined Pharmaceutical Budget 2019/20 18 164 219 Primary Care initiatives -(Community Service Card holders, Under 14s, VLCA) 11 101 135 Pay Equity Wash-up revenue 18/19 0 30 30 Additional school based Health Services Funding (decile extension) 0 20 20 Reduce Pressure on Fees Total Annual Funding 0 18 18 In Between Travel wash-up revenue 2016/17 & 2017/18, 2018/19 0 16 16 Well Child Tamaraki Ora (WCTO) 1 14 18 Violence Intervention Programme 0 9 9 Electives Revenue 18/19 0 4 4 MERAS Settlements 2019/20 0 (12) (14)

Sub-Total 185 519 1,003

Other MOH revenue includes $4,007k revenue for additional planned care services for 2019/20. As at Mar-20, this revenue being accrued to budget. To receive this revenue in full, the DHB is required to deliver 95% CWDs in the year ended 30 June 2020. As at Mar-20 we have achieved 93.5% of the required values based on the phased budget. If there is under delivery in planed care services, funding will only be made for the actual additional volumes delivered over and above the agreed DHB level base. Other Revenue is $15k favourable for the year to date. This revenue was received from the Accident Compensation Corporation (ACC) for the falls injury prevention programme and is off-set by the additional expenditure in the other external provider payments expenditure line.

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IDF Inflows are ($59k) unfavourable for the month and ($304k) unfavourable for the year to date. The main reason for the unfavourable variance is due to ($388k) under delivery for inpatient services which has been clawed back from the DHB Provider Arm. The IDF Inflows revenue is forecast to be ($378k) unfavourable for the full year for inpatients services due to the incapacity. The details are presented in the table below:

Mar-20

IDF Inflows Variance to budget Month $ YTD $ Forecast $ $000s Inpatient IDF Inflows 19/20 (59) (388) (494) Inpatient IDF Inflows 18/19 0 51 51 PHO Capitation / FFS 0 33 65

Sub-Total (59) (304) (378)

DHB Governance & Administration expenditure line shows $4k favourable variance for the month and $18k favourable for the year to date. This is because of the reduction in payment for the Smoke-free Coordinator who was previously employed by the Planning & Performance team and has been transferred to Compass Health since December 2019. This payment is now included in the local services agreement with Compass Health and captured in the Other External provider payments. Provider Arm payments are $60k favourable for the month and $333k favourable for the year to date. The reduction in payments for under delivery in inpatient IDF activity for 2019/20 financial year is the main reason for the favourable variance in the provider arm payments. Provider arm payments are forecast to be $442k favourable for the year. The details are as follows:

PROVIDER ARM FUNDING CHANGES Mar-20

Funding Changes Variance to budget

$000 Month YTD Forecast

Activity Based Wash-up IDF Wash-ups: - Inpatient IDF Inflows 2018/19 0 (51) (51) - Inpatient IDF Inflows 2019/20 60 388 494

Agreed Changes 2019/20 MERAS Settlements 0 10 14 Palliative Care Educator funding (6) (6) Violence Intervention Programme (9) (9)

Total Changes 60 333 442

Pharmaceutical costs are ($99k) unfavourable for the month and ($1k) unfavourable for the year to date. These are demand driven costs based on actual claims. The month’s result includes ($82k) higher than budgeted payment to National Haemophilia Management Group (NHMG) for 2019/20 ($126k year to date). Recently there was a memo issued by NHMG Chair to the DHB CEs indicated that the costs for this service for 2019/20 are likely to be up to $14.4 million more than anticipated nationally. Of which, Wairarapa DHB’s share will be 1.1% or approximately ($163k). This is because of the increase in blood costs. In Feb-20 the actual claims for community pharmacies were significantly higher than any other months in 2019/20. On average, the claims for February month in the last five years were $934k, however in Feb-20 the actual claims were $1,206k which is ($272k) higher than average claims for Feb month. The reason for these higher claims being currently investigated. The year to date result includes ($83k) accrual was made to pay Pharmac for Discretionary Pharmaceutical Fund top up for 2019/20 financial year ($110k for the full year). The year to date results includes $398k higher than expected Pharmac rebate received in December for the 2 previous years (2017/18 & 2018/19). The year to date result also includes a $45k GST credit claimed in relation to the WrDHB share of expenses incurred by Pharmac on behalf of all DHBs. The latest Pharmac forecast released in October 2019 indicated that the annual rebates receivable for 2019/20 would be ($107k) or ($80k) year to date less than the budgeted rebates of $4,015k. The year to date result reflects this change in rebates receivable.

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In the 2019/20 financial year we will receive $219k of additional funding for the Combined Pharmaceuticals budget ($164k for the year to date). This funding is targeted for newly subsidised Pharmaceutical Cancer Treatment (PCT) drugs for 2019/20. This service is provided by Capital and Coast DHB for Wairarapa patients. Therefore the additional costs are included in the IDF Outflows expenditure line. The October Pharmac forecast also indicated that the net full year community pharmacies cost would be ($198k) or (1.57%) higher than the budgeted cost of $12,620k. However, in the 2019/20 financial year we have received an additional $398k rebates wash-up payment from Pharmac relating to prior years. This is reflected in the December forecast and overall Pharmaceuticals costs are expected to be on budget for the 2019/20 financial year. The table below shows the components of the community pharmaceuticals expenditure.

Community Pharmaceuticals Expenditure Mar-20 $000 Variance to budget Month YTD Forecast Rebates 18/19 0 398 398 Pharmac GST Credits 0 45 45 Actual claims (Based on cash payments) 3 (158) (64) National Haemophilia Management Group (82) (126) (163) Rebates 19/20 (9) (78) (107) Discretionary Pharmaceuticals Fund (DPF) (9) (83) (110) Miscellaneous -other (2) 0 1 Total ( 99) ( 1) 0

The following graph compares the current year actual costs (blue bar) to the current year budget and the actuals for the last two previous years. The actual costs in this graph are net of Pharmac rebates and include GST Credits, Pharmac’s Discretionary Pharmaceutical Fund (DPF) and Pharmac operating costs. The graph shows a significant reduction in actual costs in March 2019. This is because of a one-off adjustment to recognise higher rebates receivable in March for 2018-19.

The graph below shows the community pharmaceuticals spending over the past 7 years by month and illustrates seasonality. This graph includes only gross drug costs (cash expenditure) and the accruals (excludes rebates and other Pharmac operating costs).

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Capitation costs are ($33k) unfavourable for the month and ($240k) unfavourable for the year to date. Of the year to date result, $101k is off-set by additional MOH revenue received for PHO Capitation services (Care Plus, VLCA, Community Services Card and Under 14s) and $38k off-set by additional IDF Inflow revenue for patients who are enrolled with a Wairarapa General Practice but not Wairarapa residents. The balance ($101k) or (0.85%) is related to higher than budgeted enrolments. The table below shows the movements in enrolment by quarter for the last five quarters.

PHO Enrolment Apr-19 Jul-19 Oct-19 Jan-20 Apr-20 Wairarapa Residents 43,731 44,173 44,434 44,708 44,929 Non-Wairarapa Residents (inflows) 1,563 1,584 1,586 1,565 1,594 Total Enrolled in Wairarapa PHOs 45,294 45,757 46,020 46,273 46,523 Wairarapa resident enrolled elsewhere (outflows) 2,021 1,906 1,943 1,943 2035 Total Wairarapa Population Enrolled 45,752 46,079 46,377 46,651 46,964 Change from previous quarter 349 327 298 274 313 Change from same time last year 810 885 1,009 1,248 1,212 %Change from same time last year 1.80% 1.96% 2.22% 2.75% 2.65%

Net IDF Volumes 458 322 357 378 441

Statistics NZ Population estimate 45,880 46,445 46,445 46,445 47,895 Population Enrolled 99.7% 99.2% 99.9% 100% 98% We are forecasting the Capitation costs to be ($336k) unfavourable to budget of which ($200k) is off-set by the additional revenue for PHO capitation services. The balance ($136k) or (1.14%) is for DHB funded services for the higher than budgeted enrolments. Aged Residential Care (ARC) costs are $38k favourable for the month and $328k favourable for the year to date ($321k rest home & $7k hospital level). These are demand driven services. ARC Services costs have been favourable mainly due to an increase in the proportion of private payers and fewer than expected new entries to ARC. We expect the ARC costs for the full year to be favourable at least by $328k to budget for 2019/20. The graph below shows the percentage of ARC Residents who are maximum contributors. Maximum contributors are the people who do not meet the Ministry of Social Development’s financial criteria for a DHB subsidy meaning that the DHB pays a lower proportion of the total ARC costs. This reflects a socio-economic impact beyond the influence of the DHB. The graph below shows an upward trend of maximum contributors for Dementia beds and downward trend for rest home beds in quarter two of 2019/20 financial year. Hospital level beds remains unchanged.

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The graph shows an increase in the proportion of the private payers NOT the actual number of people. Private payers are taking more share of the overall residents in Aged Residential Care facilities.

The following graph shows the number of new entries to ARC each month for 2019-20 financial year.

The graph below shows the number of new entries to ARC for the last six years and the forecast for 2019-20.

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Wairarapa Entry to ARC 250 3.00% 216 196 194 2.50% 200 185 180 172 173 2.00% 150 1.50% 100

1.00% Noentries of new 50 0.50%

0 0.00% 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19 2019-20 Forecast

New to ARC % pop 65+ Entering ARC

With the exception of the 2018-19 year, the proportion of older people entering residential care has been decreasing. Based on data from July to December 2019, the forecast for the 2019-20 year is expected to be about 185. The following graph compares the current year ARC actual costs (blue bar) to the current year budget and the actuals for the last three previous years.

Other HOP costs line shows ($105k) unfavourable for the month and $47k favourable for the year to date. The main reasons for the unfavourable variance in the month are because of higher utilisation in Home and Community Support Services (HCSS) and In Between Travel. The year to date results includes higher than budgeted utilisation in Residential Care: Community- Under 65s. This service is for adults (65 year old) who have a long term condition (not disability) and need residential care services. The increase in allocation of this service should reduce the costs for Health Recovery and Chronically Medically Ill services in the long term. Pay equity costs are included in the HCSS contracts and reported in the pay equity expenditure line. Other services included in this line are the community based demand driven services. The year to date variance includes underspend in Respite Care and Carer Support Services. Respite Care services provide support to informal family carers. Most of these clients would otherwise be at risk of needing full time residential care. 16

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Respite care and Carer support service lines show favourable variance for the year to date; however the allocation for these services are for the full year and the clients can choose to use their allocated hours anytime during the year. The favourable variance in this service is partially off-set by the adverse variance in the Day Programmes expenditure line. The table below shows the different types of services that are included in the Other HOP expenditure line. We are forecasting the Other HOP costs to be favourable by $47k to budget for the full year.

Health of Older People (HOP) Expenditure 2019/20 Variance to budget Forecast Month $ YTD $ $000 Variance $ Residential Care: Community -Under 65s (32) (172) (229) Day Programmes (4) (56) (75) Community Health Services and Support 0 (1) 0 Residential Care: Loans Adjustment (1) 22 23 Carer Support 5 54 72 Respite Care (9) 40 53 Home and Community Support Services (64) 160 203 Total (105) 47 47

Pay Equity costs line shows $43k favourable variance for the year to date. This is because of the favourable wash-up for mental health services for 18/19 financial year. The MOH is responsible for providing data on pay equity costs. Pay equity costs are currently being accrued to budget as we expect a wash-up on pay equity funding at the end of this financial year. Pay Equity costs are $177k less than budget as at February 20. Mental Health expenses line shows ($10k) unfavourable variance for the month and $103k favourable variance for the year to date. The year to date result includes a ($41k) additional payment to Mental Health Solutions limited to increase the SMO support by 0.6 FTEs for the Opioid Substitution Treatment Service ($14k per month). The reason for the favourable variance for the year to date is the release of $189k prior year accruals for acute mental health bed usage wash-up with Capital and Coast DHB and Hutt Valley DHB which are no longer required. This is partially off-set by the ($23k) unbudgeted expenditure for suicide prevention programme and ($15k) for placement of a client at CCDHB Rehab unit. Covid-19 Primary care payments line shows ($155k) unfavourable variance for the month and for the year to date. In March, we have received $549k funding from the Ministry for Covid-19 Primary care services. Year to date we have paid ($155k) to Tu Ora Compass for Primary Care response and virtual consultations on Ministry’s direction. The balance funding has been accounted as revenue received in advance from the Ministry. We have started receiving cost information from the Providers regarding the Covid-19 activities. It may take sometimes before we have a full picture of the Covid-19 related costs. Other External Provider Payments are $17k favourable for the month and ($47k) unfavourable for the year to date. The table below shows the different types of services that are included in the Other External Provider Payments expenditure line.

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Mar-20 Description Variance to budget Month $ YTD $ Forecast $ Comments MECCA Flow on impact provision 14 41 83 Off set by the additional costs in Mental Health expenditure line

0 15 15 Immunisation services Demand driven services (Prior year claims were less than accrued) MH Acute beds wash-up 17/18 0 14 14 Credit note received in 19/20 General Medical Subsidy (1) 10 10 Demand driven services Advance Care Planning costs 1 8 12 Off-set by the favourable variance in IDF Outflow Palliative Care services 0 0 0 Dental services 5 2 0 Demand driven services Contact Lens subsidy (3) (4) 0 Demand driven services Electives 18/19 0 (4) 0 Off-set by additional MOH Revenue Other 6 (10) 0 Other demand driven services Well Child Tamaraki Ora Services (1) (12) (18) Off-set by additional MOH Revenue Smoke-free coordinator salary costs- Off-set by the favourable (4) (14) (23) Tobacco Control services variance in Governance costs ACC Falls prevention injury prevention programme 0 (15) (15) Off-set by the additional ACC Revenue Additional SBHS-decile extension 0 (20) (20) Off-set by additional MOH Revenue Planning Costs 0 (58) (58) Sappere contract -Not budgeted in 19/20 Total 17 (47) 0 IDF Outflows are $19k favourable for the month and $860k favourable for the year to date. The year to date result includes a favourable IDF Outflows wash-up for the 2018/19 financial year. The overall IDF Outflows wash- up result for the 2018/19 financial year against the year-end accrual was $1,153k favourable. Of which, ($230k) has been accrued as IDF risks provision for the 19/20 financial year based on the information available as at Mar- 20 and ($25k) accrued for mental health acute beds wash-up with Hutt Valley DHB. The year to date result also includes ($165k) costs accrued for new PCT drugs (Funded by the MOH) and ($28k) for the PHO Capitation wash- up for the first two quarters. The following table shows the components that are reflected in this expenditure line.

IDF Wash-ups and Service Changes Mar-20 Variance to Budget $000s Month $ YTD $ Forecast

IDF Inflows Activity Based Wash-ups - Inpatient IDF Inflows 2018/19 0 51 51 - Inpatient IDF Inflows 2019/20 (59) (388) (494) Other Wash-ups - PHO Capitation / FFS 0 33 65 Total IDF Inflow Changes (59) (304) (378)

IDF Outflows Activity Based Wash-up - Inpatients 176 (112) (112) - Outpatients (68) 236 236 -PCTs (76) (550) (550) - AT&R Inpatients 19 445 445 - Community Pharms (27) (249) (249) - Mental Health Acute Beds -Hutt Valley DHB (3) (25) (25) 2018/19 IDF Wash-up - Inpatients ADHB 0 732 732 - Inpatients Other DHBs 0 266 266 - Outpatients / Non- DRG 0 113 113 - AT & R 0 42 42 Other Wash-ups and service changes - PHO Capitation / FFS 0 (28) (28)

IDF Service Changes - CCDHB - Advance Care Planning (1) (10) (10) Total IDF Outflow Changes 19 860 860

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We expect the IDF Outflows to be favourable to budget at least by the year to date result of $860k and we will review this forecast again in April to update the favourable variance for 2019/20 financial year.

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6 PROVIDER FINANCIAL RESULT

Financial Statement for the month of March 2020

Month $000s Year to Date Annual Actual Budget Variance Actual Budget Variance Budget Forecast Revenue Government and Crown Agency 1 1 0 MoH - Devolved Funding (Funds arm) 13 12 1 16 17 4 4 0 MoH - Personal Health 37 37 0 49 49 7 8 (1) MoH - Public Health 56 71 (15) 94 80 69 71 (1) MoH - Disability Support Services 628 638 (10) 851 841 25 37 (12) MoH - Maori Health 230 337 (108) 400 292 41 48 (7) Clinicial Training Revenue 369 432 (64) 577 513 98 80 18 Revenue From Other DHBs 861 717 143 956 1,100 173 169 4 ACC Revenue 1,494 1,522 (28) 2,029 1,976 4 3 0 Other Government Revenue 31 31 0 41 41 422 422 0 Total Government and Crown Agency 3,717 3,796 (79) 5,012 4,908

Non Government Revenue 6 4 2 Patient Revenue 26 39 (13) 52 39 368 364 3 Other Income 3,625 3,378 247 4,472 4,718 5,710 5,770 (60) DHB Internal Revenue 51,631 51,963 (333) 69,306 68,863 6,084 6,139 (55) Total Non Government Revenue 55,282 55,381 (99) 73,830 73,620

6,506 6,561 (55) Total Revenue 58,999 59,178 (178) 78,842 78,528

Expenditure

Employee Expenses 909 1,094 186 Medical Employees 8,479 9,800 1,321 13,114 11,123 2,007 1,947 (60) Nursing Employees 17,890 17,349 (541) 23,143 23,891 585 530 (55) Allied Health Employees 4,762 4,704 (59) 6,272 6,340 94 90 (4) Support Employees 780 811 31 1,077 1,048 656 696 40 Management and Admin Employees 5,780 6,138 358 8,205 7,837 4,252 4,358 105 Total Employee Expenses 37,692 38,801 1,110 51,810 50,239

Outsourced Personnel Expenses 626 280 (346) Medical Personnel 4,027 2,521 (1,507) 3,361 5,542 5 16 11 Nursing Personnel 120 146 26 195 169 14 10 (4) Allied Health Personnel 49 92 43 123 80 0 0 0 Support Personnel 1 0 (1) 0 1 55 57 2 Management and Admin Personnel 426 513 87 676 658 699 364 (335) Total Outsourced Personnel Expenses 4,624 3,272 (1,352) 4,355 6,450

274 305 31 Outsourced Other Expenses 2,738 2,749 10 3,665 3,664 1,039 1,012 (27) Clinical Supplies 9,527 9,218 (309) 12,296 12,655 999 1,037 37 Non Clinical Expenses 8,315 9,026 711 12,301 11,614 0 0 0 Financing Expenses 1,044 976 (68) 2,005 2,073 (77) (77) 0 Internal Allocations (693) (693) 0 (924) (924)

7,187 6,999 (188) Total Expenditure 63,247 63,350 103 85,509 85,772

(681) (438) (243) Net Surplus / (Deficit) (4,248) (4,172) (76) (6,666) (7,243)

The Provider Arm shows a net deficit of ($4,248k) for year to date March. This is favourable to budget by $76k. The full year forecast is deficit of ($7,243) which is a $577k negative variance to budget.

6.1 Revenue Total revenue for the Provider year to date is $58.99m, which is unfavourable to budget by ($178k).  MoH revenue for Kia Ora Hauora ($108k) has been transferred to revenue in advance pending the programme delivery. This is offset by a reduction in expenditure year to date.  Clinical Training Revenue unfavourable ($64k) year to date. This is offset by a reduction in cost and due to semesters timing.

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 Revenue from Other DHBs favourable $143k year to date, mainly in Radiology increased recoveries from Capital Coast $78k and RPH cost recoveries budgeted in Other Income $60k.  ACC Revenue is ($28k) unfavourable year to date, despite income of $103k coming from staff claim reimbursements, which offsets against payroll expenditure. For non-staff related ACC income, patient related claims showed favourable recoveries in AT&R $83k though under recoveries in Community Nursing ($67k) and MSW ($52k). An increase in the annual targeted revenue of $100k has yet to be achieved, with an adverse impact year to date of ($75k).  Other Income is favourable to budget by $247k year to date because of a donation from Wairarapa Community Health Trust for an Image Intensifier $110k and Countdown Kids Charity Ball $40k. Interest income of $37k and Other Income $56k for unbudgeted TAS income for additional Child Development Services $32k though has an offset in costs and $14k for nursing student placements with UCOL.  DHB Internal revenue is ($333k) adverse to budget for the year to date, and this trend has been forecast out to year end. 6.2 Expenditure Total Expenditure for the Provider is $63.24m for March year to date; underspent against budget of $103k.

Total personnel expenses (employed and outsourced) were ($230k) unfavourable in March, and ($242k) year to date. An increase in the Holiday Act provision in line with Board recommendation, has added to the YTD position as well as being included in the out months of the forecast across all employment groups.

Medical costs (including outsourced) are unfavourable to budget for year to date of ($186k) due to SMO vacancies in General Surgery 1.3 FTE, Mental Health 1.8 FTE and Anaesthetists 0.6 FTE these positions are filled by locums. March Medical Outsourced was ($346k) unfavourable in the month compared to the vacancies in employed $186k. Vacancies in General Surgery 2.0 FTE, Mental Health 2.6 FTE and high leave in Anaesthetics department. The Psychogeriatrician was budgeted as employee SMO, but has been provided as Outsourced.

Nursing (including mental health and midwifery) costs are unfavourable to budget for the year to date by ($515k); FTE are over budget by (3.3) year to date. Nursing in the month was ($60k) unfavourable due to additional 4.1 FTE required to meet demand in March and the budgeted leave calculation understating the actual leave cost taken, this is currently being reviewed. Registered nurses over budget of (4.1) in the month and (2.2) FTE year to date. Mainly in Acutes (due to non- budgeted pm to midnight shift (2.7). Outpatients (0.9), Perioperative (0.6) and Palliative Care (0.6). SSH is positive by 1.1 FTE due to a staff resignation which will not be recruited too, Mental Health vacancies showing favourable variance of 3.2 FTE which is staffing mix with Allied. HCA’s over budget of (1.7) in the month and (2.9) FTE year to date. This variance is due mainly to MSW HCA’s for patient watches (3.3) and Acutes (1.0) offset by vacancies in AT&R and Community mental health team. Midwives over budget by (1.1) FTE in the month and (0.5) year to date. A business case was approved to address the shortage of staff in Maternity and an antenatal clinic midwife has been approved. This is offset by senior nurses which are favourable 0.2 FTE in the month and 2.1 FTE year to date, in the following departments, Mental Health 1.1, Outpatients 0.9 though this is offset by RN as a senior nurse is being classified as a RN, Periop 0.7, and Clinical Nurse specialists 0.3. Medical has employed a senior nurse in general surgery (0.4) unfavourable as not budgeted this fixed term position is to ensure patient flow and care, due to the high usage of locums in general surgery.

Allied Health personnel expenses, employed and outsourced, were unfavourable by ($16k) to budget year to date, FTE favourable by 0.7 year to date. Mental Health professionals budgeted as nurses but classified as Allied in the payroll system is the main contributor to the unfavourable variance. Other vacancies in Oral Health

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Management & Admin workforce, employed and outsourced year to date were $445k favourable to budget. This is mainly due to vacancies in the first half year and budgeted outsourced support not required. Current vacancies Admin Support and Finance currently under recruitment.

Other Outsourced Expenses were favourable $10k year to date. Radiology Services, $35.6k favourable year to date but offset by additional MRI services provided by the Hutt Valley DHB ($29k) and CT Scans ($10k) from Pacific Radiology. Higher Ophthalmology costs in the year to date (16k) offset by a release in accruals for surgical clinics $27k no longer required.

Clinical Supplies costs were ($309k) unfavourable year to date March. Treatment disposables ($176k) this includes Blood costs ($145k) unfavourable mainly due increased demand for Intragam products. Procedure Packs ($48k) and Infusion injection supplies ($45k) this offset by underspends in blades and knives $30k continence & hygiene supplies $24k, medical gases $24k and protective equipment $16k. Patient Appliances $61k favourable year to date. Ostomy supplies in community nursing $31k underspent, due to current demand. Other patient appliances favourable by $35k. Implants and Prostheses are $253k favourable due, reduction in electives, against a budget is phased evenly over the twelve months. Pharmaceutical spend is ($320k) unfavourable largely due to gastro-intestinal pharms, malignant disease pharms and eye pharms offset by underspend in musculoskeletal and joint. Clinical and Client Related costs (65k) due to Outpatients ($52k) budget savings for plastic clinics will not be realised and higher expected month in Air Transport flights.

Non Clinical Expenses were $711k favourable to budget for March year to date. Hotel and laundry expenses were ($24k) unfavourable year to date due to higher than budget food and groceries ($16k) mainly due with nutritional supplements ($13k) in MSW and Rehab not taken into account in the budget. Outsourced cleaning ($18k) mainly to adhoc cleans. Linen and Laundry costs higher ($18k) mainly in MSW and CSSD. Facilities costs are $33k favourable, this includes painting maintenance for the exterior of the Hospital which last deferred till later in the year $38k favourable, medical waste removal $22k and maintenance electrical $18k, offset by Pandemic costs of ($42k), additional ($14k) plumbing expenses and grounds costs ($8k). Transport and travel ($30k) unfavourable, additional travel and accommodation ($20k) for the Imaging team making site visits to assess radiology equipment, unbudgeted secondment travel and accommodate for acting CFO and general to timing of travel against an evenly allocated budget. Taxis ($2k) used to transport staff on patients transfers and patients to other DHBs. Vehicle repairs and maintenance on fleet ($6k) ITC expenses are $140k favourable, mostly due to Central TAS 18/19 wash-up $57k and release of Outsourced IT support for oracle $58k. Telecommunications are $68k favourable, but offset by overspends in licence fees ($85k) year to date. Compliance costs are $99k favourable year to date mainly due to the release of a provision for Nursing Advisory Board expense $106k no longer required. This also offset revenue from other DHB’s who would have not been on charged ($98k). Stock Adjustments have been under review and corrections have been actioned leaving a favourable variance to budget of $147k. Review and monitoring of the Oracle transactions are ongoing. Kia Ora Hauora programme and one off extension programme, is underspent year to date, mainly due to timing of initiatives. This is offset by the additional MOH funding transferred to revenue in advance. The team is now fully resourced and initiatives are planned to complete the extension programme of work in April. Depreciation $230k favourable year to date, this is due to $56k for seismic asset rate recalculation, IT capitalization phasing $126k and Oracle implementation delay $17k. Capital Charge increased to budget by ($65k) due to late change in building valuation after budgets set.

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Employment costs - analysis and trends (excluding outsourced)

Month Wairarapa DHB Year to Date Variance $000s Variance

Actual vs Actual vs March 2020 Actual vs Actual vs Annual Actual Budget Last year Budget Last year Actual Budget Last year Budget Last year Budget

Personnel 909 1,094 1,277 186 368 Medical Employees 8,479 9,800 9,213 1,321 734 13,114 2,007 1,947 2,129 (60) 122 Nursing Employees 17,890 17,349 16,903 (541) (987) 23,143 585 530 597 (55) 12 Allied Health Employees 4,762 4,704 4,425 (59) (337) 6,272 94 90 101 (4) 6 Support Employees 780 811 756 31 (24) 1,077 710 744 985 34 276 Management and Admin Employees 6,151 6,567 6,127 416 (24) 8,776 4,306 4,406 5,089 100 783 Total Employee Expenses 38,062 39,231 37,424 1,168 (639) 52,381

Month Wairarapa DHB Year to Date Variance FTE Variance Actual vs Actual vs Actual vs Actual vs Annual March 2020 Actual Budget Last year Budget Last year Actual Budget Last year Budget Last year Budget FTE 40.4 46.7 73.9 6.2 33.4 Medical 72.3 46.7 45.0 (25.6) (27.3) 46.7 254.9 250.8 110.9 (4.1) (144.0) Nursing 111.1 250.8 251.9 139.7 140.8 250.8 77.3 75.3 45.2 (2.0) (32.2) Allied Health 45.0 75.3 72.1 30.3 27.1 75.3 16.0 15.6 259.1 (0.4) 243.1 Support 252.7 15.9 15.4 (236.8) (237.3) 15.9 109.2 115.8 16.3 6.6 (92.8) Management & Administration 15.5 116.1 111.1 100.6 95.6 116.0 497.8 504.2 505.3 6.4 7.5 Total FTE 496.6 504.9 495.5 8.3 (1.1) 504.7 Average $ cost per FTE ($000) 22,467 23,439 17,288 972 (5,179) Medical 117,355 209,896 204,731 92,541 87,377 280,883 7,876 7,763 19,199 (113) 11,324 Nursing 161,080 69,176 67,102 (91,903) (93,978) 92,277 7,571 7,042 13,225 (529) 5,653 Allied Health 105,713 62,440 61,376 (43,273) (44,337) 83,254 5,885 5,762 388 (123) (5,497) Support 3,087 50,880 49,092 47,794 46,005 67,942 6,502 6,424 60,406 (78) 53,904 Management & Administration 396,134 56,547 55,146 (339,587) (340,988) 75,619 8,649 8,737 10,071 89 1,422 Cost per FTE all Staff 76,646 77,702 75,527 1,056 (1,119) 103,783

 Medical FTEs is 6.2 favourable MTD to budget due SMO vacancies, 4.0 FTE, vacancies in General Surgery 2.0, Community Mental Health 1.8 and Anaesthetics 1.6 this due to long-term leave and reduction in FTE for a fellowship. MOSS 1.9 FTE vacancy in General Medicine and Anaesthetics.

 Nursing FTEs is 4.1 unfavourable MTD; this is due to vacancies in Community Mental Health Team and SSH offset by additional staff in Acutes 4.0, MSW 3.5, Focus 2.0 and Maternity 1.2.

 Allied Health FTE is 2.0 unfavourable MTD, vacancies in Focus Management, Physiotherapy, Pharmacy and Oral health services offset by additional staff in Community Mental Health Team and Radiology.

 Support Staff is 0.4 FTE unfavourable MTD to budget is due to the Clinical Supplies Services department.

 Management and Administration Staff is 6.6 FTE favourable to budget due to vacancies in Planning & Funding, HR, Finance, Kia Ora Hauora, Ward Admin, Smoke free and CE office, offset by additional staff in the WebPas project.

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FTE Trends (from June 2014)

Actual FTE for Month (not year to date)

Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20 Feb20 Mar20 Medical 39 40 42 44 46 43 43 44 45 46 46 42 40 39 40 Nursing 209 226 218 241 243 258 257 254 254 257 255 249 250 257 255 Allied Health 69 71 71 70 71 72 72 73 74 73 76 74 74 78 77

Actual Support 14 13 17 16 17 16 16 16 15 15 15 15 15 15 16 Mgmt/Admin 89 90 93 100 109 105 108 107 108 109 108 109 108 109 109 Actual FTE 421 440 440 471 486 495 495 493 495 499 499 488 487 498 498

Total Budget 428 423 452 453 468 494 505 505 505 505 505 505 505 505 505 Variance from Budget 7 - 17 11 - 18 - 18 - 1 10 12 10 6 6 17 18 7 7

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Annual Leave Accrual $000s

Annual Leave Accrual in $'000's Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2013 2,745 2,765 2,833 2,720 2,787 2,809 2,642 2,653 2,694 2,660 2,775 2,787 2014 2,838 2,938 2,907 2,863 2,928 2,887 2,773 2,800 2,793 2,891 2,911 3,025 2015 3,045 3,090 3,043 3,030 3,033 3,001 3,050 3,020 2,937 2,984 3,019 3,024 2016 3,105 3,173 3,057 3,024 3,097 3,093 2,950 2,961 2,902 2,929 3,004 3,115 2017 3,152 3,038 3,128 3,101 3,167 2,993 2,853 2,936 2,984 3,047 3,165 3,327 2018 3,213 3,348 3,434 3,454 3,524 3,350 3,294 3,320 3,474 3,535 3,617 3,682 2019 3,541 3,584 3,697 3,755 3,837 3,752 3,521 3,626 3,717 3,820 3,949 3,990 2020 3,925 3,993 4,087 4,114 4,132 3,949 3,745 3,788 3,874

Provider Arm Delivery

This graph shows the value of activity delivered in the provider arm (blue line) compared to the revenue passed through from the funder (blue bar). The yellow bar is other revenue, such as health workforce New Zealand and ACC. The pink bar shows the expenditure. Note that activity for the current month is likely to be understated until coding is completed.

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7 GOVERNANCE

The following table shows the governance position for March 2020.

Month $000s Year to Date Annual Actual Budget Variance Actual Budget Variance Forecast Budget Variance Revenue

Government and Crown Agency 183 188 (4) MoH - Devolved Funding (Funds arm) 1,673 1,691 (18) 2,225 2,255 (30) (0) (0) 0 Revenue From Other DHBs 42 42 0 42 42 0 183 188 (4) Total Government and Crown Agency 1,716 1,734 (18) 2,267 2,297 (30)

Non Government Revenue 0 (0) 0 Other Income 0 (0) 0 0 (0) 0 0 (0) 0 Total Non Government Revenue 0 (0) 0 0 (0) 0

183 188 (4) Total Revenue 1,716 1,734 (18) 2,267 2,297 (30)

Expenditure

Employee Expenses 53 48 (5) Management and Admin Employees 371 429 58 513 571 58 53 48 (5) Total Employee Expenses 371 429 58 513 571 58

Outsourced Personnel Expenses 11 11 0 Management and Admin Personnel 102 98 (4) 139 131 (9) 11 11 0 Total Outsourced Personnel Expenses 102 98 (4) 139 131 (9)

19 19 (0) Outsourced Other Expenses 172 172 (0) 230 230 (0) 24 25 1 Non Clinical Expenses 341 368 27 414 442 27 77 77 0 Internal Allocations 693 693 0 924 924 0

184 180 (5) Total Expenditure 1,679 1,761 82 2,220 2,297 77

(1) 8 (9) Net Surplus / (Deficit) 36 (27) 64 47 (0) 47

Governance for year to date is a net surplus of $64k to budget. Revenue for Governance is ($18k) adverse due to reassignment of Smoke Free funding to Community Provider. Management and Admin employed costs were favourable by $58k due to early year vacancies for adviser positions in Planning and Performance. These positions have now been filled with the exception of the final 0.4 FTE Mental Health advisor. This position is expected to be covered by a contractor. Outsourced Personnel year to date is ($4k) unfavourable due to increased charges for the Hutt based advisor. Non Clinical costs are $27k favourable due to the release of a prior period provision for Consumer Council fees and year to date underspend for Advisory Committee fees while in recess.

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PUBLIC

BOARD INFORMATION PAPER

Date: April 2020

Author Kieran McCann, Executive Leader Operations

Endorsed By Dale Oliff, Chief Executive Officer, Wairarapa District Health Board

Subject Hospital & Community Services Report for March 2020

RECOMMENDATION It is recommended that the Board:

a. Notes the content of this report

APPENDICIES

1. Planned Care performance, February 2020

2. Leave Statistics

3. Assessment Volumes, February 2020

1. PROVIDER OVERVIEW

The report for Hospital and Community Services for March 2020 shows delivery and outcomes against the normal monitoring and reporting indicators but also an emerging view of some of the impacts of COVID- 19 on business as usual outputs for the Provider arm services. As part of the national pandemic response the Wairarapa District Health Board (WrDHB) initiated an Incident Management Team (IMT) under a Co-Ordinated Incident Management Response (CIMS) framework as part of the New Zealand (NZ) wide response framework. This arrangement supersedes normal business as usual operating structures and activity related to its function will be reported separately to the Board.

2. STAFFING

a. Sick Leave The WrDHB sick leave rate sits at 3.5% of worked hours for March 2020. Perioperative has increased this month to 4.6% and averaging 4.2% this financial year. The Medical Surgical Ward (MSW) is at 4.9% this month averaging 3.8% this financial year. Maternity is at 6.4% and Radiology is at 6.1%. b. Annual Leave The pay period finished on the 22nd March 2020, more annual leave for March will be processed in April, and leave values over this period and leading into April will be affected by COVID-19. Some aspects of this are evident below.

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c. COVID-19 related Leave For the latter half of March, a significant impact arose for staff returning from overseas destinations being affected by isolation precautions and mandatory stand down periods due to COVID-19. It is also noted that a significant amount of overseas and approved leave cancellations have been received. Position # Returning to NZ # Leave Cancellations Senior Medical Officer (SMO) 4 7 Registered Medical Officer (RMO) 4 0 Nursing 4 14 Allied & Technical 0 5 Support Staff 3 6 TOTAL 15 32 The impact of this enforced stand down, particularly in relation to the Medical workforce was exacerbated when the contingency to source locums was further compounded by escalated travel restrictions highlighted below in the recruitment section outlined further in this report. d. Key changes Staff and recruitment (New recruitment updates) Key Staff Monthly Changes General Surgeons ∑ Fully Staffed. Medical Imaging ∑ The Imaging team is now fully staffed. Technology Child Development ∑ The additional 0.4FTE Clinical Psychologist fixed term hours have not been Service utilised during later part of March due to cessation of face to face outpatient assessments due to COVID-19 (these assessments are not suitable for telehealth). This work will be deferred to a later date. Oral Health ∑ Recruitment is underway to support the move to a 1:1 Dental Therapist: Dental Assistant model, as per the business case approved during March. Recruitment to the new Assistant FTE to implement this model should be easily achieved, and follow up is also underway with a potential Dental Therapist (1.0FTE) applicant. International recruitment We have felt the impacts from COVID-19 worldwide with regards to the travel and the uptake of locum contracts and agreements. International border restrictions, which resulted in two (2) long term Locums unable to travel to take up positions. Subsequently one of these Locums has managed to rearrange travel and arrived two weeks later than planned. In all cases the periods of isolation with international travel and the NZ lockdown has delayed recruitment. Additional immigration restrictions for family of staff has impacted our ability to recruit. In one case the inability to bring over the spouse will be a crucial factor in with the longevity of the appointment. Engagement is currently underway with the Ministry of Business Innovation and Employment (MBIE) and Immigration to seek exemptions to secure vital positions going forwards. In relation to locum appointments the COVID-19 related restrictions have caused leave adjustments and other changes across all DHBs has also seen a significant pressure placed on Wairarapa services due to heavy reliance on locum services. This meant withdrawals from agreed shifts and periods of cover. The services most impacted by these situations were Anaesthetics and Orthopaedics, with periods of acute only cover having to be implemented due to roster gaps.

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e. Existing recruitment actions Key Staff Existing Orthopaedic ∑ One offer made for MOSS status. Surgeon 3.0 FTE ∑ One candidate remains to await clearance by Council and Immigration. ∑ Two further interviews undertaken over March. One candidate will be further pursued. ∑ One site visit completed by overseas surgeon. Currently negotiating a joint appointment with CCDHB. ∑ 2nd On call support provided by CCDHB. ∑ Booked Locum use to cover shortages impacted significantly by COVID-19. ∑ Tele Acute model being trialled to support after hours during COVID-19. Anaesthetist ∑ 2.0 FTE vacancies. 2.0 FTE ∑ Locums being sourced and interviewing ongoing. No permanent candidates sourced as yet. ∑ Booked Locum use to cover shortages impacted significantly by COVID-19. ∑ Capital & Coast DHB (CCDHB) approached for interim COVID-19 support. MOSS AT&R 0.8 ∑ Vacancy in Assessment, Treatment and Rehabilitation (AT&R) offered for FTE deferred start later in year. ∑ Locum cover in place for interim. Dental ∑ 1.8FTE Vacancies. Therapist ∑ Recruitment continues, now includes recruitment agencies and an international audience. We are pursuing a Therapist returning to the region and a second Therapist expressing interest in working in the Wairarapa.

3. ACTIVITY AND OPERATIONAL PERFORMANCE

3.1. Acute Services 4. Emergency Department Waiting times Wait time performance for the six-hour Emergency Department (ED) target overall was not achieved for quarter three at 93.2%. In March 4,198 patients passed through the department and 3,911 of these were seen within six (6) hours. ED attendances dropped due to the alert level 4 notice by more than 50% (on average) to 23 a day in the last week in March at which point waiting times routinely achieved.

Month Total Within 6 Result Presentations hours Jul-18 1,439 1,332 92.6% Aug-18 1,527 1,414 92.6% Sep-18 1,493 1,374 92.0% Oct-18 1,513 1,357 89.7% Quarter Total Within 6 Result Nov-18 1,428 1,329 93.1% Presentations hours Dec-18 1,540 1,399 90.8% Jan-19 1,588 1,467 92.4% QRT1 18/19 4,459 4,120 92.4% Feb-19 1,387 1,320 95.2% QRT2 18/19 4,481 4,085 91.2% Mar-19 1,526 1,385 90.8% QRT3 18/19 4,501 4,172 92.7% Apr-19 1,352 1,283 94.9% QRT4 18/19 4,225 3,966 93.9% May-19 1,490 1,385 93.0% QRT1 19/20 4,285 3,888 90.7% Jun-19 1,383 1,298 93.9% QRT2 19/20 4,588 4,150 90.5% QRT3 19/20 4,198 3,911 93.2% Jul-19 1,502 1,369 91.1% Aug-19 1,418 1,300 91.7% Sep-19 1,365 1,219 89.3% Oct-19 1,515 1,393 91.9% Nov-19 1,513 1,352 89.4% Dec-19 1,560 1,405 90.1% Jan-20 1,481 1,390 93.9% Feb-20 1,438 1,324 92.1% Mar-20 1,279 1,197 93.6%

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Maternity Services As previously reported Maternity continues to be busy at 33 births ahead of the same period last year and 70 more maternity ward discharges. The caesarean-section rate sits at 13.33% for March 2020 and 32.2% at a year to date, with September 2019 peaking at 45.2%, 19 caesarean-sections of 42 total births.

Wairarapa DHB Hospital Births 2019 - 2020

Breech Delivery and Extraction Spontaneous Vaginal Delivery Instrumental Vaginal Delivery Caesarean Section Delivery Unknown

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Dec Jan Feb Mar 2019 2020

3.2. Average Length of Stay and Average Case Weighted Discharges 5. Medical & Rehab General Medical Average Length of Stay (ALOS) and Average Case Weighted Discharges (ACWD) have remained relatively static for the last year. Medical and surgical patients as boarders (outliers) have reduced the ALOS for AT&R area for this financial year to 12.27 days. During March 32 non-rehab patients have been admitted to AT&R with an ALOS of 4.28 days.

General Medicine ALOS & ACWD July 18 - Mar 20 Avg Length Of Stay Avg CaseWeighted Discharges Inpatient Caseweighted Discharges 2 per. Mov. Avg. (Avg Length Of Stay) 2 per. Mov. Avg. (Avg CaseWeighted Discharges)

5.00 300

4.00 250 200 3.00 150 2.00 100 1.00 50 0.00 0 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

ATR ALOS Jul 18 - Mar 20

Avg Length Of Stay Inpatient Discharges 2 per. Mov. Avg. (Avg Length Of Stay)

25.00 30

20.00 25 20 15.00 15 10.00 10

5.00 5

0.00 0 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

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3.3. Surgical Given the impact of COVID-19 through March surgical activity was significantly impacted as well as Specialist and Locum staffing issues in Orthopaedics and Anaesthetics. Most non acute and deferrable work had been postponed in advance of the formal lockdown notification as a consequence of staffing. Orthopaedic average length of stay is similar to 2019 at 2.59 days, with acute patients at 3.85 days and planned patients at 1.59 days. Long stay patients have affected the General Surgery ALOS at times. It is also noted that early reporting of data means that some of the results may change as coding is completed on patients.

General Surgery ALOS & ACWD July 18 - Mar 20

Avg Length Of Stay Avg CaseWeighted Discharges Inpatient Caseweighted Discharges 2 per. Mov. Avg. (Avg Length Of Stay) 2 per. Mov. Avg. (Avg CaseWeighted Discharges)

6.00 120 5.00 100 4.00 80 3.00 60 2.00 40 1.00 20 0.00 0 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Orthopaedics ALOS & ACWD July 18 - Mar 20

Avg Length Of Stay Avg CaseWeighted Discharges Inpatient Caseweighted Discharges 2 per. Mov. Avg. (Avg Length Of Stay) 2 per. Mov. Avg. (Avg CaseWeighted Discharges)

4.00 100 3.50 80 3.00 2.50 60 2.00 1.50 40 1.00 20 0.50 0.00 0 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Fiscal Year 2020 Fiscal Month Desc 09 - Mar

MTD Actual MTD Contract MTD Volume YTD Actual YTD Contract YTD Volume Purchase Unit code Volume Volume Variance Volume Volume Variance Caseweight Acute 160.4 418.8 (258.5) 3,345.1 3,350.6 (5.5) M00001.a - General Internal Medical Services - acute 77.6 195.5 (117.8) 1,610.2 1,563.7 46.5 M05001.a - Emergency - Inpatient Services acute 27.8 39.7 (11.9) 269.3 317.7 (48.4) M55001.a - Paediatric Medical - Inpatient Services acute 7.6 20.2 (12.6) 180.7 161.4 19.3 S00001.a - General Surgery - Inpatient Services acute 22.0 55.8 (33.8) 412.9 446.6 (33.7) S30001.a - Gynaecology - Inpatient Services acute 2.9 7.8 (4.9) 32.1 62.6 (30.5) S45001.a - Orthopaedics - Inpatient Services acute 4.2 59.1 (54.9) 361.5 472.6 (111.2) W06003.a - Neonatal - Inpatient Services acute 3.5 7.8 (4.3) 101.4 62.6 38.8 W10001.a - Maternity - Inpatient Services acute 14.7 32.9 (18.2) 377.1 263.4 113.8

Local Acute Case Weighted Discharges (CWDs) volumes are tracking behind contract by 5.5 YTD. Note that this number will continue to change due to coding for the current month not as yet being finalised.

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3.4. Planned Care (including Electives) NB* Appendix 1 corresponds to the Planned Care performance as reported to the Ministry of Health (MoH) and is aligned to the MoH dashboard for the activity delivered as of February 2020. Key Performance Area Commentary Planned Care Interventions The MoH has split the 2019/20 planned care initiative into three Delivery (case weights, components (replacing electives and ambulatory initiatives of the past): discharges and minor ∑ Inpatient surgical discharge. procedures) ∑ Minor procedures both inpatients and outpatient. ∑ Non-surgical interventions. An encouraging result with 327 (115.3%) additional interventions than planned. Currently sitting positive overall at 115.3% at year-end we need to maintain > 95% of agreed total expectations by type of intervention that is each intervention needs to be looked at separately. This is further broken down by: ∑ Inpatient Surgical discharges have increased from previous month to be close to fully achieved at 99.9%, which equates to only one less discharge than planned. CWD achieved at 97.9%. ∑ Minor procedures are positive at 165.4%, with 332 more interventions delivered than planned. ∑ Main surgical specialities, discharges and case weights below to February 2020: 6. ENT is 19 discharges (15.5 CWD’s) ahead; Hutt Valley DHB (HVDHB) provide this service for ENT patients. 7. Gynaecology is 29 patients ahead of discharge targets, 24.1 CWD’s ahead. 8. General Surgery is 51 behind of contracted discharge targets which equates to 86.2%. Also 77.9 CWD’s behind contract at 85.0%. 9. Ophthalmology this month is 18 discharges ahead targets, 5.7 CWD’s are ahead. Complex surgeries performed at CCDHB with cataracts at Wairarapa. Theatre schedules were altered to accommodate previous shortfall in discharges with success. 10. Orthopaedics currently 2.0 CWD’s under delivered (99.7%). Discharges are 32 patients behind. Orthopaedic surgery is impacted due to SMO vacancies. Use of locums has impacted on case selection relating to clinical continuity and procedural familiarisation. Currently three vacancies in Orthopaedics, covered by locums. 11.Urology currently at 108.4% of overall discharges (7 patients). 12.Minor procedures delivered to February 2020 are 840 on a plan of 508 (165.4%). Due to 189 more skin lesions than planned, 56 more Gynaecology, 87 more Avastin and eye procedures. Planned Care Interventions Delivery Actions ∑ Implementation of Production Plan monitoring and reporting is completed and now monitored. ∑ Restricted access where appropriate to planned services for Non-Wairarapa DHB domiciled patients. ∑ An interdisciplinary meeting comprising of Orthopaedic clinicians, nursing staff, theatre staff and Primary Health Organisation (PHO) liaison is currently being set up to discuss patient options and management of Orthopaedic referrals. ∑ Theatre utilisation project around Orthopaedics is being undertaken to ensure optimum theatre capacity

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Key Performance Area Commentary Elective Service Patient Flow February 2020 the WrDHB performance is yellow for ESPI two and red Indicators (ESPIs) – for ESPI five. breakdown of ESPI two and Non-compliant services ESPI Two February 2020: five ∑ Orthopaedics one (1) patient. ∑ Urology one (1) patient. Non-compliant services ESPI Five February 2020: ∑ Orthopaedics 87 patients. ∑ General Surgery two (2) patients. ∑ Ophthalmology one (1) patient. Ophthalmology ∑ All referrals are now seen at a First Specialist Assessment (FSA) and treated within the four month timeframe. However this is very dependent on Locum availability. ∑ Ophthalmology service is at risk due to Locum use. Ear, Nose and Throat ∑ Hutt Valley DHB was unable to provide clinics during December 2019 and January 2020 and there was no Locum availability. All February 2020 clinics were provided. ∑ Audiology remains an area of concern. Hutt Valley DHB is unable to provide an Audiologist to attend clinics with SMO’s. Community based Audiology services are providing this service at the present. One provider has opted not to continue due to capacity demands. All patients needing hearing aid(s) reviews from the ages of 0-15 years old are now transferred to Hutt Valley DHB. Orthopaedics and ∑ General Surgery is now compliant for both FSA and Surgery. It is General Surgery anticipated this will remain compliant; long term Locums secured. ∑ Orthopaedics is compliant for FSA but 88 non-compliant for surgery (as at end of January 2020). This is liable to deteriorate for both FSA and planned services given the staffing shortage of SMO’s. Gynaecology ∑ Compliant in both FSA and Surgery, therefore no patients waiting longer than four (4) months for assessment or treatment. Diagnostics performance CT performance is up at 94.6% for February 2020 and 90.9% for March (Computer Tomography (CT) 2020. and Magnetic Resonance MRI waiting times continue under performance against the 90% targets. Imaging (MRI)) Currently.4% in March 2020, a significant drop from the improvement recorded towards the end of 2019 (71.8% in December 2019). ACTION MRI-Scanning ∑ HVDHB provided additional evening and Saturday sessions being used to assistant with increased volumes. ∑ HVDHB outsourcing to supplement capacity. ∑ Ongoing recruitment of MITs and Radiologists. ∑ WrDHB meeting with a range of Radiology Providers to look at future capacity and planning. Cardiac Surgery – Delivery ∑ Cardiac Surgery and management is provided by CCDHB and waiting list

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3.5. First Specialist Assessments and Follow up Volumes to contract FSA is under delivery of 125 attendances and 101 Follow-ups to March 2020. Note monthly variation is often associated with phasing. There are also some coding changes being considered to recognise the variations in care provision over the period and how practice changes have been captured in regard to COVID-19 restrictions. It is worth noting that positive aspects of some of the practice changes that have started to occur as a consequence of COVID-19 lockdown restrictions. Nowhere has this been more evident than in relation to remote clinic assessments with nearly 500 undertaken in the last four (4) weeks. This represents nearly 50% of all clinic appointments for these clinical groups over that period. Early feedback from both patients and staff conducting these assessments indicates a high level of satisfaction with the virtual clinic model. Assessments / Clinic Consults undertaken by Telephone /Video 16 March 2020– 14 April 2020 Ophthalmology 11 Orthopaedics 62 Paediatrics 110 General Medicine 114 General Surgery 59 Urology 73 Gynaecology 55 Total 484 Social distancing in waiting areas and minimising contact (and waiting) have all had significant parts to play in maintaining a safe environment and may lead to future opportunities to question and review how we manage services and provide new and more patient centric experiences in a hospital environment. Further details on volumes for Assessments has been provided under appendix 3. 3.6. Elective Case Weighted Discharge Volumes to Contract

Fiscal Year 2020 Fiscal Month Desc 09 - Mar

MTD Actual MTD Contract MTD Volume YTD Actual YTD Contract YTD Volume Purchase Unit code Volume Volume Variance Volume Volume Variance Caseweight Elective 67.5 145.1 (77.6) 1,062.7 1,044.2 18.5 S00001.e - General Surgery - Inpatient Services elective 14.6 32.2 (17.6) 200.5 231.8 (31.3) S30001.e - Gynaecology - Inpatient Services elective 5.2 15.8 (10.6) 134.0 113.7 20.3 S40001.e - Ophthalmology - Inpatient Services elective 6.6 9.0 (2.4) 94.7 64.7 30.0 S45001.e - Orthopaedics - Inpatient Services elective 41.0 75.4 (34.3) 553.4 542.6 10.7 S60001.e - Plastic & Burns - Inpatient Services elective 0.0 3.4 (3.4) 16.5 24.1 (7.7) S70001.e - Urology - Inpatient Services elective 0.0 9.4 (9.4) 63.7 67.3 (3.6) Elective CWDs are ahead of plan by 18.5 YTD. Variation to contract commentary is referenced in the Planned Services report in the previous section. Note that this number will continue to change due to coding for the current month being finalised. 3.7. Theatre Utilisation and Cancellation Rate There were 30 day of surgery cancellation in February, or 8.0% of total theatre events. Areas of cancellation 13- Orthopaedic 11- Endoscopy 3- General Surgery 2- Gynaecology 1- Ophthalmology

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The reasons for cancellations were: ∑ Four (4) acute substitution; ∑ Five (5) for patient reasons including unfit and patient cancelled; ∑ Three (3) were miscellaneous/admin errors; ∑ Eight (8) were for staff issues; and ∑ 10 were cancelled due to COVID-19. Theatre utilisation for March 2020 has dropped back to 50% combined, 57% theatre 1, 43% theatre 2 and 47% theatre 3. The main drivers are vacant sessions impacted by specialist availability/vacancies. The early effects of the COVID-19 shutdown on Locum supply and population lockdown restrictions resulting in the cancellation of all non-acute and deferrable planned surgery.

Theatre Utilisation All theatres Theatre Utilisation - theatre 1

Combined Target TH1 Target

90% 100% 80% 90% 70% 80% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0%

Theatre Utilisation - theatre 2 Theatre Utilisation - theatre 3

TH2 Target TH3 Target

100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0%

As articulated throughout this report the impact of COVID-19 on planned surgery has been significant. It is also evident that this position will continue to as a consequence. Recovery plans are currently being developed outlining how the WrDHB will access all possible capacity to address both the backlog of deferred work and the impact of increased acuity form deferred treatment. This plan will be developed with flexibility and agility going forward to alter service provision as the COVID-19 situation changes. 3.5. Community Services Allied Health In addition to the specilaist outpatient clinic practice change, a large number of Allied Health outpatient clinics (physiotherapy, speech-language therapy and dietetics) have successfully transitioned to telehealth over the COVID-19 lockdown period. From a physiotherapy perspective this has been supported by ACC’s agreement to pay for telehealth consultations under their Treatment Regs contract. We need to continue to maximise telehealth capability across all disciplines post lockdown. Community Nurisng Community Nursing has remained busy over March and has also seen growth leading in to the national lockdown period. Over the remaining time services have been working under a wider community repsonse structure as part of the WrDHB IMT in order to align with other providers in the community and primary care sector.

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3.8. Diagnostics Commentary on Diagnostics wait time performance is included in the Planned Section of this report in relation to MRI. All other performance metrics and targets met for the month from the Imaging department. As noted Community Referred Radiology volumes exceeded contract for the month and is currently 1,357 tests ahead of contract. Mid-Central DHB (MCDHB) utilised our fluoroscopy clinic space and equipment to run a barium swallow Outpatient clinic in March (prior to COVID-19 lockdown), as they currently have no fluoroscopy capability within their own service. 17 MCDHB patients together with a radiologist and radiographer came over to run this clinic, and MCDHB are keen to repeat this once the lockdown is lifted. This occurred with no impact on Wairarapa clients or staff.

MRI Wait Times CT Wait Times Wai Result Target Hutt Result Wai Result Target Hutt Result 120.0%

100.0% 100.0% 95.0%

90.0% 80.0% 85.0%

80.0% 60.0% 75.0%

70.0% 40.0%

65.0% 20.0% 60.0%

55.0% 7 8 9 0 6 7 8 9 6 7 8 9 7 8 9 0 6 7 8 9 7 8 9 0.0% 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 6 7 8 9 6 7 8 9 7 8 9 0 7 8 9 0 6 7 8 9 7 8 9 ------1 1 1 1 1 1 1 2 1 1 1 2 l l l l 1 1 1 1 1 1 1 1 1 1 1 r r r r v v v v y y y n n n n ------p p p p l l l l u u u u r r r r a a a a v v v v a a a o o o o y y y n n n n a a a a e e e e p p p p J J J J u u u u a a a a J J J J o o o o a a a e e e e a a a a S S S S J J J J N N N N M M M M J J J J M M M S S S S N N N N M M M M M M M

Fiscal Year 2020 Fiscal Month Desc 09 - Mar

MTD Actual MTD Contract MTD Volume YTD Actual YTD Contract YTD Volume Purchase Unit code Volume Volume Variance Volume Volume Variance CS01001 - Community-referred radiology 1,320.5 1,291.7 28.8 11,689.9 10,333.4 1,356.5 3.9. Endoscopy Waiting Urgent and Semi Urgent targets were achieved at 100% and 83% respectively. The surveillance colonoscopy target was not achieved at 52%. The high use of Locum and variable scoping capacity has seen all urgent and semi urgent work prioritised. Additional sessions are already scheduled to catch up on surveillance work through March and April have been severely impacted by COVID-19 restrictions.

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BOARD INFORMATION PAPER

Date: April 2020

Presented By Selena McKay, Executive Leader People and Capability

Endorsed By Dale Oliff, Chief Executive Officer, Wairarapa District Health Board

Subject People and Capability Report RECOMMENDATION It is recommended that the Board: a. Notes this paper and discusses as appropriate

1 PURPOSE

The purpose of this report is to provide information and updates to the Wairarapa District Health Board (WrDHB) in relation to activity relating to People and Capability within the WrDHB. This includes people metrics and general work stream updates.

2 GENERAL PEOPLE & CAPABILITY UPDATE

2.1. Holidays Act Review: As previously indicated the Holidays Act project will been undertaken in three phases: ∑ Review - of the payroll system to identify any areas of non-compliance with the Holidays Act; ∑ Rectifying - the payroll system and associated processes, to ensure compliance; and ∑ Remediation – assessment of all individual ex-employee and employee payments back to 1st May 2010, contacting any ex-employee or employee who is owed money, and paying that money to them. We are currently in the review phase with planned activity being managed by the Project Manager this has included the development of a communications plan with updates to our union partners. Other key activities undertaken in the last period include: ∑ Engagement with Ernest Young and confirmation of the review phase requirements including initial data provision; ∑ Initial SteerCo meeting held; and ∑ Review of sampling methodology with details provided to unions. A regular report will be provided to the Financial Risk and Audit Committee (FRAC) on its progression.

3 GENERAL HUMAN RESOURCES ACTIVITY

3.1. COVID-19 The People and Capability team have been supporting the COVID-19 activity with a focus in the Workforce and Wellbeing stream in conjunction with delivering business as usual activity. The COVID-19 support has required a strong link with national activity and decisions due to regular changes. The key focus going forward will need to be on workforce, well-being, redeployment and Occupational Health requirements as we move through different national COVID-19 and Hospital service delivery levels. From a People and Capability perspective regular meetings have been set with our local union partners to ensure they are engaged in activity happening at a local level.

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PUBLIC 3.2. Values A suite of recruitment tools have been developed incorporating our updated values. We will launch these tools initially with Managers and then the wider organisation. Timing on this is pending the COVID-19 activity, but wider branding relating to the values is being undertaken with email signatures and document templates. 3.3. Recruitment The main focus of recruitment activity remains on the Senior Medical Officer (SMO) workforce with a framework being set up to support the Executive Leader Operations and Chief Medical Officer. The following vacancies under active management are: ∑ General Surgeon – 12 month Locum commenced and one (1) permanent role offered and accepted expected to commence, July 2020; ∑ Anaesthetist – 12 month Locum commenced and two (2) resumes are currently being reviewed; ∑ Orthopaedics – Five (5) resumes are being reviewed with two (2) moving towards a formal interview process; one (1) permanent offer to be made week of 13th April 2020. A permanent offer is awaiting Medical Council outcome we have been supporting this process for four (4) months; and ∑ Psychiatry – Locum cover in place three (3) months with after-hours cover provided within the Mental Health, Addictions and Intellectual Service (MHAIDs) across Hutt Valley DHB, Capital & Coast DHB and WrDHB. 3.4. Payroll Services and System Payroll services continue to be busy with ongoing public holidays and COVID19 activity. Due to COVID-19 the payroll process has been adjusted to enable social distancing requirements. This is regularly reviewed to ensure service continuity. Payroll data is also key in the provision of data for the Holidays’ Act project. An upgrade has been undertaken to the payroll kiosk which has seen the user interactions through screens updated for easier usability. 3.5. Multi-Employer Collective Agreement Bargaining and National Activity With the conclusion of the Medical Response Team (MRT) bargaining the focus is moving to upcoming agreements for this year. At this time data requests have been worked on for the Association of Salaried Medical Specialists (ASMO) and New Zealand Nurses Organisation (NZNO) agreements. The SMO agreement is due to expire 31st March 2020 and the bargaining program has commenced and an offer is currently out for ratification. The NZNO document is due to 31st July 2020 and planning is underway. Member meetings have been delayed due to COVID-19 activity. The Public Service Association (PSA), Allied Health Scientific Technical agreement is due to expire 31st October 2020 and the PSA is in planning mode for this with member meetings. Nationally there is ongoing activity in relation to Pay Equity claims in regards to Nurses, Midwifery and Administration.

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Wairarapa DHB People Metrics as at 30 March 2020 Metric Actual Target Comments Turn Over 11.9% 13% The turnover rate has remained at around the 13% level.

Sick Leave 3.5% 2.5% Sick leave is Usage tracking to similar levels to his time last year.

Annual Refer to AL is Leave (AL) Finance monitored. Leave Report Focus on Owed balances over 2 years. Levels down due to holiday period needs over Easter period. % of 42% Head count Completed 502 excl’s Appraisals SMO & RMO

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BOARD INFORMATION PAPER

Date: April 2020

Presented By Tracy Voice, Chief Digital Officer

Endorsed By Dale Oliff, Chief Executive Officer, Wairarapa District Health Board

Subject Information Communication Technology April 2020 Report

RECOMMENDATION It is recommended that the Board: a. Notes the contents of this update b. Notes the impact to ICT of responding to Covid-19

APPENDICIES 1. Wairarapa Roadmap

1 COVID-19 ICT ACTIVITY AND IMPACT

1.1 Supporting DHB Covid-19 Operations Information Communication Technology (ICT) has supported the transition of the Wairarapa DHB (WrDHB) to Covid-19 operations by: ∑ Enabling working remotely by; o Purchase of new ICT hardware such as laptops and mobile devices when equipment is available. o Increases in video and audio conference licences. o Increases in remote access software (Citrix) licences. o Development of remote working solutions. o Development of tactical solutions removing the need to be onsite such as radiology reporting from home. ∑ Providing additional infrastructure to support the EOC and Incident Management teams. ∑ Developing reporting to meet Ministry of Health (MoH) requirements. 1.2 Our workforce The preparation for Covid-19 commenced in late February and by 16 March focused our workforce to Covid-19 support activities. Since then ICT staff have worked considerable hours in a seven (7) day roster to support operational activities. An established 3DHB ICT Incident Management Team (IMT) that reports daily to each DHBs IMT on ICT related issues, logistical issues, and progress on implementing tactical work arounds. 1.3 Impact to the work plan The WrDHB has had 458 new issues raised for ICT resolution in March compared to 376 in February, an increase of 82 which were driven by Covid-19 operational activities. To manage this significant increase in raised issues and the additional effort to support Covid-19 operations, non-business critical projects have been put on hold until the country returns to alert level 3 as well as not addressing any non Covid-19 issues. This is resulting in a considerable backlog of issues to be resolved which we are reviewing alternative resourcing options to mitigate. Our Windows 10 upgrade project which requires new computing equipment will be delayed by some months due to global ICT equipment supply issues. 3DHB ICT are working with the Ministry of Business, Innovation and Employment (MBIE) to assist with hardware delays and also will move ICT assets between the Wellington regional DHBs for urgent demand.

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2 DIGITAL AND DATA STRATEGY

We had commenced work on the ‘Digital and Data Strategy’ for our three DHBs upon which any transformational change will be based on. We anticipate change will enable improved efficiency and service performance for our 3DHBs along with data interoperability across our greater Wellington Health ecosystem. The development of the Digital and Data Strategy commenced in November 2019. The early work has focused on the analysis of national, regional, and DHB strategies distilling to a common direction. In March a Digital and Data Strategy workshop was held with the three regional DHB executive teams to refine the five strategic themes. The outcome of this first phase of activity produced the following high level themes:

The Ministry of Health announced in March its intent to complete a digital and data strategy by June 2020. The Digital Data Intelligence Governance Group (DDIGG) have requested that the MoH present the draft at our next meeting. The next phase of the strategy development is the core digital and data priorities across our 3DHBs and the right delivery operating model. We aim to have this drafted by end of the month to social further across our system. 2.1 Digital Maturity Assessment We have a complex digital environment with multiple legacy systems and a significant reliance on paper based processes. To help inform the creation of a digital and data strategy we have sought an independent evaluation of our digital capability and systems maturity. The MoH is funding digital maturity assessments for all DHBs using the “HIMSS” maturity assessment tools. These tools are widely used across the world. Southern DHB and Mid-Central DHB have successfully completed their assessment process and found this to be a valuable exercise. The Wellington regional DHBs as well as Primary Health Organisations (PHO) and other primary healthcare providers completed the HIMSS digital maturity assessment in late February. The next step is a moderation meeting with HIMSS which has been deferred due to COVID-19. The final results will inform our Digital and Data Strategy and compare our maturity to other New Zealand (NZ) DHBs.

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3 DIGITAL AND DATA INTELLIGENCE GOVERNANCE

The DDIGG Group met for the first time early March. The terms of reference were agreed and we had further discussion on roles, responsibilities, and the supporting committees. The second meeting has been deferred to late May. The supporting committees are as follows with representatives from the DDIGG members’ chairing/co- chairing or participating, the terms of reference for each subcommittee will be worked on over the coming month:

4 3DHBICT PORTFOLIO OF SYSTEMS AND RISKS

4.1 Annual planning We have completed the FY2020/21 Capital and Operating budget submissions. The Capital plan submission was framed around the emerging Digital and Data strategic themes and included a shift to operating costs as we move to cloud based services. The operating submission stated risks to the proposed budget which relate to headcount and the impact to the DHB if the requested increases are not funded. Recognising the limited funding available to the DHB and that resourcing is likely to remain a constraint. In May we will propose 2020/21 initiative priorities for consideration by the Executive Leadership Teams and the Digital Data Intelligence Governance Group. 4.2 Portfolio planning We are progressing the plan to upgrade our clinical portals with the intent to standardise to one clinical portal across our three DHBs. This will involve both clinical and non-clinical staff and some change management which is not likely to occur until late 2020. We anticipate this being a significant piece of work to stabilise our clinical portal environment. The Initiate phase will be brought to the Capital Committees for endorsement in May. Work has commenced on designing how we backup our infrastructure environment, which has required us to go to the market to look at resilient options. This business case will be presented to the WrDHB executive team in May 2020. We have secured agreement to commence looking into the viability of leasing ICT hardware across the three DHBs. We will progress this work with the Capital & Coast DHB (CCDHB) Finance and Procurement with oversight from our DHBs Chief Financial Officers.

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We are reviewing the priorities of our 2019/20 work programme to manage our resource constraints as we remain headcount (Opex) constrained. We expect to have this work completed by the end of April. It is likely that some projects will need to be put on hold as we focus on the strategic high priority projects. 4.3 Moving to the cloud In December 2019 the Boards approved the acceleration to use cloud computing subject to the right security and privacy assessments. The first significant project is to migrate our existing email system onto the cloud (Microsoft Exchange Online). This will relieve capacity issues and provide the first foundational building block to enable a digital workplace. 4.4 ICT workforce The ICT team capacity cannot sustain the requested work activity. In February, remuneration gaps became apparent between the DHB ICT pay rates and the market which is causing our talent to investigate external opportunities. This is compounded by our workloads and the level of vacancies within the directorate. We are actively recruiting and are doing what we can to retain our people. The proposed role banding, adjustment to salaries, organisational change and increased headcount aims to mitigate these issues. Over the past months we continue to move away from a contractor workforce to that of a fixed or permanent workforce with the relevant cost recovery models. As part of the 2020/21 financial year planning we have included the shift in our workforce to permanent roles as well as addressing remuneration discrepancies based on market so we can attract and retain skilled individuals. In March we conducted Skills Framework for the Information Age training for all ICT Managers with the intent to update position descriptions. Going forward we aim to invest in assessments for all staff so we can build a career pathway model for ICT staff. We were right in the middle of finalising an organisational change proposal (prior to Covid-19) to align the leadership team and functions. It is proposed a number of roles (3) will report into a new Chief Technology Officer rather than the Chief Digital Officer and have a focus on operational delivery. In addition, new capabilities are proposed to be established around portfolio management (Hospital Specialist Services) plus data and information management. We intend to unify the team to one employer (CCDHB) which will impact approximately 37 staff (27 HVDHB, 10 WrDHB). Cost recovery practices will be acted upon to on charge to the appropriate DHB (HVDHB or WrDHB). We now aim to have this proposal complete end of May.

4.5 Support services Before the Covid-19 pandemic the average time to resolve an issue had been reduced to 20 days. The issue resolution is significantly above our service levels and is caused by resourcing constraints. We are working on resourcing for vacant critical support roles within the operating allowance however to make a significant performance improvement additional resources are required. We are in the midst of contracting an external provider CCL to assist with the current backlog of service requests for the next three months. We will then look at investigating longer term options to help deliver support at the expected service levels. The Regional Support and Service Assurance consultation process took effect on the 24th February which transitioned staff (14) to TAS employees rather than CCDHB.

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4.6 Risk Our current strategic risks are as follows: ∑ Limited ICT systems resilience resulting in significant disruption to patient care and hospital service delivery. ∑ Process gaps in systems access and information security which makes the DHB vulnerable to malware, hacking, lost or stolen devices, and unapproved access to systems. This can result in Patient and DHB information privacy being compromised and reputational damage for the DHB. ∑ Timeliness of referral letters including moving to electronic referrals to remove risk and delays of a manual paper based process. ∑ Outdated ICT strategy that is not aligned to the DHB and sector strategies which may result in Investments in ICT not being aligned to organisational strategies and poor prioritisation decisions. ∑ Aged telephony systems which need replacement to avoid disrupted service delivery and operational inefficiencies that result in reputational damage, poor patient experience and disruption to clinical services. ∑ 3DHB ICT is unable to meet service demand due to resourcing and capability of staff (skill sets) leading to the technology supporting our health services falling further behind resulting in degrading service performance and inability to meet public demand for better health services in the Wellington region. ∑ Scarcity of resources and being unable to attract and retain workforce in a 3DHB context will result in an inability to support our current services and deliver new capability for a modern health system resulting in poor health outcomes for the Wellington region. We are progressing projects which will resolve many of the high ICT risks. These projects are of significant size which we are in-flight or will have business cases submitted for approval. Cyber security awareness training for our Executives and EAs was completed in January with Wairarapa scheduled for the end of May. We now focus on induction training for all staff. The mitigation of our people risks are dependent on the ICT budget for 2020/21 and a shift in the operating model.

5 PLAN FOR QUARTER FOUR 2019/20

∑ Meeting DHB Covid-19 ICT needs. ∑ Prioritising non-Covid tier 1 and 2 support (break fix) over project deliveries to address the significant backlog of reported problems on existing systems. ∑ Planning on the clean-up of tactical solutions and what DHB critical initiatives we can commence delivery in the remainder of this financial year. ∑ Complete the Digital and Data Strategy ∑ Organisational Change Consultation on proposed alignment change and unifying the 3DHB ICT team. ∑ Digital and Data Governance Group – next meeting and sub working groups terms of reference. ∑ Business Continuity Plan and Disaster Recovery infrastructure remediation inclusive of transitioning to the cloud. ∑ Clinical portal consolidation Initiate Business Case. ∑ Digital Workspace (inclusive of Information Management) discovery work. ∑ Commence looking at leasing options for ICT Hardware. ∑ Ministry of Health Digital Maturity Assessments moderation.

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BOARD INFORMATION PAPER

Date: April 2020

Author Chris Stewart, Executive Leader Quality, Risk and Innovation

Endorsed By Dale Oliff, Chief Executive Officer, Wairarapa District Health Board

Subject WrDHB Quality, Risk and Innovation By Exception Report RECOMMENDATION It is recommended that the Board: a. Notes this paper and discusses as appropriate

1 EXCEPTION REPORT

Quality, Risk and Innovation reports on a quarterly basis to align with national Inpatient Experience Survey and Health Quality and Safety Commission (HQSC) data results. The February report to the Board and the next full quarterly report is due May 2020. COVID-19 has seen the Infection Prevention and Control, Occupational Health and Emergency Preparedness teams (with the support of the wider Quality Team) go above and beyond in their response. Staff in part time roles have stepped up with extra hours, providing cover and support for each other’s roles whilst providing leadership, technical expertise and speciality support to wider DHB staff in a collaborative and caring manner.

2 OCCUPATIONAL HEALTH AND SAFETY

Health, safety and well-being has been at the forefront of the DHB response, ensuring staff are well informed by regular staff communications and provided with the tools and support they need to do their roles during this COVID-19 pandemic. DHB staff have access to a 3DHB call centre service set up specifically to deal with COVID-19 related enquiries and individual risk assessment using a national COVID-19 specific Occupational Health tool that enables identification of risk factors based on medical conditions or age. The assessment enables the identification of any work restrictions or modifications required to ensure staff safety and well-being during the COVID-19 epidemic. There is a local support service utilising our social workers and other qualified staff to provide debriefs and/or support if required in addition to the vast written and online materials shared. There is also availability of support through the Employee Assistance Programme (EAP). Our Occupational Health Nurse, with the support of some casual vaccinators have as of 15 April 2020 provided flu vaccinations to 465 of our DHB staff (approx. figure of 62%) and 82 contractors. The final clinic is Thursday 16th April 2020, which will then be followed up with a personal contact for those who have not taken up the offer to try and enable us to reach our target of 90%. From the outset back in February, our Infection Prevention and Control (IPC) Nurse Specialist, supported by our Infectious Disease Specialist from HVDHB when able have delivered frequent and numerous staff sessions (all within the safe distancing requirements) across the hospital and community services ensuring all staff and contractors (all roles including kitchen staff, cleaners) were comfortable with the donning and doffing of PPE. Train the trainer sessions were held to increase coverage and as required repeat sessions have taken place.

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PUBLIC In addition general COVID-19 Question and Answer sessions with the Infectious Disease Specialists when on-site we have been arranged to enable staff to attend; the feedback has been that these sessions have been invaluable and staff have found them very reassuring. These will continue to occur as long as the need is there. Our IPC Nurse Specialist has also continued to support the ARC community by sharing relevant policies and procedures and resources and making herself available as required to provide specialist advice and directing to national resources where appropriate.

3 RISK

An updated full Risk Report Summary is provided with the Quality Quarterly Report and to the Financial Risk and Audit Committee (FRAC) bi-monthly. This report is generated from the real-time Risk Register on SharePoint. The key significant risk currently is the COVID-19 Outbreak and related risks associated to the national and local response requiring extensive resource allocation.

Risk Name Description Existing Mitigations Updates Controls Outbreak – An outbreak of Infectious Pandemic Plan. 14/04/20: IMT continues to meet on a daily Pandemic COVID-19 would Diseases COVID-19 Hospital Response basis, monitoring and responding to ongoing result in limited Policies. Plan. risks and issues identified as a result of the Identified: capacity and Infection Prevention and current Level 4 National Lockdown and on- 06/03/20 capability across Control Service. going dynamic demand and WrDHB and Emergency and incident and subsequent Hospital Response Level and the RAC 1 compromised response procedures. impact on service delivery as a result of the patient and staff Clinical assessment and threats COVID-19 poses as well. IMT Category: safety. laboratory screening. roles and managers are also monitoring and Patient Care; 3DHB Coordinated Incident responding to the impact to BAU and Health & Safety; response planning. delivery of services/care and any potential Operational; Health sector planning in risks to staff and patient safety, including Reputational conjunction with key supply chain issues. WrDHB's response agencies such as MOH, RPH, continues to reflect the requirements WREMO. outlined by MOH, All DHB and local response Clinical pathways and plan and ensures proactive communication guidelines. of such to all relevant stakeholders.

06/03/20: Chris Stewart - Planning is well established and a local IMT has been meeting regularly for the last month, linking in with 3DHB coordination.

WrDHB Quality, Risk and Innovation Public Excluded By Exception Board Report – April 2020 Page 2 of 2

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PUBLIC

BOARD INFORMATION PAPER

Date: April 2020

Author Dr Shawn Sturland, Chief Medical Officer

Endorsed By Dale Oliff, Chief Executive Officer, Wairarapa District Health Board

Subject Chief Medical Officer March Report RECOMMENDATION It is recommended that the Board: a. Notes this paper and discusses as appropriate

1 PURPOSE

The purpose of this paper is to provide the Board with an update from the Chief Medical Officer as the April Clinical Board meeting did not proceeding due to the current COVID-19 situation, it highlights clinical issues of concern across the hospital and wider Wairarapa Health Community.

2 SENIOR MEDICAL OFFICER WORKFORCE

The new Tele-Orthopaedics service (with Wairarapa District Health Board (WrDHB)) orthopaedics Senior Medical Officers (SMOs) are providing call via telemedicine) has been running successfully for three weeks. Recruitment into full time SMO positions is continuing.

3 RMO WORKFORCE

There has been a National directive that current Postgraduate Year One (PGY1) and Postgraduate Year Two (PGY2) Register Medical Officers (RMOs) will not rotate at the next planned changeover date. This means our current RMO workforce will stay on for a further 13 weeks. They are permitted to rotate between positions within Wairarapa hospital and this that has happened.

4 COVID-19

Planning for elective surgery has started, possible cases have been prioritised by specialty. These are then vetted by a committee of the four (4) vocational leads to ensure necessity, equity and appropriateness. We will be prepared to start as national restrictions are possibly lifted following the Prime Ministers update on Monday 20th April 2020.

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BOARD DECISION PAPER

Date: April 2020

Author Sir Paul Collins, Wairarapa District Health Board Chair

Subject Resolution to Exclude the Public RECOMMENDATION It is recommended that the Board a. Agrees that Public be excluded from the following parts of the of the Meeting of the Board in accordance with the NZ Public Health and Disability Act 2000 (“the Act”) where the Board is considering subject matter in the following table. b. Notes The grounds for the resolution is the Board, relying on Clause 32(a) of Schedule 3 of the Act believes the public conduct of the meeting would be likely to result in the disclosure of information for which good reason exists under the Official Information Act 1982 (OIA) to withhold, in particular:

SUBJECT REASON REFERENCE For the reasons set out in the public Board Public Excluded Minutes Section 9(2)(ba) agenda Delegation to sign contract variations for Mental Health Solutions Limited and Te Commercial activities - Negotiations Section 9(2)(j) Hauora Runanga o Wairarapa from 1 July 2019 to 30 June 2020 Wairarapa District Health Board COVID-19 Security and knowledge of which someone Section 9(2)(c) Response Update could take advantage of to cause harm Excluded Chief Executive Report to the Information provided in confidence Section 9(2)(ba) Board

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Internal Memorandum

To: Wairarapa Board Members

From: Dale Oliff, Chief Executive Officer

Date: 1st April 2020

Subject: Media of Interest for March 2020

From: Dale Oliff, Chief Executive Officer

Eketahuna aligned to wrong health board From Wairarapa Times-Age Published 11:30 05/03/2020 Wairarapa DHB chief executive Dale Oliff and chief medical officer Dr Shawn Sturland wrote to Eketahuna health providers last week to clarify the DHB position on not taking Eketahuna patients for orthopaedic and gastroenterology procedures. ... " Wairarapa DHB will always meet the acute needs of any patient presenting to Wairarapa Hospital," they said. ... "If some of our specific services don’t have capacity, out-of-domicile patients from Eketahuna are benefited by access to their own DHB," Wairarapa DHB spokeswoman Anna Cardo said.

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QUARTERLY REPORT 1 OCT 2019 - Q2 30 DEC 2019

CENTRAL REGION

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Whakamau, Whakaū, CONTENTS whakaora i te ao Māori 1. CONTRACT DETAILS 04 Recruit, Retain and Revitalise the 2. KEY HIGHLIGHTS 05 Māori Health Workforce 3. OVERVIEW OF KEY HIGHLIGHTS 06

4. SUMMARY OF ACTIVITIES (OCT-DEC 2019) 14

5. SUMMARY OF ACTIVITIES (JAN-MAR 2020) 16

6. PROGRAMME REGISTRATION AND DATA 18

7. RBA REPORTING 20

8. COMMUNICATIONS 25

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1. CONTRACT DETAILS 2. KEY HIGHLIGHTS

PROVIDER KEY ACTIVITIES THIS QUARTER: 1 OCTOBER - 31 DECEMBER 2019 Wairarapa DHB OCTOBER NOVEMBER DECEMBER PROGRAMME Promotion of Māori as a Career Programme

CONTRACT NUMBER Provider Code: 227641 Agreement ID: 359444/00

REPORT NUMBER AND TYPE DELIVERING SUPPORT TERTIARY SUPPORT SCIENCE Quarter two submitted to the Wairarapa District Health Board, RESULTS: SUCCESS: ACHIEVEMENT: UPPER CENTRAL HBDHB TUĀKANA/TĒINA PŪHORO STEM ACADEMY National Coordination Centre and Ministry of Health. APPOINTMENT INTERNS GRADUATION REPORT DUE DATE 10 February 2020

REPORTING PERIOD 1 October – 31 December 2019

ATTENTION

Karen Koopu SUPPORT SCIENCE SUPPORT TERTIARY DELIVERING Ministry of Health ACHIEVEMENT: SUCCESS: RESULTS: PO Box 5013, Wellington 6011 WrDHB KOH CHAMP TSGA OTAGO POLYTECH KOH PROGRAMME PROGRAMME MIDWIFERY TAUIRA EVALUATION STUDY [email protected]

PROGRAMME SPONSOR Jason Kerehi Executive Leader, Māori Health Māori Health Directorate Wairarapa District Health Board P.O. Box 96, Wairarapa 5840 [email protected]

REPORT AUTHOR Leigh Andrews Central Region Coordinator, Kia Ora Hauora Wairarapa District Health Board P.O. Box 96, Wairarapa 5840 [email protected]

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3. OVERVIEW OF KEY HIGHLIGHTS A. WORKSTREAM ONE - PROMOTE HEALTH CAREERS

EMPLOYMENT EXPO, WHITIREIA POLYTECH HAKA FIX, LOWER HUTT TE WHAKATŪWHERATANGA PŪHORO STEM ACADEMY WHAKATAU FOR 12 (UNLOCKING CURIOUS MINDS) – INDUSTRY INTERNS OCT UNIVERSITY OF OTAGO, WELLINGTON

15 NOV

8 OCT Left pic: (L-R) KOH Lower Central co-ordinator Leigh Andrews, KOH 5th Year Medicine tauira Grace Left pic: (L-R) CCDHB Recruitment Manager Shelly Alexander and Williams, University of Otago, Wellington Department CCDHB Nurse Co-ordinator and Cultural Support Phoenix Ahomiro. 18 of Pathology and Molecular Medicine, Senior Lecturer NOV NGĀ PŪMANAWA KI PŪREHUROA – Sara Filoche, KOH 5th Year Medicine tauira Jared HIGH PERFORMANCE SYMPOSIUM, Smiler (behind) and Te Kura Māori o ngā Mokopuna Year CENTRAL REGION ALLIED HEALTH SCIENTIFIC 11 students. MASSEY UNIVERSITY, MANAWATU FORUM, PALMERSTON NORTH HOSPITAL Left pic: (L-R) Pūhoro Manawatū kaihatū Apiata Tipene, KOH Lower Central co-ordinator Leigh Andrews, KOH tauira and MidCentral DHB KOH Champion Xavier Bowe, Pūhoro Director Naomi Manu, BACHELOR OF NURSING (MĀORI) MidCentral DHB Māori workforce representative Doug Edwards, PŌWAIWAI, WHITIREIA POLYTECH Pūhoro Evidence and Evaluation Kemp Reweti.

CHRISTMAS CARD MAIL OUT, CENTRAL REGION 24 17 OCT OCT Left pic: (L-R) Motivational speaker and influencer, Left pic: (L-R) KOH tauira and MidCentral DHB KOH Champion Hana Tapiata, and Massey University, Senior Māori Piripi Ratima (3rd Year Bach Health Science, Massey University Advisor, Apirana Pewhairangi. Palmerston North) and KOH Upper Central Co-ordinator, Lynette Laing.

Right pic: (L-R) Piripi Ratima, MidCentral DHB Māori workforce 22 representative Doug Edwards, Lynette Laing and KOH Lower Central NOV co-ordinator Leigh Andrews.

Top pic: (L-R) Whitireia kaihautū and KOH 3rd Year nursing tauira, Byron Elvey 7-9 NGĀ MANUKURA O APOPO, 1 NOV NGARUAWAHIA Lower pic: (L-R) KOH 3rd Year nursing tauira, Edith Peita DEC and KOH Lower Central co-ordinator Leigh Andrews.

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B. WORKSTREAM TWO - SUPPORT SCIENCE ACHIEVEMENT PŪHORO STEM ACADEMY YEAR 13 GRADUATION, PALMERSTON NORTH

KOH CHAMPIONS PROGRAMME, WAIRARAPA DHB

October saw the end of the Kia Ora Champions programme at Wairarapa DHB (WrDHB).

Tama Paku a Year 13, Wairarapa College student finished his time with WrDHB with a farewell morning tea which was attended by representatives of the departments he spent time in, the Executive Leader Māori Health Directorate and Director, Allied Health Scientific and Technical and his mother.

Tama started his internship in January and spent time with: (L-R) Executive Leader Māori Health Directorate Jason Kerehi, KOH Lower Central co-ordinator Leigh Andrews, Tamatea Paku, and Physiotherapy, Pharmacy, Occupational Therapy, Allied Health Scientific and Technical Director Nicky Rivers. Theatre, Urology, a kaupapa Māori community health provider and the Violence Intervention team. On Saturday the 14th of December 2019, twenty-four Māori Secondary School students graduated His project, one part of the KOH Champions programme outcome, was to interview health professionals from the first phase of the Pūhoro STEM Academy programme. Pūhoro is a Massey University initiative and update health study pathways, to later be uploaded onto the Wairarapa DHB internet and newly launched in 2016 to raise the number of Māori studying so-called STEM subjects and in the work force. created health workforce page. Kia Ora Hauora and Pūhoro have complemented each other’s initiatives regularly and recently signed two “It has been a privilege having Tama Paku here at Wairarapa DHB as our first KOH Champion. Your time Pūhoro graduates (Davis Ferguson and Xavier Bowe) onto a summer internship with the Pae Ora Māori here has highlighted what we need to do to promote and encourage young people and Māori to take Health Directorate at MidCentral District Heath Board. The boy’s will participate in a six week internship up a career in health. You have been a great ambassador for your school and have certainly made lots of starting in January 2020 and will contribute to a health project as defined by the Pae Ora team. friends and connections here with us. We are excited to walk alongside you as you progress towards your goal”, stated Jason Kerehi (Executive Leader Māori Health Directorate). Whilst Pae Ora have already carried out several internships within their team with the internship mirroring the KOH Champ role, their point of difference is that they create their internships according to the goals During his time in the KOH Champions programme Tama also met other KOH champs from MidCentral & and aspirations of each individual intern. Hutt Valley DHB’s and attended the Kia Ora Hauora Northern Rangatahi Health Symposium in Auckland earlier in the year. “When looking at designing a programme for the KOH Champs we firstly look at the area in Health that they are particularly keen on pursuing When asked what the successes were of his time spent at Wairarapa DHB Tama reflected, “I was able and build a programme around that” (Doug Edwards). to learn far more from people about their own jobs than any website could teach me. The programme broadened my horizon further and inspired me to think about my future goals”. Both Xavier (left) and Davis have enrolled on a health pathway of study at Auckland University in 2020. Armed with a KOH endorsement letter and his KOH champs attendance certificate Tama has been accepted to study health sciences at Otago University in 2020.

Wairarapa Staff Notices attached in the communications section.

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C. WORKSTREAM THREE – SUPPORT TERTIARY SUCCESS TUĀKANA/TĒINA INTERNSHIP PROGRAMME, HAWKES BAY DHB

TSGA - OTAGO POLYTECH MIDWIFERY TAUIRA A group of Māori medical students are getting hands on experience over the summer thanks to Otago Polytech, Parewahawaha the Tuakana/Teina internship programme being led Tiaki Mauri workshop to support whānau Palmerston North 7-8/09/2019 Marae, Bulls, by the Māori Health Team at Hawke’s Bay DHB. mental wellbeing 19 Students Manawatu. Māori medical students told them they were keen Otago Polytech, Otiria Marae, The Ngā Maia Māori Midwives Hui-ā-tau / to have work experience within their communities, Dunedin 21-23/10/2019 Moerewa, AGM whānau, hapū and iwi. The programme targets 4 Students Northland. students that have a whakapapa connection to Ngāti Kahungunu and whom might be interested This year the Central Region Tertiary Support Group Assistance (TSGA) fund was applied for by Otago in a medical career in Heretaunga. The interns will Polytech for their midwifery tauira. spend the summer working on projects that aim to improve Māori health outcomes whilst also gaining One initiative was applied for by the real-world experience in Māori Health. Palmerston North satellite and was (L-R) Winnie-Mae Read-Eden, Denver Ruwhui, Laura specifically created for Palmerston Gemmel, Shiloah Tuavera, Te Rina Maise “Recruiting a younger health workforce in an North tauira and the other was applied increasingly competitive environment is challenging. for by the Dunedin office to send Providing experiences that support their cultural Central Region tauira to the Ngā Maia and clinical development through manaakitanga Māori Midwives Hui-ā-tau / AGM, within the HBDHB for Māori students will hopefully which CR has been supporting since influence their decision making when looking at 2014. prospective careers and help grow the regulated Māori Health workforce.” (Ngaira Harker, Nurse Unfortunately a lot of our Central Director of Māori Health). Region tauira were unavailable to attend, therefore the Central Region Ngaira added that one of the critical success factors was able to sponsor Te Waipounamu for the internship was getting their senior clinical tauira to attend in their place. leaders to awhi and host the students within their professions and areas of expertise. Left pic (L-R) KOH CR 1st Year Midwifery student Wanaka Noanoa and KOH Lower Central co-ordinator Leigh Andrews. Back row (L-R) Hawkes Bay DHB, Nurse Director Māori The internship programme has already shown health, Ngaira Harker, kaimahi, Māori Workforce Advisor much success with two of the interns presenting (in yellow), Heneriata Paringatai 2019/2020 Tuākana - their projects to HBDHB clinical leadership. Māori Tēina Interns: Te Rina Maise 5th Year Bach Med & Surg, TSGA Reports attached in the communications section. University of Otago, Wellington, Selwyn Te Paa 4th Year Directorate and Executive teams. The hope is that Bach Med & Surg, University of Otago, Wellington and the internship will attract them back to the region Shiloah Tuavera 4th Year Bach Psychology, University once they are qualified. of Waikato. Seated (L-R): Denver Ruwhui 4th Year Bach Med & Surg, University of Otago, Wellington, Milly Bowen *Central Region Kia Ora Hauora was able to sponsor 4th Year Bach Med & Surg, Otago University, Dunedin, four of the seven interns for this year’s intake. Winnie-Mae Read-Eden 4th Year Bach Med & Surg, University of Auckland, Laura Gemmel 2nd Year Bach Health Science, Otago University, Dunedin. https://www.teaomaori.news/fresh-faces-maori- medical-students-hawkes-bay

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D. WORKSTREAM FIVE - DELIVERING RESULTS CR KOH PROGRAMME EVALUATION STUDY REPORT

KOH UPPER CENTRAL CO-ORDINATOR, LYNETTE LAING Central Region Kia Ora Hauora Programme Evaluation Study report Lynette started with Kia Ora presents the findings of a project Hauora Central Region at the undertaken by Central Region Kia Ora beginning of October 2019. Hauora and Whitireia New Zealand in With a Diploma in Sport and 2017-2018. Exercise Science, a Bachelor of Nursing and Post Graduate The project evaluated the effectiveness Certificate in Health Sciences, of three specific events (called she has years of experience in interventions) held between the years the health and fitness industry. of 2010-2017. The interventions: Tū Kaha Central Region Māori health Lynette has had experience development conference (rangatahi working in the Acute Mental stream), Workchoice Day and Work Health setting both in MidCentral Experience Day (held at Capital & Coast and Counties Manukau, and has DHB) were designed to engage secondary also spent some time working in school students in activities that would promote health professions as the community both nursing and a career option. It was found that the three interventions were effective in engaging and as a personal trainer. As Lynette maintaining students’ interest in a health-related career. was raised in the Manawatu, she has many links in the area A summary of the report was published within the Whitireia Journal of Nursing, Health and Social and is excited to build more! Services, Issue 26, November 2019.

During the month of October she: Full report and published summary attached in the communications section.

• attended the Te Waipounamu (TWP) Study to Mahi workshop, meeting two other regional co- ordinators (TWP and Northern),

• attended the Central Region Allied Health Scientific and Technical ‘Sharing good practice’ forum with the Central Region co-ordinator and met with MCDHB Pae Ora Team and their KOH Champ for 2019.

• attended the Ngā Pūmanawa ki Pūrehuroa – Māori high performance symposium at Massey University, Palmerston North and met with their Māori recruitment team.

• presented to UCOL nursing students at the Palmerston North campus and met with the Māori student support team there;

• and has met with the Pūhoro STEM Academy based at Massey University, Palmerston North.

She has also been making contact with the KOH registrees in her catchment and learning the KOH Central Region processes.

The following month will see her meet with the Hawkes Bay & Whanganui DHB Māori health teams and their districts key stakeholders.

Lynette’s passion is health in all its forms and she is very keen to share her knowledge.

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4. SUMMARY OF ACTIVITIES QUARTER 2: OCTOBER - DECEMBER 2019

The following table provides a summary of activities completed for the last quarter.

TARGET WORK TARGET WORK DATES OCTOBER SUMMARY OF ACTIVITIES DHB LOCATION DATES NOVEMBER SUMMARY OF ACTIVITIES DHB LOCATION GROUP STREAM GROUP STREAM

Introduction of KOH to 1st Year Massey nursing Capital & Wellington Turangawaewae, 1 Oct Tertiary 3 7-8 Nov Attended Ngā Manukura o Āpōpō National Strategy 5 students Coast Hospital Ngaruwahia End of KOH Champions Programme farewell Masterton Met with AHST Director re: WrDHB workforce Masterton 3 Oct Wairarapa Secondary 2 11 Nov Wairarapa Strategy 5 morning tea Hospital initiatives Hospital Capital & Whitireia KOH and HBDHB catch up. Introductions to Hawkes Hastings 8 Oct Whitireia, Employment Expo Tertiary 1 12 Nov Strategy 5 Coast Polytech Upper Central co-ordinator Bay Hospital Met with Director of Midwifery re: pipeline for Capital & Wellington Networking with Massey University Student MidCentral Massey 10 Oct Strategy 5 14 Nov Strategy 5 midwifery Coast hospital Recruitment Adviser – Māori DHB University Attend Study to Mahi workshop to orientate Central Ara Institute, Unlocking Curious Minds Capital & Porirua, 14 Oct Strategy 5 15 Nov Secondary 2 Upper Central Region Christchurch end of year celebration Coast Wellington Attend NEtP as cultural support for KOH Capital & Wellington Attended National Māori Psychology (He Paiaka WINTEC, 16 Oct Tertiary 4 15 – 17 Nov National Tertiary 1 registree Coast hospital Totara) Hui-ā-tau Hamilton Palmerston KOH presentation to CR AHST Forum ‘Sharing Central Massey 17 Oct North Strategy 5 18 Nov Pūhoro STEM Academy – whakatau for interns MidCentral Secondary 2 innovation and good practice’ Region University Hospital Met with Whitireia – KOH published in Capital & Whitireia The Ngā Maia Māori Midwives Hui-a-tau / AGM Moerewa, 22 Nov Strategy 5 21 – 22 Oct National Tertiary 3 Whitireia journal Coast Porirua - Otirea Marae (TSGA) Northland Capital & Whitireia Massey 22 Nov Bachelor of Nursing – Māori Pōwaiwai Tertiary 1 24 Oct Attend Māori High Performance Symposium MidCentral Strategy 1 Coast Porirua University Auckland - Introduce NZQA CR Māori manager to Capital & Uni.of Otago, 28 – 29 Nov NCC Operations Hui National Strategy 5 25 Oct Strategy 5 Metro Unlocking Curious Minds programme Coast WGN

25 Oct NCC Operations Hui National Zoom Strategy 5 TARGET WORK DATES DECEMBER SUMMARY OF ACTIVITIES DHB LOCATION UCOL, GROUP STREAM KOH Presentation at UCOL “Hauora Wellness 30 Oct MidCentral Palmerston Tertiary 1 Education Day” Central North 1 Dec KOH Central Christmas Card mail out ALL ALL 5 Region Networking with Massey University Pūhoro Massey 31 Oct MidCentral Strategy 5 Capital & Wellington STEM Academy University 3 Dec Met with recruitment re: Strategy Plan Strategy 5 Coast Hospital Capital & Wellington 10 Dec Earn and learn meeting with directorates Strategy 5 Coast DHB Hospital UCOL, 11 Dec KOH Presentation to nursing tauira MidCentral Palmerston Strategy 5 North Palmerston 14 Dec Pūhoro STEM Academy Year 13 Graduation MidCentral Secondary 2 North

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5. SUMMARY OF ACTIVITIES QUARTER 3: JANUARY - MARCH 2020

The following table provides a summary of activities planned within the Central Region, during the next quarter reporting period.

TARGET WORK TARGET WORK DATES JANUARY SUMMARY OF ACTIVITIES DHB LOCATION DATES FEBRUARY ACTIVITIES CONTINUED... DHB LOCATION GROUP STREAM GROUP STREAM Met with Associate Director of Allied Health, Capital & Wellington 18 Feb Café Kōrero Whanganui Whanganui Tertiary 3 6 Jan Strategy 5 Scientific & Technical – Māori Health Coast Hospital Palm.North 18 Feb Meet with Senior Lecturer – school of Midwifery Whanganui UCOL Strategy 5 8 Jan Mihi whakatau for KOH Champs MidCentral High School 2 Hospital Walter Nash THINK 19 Feb FREE First Aid Training Hutt Valley Tertiary 3 8 Jan Met with Clinical Director of THINK Hauora MidCentral Strategy 5 Centre, Taita Hauora 20 Feb Café Kōrero Hutt Valley Taita Tertiary 3 Wairarapa Masterton 14 Jan Met with Recruitment contractor Strategy 5 DHB Hospital Capital & St Johns, 22 Feb FREE First Aid Training Tertiary 3 Facetime with Te Puni Tūmatawhānui and EIT Hawkes Palmerston Coast Wellington 17 Jan Strategy 5 Cultural Support Advisor Bay North Capital & 23 Feb Café Kōrero Wellington Tertiary 3 Palmerston Coast 17 Jan Met with health team at Te Au Rere a te Tonga MidCentral Strategy 5 North Māori Suicide Prevention Research, Policy & Capital & University of 24 Feb Tertiary 3 Met with KOH Champs and communications Palm.North Practice- Summer School Coast Otago, WGN 21 Jan MidCentral Strategy 5 team at MCDHB Hospital Meet with GM Network Development & THINK 28 Feb MidCentral Strategy 5 Hawkes Hastings Support at THINK Hauora Hauora 23 Jan Summer Internship Presentations Tertiary 3 Bay Hospital Hawkes TARGET WORK 23 Jan Met with EIT Nursing Lecturer Hastings Strategy 5 DATES MARCH SUMMARY OF ACTIVITIES DHB LOCATION Bay GROUP STREAM Central 23 – 24 Jan NCC Ops hui National Wellington Strategy 5 Hauora Māori Scholarship Workshops ALL Tertiary 3 Region Hawkes Met with health team at Te Au Rere a te Tonga Palmerston 24 Jan Met with Bureau/Flight Nurse Hastings Strategy 5 9 Mar MidCentral Strategy 5 Bay (Youth Justice) North Capital & Wellington St Johns, 29 Jan Met with Radiation therapy lecturer Strategy 5 17 Mar FREE First Aid Training Whanganui Tertiary 3 Coast Hospital Whanganui Palmerston 29 Jan Met with kaiwhakahaere from Ngā Pou Mana MidCentral Strategy 5 North 18 Mar Café Kōrero Whanganui Whanganui Tertiary 3 Capital & St Johns, 17 Mar FREE First Aid Training Tertiary 3 TARGET WORK Coast Porirua DATES FEBRUARY SUMMARY OF ACTIVITIES DHB LOCATION GROUP STREAM Capital & 18 Mar Café Kōrero Porirua Tertiary 3 Interprofessional Education: Capital & University of Coast 3 Feb Tertiary 3 Whakawhanaungatanga Session Coast Otago, WGN St Johns, 23 Mar FREE First Aid Training MidCentral Tertiary 3 Massey Palm North 4 Feb Pūhoro Internship – Pō whakanui MidCentral Tertiary 3 University Palmerston 24 Mar Café Kōrero MidCentral Tertiary 3 Hawkes St Johns, North 10 Feb FREE First Aid Training Tertiary 3 Bay Taradale Capital & St Johns, 24 Mar FREE First Aid Training Tertiary 3 Hawkes Coast Porirua 11 Feb Café Kōrero Taradale Tertiary 3 Bay Capital & 25 Mar Café Kōrero Porirua Tertiary 3 Palm.North Coast 13 Feb KOH Champs graduation/presentations MidCentral Tertiary 3 Hospital St Johns, 17 Feb FREE First Aid Training Whanganui Tertiary 3 Whanganui

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6. PROGRAMME REGISTRATION AND DATA

CENTRAL REGION PROGRESS LOCAL KOH TARGETS OCTOBER - DECEMBER 2019 • The spread of Māori secondary school students registered within the programme is shown in the NATIONAL TARGET QUARTER Q3 Q4 Q1 Q2 ANNUAL # RESULT (2019) TARGET RESULT RESULT RESULT RESULT TARGET table below, as per the Central Region & education year. New Māori on health study 1 35 118 80 81 57 336 140 pathway YEAR 9 YEAR 10 YEAR 11 YEAR 12 YEAR 13 TOTAL Support transition into 2 10 12 0 37 0 49 40 tertiary- 1st & 2nd Yrs only 2 13 12 18 54 99 Support transition to 3 10 26 8 9 0 43 40 employment

As at October-December 2019 there are currently 3,561 Māori registered on the programme. Of that • The spread of Māori tertiary students registered within the programme is shown in the table below, 588 are Central Region registered which comprises of 17% of programme total. as per Education Level. Demographics of registered users for Central Region are FOURTH, FIFTH, FIRST YEAR SECOND YEAR THIRD YEAR FINAL YEAR TOTAL SIXTH YEAR • 588/100% Māori 389 as per DB • 506/87% female and 75/13% male 119 80 123 60 7 exported SS • The spread of Māori registered per DHB region within the programme is shown in the table below, as per Region & DHB.

TOTAL AS OF TOTAL AS OF TOTAL AS OF TOTAL AS OF % AS OF OCT- DHB JAN-MAR APR-JUN JUL-SEP 2019 OCT-DEC DEC 2019

Wairarapa 41 36 41 49 8%

Hutt Valley 46 47 46 57 10%

Capital and Coast 166 151 162 164 28%

MidCentral 108 85 97 106 18%

Whanganui 63 54 54 64 11%

Hawkes Bay 95 93 132 147 25%

TOTAL 519 467 532 588 100%

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7. RBA REPORTING JULY - SEPTEMBER 2019

Completed/Reported Every Qtr 1,2,3,4 Completed/Reported 6 Mthly - July, Jan Completed/Reported Ann -Jan Completed/Reported Every Qtr 1,2,3,4 Completed/Reported 6 Mthly - July, Jan Completed/Reported Ann -Jan

HOW MUCH? (#) (Quarterly): Jan-Mar, Apr-Jun, Jul-Sept, Oct-Dec WHO’S BETTER OFF? (#) (Quarterly): Jan-Mar, Apr-Jun, Jul-Sept, Oct-Dec PERFORMANCE QUANTITY PERFORMANCE QUANTITY REPORTING SOURCE COMMENTS REPORTING SOURCE COMMENTS OBJECTIVE (BASED ON CONTRACT) OBJECTIVE (BASED ON CONTRACT) #588 of KOH students Numerator = 57 of new Māori Central Region quarterly Note: 25% of ALL senior Secondary Total senior rangatahi Numerator # = Year (clients) registered on the Denominator = 588 infographics provided by Denominator = secondary students Numerator = 21 engaged in science 11 – 13 High school programme NCC Total number of (clients) who have been Denominator = 84 eligible senior activities = 21: students engaged in (9.7% are new Māori KOH registered on actively supported to secondary students 1. KOH Champs (2) science activity (6 registered) programme as indicated achieve NCEA (Levels 1-3) 2. Pūhoro (4) monthly period) in Central Region in science (BC, O) 3. Te Whakatūteratanga cumulative. (15) Denominator # = Total 9% of KOH secondary Numerator = 9 engaged Attendance and Denominator # taken 4. See the Solutions (?) number of Year 11 – 13 school students (clients) Denominator = 99 registration to events / from ‘current status’ High school students. engaged in the programme Total sec school student programmes taken over infographic 47% of ALL tertiary Tertiary Total 3rd Year tauira Numerator # = 3rd the quarter. students (clients) who have Numerator = 55 engaged to achieve Year tertiary students 4.7% of KOH Māori Numerator = 16 engaged Attendance and Denominator # taken been actively supported Denominator = 123 eligible 3rd tertiary quals = 55: engaged in activity (6 tertiary students (clients) Denominator = 341 Total tertiary registration to events / from ‘current status’ to achieve tertiary level Year tertiary students 1. Study to Mahi monthly period) engaged in the programme student programmes taken over infographic qualifications in health / by workshops, x35 the quarter. type (BC, O) 2. NZNO, Hui a tau x12 Denominator # = Total 3. O.P. Midwifery number of 3rd Year # secondary school 3 Implemented in Qtr. 2 As per regional work plan students x8 tauira. science KOH activities/ 2 Planned activity for Qtr. 2 programmes % of ALL graduates who Numerator = 30 Database Tags: Trans to Numerator # = (clients) transition into NZ health Denominator = 105 mahi – 2019 (30) who transition into # tertiary KOH activities/ 4 Implemented in Qtr. 2 As per regional work plan sector employment NZ health sector programmes 1 Planned activities for Qtr. 2 within 12 months’ post- Contracted 6 per every 6 months Database Current Status: employment within 12 graduation (CC, S) Graduated (105) months’ NOTE: ALL clients, not HOW WELL? (%) (Quarterly): Jan-Mar, Apr-Jun, Jul-Sept, Oct-Dec CANNOT BE just graduates. DETERMINED PERFORMANCE QUANTITY REPORTING SOURCE COMMENTS Denominator # = Total OBJECTIVE (BASED ON CONTRACT) number of graduates. 74.8% eligible KOH Secondary % = Total # of KOH Numerator # = NOTE: Graduated students Numerator = 99 clients registered on the Secondary + Tertiary date not recorded by registered on the Denominator = 588 eligible programme / total eligible students as taken from month/ year. programme by type student students. ‘current status’ on CR Narrative: Captures qualitative data secondary/tertiary Tertiary cumulative infographic What worked well Numerator = 341 440/588 = 74.8% Denominator = 588 eligible • Increased participation in activities by student and industry. student • High attendance at new Study to Mahi workshops. 5.7% KOH students Secondary = 9% Secondary students Tertiary students What didn’t work well (clients) who are engaged Numerator = 9 engaged in: engaged in: • Access to updated KOH student information in order to edit in KOH database. in the programme Denominator = 99 students • Te • Whitireia Powaiwai • Access to See the Solutions student list / report. activities by type registered Whakatuwheratanga – 9 Possible solutions Tertiary = 4.7% - 6 • TSGA Midwifery hui • Contact students direct for updated details bypassing industry partners (i.e. DHB, University of Otago, Numerator = 16 • KOH Champs - 20 Wellington). Denominator = 341 Students programme MCDHB & • Tuakana / Teina registered WrDHB - 3 internships- 7 • NCC to add See the Solutions tag to database. • Total secondary • Total tertiary Trends students engaged = 9 students engaged • Increased participation in activities. = 16

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114 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices 28 33 30 16 22 64 49 57 728 147 106 164 PARAMEDIC 8% 25% 11% 18% 10% 28% 26 456 67 42 55 33 53 323 PHARMACIST 256 223 68 78 68 40 HEALTH PROMO HEALTH DISTRICT DISTRICT BOARD: HEALTH 112 SURGEON 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5+YEARS YEARS WITH REGISTERED ORA KIA HAUORA: 119 50 242 86 140 3 ORAL HEALTH ORAL PARAMEDIC 40 / 7% 66 / 11% 5 482 / 82% 185 PHARMACIST PSYCHOLOGY 18 PROMO HEALTH HEALTH TE TOTAL 337 TOTAL TOTAL TOTAL 293 249 153 467 / 13% 784 / 22% CENTRAL 5 0 199 MIDLAND NORTHERN 50 45 40 35 30 25 20 15 10 2,310 / 65% 6 SOCIAL WORK SOCIAL TERTIARY INSTITUTE: TERTIARY WAIPOUNAMU TERTIARY INSTITUTE BY REGION: REGION: INSTITUTE BY TERTIARY SURGEON ORAL ORAL 11 HEALTH 203 MIDWIFERY 99 479 100 245 923 41 TOTAL 128 5+ YR PSYCHOLOGY 191 66 53 87 146 352 PHYSIOTHERAPY 44 YR13 WORK SOCIAL SOCIAL YR13 87 5TH YR SECONDARY (99) SECONDARY 30 18 66 148 262 YR12 33 451 MEDICINE YR12 MIDWIFERY 157 23% 4 13 64 4TH YR 105 186 INTERESTED YR11 23 PHYSIO- PHYSIO- THERAPY 0 49 13 24 86 YR11 404 YR10 3RD YR NURSING YES NO/BLANK 1,059 4 HEALTH STUDY PATHWAY: STUDY HEALTH STUDY: OF AREA 78% 0 2 4 TIONAL TIONAL 31 37 THERAPY OCCUPA- YR9 YR10 443 2ND YR NO 249 NURSING INTERESTED YES HEALTH STUDY PATHWAY: STUDY HEALTH AREA OF STUDY: STUDY: OF AREA YR9 578 1ST YR 1ST TOTAL CENTRAL MIDLAND NORTHERN 4% 3% YEAR LEVEL 0 0 16% 27% 50% 60 45 30 15 EDUCATION LEVEL: EDUCATION SECONDARY STUDENTS: SECONDARY 600 500 400 300 200 100 TE WAIPOUNAMU TERTIARY STUDENTS: TERTIARY SECONDARY STUDENTS: SECONDARY TERTIARY (341) TERTIARY 5% 2% 18% 17% 58% 10 43 PART-TIME PART-TIME 367 ROLES CLINICAL 194 NON-CLINICAL ROLES 66 ROLES CLINICAL 41 NON-CLINICAL ROLES 253 DHB 202 PHO / NGO 106 EMPLOYER OTHER 58 DHB 18 PHO / NGO 31 EMPLOYER OTHER 561 STUDENTS EMPLOYED 107 STUDENTS EMPLOYED EMPLOYED - HEALTH SECTOR - HEALTH EMPLOYED 561 SECTOR - OTHER EMPLOYED 132 STUDENT SECONDARY 953 STUDENT TERTIARY 1,797 TBC 118 EMPLOYED - HEALTH SECTOR - HEALTH EMPLOYED 107 SECTOR - OTHER EMPLOYED 29 STUDENT SECONDARY 99 STUDENT TERTIARY 341 TBC 12 65 416 FULL-TIME FULL-TIME EMPLOYMENT: EMPLOYMENT: PROGRAMME STATISTICS DECEMBER 2019 DECEMBER STATISTICS PROGRAMME 2019 - DEC PROGRAMME STATS CUMULATIVE TOTAL CURRENT STATUS: STATUS: CURRENT CURRENT STATUS: STATUS: CURRENT

A 0 75

M 63 I

R 0% NGĀTI NGĀTI 1,092 13% 24% 5+ YEARS NOT STATED NOT 31% RAUKAWA NOT STATED NOT

H 36 60

BEGINNER 343 CONVERSATIONAL/ FLUENT 151 ANSWER N O/DIDN’T 94 W BEGINNER 1,985 CONVERSATIONAL/ FLUENT 803 ANSWER NO/DIDN’T 773 253 4 YEARS 41+YRS 14% 7% 1,256 / 35% NORTHERN 699 / 20% MIDLAND 588 / 17% CENTRAL 874 / 25% TE WAIPOUNAMU 144 / 4% OVERSEAS 16% 41+YRS WAIKATO 616 / 17% MALE 58 / 2% OTHER 2,887 / 81% FEMALE 506

U 16%

R 87% 58% 22%

56%

O 34 T NGĀI NGĀI TAHU 120 590 3 YEARS 13% 33% 26-40YRS 17% 26-40YRS 26% 23% 588

U R 46 NGĀTI NGĀTI 3,561 187 POROU 2 YEARS 17% 1,626 51% UNDER 25 46% UNDER 25

A T 85 MĀORI REGISTERED WITH KOH IN THE IN WITH KOH REGISTERED MĀORI 1 YEAR NGAPUHI 32% MĀORI REGISTERED ON THE PROGRAMME ON REGISTERED MĀORI CENTRAL CENTRAL REGION: GENDER: AGE: TE REO FLUENCY: WITH KOH YEARS REGISTERED GENDER: AGE: TE REO FLUENCY: 5 IWI: TOP REGION REGION INFO: NATIONAL PROGRAMME STATISTICS DECEMBER 2019 DECEMBER STATISTICS PROGRAMME NATIONAL 2019 – DECEMBER STATISTICS PROGRAMME CUMULATIVE TOTAL REGION CENTRAL

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8. COMMUNICATIONS 9 7 9 5 14 13 WORKSTREAM 2 - SUPPORT SCIENCE ACHIEVEMENT: KOH CHAMPIONS PROGRAMME, WAIRARAPA DHB DISTRICT DISTRICT BOARD: HEALTH 0 PARAMEDIC 3 / 7% 1 / 2% 0 40 / 91% PHARMACIST 4 PROMO HEALTH HEALTH 5 0 50 45 40 35 30 25 20 15 10 1 TERTIARY INSTITUTE: TERTIARY SURGEON 0 ORAL ORAL HEALTH 8 PSYCHOLOGY YR13 9 WORK SOCIAL SOCIAL 1ST YEAR 1ST (19) 3 YR12 MIDWIFERY 1 PHYSIO- PHYSIO- THERAPY YR11 1 TIONAL TIONAL THERAPY OCCUPA- INTERESTED YR10 NO 14 YES NURSING HEALTH STUDY PATHWAY: STUDY HEALTH AREA OF STUDY: STUDY: OF AREA 5TH+ YEAR (3) YR9 4TH YEAR (2) 2ND YEAR (7) 5 4 3 2 1 0 SECONDARY STUDENTS: SECONDARY 3RD YEAR (3) TERTIARY STUDENTS: TERTIARY 4% 9% 18% 60% 11% 0 PART-TIME 1 ROLES CLINICAL 0 NON-CLINICAL ROLES 1 DHB 0 PHO / NGO 0 EMPLOYER OTHER 2 STUDENTS EMPLOYED EMPLOYED - HEALTH SECTOR - HEALTH EMPLOYED 2 SECTOR - OTHER EMPLOYED 10 STUDENT SECONDARY 5 STUDENT TERTIARY 34 TBC 6 1 FULL-TIME EMPLOYMENT: PROGRAMME STATISTICS | Q2 OCT-DEC 2019 | Q2 OCT-DEC STATISTICS PROGRAMME CURRENT STATUS: STATUS: CURRENT 8 57 15% NOT STATED NOT 100% 0 BEGINNER 34 CONVERSATIONAL/ FLUENT 12 ANSWER N O/DIDN’T 11 0% 41+YRS 47 19% 85% 60% 0 0% 26-40YRS 57 21% 0 0% UNDER 25 MĀORI REGISTERED THIS QUARTER IN THE IN THIS QUARTER REGISTERED MĀORI TE REO TE REO FLUENCY: CENTRAL CENTRAL REGION: GENDER: AGE: CENTRAL REGION QUARTER 2 STATISTICS OCTOBER-DECEMBER 2019 OCTOBER-DECEMBER 2 STATISTICS QUARTER REGION CENTRAL

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WORKSTREAM 3 - SUPPORT TERTIARY SUCCESS: TSGA 7 – 8 SEPTEMBER, 2019. TIAKI MAURI WORKSHOP, BULLS, MANAWATU

TERTIARY SUPPORT GROUP ASSISTANCE REFLECTION

KEY CONTACT: Julie Robb-O’Connell TERTIARY INSTITUTE: Otago Polytechnic

TELEPHONE: 0284178823 EMAIL: [email protected]

EVENT/ACTIVITY: Tiaki Mauri Healing Noho Marae DATE: 7-8 September STUDENT ATTENDEES: 16

KEY HIGHLIGHTS: • Wananga being held • Connecting Non- • Using Oku to make • The Marae provided on the Marae, Māori to Māori punga a safe space for our knowledge and tauira to be vulnerable. • Healing was the focus • Aromatherapy practices • Connecting 1st Wanaka Noanoa 1st year Tauira Midwife Otago Polytechnic Stevie Love 2nd year Tauira Midife Orago Polytechnic • Reconnection of • Attendance of Whanau Whānau cohesion Whanau participation. Do the mahi get the treats • Kai mirimiri x2 and 2nd year tauira whanau Māori back • Applying Te whare wha Tuakana-Teina • Kai raranga to their traditional to support and nurture knowledge • Access consciousness our tauira Midwives. BARS

NARRATIVE REPORT: The Tiaki Mauri noho Marae was such a wonderful and timely event. It was a spiritual journey for all, with the focus of healing. Having the noho on the Marae allowed for a safe space for our Tauira to be vulnerable and look first inward and then outward for the answers they require to take care of themselves, their whanau and travel the journey they need to to become Midwives. Again being on the Marae allowed tauira Māori to reconnect with their traditional knowledge and practices around wellbeing, this included kai mirirmiri (mirimiri with hot rocks and Aromatherapy touch), kai raranga (weaving), making a punga with oku (clay) keeping us grounded as well as the BARS (mirimiri for the hinengaro). The noho also allowed for non-Māori to connect to Te Ao Māori knowledge and practices and understand the true essence of wellbeing for Māori. The tauira loved having their whanau, their pepi experience this noho with them. This allowed them to relax Creating a safe space for our whanau to thrive Lisa Thompson 2nd year tauira Midwife Otago Polytechnic more and fully capture the intention of the noho as well as, get to know and connect to each other as a Tuakana-teina whanau. The tauira and their whanau expressed how calm, inviting, loving and fulfilling the noho was. All the tauira and the tamariki were saddened when the noho was coming to an end, and stated, “we want to stay here forever, this is our home”, thus showing their connection to the noho and to each other as tuakana and teina was deeply meaningful. The tauira have expressed the need for more noho with each other and their whanau with a focus on healing and connecting. What this reflects to me is the need to continue to apply Te Whare Tapa Wha to support and nurture our next generation of Midwives. Likewise how Māori models of health and wellbeing can transcend over all cultures. Below is a post from an attendee.

Hi Julie, Just wanted to say a big thank you again for such a magical few days! It has totally changed my perspective on midwifery and made me remember why I started on this journey in the first place. I managed to bring that energy to my shift yesterday and I hope to hold on to it in everything I do. I’ll be seeking out other experiences like this as often as I can, so I don’t forget again! Hazel has asked me at least 10 times when we can return, she loved it too! Hope your week has started well, Amber.

Thank you so much for supporting Otago Polytechnic tauira Māori Midwives. Nga mihi Julie Making punga- Sharing the knowledge and practices of our tupuna. Connection to Te Ao Māori

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WORKSTREAM 3 - SUPPORT TERTIARY SUCCESS: TSGA 21 – 23 OCTOBER, 2019. NGĀ MAIA MIDWIVES HUI-Ā-TAU, NORTHLAND

TERTIARY SUPPORT GROUP ASSISTANCE REFLECTION

KEY CONTACT: Mara Bathgate TERTIARY INSTITUTE: Otago Polytechnic

TELEPHONE: 02108176327 EMAIL: [email protected]

EVENT/ACTIVITY: Ngā Maia Hui 2019 DATE: 21-23 October STUDENT ATTENDEES: 3

KEY HIGHLIGHTS: • The speakers • NZCOM president Nicole Pihema, Jean Te Huia, Ngarangi Pritchard, Mahia Winder, Nearly the whole cast of My Māori Midwife series (we were a bit star struck!) local Labour MP Willow-Jean Prime, Summers- Mary Prime (star struck again!), The Moerewa kapa haka group (incredible!), meeting fellow students and making interschool connections. • The local lore and knowledge shared, the sense of every aspect or te whare tapa wha being met. • Being able to experience this together as a group.

NARRATIVE REPORT: Nardia, Emma and I, as student midwives at Otago Polytechnic are studying in a course devoid of Māori midwife/birth specific tikanga and in the Dunedin area there are no currently practicing Māori midwives to experience placements alongside. As such we have all struggled either academically or spiritually to meet assessments in a way that is true to te ao māori while meeting the OP requirements. Ngā Maia Māori Midwives Aotearoa “Te Huringa o Te Ao” Days Tumatauenga wharenui, Otirea Marae, Moerewa, Northland We applied and were most grateful to achieve funding to attend the Nga Maia Hui in Moerewa, without this 1 & 2 Programme funding our dream to attend may not have come to fruition. We met at Dunedin airport at 0830 for our flight to Auckland, greeted by one of our tutors and Māori student liaison Julie Robb-O’Connell. The kōrero was enriching, real, raw, validating and we were all aware that these few days were going to be just what we needed, we were all wary after a strenuous year of study with exams ahead. After our drive North, we arrived for the powhiri at 1730. Our day ended with whakawhanaungatanga went through the night to 0400. We started the day at 0630 with kanikani, followed by a full day of incredible speakers; kaupapa māori antenatal class providers, experience of a homebirth whānau, kōrero about the hauora of our people and whānau, a guided trip to ruapekapeka pā, the whole time enriched by the most incredible local orators. The day was rounded off with a trip to the Ngawha hot springs to heal and regenerate, again the kōrero went well into the night to 0130. The final day we had the Nga Maia AGM, there were korowai gifted to 6 honoured membered to acknowledge the length of their commitment to the movement. There was a symposium put to student representatives that attended from 3/5 of the aotearoa midwifery schools, we were honoured as wāhine, the future of midwifery and our questions respected and discussed fully with each panel member contributing their answer. It ended too soon, we cannot wait to attend the Nga Maia Hui again, we see it as vital and essential for our self-care. What we all took away from the experience was the awhi, new friendships and connections, renewed passion for our studies and future careers and the knowledge that our experiences are shared, we belong, we can do this. We returned to our whānau and studies as new wāhine, those who had thought if they did not get through the exams that they would pursue it no further reinvigorated with the knowledge that his was their pathway and they would get there no matter what (and they did too, largely in part due to this experience). So thank you, really well and truly. The worth of your support exceeds the words we can conjur to express our gratitude. Tumatauenga wharenui, Otirea Marae, Moerewa, Northland

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WORKSTREAM 5 - DELIVERING RESULTS: CENTRAL REGION KIA ORA HAUORA PROGRAMME EVALUATION STUDY REPORT

Central Region Kia Ora Hauora Programme Evaluation Study report This evaluation was undertaken in 2017-18 by a team from Whitireia New Zealand and Central Region Kia Ora Hauora.

Evaluation Team

Leigh Andrews 2019 Central Region Co-ordinator, Kia Ora Hauora (Māori Health as a career programme).

Dr Ruth Crawford Manager, Teaching Excellence and Flexible Learning, Whitireia and WelTec, Wellington New Zealand

Kia Ora Hauora programme Kerri Arcus Programme Manager, Postgraduate Studies and Research, Whitireia and WelTec, evaluation study Wellington New Zealand.

Acknowledgements The evaluation team wishes to thank the following people for their contributions to this evaluative study: Cheryl Goodyer, Manager, Capability, Māori Health Development Group, Capital and Coast District Health Board; Maryanne Johnson, data collation; Frances Fowler, data analysis; Diana Fergusson, report collation; and Janet Collier-Taniela, Programme Manager, Health Māori, Whitireia and WelTec, Wellington New Zealand

Our thanks also to the Whitireia/WelTec Research Innovation Fund and Central Region Kia Ora Hauora for funding to enable this evaluation.

Whitireia

New Zealand Central Region Kia Ora Hauora

Kia Ora Hauora programme evaluation study report 1

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Executive Summary of the four hubs. This project evaluated events (interventions) that engaged secondary school students in specifically designed activities promoting health careers. This report presents the findings of a project undertaken by Central Region Kia Ora Hauora

and Whitireia New Zealand in 2017-2018. Kia Ora Hauora operated in partnership with The Central Region Kia Ora Hauora Programme is currently led by Wairarapa District Health Capital & Coast District Health Board until 2017 and from 2018 with the Wairarapa District Board (WrDHB). It was previously led by Capital and Coast DHB (CCDHB). Health Board. The project evaluated the effectiveness of three specific events (called interventions) held between the years of 2010-2017. The interventions: Tū Kaha, Methods Workchoice Day and Work Experience Day were designed to engage secondary school Following registration into the Central KOH (CR KOH) programme (Appendix 1), registered students in activities that would promote the health professions as a career option. students from secondary schools in the region were contacted via email and social media and encouraged to attend a range of promotion events (interventions) about health- Background related careers. Students attended the intervention of their choice and completed a paper- There is a global shortage of health professionals and demand for healthcare services based evaluation of the intervention (Appendix 2). There had been no evaluation to date, continues to increase (World Health Organisation, 2014). In New Zealand, a key workforce of the effectiveness of the interventions offered as part of the programme to increase the priority is the recruitment and retention of Māori into the health sector workforce (Kia Ora recruitment of Māori into a range of health careers. Hauora, 2015). In 2006, the Ministry of Health launched Raranga Tupuake, the Māori Health Workforce Development Plan, to facilitate a co-ordinated approach to address the Purpose under-representation of Māori in the NZ health and disability workforce (Ratima et al., The purpose of this project was to retrospectively analyse data previously collected during 2007). A report commissioned by the Ministry of Health and the Health Research Council specific KOH interventions. Interventions included in this report are Tū Kaha Central of New Zealand, the Rauringa Raupa report (Ratima et al., 2007) provided an analysis of Region Māori health development conference (TK), Workchoice Day (WC) and Work the barriers and influences which increase Māori participation in the workforce and Experience Day (WED). Workchoice Day is a mainstream health careers promotional day, identified retention issues (Kia Ora Hauora, 2015). developed and led by Workchoice Trust for senior secondary school students (Years 12 &

13). This day was not targeted solely at Māori students. CR KOH funded Workchoice Trust Māori are highly underrepresented in the health and disability workforce, especially in the to deliver the WC programme at Wellington Hospital in 2012 & 2013. Work Experience professional occupational groups (Ministry of Health, 2007). The Public Health Workforce Day was designed by CR KOH in collaboration with CCDHB Māori Health Development Development Plan (Ministry of Health, 2007) noted that Māori make up 33% of the Group to target a younger Māori audience (Years 9 – 11) and to lower running costs by workforce but are concentrated in lower paid positions with limited decision-making. developing the programme in-house. Gilchrist and Rector (2007) observe that a culturally diverse workforce easily identifiable to minority groups, makes it more probable that the latter will access health services. Key findings Overall, the three interventions which were the focus of this project: Tū Kaha, Workchoice In August 2008, an interim project team of District Health Board, Ministry and Sector Day and Work Experience Day, were effective in engaging and maintaining students Stakeholder representatives was established to initiate the design of the Health as a interest in a health-related career: Careers Programme, known as Kia Ora Hauora (Kia Ora Hauora, 2015). In April 2009, the • Pre-intervention 48% of students said they were considering a career in health programme was fully endorsed by Tumu Whakarae, the Māori Workforce Champions Group • Post-intervention 62% of students said they were considering a career in health and District Health Board New Zealand (Kia Ora Hauora, 2015). • Students attending CR KOH interventions were mainly female (64%), Year 10 (21.5%) and identified as Māori (69%) Kia Ora Hauora (KOH), Supporting Māori into Health, is a national programme established • Work Experience Day (WED) was the most attended intervention in 2008 to increase the recruitment of Māori into a range of health careers. The programme • The most effective intervention motivating an interest in a health career was Workchoice Day (90%), closely followed by Work Experience Day (84.5%) is a nationally coordinated and regionally driven workforce development programme, led • The most popular activities at interventions were simulation experiences (Operating by Canterbury District Health Board, linking with four regional hubs. Central Region is one Theatre, Air Ambulance), followed by engaging with real health professionals.

Kia Ora Hauora programme evaluation study report Kia Ora Hauora programme evaluation study report 2 3

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Conclusion ū Contents ā Evaluation Team ...... 1 Acknowledgements ...... 1 Executive Summary ...... 2 Recommendations Background ...... 2 • Methods ...... 3 ā Purpose ...... 3 • Key findings ...... 3 Conclusion ...... 4 • Recommendations ...... 4 • Introduction ...... 7 Method ...... 8

Attendance ...... 8 Gender ...... 9

Year at School ...... 10 Ethnicity ...... 11

Ethnicity across all interventions ...... 11 Ethnicity by intervention ...... 12

TK Intervention ...... 12 WC Intervention ...... 13

WED Intervention...... 15 Student interest in a health career pre- & post-intervention...... 17 “I am a future Māori paediatrician! Thank you so much amazing opportunity and for really showing me that as a Māori woman I can do all Pre-intervention ...... 17 ” All interventions ...... 17 Individual interventions ...... 18 Post-intervention ...... 19 Thematic analysis of comments ...... 20 Thematic analysis of answers to: “Is there anything else important you think we should know?” ..... 21 Tū Kaha Māori Health Development conferences...... 21 Workchoice Day ...... 22 Work Experience Day ...... 23 Comparing findings across all interventions for the question: “Is there anything else important you think we should know?” ...... 25 Thematic analysis of answers to: “What was the event or the presentation you will remember the most?” ...... 25 Tū Kaha Māori Health Development conferences ...... 25

Tū Kaha 2010 ...... 25 1 Young person, between ages of 12-24

Kia Ora Hauora programme evaluation study report Kia Ora Hauora programme evaluation study report 4 5

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Tū Kaha 2012 Introduction Tū Kaha 2014 “Shayne Walker”* [Hawke’s ay n=1 Tū Kaha 2016 priority is the recruitment and retention of Māori into the health sector workforce ( orkhoie ay: Māori , Supporting Māori into H ork periene ay: in 2008 to increase the recruitment of Māori into a range of health careers. – ecruit and support 1500 new Māori onto a and support at least 300 new Māori into first year tertiary study. In 2015 it was reported that the national programme exceeded goals with 3,651 Māori registered in the programme since 2010 and 2,555 Māori identified on a health study pathway since 2010. Comparing findings across all interventions for the question: “What was the event or presentation you will remember the most?” ummary onlusion offered as part of the programme to increase the recruitment of Māori eommendations eferenes ppendi : ample of registration form ā ppendi : ample of ealuation form

ū Māori Health Development Conference • • • Must be Māori • •

• • • •

• • • ā • –

tended family

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Method Gender – emale seondary shool students omprised n=391 of the total he indiidual interentions aried etween female attendane with attending interentions – n=24 – n=33 – n=33 – n=38 at interentions effective to increase the recruitment of Māori into a range of health careers? – n=25 – n=47 and attending the interention – n=30 – n=36 – n=48 – n=77 he greatest numers of females attended the programmes ut the greatest perentage of females attended the programmes – – – – Attendance – – – – – –

• ū ender • •

ale emale ttendanes y Interention

ia ra auora programme ealuation study report ia ra auora programme ealuation study report

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Gender Males Females Unknown TOTAL n=59 n=67 TK 2010 37 n=74 n=44 TK 2012 44

TK 2014 42 Ethnicity TK 2016 46

WC 2012 54 Ethnicity across all interventions WC 2013 67 Across all interventions, 427 students identified as Māori ( Māori WED 2014 67 shows Māori and nonMāori WED 2015 58 WED 2016 71 WED 2017 122 ā ā TOTAL 206 391 11 608

Year at School

• • •

Non-Māori Māori . All intervention Māori and nonMāori ethnicity Māori ethnicity across all interventions has been analysed according to the Māori cohort and 11.5% of the total student cohort Māori cohort and 9.5% of the total Yr. level DNC Yr. 9 Yr. 10 Yr. 11 Yr. 12 Yr. 13 Yr. 14 TOTAL TK 2010 37 Māori cohort and TK 2012 44 Māori cohort and 2% of TK 2014 42 TK 2016 46 Māori cohort and 1.5% of the total student cohort Māori ethn WC 2012 54 WC 2013 67 WED 2014 67 WED 2015 58 WED 2016 71 WED 2017 122 TOTAL 23 109 131 90 130 118 7 608

n=109 n=131 n=90

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ā (76.5%) identified as Māori. The remaining

Māori identified with both Māori and Pacific people ethnicity. identified with both Māori and Māori

Ethnicity by intervention TK Intervention  identifying first as Māori and then also indicating as a Pacific people as a Māori This intervention was targeted for Māori. Māori v nonMāori Māori vs NonMāori – (Tū Kaha) – –

Total Eleven students (7%)

WC Intervention %) attending the WC interventions identified as Māori Māori shows the Māori v nonMāori attendance across

Non-Māori Māori

. Māori v nonMāori attendance across the TK programmes

identified as Māori. In the , 31 students (83.5%) identified as Māori. The remaining

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Total Five students (21%) Māori vs NonMāori WED Intervention

as Māori. Māori. invite Māori students. shows the Māori v nonMāori attendance across the WED

Māori vs NonMāori

Non-Māori Māori

. Māori v nonMāori attendance across the WC programmes

%) identifying as Māori. The Non-Māori Māori

identifying as Māori. The . Māori v nonMāori attendance across the WED programmes %) identifying as Māori. 47 students (81%) identifying as Māori. Nine of the The WED 2016 programme registered 48 students (67%) identifying as Māori. The 23

The WED 2017 programme registered 113 students (92.5%) who identified as Māori. The Māori

 identifying first as Māori and then also indicating as a Pacific people as a

– –

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Student interest in a health career pre- & post-intervention Pre-intervention

All interventions

Māori

 identifying first as Māori and then also indicating as a Pacific people as a

–

Total 43 students (17.5%)

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Post-intervention

DNC

Tū No

e Mayb

Yes

WC WC ALL

DNC

e Mayb

Yes

ALL ALL WED WED

DNC

Mayb

Yes

TK TK ALL ALL Individual interventions Individual

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129 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices Thematic analysis of answers to: “Is there anything else important you

think we should know?”

Tū Kaha Māori Health Development conferences.

DNC

ata ee aalable o all T oaes T T T T eet [tell us about] “T [tell about] us o stuets T a T . ata ee ollate o te ea

stuets.

No ” TūKaha,WorkchoiceDay, ote stuets . ot oet. Tettee stuets state “o

oet” o sla. Tele stuets . ol oete to sa a et

stuets eesse stateets elate to “a u t as aesoe” o sla. Maybe Tee stuets oete o te eesets.

oe eeees ee eoee b ou stuets . Yes

. at as oo eoable oste oets

WC WC ALL

t stuets ae oets se to at te eoe o ate as a

oste eeee. Te ollo ae eets o te ealuatos tae ebat. DNC • “eall eoe a eet seaes”

• “Tū aa as tout a oubt te best eeee e a. e ae so a

e es a ee all o to sta otat. Tees bee so a

satoal eole a o te oeee e bee se to o ute ta

so a beoe a oto”

• “Tū aa as a eae so u et so a as ou Māori le Maybe sel. oe to oe ba a sae journey when I finish my study”

• “eall a a eall oo te. t as eall oate. eoe te oa

o ote aata o e a te sae alues a teest et. eall “ Yes

lee” • “Ta ou o a e eel a lttle bt ole”

• “ T MĀORI aeata Ta ou so u o o us t ts ”. ALL ALL WED WED aa ootut a o eall so e tat as a Māo oa a o all ts”

• “ think having rangatahi was good” • DNC “I think that staying at the Marae was cool because it ‘Māorie’ te eeee

more”

Te a tees o tese oets ae a. stuets eelo elatoss a b.

stuets eel eoee to see a aee ealt.

. at stuets ot le eate oets Maybe

comments

e stuets ae oets o at te ot le o ate a eate

of Yes eeee. Te ollo ae eets o te ealuatos.

• “ee aata oe oe a teeste” TK TK ALL ALL • “ t soe o te tals e a to lste to ee a to ollo beause t ast about stu tat olved us, so I couldn't follow it” • “ esoall ou te eet bo as eel tat oul ot elate toas soe o te ole seaes as t elt tat te ee oe ea to eole o ee already in health professions” hematic analysis

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• “I think some of the talks we had to listen to were hard to follow because it wasn't • “Yes, thin it would be un and interesting to be a radiologist” about stuff that involved us, so I couldn't follow it” • “Yes, it encouraged me to ollow my dream ob in being a nurse” • “eople were being a bit disrespectful but besides that 'everything was kei te pai'” • “his trip has helped me decide about a possible career in nursingradiographer” • “ want to get a Bachelor o Nursing aciic” he main theme is students finding it difficult to relate to some activities. • “Music helps students pay attention” • “ really enoyed the instructive rotations with demonstrations” iii. hat is needed he main theme is that students ound some career direction within health ourteen students provided feedback on what could be improved or what they were looking for. he following are ecerpts from the evaluations. ii What students did not lie negative comments

• “outh need more ecitement and youth surrounded workshops. ore downtime Four students ) made comments speciic to what they did not lie or indicated a for rangatahi” negative eperience he ollowing are ecerpts rom the evaluations • “ore youth stuff usic, apa aka, Dance etc.” • “hanks for the opportunity for us rangatahi to be heard. he organisation could • "didn't interact much with dierent schools ighlight o day seeingmeeting the have been a bit more organised and more teenage things” ospital ecruitment Manager" • “ore rangatahi and more fun stuff” • " want to be a pediatric sic but there wasn't that opportunity really enoyed • “eed more activities for rangatahi” the blood test collecting ob because ound that really helpul or looing ater my • “eed to make it more active for the youth. reat people and really good to be able son, the hours are helpul" to connect with others who are looking at the same work” • "No but…the guy with the blue shirt needs to be a little less serious" • “Add more practical things” • “Add more practical work” here was no clear theme identiied in this section • “here should've been more handson activities. A disco or something…less talking and more handson activities” iii What is needed • “ore physical activity” • “ore interaction time 'straight' to the point' speakers” en students ) provided eedbac on what could be improved or what they were • “I think this conference should continue to be open to youth” looing or he ollowing are ecerpts rom the evaluations • “Overall conference was great but the rangatahi should be ear s” • “ave more time with the professionals. he speakers spoke for a long time so I • got bored after minutes or so but some things were really interesting. ust think “More pharmacy” • they should speak for a shorter time. onger onference dinner. OVED E “ thin it's be great to do a section on paediatrics” • VIDEO” “Would have loved to see a hysiotherapist, but my "guide" was lovely miley Face)” • “ould be more ocused on career pathways subects ino where to study dierent he main theme is that students reuested more active and practical sessions. subects practical ino ust about in the hospital unction) nd should tal about primary care not ust hospital ocus a ai” • "Mae this presentation involve all ethnicities, not ust Māori aciica upporting Data were collated for both programmes , , a total of students. Māori students into health)" • “Mae the presentations a little longer” • ity students did not comment. wentyfour students . responded or “Mae the presentation a little bit longer” • similar. ive students only commented to say and seven students “Mae sure people aren't sipping rotations, although we do apologise or taing epressed statements related to or similar. o students too long” • commented on the refreshments. wo students . commented on their future by “Be on time, don't go overtime” • referring to returning to work in the organisation. “More paper, so we don't have to memorise everything”

i. hat was good enoyable positive comments he main theme in this subsection ocussed on students wanting more speciic health career inormation ine students made comments specific to what they enoyed or indicated as a positive eperience. he following are ecerpts from the evaluations. ata were available or Ws , , and , a total o students • “elt the tour focused a lot on roles not reuiring medicine as in doctor's which was interesting as other roles are often overlooked” ne hundred and twentyone students ) did not comment ne hundred and one • “as a very successful day. howed lots of interesting pathways I was unaware of” students ) stated or similar even students ) only commented to say • “est careers trip ever” and students ) epressed statements related to or similar hirteen students ) commented on the rereshments

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i What was good enoyable positive comments • “his as ea fun ont foet to isten and foo a comments t miht he aui oa descendents of the sun ai oa oos of ife aaia as amain” Fourteen students ) made comments speciic to what they enoyed or indicated as positive eperience he ollowing are ecerpts rom the evaluations he main theme focussed on students antin moe secific heath caee infomation

“I want to be a Surgeon” “ “My favourite one was the air ambulance” “Theatre scenario was the funniest. Airway management presenter was funny” ” “Anything to do with theatre/air ambulance please update me” “It was really fun and encouraged my choice in health profession” coss a thee oammes students indicated simia ositie findins ith comments “I had a great day and when I get older I will be looking to study and get a job at focussed most on findin a caee diection ithin heath he oamme feedac Wellington Hospital” eeaed students anted a one oamme and the found it difficut to eate to some “The German dentist lady deserves a hug” actiities fte anasis of comments eated to the and oammes no cea “Was a fun day and I learnt a lot” themes emeed tudents had moe to mae than ositie and “Increased my knowledge and interest” neatie comments he oamme main theme as a euest fo moe actie and “Learnt heaps, cheers” actica sessions heeas the and oammes eeaed students anted moe “Very educational and interesting. Thank you very much. My father is a surgeon secific heath caee infomation here and at our other hospitals can as him or advice” “I could help my family's health” Thematic analysis of answers to: “ “I enjoyed it, thank you very much. Does dyslexia prevent people from becoming a doctor?” ” “han you or having us and teaching us )” he students ee ased to identif asects of the oamme that the ememeed the most as at of thei ostinteention eauation he fooin anasis is undetaen he main themes are students learning about a health career and students identiying oamme so that diffeences can e identified eteen inteentions potential pathways Tū Kaha Mā ii What students did not lie negative comments ata ee anased fo a oammes and ae eoted seaate as the diffeed in outcomes e note seaes at the Tū aha hree students ) made comments speciic to what they did not lie or indicated a confeences ae identified ith an asteis afte thei name negative eperience he ollowing are ecerpts rom the evaluations

“ was tired at irway Management because this was the last session” ū “hat it was an alright day, last year better” hitseen students attended and fou comments ee made ut no data as “You should have more drin options”. aaiae fo one student and eiht students did not esond here was no clear theme in this section he ten to actiit oshosesentation ae isted eo in aned ode ith some of the associated student’s comments iii What is needed • “” seua heath theate ou– “funn eate to hat as haenin had en students ) provided eedbac on what could be improved or what they were eat messae” looing or he ollowing are ecerpts rom the evaluations • “onfeence maste of ceemonies” hiaious • “ā oo” esentation • “More body stu” • “eetin eoe” • “nowing about more ancer” • “eate– humoous aesome” • “Wanted to see Plastic Surgery” • “eath ofessiona seae” eeant • “lthough it ocused on all health careers, maybe looing at dierent types o • “tain at the maae” medicine specialisation” • “i ason uie” ofesso of Māori tudies • “ thin it would be cool to have a orensic part” • “aiata” ames • “Mae some o the worshops more interactive” • “The inspiring speeches that gave us Māori hope” • " loved the trip have another one" • “onger sessions” • “ had a good day, love all o it ust need to now more”

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he most common memoae asect of the oamme ith comments eated to • “” the seua heath theate ou een students identified to o moe eents esentations Tū aha . The ‘Iron Māori’ debate was commented on otfou students attended the oamme hitsi comments ee made no data as aaiae fo students and thee students did not esond ū aa he ten to actiit oshosesentation ae isted eo hese ae isted eo in aned ode ith some of the associated comments • “eath esentes” schooist hsician th ea medica students tain to eoe aout caee aths heath caee esentes meetin m mento • “ ” • “eate cac u” • “ ” • “anc uaine” e ananui i eath uthoit • “ ”  • “i ason uie” ofesso of Māori tudies • “ ” • “e honoe in sin anuae” • “ ” • “e ānana” • “  ” • “eetin the st ations” eoe fom • “ ” • “ea outs” • “ seaes ee eite” • “onfeence dinne” n

he most common memoae asects of the oamme ee the heath esentes Tū Kaha Interventions Summary and then the deate en students identified to o moe eents ū esentations Tū aha otto students attended the oamme otnine comments ee made and si ke a students did not esond he to actiit oshosesentation ae isted eo in aned ode ith some of the associated comments • “eed datin””tain to heath ofessionas” “caees ta” ”meetin tetia students” “e motiatin and aesome” • “he ron Māori deate” “ea inteestin and et me focused and motiated” n • “eetin eoe haahanaunatana” • • “oshos” • • “niesit stas” • • “aimiiani’s seech” tetia student eious ia a auoa student • • “i ason uie” • • “hayne aler” Hawke’s ay n=1 • • • “atu m” • • “enta heath inteie” • •

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• • •

• • • • • • • • • • • • Workchoice Days Interventions Summary • k eee a • • • • • • • • – • • • • • • • • – • •

WED Interventions Summary • • •

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134 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

a s ass a ees e es “a was e ee esea w eee e s” verall the entral region ia ra auora interventions increased the amount of interest the students had in a health career rior to the intervention indicated they Analysis of all interventions highlights two key themes as indicated by students’ responses were interested in a health career rising to postintervention when asked if the of their most memorable event or presentation attended irstly opportunities provided intervention motivated them to consider a career in health responded pre by simulated eperiences were overwhelmingly the most popular particularly in the intervention dropping to postintervention hose indicating a dropped slightly intervention econdly interaction with health professionals themselves was identified from to across all interventions as memorable his included opportunities to talk to health professionals themselves attending careers talks and ‘speed dating’ activities ogether he intervention where success in motivating interest in a health career was greatest was this suggests that students most enoyed practical eperiences and engagement with the intervention with of students indicating a ombining and health care professionals coding indicates students potential interest was also greatest in the intervention followed by intervention and then the intervention a A total of secondary school students registered for three interventions (Tū Kaha (TK), tudents were most highly engaged in practical activities such as simulation and orkchoice day ork perience ay undertaken on ten occasions between interactions with health care workers and professionals and emale secondary school students comprised most attendees with male students Across all interventions the greatest number of students attending • reintervention of students said they were considering a career in health were in ear closely followed by ear ear comprised of the student cohort with ear students ear represented the lowest numbers • ostintervention of students said they were considering a career in health of students attending our hundred and twentyseven students identified as Māori and as nonMāori ( with five students not indicating ethnicity A • tudents attending interventions were mainly female ear further analysis of the onMāori shows students of total student cohort and identified as āori as acific people acific amoan ongan okelauan ook sland or iian nine students of total student cohort as ndian students of total student cohort • ork perience ay was the most attended intervention as Asian of total student cohort as AA iddle astern atin American and African and students of total student cohort identifying as uropean • he most effective intervention motivating an interest in a health career was orkchoice ay closely followed by ork perience ay tudents were asked if they are considering a career in health to the interventions • hey could respond with or Across all interventions students he most popular activities at interventions were simulation eperiences responded responded and students did not perating heatre Air Ambulance followed by engaging with real health respond professionals

ollowing the intervention students were asked about the etent to which the hese results indicate that the entral egion ia ra Hauora programme, specifically Tū hey could respond with aha ork perience ay and orkchoice ay interventions are engaging Māori or Across all interventions students responded students secondary school students in activities and events that result in increased interest in health responded and students responded students did careers with the intention of recruiting āori youth into a health focused study pathway not respond

n all three interventions when asked what they would like ia ra auora to know about their eperiences students indicated similar positive findings comments focussed mostly • hat the entral egion ia ra auora programme continues to receive funding to on finding a career direction within health tudents had more to make provide interventions to support āori rangatahi into a healthrelated career than positive and negative comments he programme main theme was a reuest for more active and practical sessions whereby the and programmes revealed • hat interventions continue have a strong focus on simulationhandson activities and students wanting more specific health career information meeting health professionals

tudents indicated two key themes across all interventions when evaluating the most • hat the programme provides more specific information on health careers and memorable event or presentation irstly simulation was overwhelmingly the most career pathways indicated item particularly in the intervention ealth care role interaction was identified in the intervention talking to health professionals careers talk as well as • hat further research is undertaken to find out how many students from the the and interventions ogether these suggest that students most enoyed programme enter healthrelated tertiary study and then move into a health career practical eperiences and engagement with health care workers

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. Journal of Transcultural Nursing, 18

ia ra auora ellington ew ealand Author

inistry of ealth etrieved from httpswwwhealthgovtnsystemfilesdocumentspublicationspublichealth workforcedevelopmentplanpdf

atima rown arrett ikaire gawati Aspin otaka nd retention of Māori in the health and disability workforce. A niversity etrieved from httpswwwmacomauournalstrengtheningmaoriparticipation newealandhealthanddisabilityworkforce

orld ealth rganisation etrieved from httpswwwwhointworkforceallianceknowledgeresourcesA auniversaltruthreportpdf

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WORKSTREAM 5 - DELIVERING RESULTS: CENTRAL REGION KIA ORA HAUORA PROGRAMME EVALUATION STUDY REPORT

Kia Ora Hauora: Guiding Māori Secondary School Students toward Health Careers

LEIGH ANDREWS, RUTH CRAWFORD AND KERRI ARCUS

Kia Ora Hauora is a national programme which aims to increase the number of Māori working in health and disability services in Aotearoa New Zealand. The Central Region Kia Ora Hauora programme provides activities and events (interventions) for Māori secondary school students to interest them in health careers. At an intervention, students learn about health disciplines, meet health professionals and participate in simulated practice. Three intervention days were delivered in each of the years 2010–2017, and written evaluations were collected from participating students. In 2017–2018 a project team from Central Region Kia Ora Hauora and Whitireia New Zealand analysed the effectiveness of these interventions based on these evaluations. Findings suggest that the interventions were successful in stimulating and increasing students’ interest in health careers. Relational activities such as meeting health professionals and taking part in simulated practice experiences appear to be influential. KEYWORDS: Kia Ora Hauora; Māori; secondary school students; health careers; career advice

s the demand for healthcare services The Ministry of Health (2007) identified A increases globally, so does the international that although Māori comprised 33% of the shortage of health professionals (Liu, Goryakin, workforce, they were concentrated in lower- Maeda, Bruckner & Sheffler, 2017; World Health paid positions with limited decision-making. Organisation, 2014). In the New Zealand context, Te Uru Kahikatea 2007–2016, the Public attracting and retaining Māori in the health and Health Workforce Development Plan (Ministry disability sector is of particular importance and of Health, 2007) identified the need for im- a key workforce priority (Kia Ora Hauora, 2015; proved Māori health outcomes as the key driver Simmonds, 2018). Māori are highly under- of public health workforce development. represented in professional health occ upations in A culturally diverse workforce that is visible New Zealand (Ministry of Health, 2007; 2016). to minority groups has the potential to improve In response to this, the Ministry of Health com- their participation and access to health services missioned and launched Raranga Tupuake, the (Gilchrist & Rector, 2007). Recruitment and Māori Health Workforce Development Plan, in retention of Māori in the health professions is 2006 as a co-ordinated strategic approach to a key priority in New Zealand that requires address these concerns (Ratima et al., 2007). culturally relevant approaches. Barriers and enablers which impacted Māori A project team of District Health Board participation in health careers were analysed, and (DHB), Ministry of Health and sector representa- retention was identified as a concern (Kia Ora tives initiated and designed the ‘Māori Health as Hauora, 2015). a Career Programme’, known as Kia Ora Hauora

58 Whitireia Journal of Nursing, Health & Social Services 26/2019 Pages 58–62

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Kia Ora Hauora: Guiding Māori Secondary School Students toward Health Careers L. ANDREWS, R. CRAWFORD AND K. ARCUS

Could be more focused on career pathways; (KOH), in 2008 (Kia Ora Hauora, 2015). Kia collaborated to collate and analyse these partici- career, was Workchoice Day (90%), followed subjects info; where to study subjects; prac- Ora Hauora: Supporting Māori into Health, was pant evaluations. by Work Experience Day (84.5%). Students tical info OR just about HR in the hospital established with the aim of increasing Māori rep orted that they particularly benefited from (function). And should talk about primary recruitment into the health professions. The METHODS the simulation experiences. The three most care not just hospital focus. Ka Pai!! programme was endorsed by Tumu Whakarae, Following ethical approval by the Whitireia– ‘memorable’ interventions were the Operating the Māori Workforce Champions Group and WelTec Ethics and Research Committee Theatre simulated scenario (WC), followed by The simulation opportunities were well received, District Health Boards New Zealand (Kia Ora (RP120-2016: 1 June 2016), existing CR KOH the Air Ambulance simulation (WED), followed such as a theatre scenario where students acted Hauora, 2015). KOH is co-ordinated nation- evaluations of TK, WC and WED interventions by engaging with practising health professionals out different roles directed by health profes- ally, but the programme is adapted and delivered from 2010–2017 were collated and analysed to (all interventions). sionals. The WC interventions introduced eleven regionally. The national programme is led by answer the research question: What interventions health career workshops, and students identified the Canterbury DHB, with four regional in the Central Region Kia Ora Hauora programme Tū Kaha the most memorable as: radiology (n = 32), hubs throughout the country. Central Region are most effective for increasing the recruitment Students reportedly enjoyed the TK conferences, theatre scenario (n = 22), medical technician Kia Ora Hauora (CR KOH) is one of the four of Māori into a range of health careers? and the main themes identified from evaluation (n = 19), phlebotomy (n = 10), paramedic hubs. During the time the interventions in this Descriptive statistics, simple inferential comments were that they enjoyed develop- (n = 10) and nursing (n = 9). However, num- evaluation were held, the CR KOH operated in statistics and NVivo thematic analysis were used ing relationships and felt empowered to seek bers attending WC were variable in different years partnership with six DHBs, including Capital to analyse the evaluation data. Key statistical data a career in health. Students rated the keynote and not all options were available at every WC and Coast DHB (as lead DHB for the Central are reported below, but the focus of this research speakers highly, but some students had trouble intervention, which influenced the aggregated Region, 2010–2017, however CR KOH is now brief is on thematic analysis of written com - relating to the experiences and requested more results across the WC interventions. led out of Wairarapa DHB). ments from students’ evaluations in response practical sessions. The most memorable aspects CR KOH engaged students through social to the sections: ‘Anything else important you were the events focused on specific careers Work Experience Day media and relationships with schools. Students think we should know?’ and ‘The event or the and particularly a speed-dating activity which A total of 308 students attended the WED in- were invited to attend interventions designed presentation you will remember the most’. involved talking to health professionals. Two terventions. Practical experiences created the to offer them a variety of experiences and attendees commented: most impact with the simulated theatre scenario activities to explore health as a career pathway. KEY FINDINGS being recorded as the most memorable event I AM A FUTURE MĀORI Paediatrician! Thank The three main interventions were: Tū Kaha Across all interventions, 608 secondary school (n = 77), followed by Air Ambulance (n = 61). you so much for providing us with this amaz- Central Region Māori Health Development students attended a single intervention, eight Comments showed that students were enthusi- ing opportunity and for really showing me conference (TK); Workchoice Day (WC), a students attended interventions twice (1.3%) astic learning about a health career and identify- that as a Māori woman, I can do all things! mainstream health careers promotional day and one student attended three times (0.16%). ing a potential pathway to follow, although again led by Workchoice Trust for senior secondary Between 2010–2017, Tū Kaha was attended by Tū Kaha was without a doubt the best experi- some wanted more specific information. The school students; and Work Experience Day 169 students, Workchoice Day was attended by ence I’ve had. I’ve made so many new friends following are excerpts from the evaluations: (WED), an intervention designed by CR 121 students, and Work Experience Day was and we’re all going to stay in contact. There’s It was really fun and encouraged my choice in KOH in collaboration with Capital and Coast attended by 318 students. Total numbers of stu- been so many inspirational people and from health profession. DHB Māori Health Development Group to dents attending interventions increased over the the conference I’ve been inspired to go further target a younger Māori audience (Years 9–11). seven years, peaking in 2017. Attendees were than physio and become a doctor. I had a great day and when I get older I will be These interventions were offered annually from mainly female (64%), Year 10 (21.5%) and iden- looking to study and get a job at Wellington 2010–2017. tified as Māori (69%). Workchoice Day Hospital. Written feedback from participants after It was found overall that the three WC interventions were attended by 121 students each intervention provided useful information interventions were effective in engaging and and some students found career direction within DISCUSSION for further programme development but, maintaining students’ interest in a health-related health: Kia Ora Hauora is a strategic, targeted approach until now, had not been analysed as a career. Pre-intervention 48% of students said to influencing Māori youth to consider a health Yes, I think it would be fun and interesting to dataset. In 2017–2018, a project was under- they were considering a career in health, but career as an attractive and achievable option be a radiologist. taken to retrospectively analyse previously post-intervention this increased to 62%. (Kia Ora Hauora, 2015). Students need to be collected data during specific interventions Of the three interventions, Work Experience I want to get a Bachelor of Nursing Pacific. influenced early enough to enable them to struc- to understand to what extent CR KOH interven- Day (WED) was the most attended intervention. ture their learning pathways appropriately, such tions influence secondary students’ decisions However, the most effective intervention, based However, they also requested more specific and as opting for a science pathway in preparation to pursue health careers. In 2017–2018 CR on student feedback (combining Yes and Maybe individualised career information: for entry into a health qualification (Pool, 2008). KOH and Whitireia New Zealand (Whitireia) coding) that motivated an interest in a health

Whitireia Journal of Nursing, Health & Social Services 26/2019 Pages 58–62 59 60 Whitireia Journal of Nursing, Health & Social Services 26/2019 Pages 58–62

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Kia Ora Hauora: Guiding Māori Secondary School Students toward Health Careers L. ANDREWS, R. CRAWFORD AND K. ARCUS

Students enjoyed relational opportunities, CONCLUSION LEIGH ANDREWS is Central Region Programme Co-ordinator, Kia Ora Hauora (Māori Health as a Career particularly the chance to meet and talk with The Central Region Kia Ora Hauora programme, Programme). health professionals. Students also valued active specifically Tū Kaha, Work Experience Day and RUTH CRAWFORD RN, PhD, BA, M.Phil (Soc.Sci) is Director, School of Nursing, Health and Wellness at the learning opportunities and hands-on, real-life Workchoice Day interventions, achieved the Western Institute of Technology at Taranaki (WITT) New Plymouth, New Zealand. scenarios. Simulation is increasingly recognised goal of recruiting Māori youth into specifically KERRI ARCUS RN, MA (Applied) Nursing, BN; Dip.Adult Learning/Teaching is Programme Manager, as a valuable learning tool in health professional designed activities that promoted and maintained Postgraduate Studies and Research, Whitireia and WelTec, Wellington, New Zealand. education (Aldridge & Wanless, 2012), but this an interest in a health-focused study pathway. Four KOH study highlights how influential simulation key recommendations arose from this report: can be in providing positive learning experiences 1. That the Central Region Kia Ora Hauora for young people and its potential place in career programme continues to receive funding counselling, advice and choice. to provide interventions to support Māori The evidence suggests that the CR KOH rangatahi into health-related careers. programme is meeting its aim of influencing 2. That interventions continue to have a strong Māori rangatahi regarding health careers. Further focus on simulation/hands-on activities and longitudinal research is needed to track KOH meeting health professionals. participants through and beyond secondary 3. That the CR KOH programme provides school to identify whether students who engaged more specific information on health in KOH enrol in health career study pathways in careers and career pathways. increased numbers over non-attendees. There 4. That further research is undertaken to find is also work to be done, more generally, in out how many students from the CR KOH encouraging Māori (and other) students to take programme enter health-related tertiary science subjects at secondary school. study and then move into a health career.

REFERENCES

Aldridge, M., & Wanless, S. (Eds.). (2012). Developing Pool, L. G. (2008). Choosing a career. Why not nursing? healthcare skills through simulation. London, United (Unpublished master’s thesis), Massey University, Kingdom: Sage. New Zealand. Gilchrist, K.L., & Rector, C. (2007). Can you keep Ratima, M., Brown, R., Garrett, N., Wikaire, E., them? Strategies to attract and retain nursing Ngawati, R., Aspin, C., & Potaka, U. (2007). students from diverse populations: Best practices Strengthening Māori participation in the New in nursing education. Journal of Transcultural Nursing, Zealand health and disability workforce. The 18(3), 277–285. Medical Journal of Australia, 186(10), 541–543. doi: Kia Ora Hauora. (2015). Central Region annual plan, 10.5694/j.1326-5377.2007.tb01034.x 2015–16. Wellington, New Zealand: Author. Simmonds, S. (2018). Māori health workforce priorities: A Liu, J.X., Goryakin, Y., Maeda, A., Bruckner, T., & report on the Māori health workforce within District Health Sheffler, R. (2017). Global health workforce labor Boards in the central region, Aotearoa. Commissioned market projections for 2030. Human Resources for by Capital and Coast DHB for Kia Ora Hauora Health 15, (11). doi:10.1186/s12960-017-0187-2 Central Region. Ministry of Health. (2007). Te uru kahikatea: Public health World Health Organisation. (2014). A universal truth: workforce development plan. Wellington, New Zealand: No health without a workforce. Retrieved from Author. https://www.who.int/workforcealliance/ Ministry of Health. (2016). Health of the health workforce knowledge/resources/GHWA-a_universal_ 2015. Wellington, New Zealand: Author. truth_report.pdf

Whitireia Journal of Nursing, Health & Social Services 26/2019 Pages 58–62 61 62 Whitireia Journal of Nursing, Health & Social Services 26/2019 Pages 58–62

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140 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

Wairarapa DHB Planned Care Performance for February 20

5 6 7 8 9 10 11 12 13 14 15 16 Planned volumeActual volume Planned caseweightsActual caseweights PLANNED CARE INTERVENTIONS ▲ 115.3% PLANNED CARE INTERVENTIONS / ACUTE READMISSION AR ▼ 10.6% PATIENT EXPERIENCE SURVEYS PERIOD: August 2019

Response 2019 2020 Interventions Caseweights Inpatient Experience Survey questions: (% Yes, completely / Yes, always) Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Plan Actual % Plan Actual % Nov 18 Feb 19 May 19 Aug 19 Planned 237 550 844 1,142 1,449 1,673 1,915 2,143 2,444 2,669 2,976 3,232 Non Surgical PUC with Surgical DRG 50 66 132.0% 107.1 171.1 159.8% Before the operation did staff explain the risks and benefits in a way you could understand? 85.3 84.8 87.0 91.2 Actual 354 670 986 1,305 1,612 1,905 2,195 2,470 Surgical PUC 1,581 1,564 98.9% 2,142.5 2,030.2 94.8% Did staff tell you how the operation went in a way you could understand? 74.3 71.9 82.6 82.9 Variance 117 120 142 163 163 232 280 327 Inpatient Surgical Discharges 1,631 1,630 99.9% 2,249.6 2,201.4 97.9% Did hospital staff include your family/whānau or someone close to you in discussions about your care? 60.8 61.8 64.0 54.9 %Achievement 149% 122% 117% 114% 111% 114% 115% 115% Inpatient Minor Procedures 55 96 174.5% Response (% , Aug 2019) 3,500 Primary Care Patient Experience Survey questions: Outpatient Minor Procedures Hospital 453 744 164.2% < 1 week 1-4 weeks 1-3 months > 3 months 3,000 Outpatient Minor Procedures Community 0 0 0.0% 1. How long did you wait to see the specialist doctor? 37.3 39.2 9.8 13.7 Response 2,500 Minor Procedures 508 840 165.4% (% Yes, always) 2,000 2. When you received care or treatment from specialist doctors, did they do the following: Nov 18 Feb 19 May 19 Aug 19 Non Surgical Interventions 4 0 0.0% a) Ask what is important to you? 44.4 55.9 52.2 46.6 1,500 Total 2,143 2,470 115.3% b) Tell you about treatment choices in ways you could understand? 78.8 74.0 71.4 60.8

1,000 c) Involve you in decisions about your care or treatment as much as you wanted to be? 70.7 70.9 71.4 59.2

500 Acute Readmission Measure (0 - Standardized Acute Number of Agreed AR 3. Does your GP/nurse seem informed about the care you get from specialist doctors? 69.0 67.3 66.0 69.4 28 days) Readmission Rate Readmissions Target Rate 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Year to Sep 2019 10.6% 801 10.1% For more information regarding the patient experience surveys please contact your DHB’s System Level Measure ACCESS, QUALITY, EXPERIENCE (SLM) team or visit your DHB’s patient experience survey reporting portals. Non Surgical Intervention Minor Procedures Inpatient Surgical Discharges Planned 2019/20 Year to Sep 2018 11.3% 970

Colume look up 8 9 10 11 12 13 14 15 ESPI colum lookup4 17 20 23 26 29 32 35 38 40 ESPI colum lookup4 17 20 23 26 29 32 35 38

ESPI RESULTS 28 Consecutive Months Red FCT (31 DAY) 100.0% ESPI 2 - BY SERVICE 2 Non Compliant Services ESPI 5 - BY SERVICE 3 Non Compliant Services

#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! Consecutiv # #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! 0 #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! e months 3 month 2019 2020 2019 2020 3 mth 2019 2020 3 mth red ESPI to trend Imp Req Imp Req Jul Aug Sep Oct Nov Dec Jan Feb Feb 20 Jul Aug Sep Oct Nov Dec Jan Feb Trend Jul Aug Sep Oct Nov Dec Jan Feb Trend ESPI 1 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Urology 1.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.5% 1 ▲ Y Orthopaedics 22.9% 27.7% 35.7% 42.6% 48.3% 45.0% 46.6% 48.6% 87 ▲ 0 ▬ 0 Level 0 0 0 0 0 0 0 0 Orthopaedics 0.0% 0.0% 0.9% 0.0% 1.1% 0.0% 0.0% 0.6% 1 ▲ Y General Surgery 25.9% 13.5% 10.4% 8.9% 6.3% 5.6% 4.0% 4.1% 2 ▼ ESPI 2 10.5% 5.8% 5.6% 2.0% 2.9% 0.8% 0.0% 0.2% Ophthalmology 0.0% 0.0% 4.3% 9.8% 14.8% 14.1% 0.0% 1.5% 1 ▼ 0 ▼ 0 Level 87 53 51 18 22 7 0 2 ESPI 3 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 ▬ 0 Level 0 0 0 0 0 0 0 0 ESPI 5 15.9% 16.3% 20.1% 24.7% 29.1% 26.9% 23.7% 24.6% 28 ▼ # Level 77 76 91 107 118 108 90 90 ESPI 8 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0 ▬ 0 Level 0 0 0 0 0 0 0 0

ACCESS, TIMELINESS Faster Cancer 2019 2020 3 month Treatment Jul Aug Sep Oct Nov Dec Jan Feb trend FCT % 83.3% 93.8% 96.2% 93.8% 100.0% 90.9% 80.0% 100.0% ▲ Level 15 15 25 15 28 20 12 2

5 6 7 8 9 10 11 12 13 14 15 16 Ophthalmology ESPI 254 Colour65 76 87 98 109 1110 1211 1312 1413 1514 1615 18 180 180 180 180 180 190 190 190 190 190 190 190 DIAGNOSTICS PERFORMANCE CT 94.6% MRI 50.7% Angiography OPHTHALMOLOGY WAITING TIMES ESPI 2 0.0% ESPI 5 1.5% FUA (50%) 0.0% CARDIAC SURGERY DELIVERY 61.6% WAITING OVER TIMEFRAME 30 Cardiac Provider: Capital and Coast DHB 2019 2020 2019 2020 2019 2020 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

CT 98.9% 97.2% 96.8% 97.9% 96.9% 98.3% 97.1% 97.1% 95.5% 93.7% 89.1% 94.6% ESPI 2 64.7% 65.0% 58.9% 43.5% 32.7% 20.0% 17.9% 2.9% 14.2% 0.0% 0.0% 0.0%

28Jul 25Aug 29Sep 27Oct 24Nov 29Dec 26Jan 23Feb 29Mar 31May 28Jun Ophthalmology ESPI 2 % 26Apr MRI 53.7% 52.4% 55.3% 49.0% 51.7% 64.0% 66.7% 56.0% 65.7% 71.8% 56.4% 50.7% OphthalmologyESPI 5 ESPI 5 %0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.3% 9.8% 14.8% 14.1% 0.0% 1.5% 0 Delivery 47.1% 59.7% 63.0% 64.3% 60.1% 60.0% 60.4% 61.6% # Overdue Followups 0 0 0 0 0 0 0 0 0 0 0 0 Waiting list 66 63 68 56 81 77 84 88 50% Overdue 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 Max Waiting 76 76 76 76 76 76 76 76 100.0% 0 100% Overdue 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% OverTimeframe 21 9 20 17 28 32 34 30

80.0% 0 100 120% 70.0% 90 110% 60.0% 60.0% 80 100% 50.0% 70 40.0% 60 40.0% 90% TIMELINESS 50 40 80% 20.0% 30.0% Delivery Waiting listWaiting 30 20.0% 70% 20 60% 0.0% 10.0% 10 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 0.0% 0 50% 2019 2020 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 28 Jul 25 Aug 29 Sep 27 Oct 24 Nov 29 Dec 26 Jan 23 Feb 29 Mar 26 Apr 31 May 28 Jun 2019 2020 2019 2020 CT MRI Angiography CT and Angiography Indicator (95%) MRI Indicator (90%) ESPI 2 ESPI 5 50% Over Due 100% Over Due Waiting list Outside timeframe Max Waiting Delivery

Report to: Feb 20 Data Extracted on: 06/04/20

141 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

Definitions & Information

PLANNED CARE INTERVENTIONS PLANNED CARE INTERVENTIONS / ACUTE READMISSION PATIENT EXPERIENCE SURVEYS

Data Source - Planned Care Interventions Data Source Data Source

This data is sourced from the DHB monthly Planned Care Interventions (PCI) report summary page. This table and This data is sourced from the DHB monthly PCI report and YTD performance against plan for the Planned Care These data are sourced from the Health Quality and Safety Commission’s (the Commission) quarterly national graph shows monthly YTD delivery against the planned YTD delivery. Intervention Groups, YTD Caseweight Summary for Inpatient Surgical Discharges adult inpatient and primary care patient experience surveys. Selected questions from both surveys have been What do the colours mean? What do the colours mean? chosen to recognise the Experience and Equity principles within the Planned Care Programme. A rolling four quarters of data are displayed. The colour code below determines whether the performance meets expectations (green) or does not (red). This is The colour code below determines whether the performance meets expectations (green) or does not (red). This the same as in the Planned Care Interventions reports. is the same as in the Planned Care Interventions reports. For the wait time to see a specialist question, the percent of respondents who selected each response option in Green Greater than or equal to 100% ▬, ▲, Green Greater than or equal to 100% ▬, ▲, the latest quarter is provided. For all other questions, the percentage displayed is the percentage providing the Change from previous month Change from previous month Red Less than 100% or ▼ Red Less than 100% or ▼ most positive response to the question. What other information is available regarding the patient experience surveys? Data Source - Acute Readmissions For more information regarding the patient experience surveys please contact your DHB's System Level This data is sourced from the quarterly Acute Readmission (AR) reporting. The figures are the most recent Measure (SLM) team; visit your DHB's patient experience survey reporting portals; or visit the Commission’s quarter's Standardised Acute Readmission rate and number of Observed Readmissions for the 0-28 days website measure, and the same numbers for the same period 12 months ago. (https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/patient-experience) What do the colours mean? In the top right hand corner of this box next to the title is the % result for the latest period, the colour code below determines whether the performance meets expectations (green) or does not (red). Green Less than or equal to planned AR rate ACCESS, QUALITY, EXPERIENCE ▬, ▲, Change from previous period's standardised Red Greater than planned AR rate or ▼ rate

ESPI - DHB LEVEL / FCT (31 DAY) ESPI 2 - BY SERVICE ESPI 5 - BY SERVICE

Data Source - Elective Services Patient Flow Indicator (ESPIs) Data Source Data Source This data is sourced from the DHB Final ESPI Reports. Also included is the Total number of consecutive months of Red ESPI performance, and a 3 month trend of ESPI performance for each ESPI. This data is sourced from the DHB monthly Final ESPI Reports, including the Improvement Required, and a 3 This data is sourced from the DHB monthly Final ESPI Reports, including the Improvement Required, and a 3 month trend arrow. The ESPI result in this report is for an 8 month period, and only services which are currently month trend arrow. The ESPI result in this report is for an 8 month period, and only services which are currently What do the colours mean in the title bar? non compliant, or have been non compliant at least once in the last 4 months will appear on this report. non compliant, or have been non compliant at least once in the last 4 months will appear on this report. In the top right hand corner of this box next to the title is the period of Red level ESPIs non compliance. Green All ESPI Results at a DHB Level are either Green or Yellow What do the colours mean in the title bar? What do the colours mean in the title bar? Orange The first month of the DHB having a Red ESPI at a DHB Level In the top right hand corner of this box next to the title is the number of non compliant services for ESPI2 for the In the top right hand corner of this box next to the title is the number of non compliant services for ESPI5 for the Red The DHB has had 2 or more consecutive months with a Red ESPI at a DHB Level current month. current month. What do the colours mean in the table? Green All services are compliant Green All services are compliant The colours show whether a DHB is compliant (green) or non compliant (yellow and red) for each ESPI. Orange Equal to or less than 3 services non compliant Orange Equal to or less than 3 services non compliant Data Source - Faster Cancer Treatment (FCT) 31 Day Indicator Red Greater than 3 services are non compliant Red Greater than 3 services are non compliant

This data is sourced from the DHB Faster Cancer Treatment (FCT) Reporting Database. This measure indicates whether 85% of What do the colours mean in the table? What do the colours mean in the table? patients receive their first cancer treatment (or other management) within 31 days from date of decision-to-treat. Please note that The colours for each cell show whether a DHB is compliant (green) or non compliant (yellow or red) for each The colours for each cell show whether a DHB is compliant (green) or non compliant (yellow or red) for each

the FCT data may vary from the SS01 Quarterly Reporting measure due to the date of extraction. service. A warning light (box will turn orange) for the 3 Month Trend arrow when a service if the three month service. A warning light (box will turn orange) for the 3 Month Trend arrow when a service if the three month ACCESS, TIMELINESS What do the colours mean in the title bar? trend is worsening. trend is worsening. Green DHB met 85% Indicator for the latest month. Red DHB not met 85% Indicator for the latest month. From July 2012 onwards Prior to July 2013 the definition of ESPI 2 is the number of patients waiting From July 2012 onwards Prior to July 2013 the definition of ESPI 5 is the number of patients waiting What do the colours mean in the table? Green = 0% over 6 months for FSA. Between July 2013 and December 2014 the Green = 0 % over 6 months for Treatment. Between July 2013 and December 2014 the definition of ESPI 2 is the number of patients waiting over 5 months for FSA, definition of ESPI 5 is the number of patients waiting over 5 months for Green DHB met 85% Indicator for the month. Red DHB not met 85% Indicator for the month. Yellow > 0% but < 0.4% and from January 2015 the definition of ESPI 2 is the number of patients Yellow > 0% but < 1% Treatment, and from January 2015 ESPI 5 is the number of patients waiting Red > = 0.4% waiting over 4 months for FSA. Red > = 1% over 4 months for Treatment.

DIAGNOSTICS PERFORMANCE OPHTHALMOLOGY WAITING TIMES CARDIAC SURGERY

Data Source Data Source Data Source This data is sourced for FSA and Treatment waiting times from the monthly DHB ESPI reporting, and the follow This data is sourced from the weekly reporting supplied from each of the five DHB cardiac units (Auckland, The data is sourced from the monthly Diagnotics Reporting, the table and graph show the DHB % for a 12 month up information is sourced from the collection used through the Ophthalmology service improvement Waikato, Capital & Coast, Canterbury, and Southern). trend for CT, MRI and Angiography against the respective national indicator percentage expectations. programme. What does the coloured cells mean in the title bar and in the table? What does the coloured traffic light mean? In the top right hand corner of this box next to the title is the regional provider % delivery for the latest week and What does the coloured cells mean in the title bar and in the table? the national number of patients waiting greater than the 90 day expectation for surgery. This is also shown in the In the top right hand corner of this box next to the title is the DHB % result for the latest month for waiting time table below with the % every four weeks, the colour code below determines whether the performance meets In the top right hand corner of this box next to the title is the DHB % result for the latest month for CT, MRI and results for Ophthalmology for ESPI 2, ESPI 5 and % of patients waiting longer than 50% overdue for their follow expectations (green) or does not (red). Angiography. This is also shown in the table below with the % by month for the 12 month period, the colour code up appointment or treatment. This is also shown in the table below with the % for a 12 month period, the colour below determines whether the performance meets expectations (green) or does not (red). This is the same as in code below determines whether the performance meets expectations (green) or does not (red). This is the The graph shows the total waiting list, the number on the waiting list for greater than the expected timeframe, the the Diagnostics reporting. same as in the ESPI reports for ESPI 2 and ESPI 5. maximum acceptable waitlist and the delivery.

CT MRI Angiography ESPI 2 ESPI 5 Follow up (50% and 100%) TIMELINESS Greater than or equal Greater than or Greater than or equal Green = 0% Green = 0 % Green = 0 % Green Green Green to 95% equal to 90% to 95% Yellow > 0% but < 0.4% Yellow > 0% but < 1% Red > 0% Red Less than 95% Red Less than 90% Red Less than 95% Red > = 0.4% Red > = 1% NOTES: % delivery Waiting over timeframe The measure is a DHB of service measure, where NA is present this means the DHB is not the provider for Green 100% Green 0 patients NA the service and other DHB provides this service. Red Less than 100% Red Greater than 0 ND This indicates that no data is currently available, as the DHB has been unable to supply this.

142 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

Appendix 2, Leave Statistics

Perioperative - Sick Leave as % of Worked Hours

Sick as a % of Worked - DHB Wide Sick as a % of Worked - Periop Linear ( Sick as a % of Worked - DHB Wide) Linear (Sick as a % of Worked - Periop)

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0% l r r r r r r r r r t t t t v v v v c c c c y y y y g g g g y y y n n n n n b p b p b p b p b e e e n l l l c c c c u p p p p a a a a a e e e e o o o o a a a a u u u u a a a a a e e e e e e e e e n n n J u u u u J J J J J J O O O O A A A A F S F S F S F S F J J J D D D D u u u A A A A N N N N M M M M M M M M M J J J 2016 2017 2018 2019 2020

Maternity - Sick Leave as % of Worked Hours

Sick as a % of Worked - DHB Wide Sick as a % of Worked - Maty Linear ( Sick as a % of Worked - DHB Wide) Linear (Sick as a % of Worked - Maty)

9.0%

8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0% l r r r r r r r r r t t t t c c c c v v v v y y y y g g g g y y y b p b p b p b p b n n n n n e e e n l l l c c c c u a a a a a p p p p e e e e o o o o a a a a u u u u a a a a a e e e e e e e e e n n n J u u u u J J J J J J O O O O A A A A F S F S F S F S F J D J D D J D u u u A A A A N N N N M M M M M M M M M J J J 2016 2017 2018 2019 2020

143 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

MSW - Sick Leave as % of Worked Hours

Sick as a % of Worked - DHB Wide Sick as a % of Worked - MSW Linear ( Sick as a % of Worked - DHB Wide) Linear (Sick as a % of Worked - MSW)

10.0%

9.0%

8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0% l r r r r r r r r r t t t t c c c c v v v v y y y y g g g g y y y n n n n n b p b p b p b p b e e e n l l l c c c c u p p p p a a a a a e e e e o o o o a a a a u u u u a a a a a e e e e e e e e e n n n J u u u u J J J J J J O O O O A A A A F S F S F S F S F J D J D D J D u u u A A A A N N N N M M M M M M M M M J J J 2016 2017 2018 2019 2020

Radiology - Sick Leave as % of Worked Hours

Sick as a % of Worked - radiology Sick as a % of Worked - DHB Wide Linear (Sick as a % of Worked - radiology) Linear ( Sick as a % of Worked - DHB Wide) 10.0%

9.0%

8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0% l r r r r r r r r r t t t t v v v v y y y y c c c c g g g g y y y n n n n n b p b p b p b p b e e e n l l l c c c c u a a a a a p p p p o o o o e e e e a a a a u u u u a a a a a e e e e e e e e e n n n J u u u u J J J J J J O O O O A A A A F S F S F S F S F J D J D D J D A A A A u u u N N N N M M M M M M M M M J J J 2016 2017 2018 2019 2020

144 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

Total Annual & Anticipated Annual Leave Hours Coded in Payroll 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 t t r r r r r y y c c y y v v n n n g g e e b p b p b l l c c a a a p p e e a a o o e e e e e a a a u u n n u u J J J O O A A F S F S F J D J D u u A A N N M M M M M J J 2018 2019 2020

Annual Leave and Anticipated annual leave Hours Coded in Payroll - by employee category

Allied Medical Mgmt & Admin Nursing Support

4000 3500 3000 2500 2000 1500 1000 500 0 t t r r r r r c c v v y y y y n n n g g e e b p b p b l l c c a a a p p o o e e a a e e e e e a a a u u n n u u J J J O O A A F S F S F J J u u D D A A N N M M M M M J J 2018 2019 2020

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Appendix 3, Assessment Volumes February 2020

Fiscal Year 2020 Fiscal Month Desc 09 - Mar

MTD Actual MTD Contract MTD Volume YTD Actual YTD Contract YTD Volume Purchase Unit code Volume Volume Variance Volume Volume Variance

Outpatients - First Assessments 663 714 -51 5,586 5,711 -125 D01002 - Dental - 1st attendance 7 9 -2 59 68 -9 M00002 - General Medicine - 1st attendance 109 67 42 599 533 66 M00010 - Virtual FSA - Medical 0 26 -26 287 209 78 M10002 - Cardiology - 1st attendance 0 13 -13 0 107 -107 M20002 - Endocrinology - 1st attendance 4 6 -2 45 50 -5 M20004 - Diabetes - 1st attendance 0 4 -4 13 28 -15 M25002 - Gastroenterology - 1st attendance 0 9 -9 71 69 2 M55002 - Paediatric Medical Outpatient - 1st attendance 38 44 -6 405 353 52 MS01001 - Nurse Led Outpatient Clinics 54 50 4 449 400 49 MS02002 - Botulinum toxin therapy 8 7 1 40 56 -16 S00002 - General Surgery - 1st attendance 136 125 11 963 1,000 -37 S00011 - Virtual FSA - Surgical 29 62 -33 508 500 8 S25002 - ENT - 1st attendance 46 37 9 304 292 12 S30002 - Gynaecology - 1st attendance 72 66 6 368 527 -159 S40002 - Ophthalmology - 1st attendance 27 58 -31 531 466 65 S45002 - Orthopaedics - 1st attendance 65 58 7 457 460 -3 S45004 - Fracture Clinic - 1st attendance 5 7 -2 79 56 23 S60002 - Plastics (inc Burns & Maxillofacial) - 1st attend. 23 43 -20 257 347 -90 S70002 - Urology - 1st attendance 40 24 16 151 191 -40

Outpatients - Subsequent Assessments 904 861 43 6,790 6,891 -101 M00003 - General Medicine - Subsequent attendance 85 100 -15 605 800 -195 M10003 - Cardiology - Subsequent attendance 0 0 0 0 3 -3 M20003 - Endocrinology - Subsequent attendance 22 7 15 67 53 14 M20005 - Diabetes - Subsequent attendance 0 12 -12 106 95 11 M25003 - Gastroenterology - Subsequent attendance 0 47 -47 133 377 -244 M55003 - Paediatric Medical Outpatient - Subsequent attend. 135 133 2 1,016 1,067 -51 S00003 - General Surgery - Subsequent attendance 118 133 -15 985 1,067 -82 S25003 - ENT - Susequent attendance 39 45 -6 322 358 -36 S30003 - Gynaecology - Subsequent attendance 62 71 -9 434 569 -135 S40003 - Ophthalmology - Subsequent attendance 241 165 76 1,765 1,320 445 S45003 - Orthopaedics - Subsequent attendance 74 72 2 608 578 30 S45005 - Fracture Clinic - Subsequent attendance 23 34 -11 191 276 -85 S60003 - Plastics (inc Burns & Maxillofacial) - Sub attend. 31 19 12 154 148 6 S70003 - Urology - Subsequent attendance 74 23 51 404 180 224

146 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

CPHAC - PUBLIC MEETING - DECISION

Life2go

– The strategy!

147 2020 04 28 Wairarapa Board Meeting PUBLIC - Appendices

CPHAC - PUBLIC MEETING - DECISION

Daniel’s story…

Four years back life was looking good. I was studying for a Bachelor of Arts double majoring in sociology and philosophy. Yeah, things were looking up alright.

After having acquired a large bag of marijuana during the holidays I returned to the hostel where I lived and set about getting stoned. At every conceivable opportunity I smoked pot, smoking so much my lungs ached. But no matter how much you abuse a substance it is never enough. So in a short space of 10 days, that large bag was reduced to nothing. To follow this, began the first of several psychotic episodes that would forever change me and plague my mind. I remember being awake for 3 hours and still counting. A deep insomnia possessed me…. but then came the paranoia. My mood would change from elation to desperate despair. Like a surge of power caused by faulty wiring.

Life had taken a sudden u-turn on an already busy motorway and now I was driving on the wrong side of the road with my foot pressed hard down on the accelerator, all the while completely oblivious to the fact that what was going on with me was not real - just in my head. But it is real, it felt real anyway.

For a whole week I had still been unable to get to sleep. I had not even showered all that time, and had little to eat. I was physically drained. Lucky for me, people at the hostel noticed that something was not right with me. My sudden outbursts, muddled speech and appearance must have given a definite indication.

A friend of mine came into my room and asked me to go to the University’s medical clinic with her. She was worried. I was deeply psychotic. At the clinic questions were asked and I was given some tablets. That night I got to sleep for the first time in over a week.

I was then introduced to the mental health service through the early intervention service at the hospital and had regular weekly appointments. One thing the psychiatric nurse, Julie, always told me was that there is always hope. This seemed to stick in the farthest corner of my mind. The psychoses had passed how a bad storm does, and now I was left with trying to rebuild my life.

But the psychotic episode had left me numb. By numb I mean, I had little emotion. No longer myself, just an empty shell wandering the streets aimlessly. This was rock bottom. So alone, so bored and so agonisingly depressed. My confidence was shattered, I became withdrawn. Even suicide was a serious, viable option.

A solution came to end this situation. I left the hostel and went home to live in Masterton. At last I was at least half way to some so-called idea of happiness. After having endured the longest and hardest few months of my existence, this experience set a template for times to come, and how it changed my view of life to ‘there’s always hope”.

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From a member of the Youth Advisory Group:

Why am I doing this? My life is busy enough just dealing with the demands of school, why would I want to take time to be involved in the formation of the Youth Health

Strategy? I believe it is because I want to make a difference to the life, health and future of Wairarapa youth. I can see, and have known myself, how horrible experiences such as Daniel’s can be. Daniel’s story is not uncommon; it is a real life example of the sometimes troubled state of youth health in the Wairarapa. This strategy works to bring to the floor and address the issues and needs of youth in the Wairarapa, and link these to current and possible future services.

I believe that if we can pull together and coordinate the existing services for youth in the Wairarapa then we will have a greater, more positive and wider reaching effect on youth. The sum of the parts is greater than the individual. I think this would be more appropriate for youth; often many factors contribute to poor health of a young person.

To effectively treat and deal with the issues facing any one young person we need to address each aspect of their health. One service on its own can only address the issues that fall into their area of expertise; this is not a realistic approach for youth health.

We need to work together.

Every young person’s story is different, some extreme, some not so, each are every bit as important. But I believe that all youth in the Wairarapa can benefit from this strategy, be it by the mere publication of it and the improved knowledge and awareness it brings, and the future implications of it. I hope this strategy is more than just picked up and read by the people of the Wairarapa, I hope it is taken in.

Kate Murray

Aged 16

Youth Steering Group Member

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Table of Contents

Life2go – The Strategy Tree...... 1

Life2go – Introduction...... 2

What are the issues? ...... 3

What’s important? ...... 4

Three Strategic Priorities...... 5

Next Steps...... 11

Appendix Found in a separate document

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Life2go – The Strategy Tree

Health Priorities Objectives 3 Strategic Priorities and their key actions Measures of Progress Support and build capacity and capability in 1. Youth Participation community and school-based education and Governance of Youth Health Motor Vehicle Hospital Admissions Address the incidence and impact of motor vehicle x support services Strategy provided by Youth accidents Increase access to community based youth Advisory Group Motor Vehicle Fatalities services x Management teams developed for each service x Governance and management Youth with dual diagnosis are identified and all group membership comprises Suicide Rate needs supported 50% youth Improve the mental wellbeing of all youth 2. Communities Working Together Rates of self harm Reduction in at risk use of alcohol and drugs x Increased focus on health a r o u a n a h w g n i v e i h c A Number of people seeking support for s e i t i l a u q e n I e c u d e R promotion and education mental health and alcohol and drug Educate friends and whanau in identifying x Increase in joint approaches that warning bells ensure effective use of resources issues reaches the widest possible audiences Alcohol and drug related hospital admissions Reduce drug and alcohol Develop support systems for parents of youth x Te Whare Tapa Wha model is related incidence with challenging behaviour applied to actions that advance Improved management of chronic this strategy illnesses such asthma Number of people diagnosed with STI Reduce the incidence of STIs Reduced sick days from school Improve sexual health 3. Youth Health Services Number of terminations of teen Reduce the number of unwanted teenage x School based health services pregnancies pregnancy developed in secondary schools Number of Teenage births Community based clinics Promote and encourage healthy eating x targeting young people not Avoidable hospital admissions Promote and encourage healthy action connected to school community Reduce the number of youth who smoke x Programs targeting specific Incidence of smoking among young Encourage healthy lifestyles groups will be developed people Good oral health Lower level of decayed, missing or filled teeth in adolescents Reduction in incidents associated with violence Vision and hearing outcomes

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Life2go – Introduction

Most young people are healthy and think that they have strong positive relationships with their parents and school environment1. In fact, over 80% of them report through a range of studies that they feel healthy, do not engage in multiple risky behaviours and report that they have positive connections to families, schools and their peers.

However, there is a lot of evidence that suggests that the other 20% do not connect well with services, and experience significant health issues that have long term effects on their emotional, mental and physical well being. Many of these health issues go untreated for long periods of time which in turn impacts on the seriousness of the illness and the effectiveness of the treatment when it is eventually provided. Education, early identification and early intervention of all health and social issues are the keys to improving health and social outcomes for young people.

However, encouraging young people to seek help from health services is not a simple matter. When asked why they are reluctant to seek help for an illness or health issue, young people indicated the following barriers:

x The cost of health services x A perceived lack of confidentiality of services x Embarrassment about their health issue, and x A lack of understanding of the services currently available and how they operate.

When asked what they really need from health services, young people answered:

x Sexual health advice and access to checkups and contraceptive prescriptions x Counselling and support for personal problems, and x Counselling and support for problems associated with being in a family with issues relating to mental health, alcohol or family violence.2

In July 2005 the DHB published ‘Life2go! Youth health in the Wairarapa’.3 This booklet described the many facets of health and social issues, services and points of view that impact on the wellbeing of young people in the Wairarapa. This document – Life2go – the Strategy takes things a step further and describes the health objectives that need to be targeted and why. It describes how the DHB will work with young people and agencies to make real health gains in the future. It sets directions and actions that will really make a difference to the health of youth / rangatahi in the long term.

1 NZ Youth / rangatahi – A profile of their health and wellbeing, April 2003 2 Wairarapa District Health Board On line survey of youth health issues – October 2004 3 Life2go! Youth health in the Wairarapa – Wairarapa District Health Board July 2005

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What are the issues?

Most young people are healthy, many go to the doctor when they do have a health problem, and are well supported by their friends, family / whanau, and school relationships. In many areas of youth health the Wairarapa is doing really well; many serious outcomes of risky behaviour are declining, for example, the number of young people involved in serious car accidents is declining, the number of babies born to young mothers is declining, and the incidence of smoking among teenagers across all age and gender groups is also declining.4

However the rate of improvement has slowed down and the communities that young people live in believe that these indicators do not entirely reflect what is happening for youth, that there are many who do not go to the doctor, and who do not know where to find help for emotional and social issues.

There are health indicators that show that there are areas that need a concerted effort if they are to improve. Life2go – the strategy will focus on these and take an early intervention approach to addressing them.

Statistics about Wairarapa’s young people aged between 10 and 24… x Make up 21% of the population x 23% of these are Maori x 62% live in Masterton, 17% live in Carterton, and 21% live in South Wairarapa x 68% of them fall into the lower decile population groups x Overall, the population of young people is declining x Road traffic accidents are the main cause of fatalities and hospital admissions x There is a declining rate of births to young mothers, but, x The rate is 4th highest in New Zealand x The risk of suicide among young people is of high concern x Self harm has caused 35 admissions to Masterton Hospital Emergency Department in the past 2 years. x The rate of self harm in the Wairarapa is high compared to national averages. x Hospital admissions for self harm are thought to be the tip of the iceberg for this problem x Binge drinking affects large numbers of under 18’s x The number of Year 10 males who smoke is higher than the rest of the country x Smoking accounted for 3% of stand downs and 2% of suspensions from secondary schools during 2003/04 x Only 67% of 13 – 18 year olds complete their treatment at the dentist each year x An estimated 8% of young people live with a disability that affects their daily activities

Healthy Eating - Healthy Action - In Action!

4 Appendix 1 – Life2go – the background – 1.3 What are their health needs?

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What’s important?

Through a process of consulting with the community six overarching principles that are important in the development or delivery of youth / rangatahi health services in the Wairarapa have been identified.

Six Overarching Principles 1. Achieving whanau ora is the overarching objective of this strategy 2. Youth participation in the development and delivery of services is essential 3. Information is provided to young people, their families and whanau that allows them to make well informed choices about their health and wellbeing 4. Collaboration between service providers, families / whanau, schools and youth finds coordinated ways to better meet needs of youth / rangatahi and acknowledge the importance of education, employment and health in a young person’s life 5. Accessibility for young people to health and social services is paramount 6. Acceptability of services to youth / rangatahi and their family /whanau is a priority.

Five Health Priorities A review of a range of information from several sectors was undertaken by the Youth Advisory Group and identified those areas of health concerns that the DHB will channel energy into improving through the implementation of this strategy. These concerns are reflected in five health priorities that will be targeted through youth specific services in the future.

1. Reduce motor vehicle accidents 2. Improve the mental wellbeing of all youth / rangatahi 3. Reduce drug and alcohol related disorders and problems 4. Improve sexual health 5. Encourage healthy lifestyles.

These health priorities are not peculiar to the Wairarapa and are in fact, considered high priority areas in most DHBs.

Addressing these health priorities effectively requires a coordinated effort by families / whanau and the whole community, working across all sectors and the agencies that represent them to influence young people and their families and friends to make good choices about health and social issues.

The lives of young people are influenced by many sectors; while education is arguably the most important, health, police, transport, ACC and community groups also have a big role to play and clearly, no one sector or agency can address all health and social issues on their own. Through the collective actions taken by the whole community a ‘Magically Wairarapa’ response to improving the health and wellbeing of our young people will emerge.

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Three Strategic Priorities

This strategy aligns itself with the DHB’s continuum of care identified in the DHBs Strategic Plan.5 The continuum of care identifies that two different levels of focus are needed in order to make long term health gains. The first level focuses on the whole community working together to improve the health and wellbeing of its young people by supporting and educating the whole community to make better health choices for itself and its young people. The second level of focus is on the specific health needs of each young person individually and meeting these needs as promptly and effectively as possible.

To achieve this, three strategic priorities will be advanced. These priorities require input from all corners of the community, and require a collaborative and intersectoral approach if they are to provide the structure that will support the implementation of this plan.

1. Youth Participation The DHB intends to adopt a full partnership with youth in the implementation of this strategy. The following groups whose membership comprises 50% young people will be established: x Wairarapa DHB Youth Advisory Group will provide governance over strategy implementation x Management teams guide the development and operation of individual services.

2. Communities Working Together Communities surrounding young people will work together to initiate long term change in behaviours that impact on health and well being. This will involve: x Increased focus on health promotion and education using many approaches to achieve a greater understanding of the importance of healthier lifestyles x More joint approaches that ensure effective use of resources reach the widest possible audience x The health concept Te Whare Tapa Wha underpins all work undertaken in the school community ensuring holistic approaches are developed and applied to support long term behavioral changes in both the young person and their family/whanau

3. Youth Health Services The DHB will develop a network of youth health services and programs across secondary schools and the community in order of assessed priority as resources become available over the next three to five years: x School based health services will be developed in secondary schools x Community based clinics that target young people who are not at school will be developed x Programs targeting the needs of specific groups will be developed to complement existing ones as opportunities present.

These three directions are discussed further in the sections that follow.

5 Appendix 3 – Continuum of Care Diagram – WDHB Strategic Plan 2005 - 2008

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Strategic Direction 1 – Youth Participation

Actions: x Governance for the strategy will be provided through the DHB Youth Advisory Group. x The groups terms of reference and membership will be reviewed to allow it to effectively perform this function x Management teams will be developed for individual services.

Youth participation in the planning and delivery of services is a fundamental principle that will be applied to the implementation of Life2go. The DHB’s Youth Advisory Group membership will ideally consist of 50% youth; services will be encouraged to adopt the same principle in establishing their management teams.

Ensuring that Life2go is implemented effectively and meets the needs of the community will be the role of the Youth Advisory Group. This group’s terms of reference will be reviewed annually.

Each youth service or project will have its own management team. This team will provide oversight of the service and aim to ensure that the it meets the needs of its community. Services will be encouraged to ensure that their management team consists of 50% youth in its members.

The following diagram depicts the relationships between each of the groups mentioned.

DHB

Youth Advisory Group

Project Management Teams Out of school youth Intersectoral Groups and Each project develops its own service Young people not engaged with school organizations management team that is represented will be invited to participate in the YAG Eg Youth Offending Team, CYFS, on the Youth Advisory Group ACC, Police

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Strategic Direction 2 – Communities Working Together Actions: x Increased focus on health promotion and education x More joint approaches to ensure effective use of resources reaching the widest possible audiences x Te Whare Tapa Wha model is applied to actions that advance this strategy

Developing the Community Approach Over the past ten years there has been much improvement in several of the key determinants of the health of young people. Statistics show that there has been a gradual reduction in: x The number of births to teen mums x The number of young people smoking and x The number of fatalities and injuries from road accidents.

However, the rates of improvement have declined in recent times and some areas show that things are either, at best, not improving or in some cases, deteriorating: x The rate of exclusions from secondary schools in the Wairarapa is high x The extent to which teenagers report incidents of binge drinking has increased x The number of young teenagers smoking is increasing again x The level of sexual activity is increasing, and the numbers of terminations of pregnancies is increasing x Youth offending continues to be a problem with many of the offenders known to be truant from school x Levels of obesity are increasing and physical activity is decreasing x The numbers of young adults that engage with dental services remains at about 67%.

It is well identified through work done in other youth specific services throughout New Zealand that it is only by taking a holistic view of all the factors that impact on young people’s lives, the negative cycle of deprivation, low income and low educational attainment leading to health related problems can be improved.

DHB health promotion and education teams are currently working across the Wairarapa to promote healthy lifestyle approaches. There is much more yet to be done, obesity is an issue, our under 18s are regularly supplied with alcohol by their friends and families, there are high levels of self harm among young women in particular and suicide affects all too many of our young people.

The importance of effective health promotion and education programmes cannot be understated. Public Health Teams are currently reviewing the way that they work and developing new programs to complement existing ones. These will continue to be linked with all agencies in the Wairarapa. There is a need to extend this work to reach into the lives of families / whanau in order to achieve long term health benefits across all aspects of a young person’s life.

Many agencies have contributed to the development of this strategy and in doing so demonstrate a genuine willingness to work together to increase the likelihood that any new initiatives are well coordinated and will result in improving health, educational and wellbeing outcomes for both the students and their communities. Health services that target only the unwell person will be opportunistic and unlikely to result in long term behaviour changes therefore health promotion and education are key to affecting this change but it will also involve working intersectorally to:

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x Develop programs that target truants, young offenders and students at risk of harmful behaviours x Use multiple channels to assist families / whanau to work with their children to make healthy choices x Provide resources and support to school staff in the delivery of the health curriculum and the education of their school community.

Te Whare Tapa Wha model applies Mason Duries’ Te Whare Tapa Wha model clarifies the importance of adopting a ‘whole person’ approach to improving the health of young people by recognising the importance of the balance between the four aspects of a person’s health: x Taha wairua - spiritual health x Taha hinengaro – mental and emotional health x Taha tinana – physical health x Taha whanau – whanau health This model depicts the components of Hauora (wellbeing) as the four walls of the whare. Each wall represents a different aspect that relates to the above dimensions of health.

Each of these four dimensions influences and supports the others; not one can be seen in isolation of the others and from a youth health perspective, importantly recognises the role of friends and family / whanau in the health and well being of youth.

The Wairarapa community must be encouraged to provide support and leadership to its young people, set reasonable boundaries, and guide them as they move through adolescence to adulthood.

The Wairarapa DHB is committed to a partnership with Maori under the Treaty of Waitangi. Population forecasts show that the numbers of Maori youth in the Wairarapa are increasing to a significantly larger percentage of the total Wairarapa population from currently comprising approximately 20% of the total youth population in 2006 to almost 40% in 20 years time.

The involvement of whanau in the planning of Wairarapa youth health services is central to their effectiveness. Maori community consultation and input will enable the development of services that are comfortable, accessible and helpful for the rangatahi and family / whanau using them.

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Strategic Direction 3 – Youth Health Services

Actions: x School based health services will be developed in secondary schools x Community based clinics that target young people who are not at school will be developed x Programs targeting the needs of specific groups will be developed to complement existing ones as opportunities present.

Early intervention approach will be adopted across all services This strategy identifies that a proactive approach to early identification and appropriate follow up of all health and social issues is paramount in ensuring that improved health outcomes for youth are achieved. Evaluations of school based services provided in other DHBs indicate clearly that there are many significant health problems that would have remained undetected if a service responds only to requests for health assistance. Undetected health issues impact on the student’s ability to function well in the education environment and can often lead to much larger issues if they remain untreated.

Current Services for Youth in the Wairarapa School Based Services in Counties Manakau Youth health services in the Wairarapa have Studies done in Counties Manakau DHB where school based been developed in schools on an ad hoc services have been developed through the Ministry of 1 basis in direct response to specific needs or Education’s AIMHI program revealed: service gaps. x 75% of Year 9 students received a comprehensive health assessment and of these: o 34% required referral to further health care due Over the past few years it has been the to unmet needs DHBs Public Health Service and the Nursing o 18% of students required referral to social Innovations Programme (now delivered by services the Wairarapa Primary Health Organisation) o 13% of students failed the vision screen – most that has responded to the need to deliver did not know that they had visual problems health services in the communities where o 7% failed the hearing screen young people live. This has resulted in o 31% had BMIs of over 30. several schools in the Wairarapa having access to nurse led clinics either on site or Across all students in the schools involved there was: An increased awareness of personal hygiene through nearby as is the case in Greytown. Some x regular assessments significantly reducing the need for also have a doctor provide services on site more acute treatment for conditions such as boils and once a week. Wairarapa College provides abscesses and funds a nurse and GP hours from their x Reduced fragmentation and frustration and improved own funds, while the three boarding schools outcomes for students who have multiple agencies and also provide some access to health providers involved in their care through better coordination professionals for their students. x Reduced impact of sports related injuries through better follow up and the inclusion of a physiotherapist on the All of these clinics have been limited in the youth health team number of hours that they are available to x A reduction in one school from 17 unplanned and students, and are also limited in the unsupported pregnancies per year to an average of 2 numbers of schools that have access to supported pregnancies per year them. While there is no doubt that they have x A reduction in school average Body Mass Index from 31 to 27 been well received by the young people that A changing culture across the schools eg ‘Healthy Eating’ they target, there is anecdotal community x perception that this is not sufficient to make a real difference to the overall health of the young people in the Wairarapa.

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Youth Services in the Wairarapa in the future The DHB aims to increase resourcing of youth health services to a level that allows Community Based Services health professionals to provide holistic Some communities have developed Youth One Stop services including comprehensive screening Shops (YOSS). In December 2004 a group of 15 YAG of all students as they enter their secondary members visited three Youth One Stop Shops in the school years. It is expected that this will also lower North Island. The services visited were: allow young people to develop better Youth One Stop Shop – Palmerston North x relationships with health professionals which Evolve – Wellington City x in turn will improve the likelihood of them x Hutt Valley Youth Health Service – Lower Hutt YAG members had mixed sentiments about these seeking help when problems occur in the services. Comments from them included: future. x They appreciated the youth friendly environments especially those with ‘drop in Providers will be encouraged to work centre’ approaches holistically with young people in the context x Liked the concept of a youth focused centre of their whole lives, in ways that ensure all x Noted the centres tended to focus on ‘the services are working collaboratively, are well naughty kids’ and acknowledged the risk that coordinated and no matter where a young this may exclude kids not in a particular group person seeks help from, ensuring that their needs can be met; that they are not turned away feeling there is no one service or person that can help them. Feedback from the Greytown community based youth health clinic, which works in this collaborative way, shows that this approach produces very positive outcomes.

Having explored a range of options for increasing youth health services the DHB is committed to ensuring that new services developed increases access for as many young people as possible.

For this reason, first priority will be given to the development of health services WIPA Services in Porirua Schools based in secondary schools with the Porirua City School Based Services highest level of need. A staged roll out of Wellington Independent Practitioners Association has these services will allow for a robust been providing school based clinics in 4 secondary model of service delivery to be developed schools in the Wellington district since May 2000. Key in one or two schools that is also flexible learnings from their experience include: Schools with a nurse on site every day have enough to adapt to meet the needs of x higher access rates than those where the each schools community. nurse does not attend every day x School services are resourced at a rate of 7 Once higher needs secondary schools nurse hours and 3 GP hours per 500 pupils have robust health services operating, the x This level of resourcing does not allow nurses next priority will be given to establishing a to participate in longer consultations, youth health clinic in the Masterton counselling, or health promotion and community to cater for those young education people who are no longer associated with x Service uptake was instant a school, or for those young people that x 56% of Maori students in the schools access attend schools that do not have a health services clinic on site. Due to a relatively small population such a clinic will operate in carefully selected timeslots such as later afternoons or Saturday mornings to maximize the opportunities to capture clients.

All services will be developed in ways that enable the most efficient use of both existing and new resources and that services are not duplicated. Therefore, it is anticipated that the Nursing Innovations Programme will continue to provide clinics in the Greytown community and that the Public Health Team will also continue to work in secondary schools in ways that complement any school based health service yet to be developed.

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Next Steps Strategic Direction 1 – Youth Participation x Work with 3 District Council Youth council to develop a Wairarapa wide, multi agency youth council x DHB and Youth Council annually identify a health focused project x Support Youth Council to provide advice to the DHB on youth related health issues Establish management committees for youth health services as needed Membership – no more than 10 – 12 members with representatives from the service base (eg the school) and health professionals. Membership should consist of, at least 50% youth Purpose – to ensure onsite youth focussed input into youth health service development and delivery Responsibilities – meet regularly – at least 4 times a year x Oversee each service development and delivery x Monitor performance of service and provide advice regarding service efficacy Strategic Direction 2 – Community collaboration Take an ‘all of school community ‘ approach to working intersectorally to promote healthy living and reducing risky behaviours Purpose: improve child and youth health through health promotion and education for families, teachers and students together Clarify and improve understanding of roles and boundaries within the ‘healthy schools’ service Provide resourcing for intersectoral forums and projects that aim to improve the health and well being of youth eg obesity Establish a DHB wide Youth Health Promotion Annual Plan Process Fully implement the Family Violence Intervention Guidelines as applied to youth health, linking with other providers and agencies Participate in nationwide project to improve collaboration between Child and Youth Family Services and Child and Adolescent Mental Health Services Strategic direction 3 – Youth health services Increase access for youth to youth specific health services including: x Development of school based health services prioritised to reduce inequalities x Ongoing development of community based youth health services x Access to allied health services – physiotherapy, speech language, dietician x Specialist mental health and addiction services x Clinical nurse and GP services Reshape service agreements to achieve: x Support for youth focussed outcomes x Coordination and collaboration between agencies x Identification and removal of contractual barriers or disincentives preventing improvements in child health x Collaboration between community and DHB provided specialist medical and nursing services, PHOs and Public Health teams Increase the level of expertise in youth health by supporting and promoting youth related professional development of all staff involved with youth health services

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Develop wider range of respite care and support options for CAMHS service users and their families Develop a wider range of alcohol and drug programs across the health care continuum

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Feasibility study

The effective delivery of youth health services in the Wairarapa

Maria Mckenzie

MA (Honours) Educational Psychology, PGDip Teach, PGDip RTLB

December 2019

1 MLMckenzie DHB Tu Ora Compass report on Wairarapa youth health services December 2019

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NON-JUDGEMENTAL AND FRIENDLY ATTITUDE OF STAFF - ABOVE AND BEYOND -

MANY THINGS IN ONE BUILDING - A LOT OF PEOPLE HAVE MULTIPLE NEEDS - IT’S

REALLY EMPOWERING - FUN PLACE TO BE - NO BAD VIBES - IT’S DIFFERENT - FREE

AND I’M SUPER BROKE - LOTS OF DIFFERENT SUPPORT IN THE SAME AREA - I CAN

COME HERE FOR ALL TYPES OF HELP - FEEL AT HOME - OPEN TO ALTERNATIVE

LIFESTYLES - SERVICES ARE FREE - EASY TO GET TO - KIND, FRIENDLY AND

APPROACHABLE - THEY TALKED TO ME LIKE A FRIEND - IT SHOWS ME RESPECT

FOR MY HEALTH - I CAN TALK ABOUT ANYTHING AND I DON’T FEEL JUDGED - I

CAN BE OPEN - FRIENDLY AND SUPPORTIVE - RESPECTFUL, GENUINE,

NONJUDGEMENTAL - GIVE ME HOPE - POLITE AND ASK PRONOUNS - FRIENDLY,

WELCOMING, RESPECTFUL AND NOT FORMAL - TREAT US LIKE EQUALS - GIVE

YOU THAT BELONGING FEELING - MORE CASUAL THAN MOST PLACES -

EVERYONE IS EMPATHETIC - NO PRESSURE

How Youth One Stop Shops in New Zealand make young people feel (Gibson-Rothman, 2017).

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Contents

Project outline ...... 4 Executive Summary ...... 6 Adolescence ...... 11 Positive Youth Development ...... 12 Positive Wairarapa Youth Development ...... 13 Youth Participation ...... 14 Wairarapa Youth participation ...... 14 Youth health challenges ...... 16 Wairarapa Youth Health Challenges ...... 19 The long term impact of youth health challenges ...... 20 Youth Health Services ...... 22 Medical centres ...... 22 Wairarapa Medical Centres ...... 23 Integrated models of health service for youth ...... 27 Wairarapa School health services ...... 28 Individual School based health services ...... 31 Youth One Stop Shops ...... 37 Youth Kinex Masterton ...... 38 Other services supporting youth health ...... 41 Factors impacting the effective delivery of health services for youth...... 45 1. Privacy and confidentiality ...... 46 2. Cost of the service ...... 47 3. Service Access...... 49 4. Manaakitanga ...... 50 5. Organisational Kaupapa...... 52 6. Youth Health literacy ...... 54 7. Kotahitanga- collective decision making ...... 56 8. Education and training of health professionals ...... 58 The term ‘Youth’ ...... 59 Summary of Youth Health Service provision across the Wairarapa ...... 59 Strengths and gaps in the provision of youth services across the Wairarapa ...... 60 Medical Centres ...... 60 School based health services ...... 61 Youth Kinex ...... 62 Recommendations for the effective provision of a Wairarapa youth health service ...... 62 Robust Governance ...... 63 Robust workforce development ...... 65 Improve youth and whanau ‘health literacy’ ...... 66 Youth Friendly Medical Centres ...... 67 Equitable School based services ...... 67 Youth Health Hubs...... 68 References ...... 70

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Project outline

Tū Ora Compass Health, Masterton Medical Ltd and Wairarapa DHB are considering the relocation of the Youth Health clinic (Youth Kinex) in Masterton. The current facility which houses the service is inadequate. Before any decision is made about the location of the health specific youth service, there is an opportunity to broaden this discussion to include a wider variety of services, and delivery to young people in other Wairarapa locations. Clearly this discussion needs to take place across a number of agencies, and most importantly, with the young people of Wairarapa.

Project design process

1. Literature review of best practice on adolescent brain development, positive youth health, the importance of youth participation, youth health needs, the long term impact of youth health challenges and forgone care 2. A summary of global, New Zealand and Wairarapa youth health issues including a review of DHB strategy, documentation, statistics and data. 3. A summary of youth health services in New Zealand and the Wairarapa 4. A thematic analysis of factors impacting on the effective provision of youth health services 5. A summary of Engagement with service providers · The main health issues for Wairarapa youth · The service they currently provide for youth (client statistics, costs, access, location, referrals, opening hours, usage, funding) · The kaupapa (the policies, practices used to engage youth) · The challenges in providing effective health care for youth · Suggestions for improvements to the provision of effective health service for youth across the Wairarapa 6. A summary of young people’s views on youth health · The main health issues for Wairarapa youth · The services they use. · The important aspects of a good health service? · The barriers they face in accessing and using a health service · Suggestions for an effective health service for youth 7. Recommendations for the improvement of youth health services across the Wairarapa

Disclaimer

Every care has been taken in collecting and reporting the information to date, however it is not possible to guarantee that all information is error free.

Acknowledgements

The Author wishes to acknowledge all of those people and health professionals who gave their time and expertise to examine the youth health service provision across the Wairarapa. There are many people who made themselves available, often at short notice, and whose genuine thoughtfulness and at times challenging feedback helped the review become a more robust process.

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It was an honour to work alongside Wairarapa youth. The commitment from young people to participate in this kaupapa, to share their experiences and ideas openly and honestly and provide potential solutions was inspiring.

Participants

Professionals working in Youth Kinex, Makoura College Health Service, Kuranui College Health Clinic, Wairarapa College Health Clinic, Rathkeale and St Matthews Collegiate Health Clinic

Professionals working in Carterton Medical Centre, Masterton Medical Centre, Greytown Medical Centre and Featherston Medical Centre.

Professionals working in Community services: Connecting Communities Wairarapa, Carterton District Council, Wairarapa Whanau Trust, Fab Feathy Community Development, REAP and YETE (Youth Education, Training and Employment)

Youth from the Wairarapa Youth Council, YETE (Youth Education, Training and Employment) Employability Skills Programme participants, students attending secondary school across the Wairarapa and Wairarapa Whanau Trust.

Terminology

For the purposes of this report the terms ‘Rangatahi’, ‘youth’, ‘young people’ and ‘adolescent’ will be interchanged throughout. This refers loosely to people aged between 10 and 24 years old.

To ensure anonymity of those who contributed to this review, individuals are not identified in this report. They have been referenced as ‘young people’ or ‘health professionals’.

Limitations of the study

Given the timing and short duration of the study there are inevitable gaps in the health services reported on. This report focused on those services that provide traditional medical health care for youth and do not include an in-depth study of services in the mental health or community sector.

As there was a major review of the mental health services in the Wairarapa Mental Health and Addiction Service Review Report conducted by the Wairarapa District Health Board in December 2018 it is suggested that those recommendations are included in any decisions about youth health care across the Wairarapa.

December is a difficult and busy time of the year and thus some of the core health services were unable to participate.

December is also a busy time for young people with exams and wrap up of the year end. A more formalised analysis of youth voice would provide quantitative data to the factors identified as important in the provision of health services.

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Executive Summary

Adolescence · Adolescence is a unique time of transition from childhood to adulthood · Adolescence is a time when trajectories that influence either positive or negative outcomes may develop · Adolescence is a time of vulnerability, change and experimentation · Major parts of the brain are developing · Changes in the limbic system are associated with adolescents becoming more emotional, more sensitive to the opinions and evaluations of others and being drawn to exciting and intense, sometimes risky experiences · The frontal cortex, involved in planning, decision making, reasoning ability, problem solving, understanding consequences and controlling impulses is still developing

Positive youth development · Adolescence is often portrayed as a time of difficult and challenging behaviours, however, there is much to celebrate regarding the adolescents in this country. Overall, most Rangatahi in Aotearoa are doing very well · The majority of Wairarapa Rangatahi are healthy and active participants in their families, culture, educational institutions, and communities · There have been reductions in smoking, teen pregnancy, motor vehicle crashes, high risk behaviours, drinking behaviours and an increase in celebrating diversity in adolescents across New Zealand

Youth participation · Providing opportunities for young people to be involved in real issues in partnership with adults shows young people that their skills, ideas and views are valued · Adults as well as young people can gain new skills and experience through youth participation · Evidence shows that policies and programmes designed after consultation with users are more likely to be effective · The Wairarapa Rangatahi Development Strategy 2016 – 2021 (WRDS) is an example of youth participation and aims to strengthen youth voice and support their potential · The Wairarapa DHB published ‘Life2go! Youth health in the Wairarapa’ in 2005. This strategy described the many facets of health and social issues, services and points of view that impact on the wellbeing of young people in the Wairarapa · The strategy embeds sound principles of ‘youth participation’ and there appear to be some informal markers of progress in the strategic priorities. A major progression has been the development of a Youth health service ‘Youth Kinex’. However, no formal evidence of evaluation and monitoring has been found. It appears there is limited awareness of this strategy among health professionals working with youth across the Wairarapa.

Youth health · Youth health issues are characterised by specific adolescent characteristics and developmental needs · New Zealand youth have high rates of accidents, mental illness, substance abuse, suicide, obesity, and violence

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· Wairarapa youth have high rates of mental illness, suicide, drug and alcohol use and teenage pregnancy

Youth health services · Young people access health services in a range of settings, including school-based clinics, general practices, community-based health centres and through mobile and out-reach clinics. They are known to ‘snack’ or ‘graze’ on services according to their present situation and needs · From 2008 funding has been provided for school nurses or school-based health services in the secondary schools attended by young people of highest need: decile 1 and 2 secondary schools, teen parent units and alternative education facilities. From 2013 this was extended to decile 3 schools, under the Prime Minister’s youth mental health initiative · Medical centres provide services to all enrolled patients including youth · A number of community youth health organisations have established Youth One Stop Shops in New Zealand over the past 15 years designed specifically for youth

Wairarapa youth health services

· Each town in the Wairarapa has Medical Centre that provide services of all community members including youth · There are school based services available to students at Makoura College and Kuranui College. The Teen Parent Unit and Kura Kaupapa are serviced through the Makoura Health Clinic · Wairarapa College, Rathkeale and St Matthews Collegiate fund their own health clinic. · Chanel College and Solway College do not have a school based health clinic. Some initial discussions are in place with the Tu Ora Compass health and DHB to provide a service in 2020 for Chanel College · Youth Kinex was opened in May 2014 by Masterton Medical Centre in partnership with Tu Ora Compass Health and Connecting Communities. The idea behind this was to create a youth hub in a central location where youth specific services could be delivered. The purpose was to alleviate some of the barriers young people encounter when accessing healthcare, to provide timely, free and appropriate care in a confidential youth friendly environment · Currently this service is still emerging and has potential to grow into a fully integrated Youth hub

Factors that impact on the effective provision of youth health services

Factors that are vital to the effective provision of youth health services include: · Privacy and confidentiality including concerns about GP’s disclosing information to parents, reception staff not protecting confidentiality, the small community and the potential impact of confidentiality on the delivery of consistent care for young people. · Cost and funding factors include awareness of a free service, travel costs and funding models that do not support adolescent health care behaviour · Access to health care includes opening hours, location and appointments processes · Manaakitanga - Hospitality including attitudes and communication of health professionals, reception and waiting rooms

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· Organisational kaupapa – The way of doing things including the kaupapa, theory and ideology of the service and whether it embraces youth-focused, youth-centred, culturally responsive and strengths-based practice · Youth health literacy including help seeking behaviour, attitudes towards health care and Doctors, and the influence of family attitudes towards health care · Kotahitanga – Cross sector Collaboration and Collective decision making among health care professionals · Professional training including the passion, understanding and experience of youth in holistic, strengths based practices and youth specific health issues

What Wairarapa youth need

· Young people want to be involved in the planning, implementation and delivery of services that they will use. They want to be involved in designing the environment, be engaged as staff members and to be seen as positive contributing members of the community · They need understanding of what is available to them and how they can access health care · Young people want a free, private, confidential health service where they can drop in and receive the help they need when they need it in their own communities · They want a service where they can access all different types of support to develop their health, wellbeing, employability skills and social connections · Youth mental health services should be integrated with other services including physical health services, and vocational and social services · They want timely access to sexual and reproductive health services · Young people want to get health care in an environment that is welcoming and youth friendly · Young people want professionals to be welcoming, use informal communication styles, and use a variety of ways to establish rapport with them

What Wairarapa health professionals need

· Health professionals want funding to provide free health care for all young people regardless of what setting they are in · Health professionals need training in youth specific health care. They want a better understanding of adolescent brain development and behaviour, and strategies to meet their needs. They also need support to develop cultural competency · Health professionals want opportunities to share best practice and network. They want access to specialist youth professionals to share complex cases with and assist in referrals for further intervention · They want systems and processes that make it easy to share information with other relevant professionals in the life of the young person · They need the time and skills to assess and intervene in a holistic manner. Opportunities for cross sector collaboration are important · They want to provide continuous care for all young people regardless of the services youth choose to use

Strengths and gaps in the provision of youth services across the Wairarapa

· There is no cohesive youth health strategy that drives decisions, practice and policy across the Wairarapa

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· Young people are not active participants in the design and delivery of the services that serve them · Privacy and confidentiality issues are a barrier to young peoples’ utilisation of local medical centres · Cost is a major barrier for young people accessing health care in local Medical Centres across the Wairarapa · Young people are intimidated by appointment and booking procedures · Young people report that medical centres are not youth friendly · There is a need to improve the cultural capability, youth specific policies, and practices of the medical centres where youth have enrolled · Young people have limited health literacy or knowledge of services available. They have difficulty knowing how to contact, when to contact and who to contact for health care · Medical centres work in isolation to community services · Young people trust the health professionals in school based health services to maintain privacy and confidentiality · Young people are deeply appreciative of the free access to health care in school based services · Varied opening times and service availability were a concern for young people trying to access health care in schools · Young people report that school based health services provide a holistic, youth focussed service · School based health professionals report a strong focus on holistic health and being youth friendly in all their approaches · Comprehensive health assessments (HEADSSS) provide important information on individual and population health and assist professionals to provide comprehensive and holistic care · Youth Kinex provides a free, confidential, youth friendly service in a safe, friendly environment encompassing all the tenets of manaakitanga · The current venue is woefully inadequate and hinders cross sector collaboration and ability to meet demand · Young people who have left school need greater awareness of the service available to them · Youth in the South Wairarapa may have difficulty accessing a youth health service. · There is not enough time available and too many young people requiring support to take the time needed to provide comprehensive, holistic youth health care · There is an opportunity to extend the services available at Youth Kinex to include all aspects of youth health and wellbeing. This will require coordination and cross sector collaboration

Recommendations for an effective youth health service across the Wairarapa

There is no one integrated model of youth services that will achieve optimal outcomes for all young people. Rather, it is a mixed model comprising school-based services, community- based services such as youth one-stop shops services, and general practice services.

· Develop a District Health Board Youth Health Plan: Develop a Youth Health Plan and incorporate it into the overall District Health Board strategy. Develop specific measurable actions that are implemented, resourced and monitored and evaluated.

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· Create a vision for youth health across the Wairarapa. Develop a strategy that incorporates the principles of effective youth health · Establish a cross sector, collaborative steering group. Create a Youth Health Steering group governed by a partnership of local organisations · Commit to Youth participation. Create a Youth Health Advisory Group to provide governance over the implementation of the DHB youth health plan · Establish a Wairarapa Youth Health Service Specialist team. This group would be mobile and support all school, practices and the youth clinic. These would be dedicated professionals who are trained in youth health and development · Train health professionals to provide best practice health care. Develop and implement a training programme for health professionals in youth development, adolescent brain development and their behaviour, social and emotional development and health · Improve youth and whanau ‘health literacy’ through support to school’s educational health programmes and direct communication to current enrolled patients via ‘youth health packs’ · Develop a fair, flexible youth centred funding model. Realign funding to be allocated to the young person regardless of what service they choose to access and ensure it is simple for health professionals to access · Implement a coordinated Patient Management System across all services that allows youth health care to be continuous and information shared among relevant health professionals · Incorporate best practice for youth health care across all medical centres: Integrate kaupapa, theory and ideology that embraces youth-focused, youth-centred and strengths-based practice into all areas and levels of the organisation, and ensure this drives all decision making and interaction with young people · Provide a fully resourced, equitable school based health service to every school in the Wairarapa. This would include regular access to and support from a GP or health practitioner; Health professionals who are trained and resourced to complete a HEADSS assessment for targeted students; Regular networking and professional development opportunities for staff working across the sector and support from a social worker to work collaboratively with the Guidance counsellor and other health professionals · Expand Youth Kinex to become a hub for holistic youth health care across the Wairarapa through enlarging the facility to allow for cross sector services to develop and cohabitate `and improve privacy; increasing the capacity to provide longer hours and more days; acting as a base for a Youth specialist team who are mobile and can serve satellite health clinics in schools; cohabiting with other youth services such as the Youth wellbeing café and YETE job club · Support the development of a Youth Health Hub in Featherston. Work alongside South Wairarapa community development initiatives to support the establishment of a youth health service in Featherston

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Adolescence

Adolescence is a unique time of transition from childhood to adulthood. Like the early years, adolescence is a time when trajectories that influence either positive or negative outcomes may develop. Lifetime problems with health and the failure to develop the skills and knowledge that are needed to succeed in employment and community life can all have their roots in adolescence (Steinberg, 2016).

Puberty, the start of adolescence now starts earlier than it has in the past, sometimes as young as seven or eight years for females. Adolescence is now thought to end in the early to mid- twenties with a transition into adult roles and responsibilities.

There are two primary brain regions where important changes take place over the period of adolescence.

The limbic system, which plays an important part in the processing of emotions, social information and reward, becomes more easily aroused around the time of puberty. Changes in this area are associated with adolescents becoming more emotional, more sensitive to the opinions and evaluations of others and being drawn to exciting and intense, sometimes risky experiences

The second part of the brain undergoing major reorganisation and growth during adolescence is the prefrontal cortex. Areas involved in planning, decision making, reasoning ability, problem solving, understanding consequences and controlling impulses are the last region in the brain to mature, somewhere around the mid-twenties. Efficient use of these functions is essential for taking on the roles and responsibilities of adulthood.

Adolescence is a time where young people make many important life choices which have long term consequences. It is a time of experimenting with different ways of appearing, behaving and sounding. Risk-taking is often seen as one of the defining features of adolescence. This has been an important rite of passage in evolutionary terms and, although it may not be so adaptive for the way we live now, it is still an inherent part of adolescent development that is ‘hard-wired’ in the brain.

Adolescent behaviours and attitudes are not only influenced by changes in the brain. As in all development, there are on-going and dynamic interactions between biological, social and cultural factors that contribute to development. Conditions in the family, at school and in the community will all play a part in adolescent development and trajectories.

“In order to provide the best opportunities for development and optimise healthy choices, it is important to provide for the specific health and social needs that adolescence brings” (Ministry of Health, 2009).

World Adolescent Population

Around 1.2 billion people, or 1 in 6 of the world’s population, are adolescents aged 10 to 19.

New Zealand Adolescent Population (Collaborative Trust, 2011)

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877, 185 young people are aged between 12 and 24 years old in NZ (444,639 Males, 432546 females) 21.7% population

169,033 Young Maori Rangatahi 19% of total

80,000 Young Pacific people 9.2% of total

105,000 Asian young people 12% of total

75% live in urban areas

Wairarapa Adolescent Population (Statistics New Zealand and Profile 2016 cited in Masterton and Carterton District Council, 2016)

6, 231 Rangatahi are 12 – 24 years’ old

15.2% of the Wairarapa population

8.4% of these are secondary school aged.

28% of the District’s youth aged 15–24 years are Māori. (Rangahau Hauora, 2015)

Positive Youth Development

Adolescence is often portrayed as a time of difficult and challenging behaviours. Yet it’s possible to view adolescence in a much more positive light. Recent research may help adults understand and appreciate the remarkable changes that are taking place.

For a long time, the teen years have been seen as a time of ‘storm & stress’. We assume that Rangatahi cause problems; problems for themselves, and for those around them. Hormones are frequently attributed. Whānau and others ‘need to cross their fingers and hope to make it out the other side, preferably in one piece.’ This view is widespread and reinforced by media, parents, and sometimes even ‘experts’ on adolescents. Parents of young children sometimes dread their Tamariki becoming Rangatahi.

When we expect the worst, we are more likely to get it.

Studies have shown that the more parents expect their teen to be rebellious and take risks, the more likely this is to actually happen (Buchanan & Hughes, cited in O’Neill, 2019).

Similarly, parents who believed that their teen was likely to drink, had teens who drank more (Madon, et al., 2006, cited in Steinberg, 2016).

In other words, research suggests that not only are these negative stereotypes wrong much of the time, they can also contribute to poorer outcomes.

This view has influenced the study of adolescents since early last century. These ideas began to change as researchers started to realise that most Rangatahi actually do well during their teen years. Positive Youth Development (PYD), shifts our view of Rangatahi from ‘problems to be solved’ to ‘resources to be developed’.

There is much to celebrate regarding the Rangatahi in this country. Overall, most young people in Aotearoa are doing very well. The majority of Rangatahi negotiate this transition in

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healthy ways. They’re mostly demonstrating good choices and self-management, they mostly live by strong morals and values, and generally function well in relationships with their peers, parents and other adults. Research demonstrates that the majority are healthy, happy and well adjusted. Most young people report having positive relationships in their lives and positive aspirations for their future (Denny, 2014).

In 2012, most students (91%) reported that their general health was excellent, very good or good (Clarke, 2013).

We have seen many improvements in adolescent health and wellbeing including

A reduction in daily smoking from 15.6% in 1999 to 4.1% in 2012 (ASH, 2012)

Teen pregnancy has decreased significantly since 1971 with 7 births per 100 (15-19 years) to 2.8 births per 100 teenage women in 2011 (Families Commission, 2011)

Motor vehicle crash deaths have reduced from 51 per 100,000 in the 1985-1989 period to 19 per 100,000 in the 2005-2009 period (15-24 years) (Ministry of Social Development, 2010)

New Zealand research carried out by Noel (2013) found that about 80% of secondary school students were not engaging in high risk behaviours.

While it may feel as though ‘everyone else is drinking,’ the reality is a large proportion of under-18s are not. The 2011/12 New Zealand Health Survey (Ministry of Health, 2013) reported that overall fewer 1517 year olds were drinking alcohol - significantly reduced from 75% in 2006/07 to 59% in 2011/12.

Aotearoa New Zealand is becoming increasingly diverse. Young people’s ethnic identities (both in traditional and contemporary form) are a common source of pride and having a positive ethnic identity is an important contributor to their wellbeing (Clark, 2014).

Positive Wairarapa Youth Development

The Wairarapa also has much to celebrate in their young people. The Wairarapa Safer Community Trust Rangatahi Health and Wellbeing Report (WSCT, 2016) asked small town, rural and semi-rural Rangatahi about their health and wellbeing experiences as young people growing up in these environments. Rangatahi are healthy and active participants in their families, culture, educational institutions, and communities. It found:

78% described their health as ‘excellent’, ‘very good’ or ‘good’.

Rangatahi who have good nutrition and engage in physical activity generally feel good about themselves.

There has been a significant decrease in the proportion of Wairarapa Māori aged 15– 17 years who smoke regularly (Rangahau Hauora, 2015).

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Youth Participation

“Youth participation is a central feature of successful youth programming and effective policy-making. It is an important part of the development of citizenship and youth development. Young people bring with them new ways of thinking and acting that add value to the work of organisations” (Ministry of Youth Development, 2009).

Adolescence brings with it an opportunity for the successful development of children into healthy and fully contributing adult members of our community.

We can contribute to the positive development of young people by creating opportunities for them to influence, inform, shape, design and contribute to an idea or activity. Learning by doing, and being involved in decision-making, is part of young people’s contribution to changes in society.

Providing opportunities for young people to be involved in real issues in partnership with adults shows young people that their skills, ideas and views are valued. Adults as well as young people can gain new skills and experience through youth participation.

Evidence shows that policies and programmes designed after consultation with users are more likely to be effective.

By utilising youth participation principles an initiative is more likely to avoid wasting time and money on services young people don’t want to use.

Organisations committed to effective youth participation can boost their profile and credibility with stakeholders, funders and the community. Encouraging youth participation contributes to the positive image of the organisation, making it easier to attract young people, their friends and families, and to promote the organisation to them.

Wairarapa Youth participation

There are many areas where youth play a positive part in decision making in the Wairarapa. For the purpose of this report two areas where young people can pay an important role have been highlighted.

Wairarapa District Health Board Youth Health strategy

Each District Health Board is required to have a youth health plan as part of their responsibilities for the health of their catchment population.

In July 2005 the DHB published ‘Life2go! Youth health in the Wairarapa’. This document described the many facets of health and social issues, services and points of view that impact on the wellbeing of young people in the Wairarapa. It outlined the health objectives that need to be targeted and why. It described how the DHB would work with young people and agencies to make demonstrative health gains in the future. It set directions and actions that would directly impact the health of youth / Rangatahi in the long term.

Six Overarching Principles were identified.

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Achieving whanau ora Youth participation in the development and delivery of services Information that allows them to make well informed choices about their health and wellbeing Collaboration between service providers, families / whanau, schools and youth Accessibility for young people to health and social services Acceptability of services to youth / Rangatahi and their family /whanau

Five Health Priorities were also identified

Reduce motor vehicle accidents Improve the mental wellbeing of all youth / Rangatahi Reduce drug and alcohol related disorders and problems Improve sexual health Encourage healthy lifestyles.

To achieve this, three strategic priorities were advanced. These priorities required input from all corners of the community, and required a collaborative and intersectorial approach.

Youth Participation including establishing a Wairarapa DHB Youth Advisory Group who would provide governance over strategy implementation and management teams to guide the development and operation of individual services.

Communities Working Together through an increased focus on health promotion and education, joint approaches would ensure effective use of resources, underpinning all action. Use of the health concept Te Whare Tapa Wha, and holistic approaches would support long term behavioural changes in both the young person and their family/whanau.

Youth Health Services. The DHB aimed to develop a network of youth health services and programs across secondary schools and the community in order of assessed priority as resources become available over the next three to five years. These would include school based health services in secondary schools, community based clinics that target young people who are not at school and programmes targeting the needs of specific groups to complement existing ones as opportunities present.

The strategy embeds sound principles of ‘youth participation’ and there appear to be some informal markers of progress in the strategic priorities. A major progression has been the development of a Youth health service ‘Youth Kinex’. However, no formal evidence of evaluation and monitoring has been found. It appears there is limited awareness of this strategy among health professionals working with youth across the Wairarapa.

Wairarapa Rangatahi Development Strategy 2016 – 21

The Wairarapa Rangatahi Development Strategy 2016 – 2021 (WRDS) was developed by the Wairarapa District Councils of Carterton and Masterton.

The WRDS was developed to reaffirm the Carterton and Masterton District Councils’ commitment to Rangatahi and outline the ways in which the Councils will work together. In particular, the WRDS focuses on strengthening Rangatahi voice and supporting Rangatahi potential. It outlines a strategy for District Councils to work together with the Rangatahi development and services sector to maximise their community development, funding and

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partnership resources for the benefit of Rangatahi. The strategy provides an excellent example of youth participation and positive youth development.

Two key goals have been identified for this strategy:

Strengthening Rangatahi Voice. This is reflected in positive participation in Council and community affairs and ensuring their participation in the democratic process.

Supporting Rangatahi. Potential to grow into vibrant, optimistic and connected adults and future citizens through support with positive environments and opportunities to reach their full potential.

Reports in November 2019 indicate progress in the implementation of the strategy across the Wairarapa

Rangatahi actively participate in Council and community affairs and the democratic process

Councils have implemented ‘Best Practice’ Youth development processes into relevant job descriptions and professional development meetings

Mayors and Councilors have visited secondary schools to promote the Youth Council and encourage civic engagement

Youth Council representatives attend Council meetings and/or Wellbeing Committee meetings where relevant issues are discussed

Youth Council & R2R deliver Rangatahi engagement workshops to newly elected Councils

Annual Governance training is delivered to all Youth Council members

Youth leadership and participation is celebrated in the Annual Youth Awards

Youth health challenges

Normal development entails facing challenges across the lifespan. Being able to cope with adversity, and to seek and receive help during these times is important for development. The Collaborative Trust (2011) have identified specific characteristics of youth health issues and developmental needs.

The causes of ill health in young people are characterised predominantly by psychosocial rather than biological issues.

They engage in health risk behaviours that reflect the adolescent developmental process of experimentation and exploration.

Young people often lack awareness of the harm associated with risk behaviours and the skills needed to protect themselves.

Young people lack knowledge about where and when to seek help for themselves

Developmental difficulties and conditions related to pubertal growth commonly occur during adolescence.

Adolescent health problems are often complex and frequently one health problem frequently raises risk for another health problem.

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Many of the risk behaviours and lifestyles developed in adolescence establish a pattern of behaviour that continues into adulthood and contribute to long term health issues across the life span.

Young people’s health status is often influenced by family social and cultural factors as well as environmental hazards to which they are exposed. Their wellness is dependent on the wellness of their whānau and communities (Deane, 2019).

Young people themselves have talked about the challenges they experience and see in their everyday lives. They identified mental health and education, economic insecurity, body image, oppression, the environment, community, role models, and a desire to contribute to positive change as significant issues in their lives (Nga Kōrero Hauora o Ngā Taiohi Action Station, 2018). New Zealand youth have higher rates of mental illness, suicide, teen pregnancy, abortion and suffer more injuries than their counterparts in other Organisation for Economic Co-operation and Development (OECD) countries.

Globally more than 1.1 million adolescents aged 10-19 years died in 2016, over 3000 every day, mostly from preventable or treatable causes. The World Health Organization (WHO 2017) identifies that almost two-thirds of premature deaths and one-third of total disease burden in adults can be accredited to the state of youth health and behaviours they choose to partake in. This includes tobacco, drug and alcohol use, decreased physical activity and poor diet, unprotected sexual intercourse, exposure to violence and abuse and untreated mental health issues. Addressing these issues when people are young is likely to lead to improved health outcomes as well as higher health literacy in adult life, and inevitably to reduced health costs in the future (cited in Helman, 2019).

Accidents

Unintentional injuries are the leading cause of death and disability among adolescents across the world.

In 2016, over 135 000 adolescents died as a result of road traffic accidents. (WHO, 2011).

Drowning is also among the top 10 causes of death among adolescents – nearly 50 000 adolescents, over two thirds of them boys, are estimated to have drowned in 2016 (WHO, 2011).

In New Zealand there were 2366 accidental deaths in 2003-2008 among15-24 year olds. The leading causes of death for young people in NZ at ages 15-24 are external factors such as accidents, poisoning and violence including car accidents, self-inflicted injuries and suicide. These are mostly due to risk behaviours where earlier intervention could have prevented these deaths (Collaborative Trust, 2011).

Mental health

Mental Health and mental distress encapsulates the main concerns facing young people today. Mental health includes an individual’s self-esteem and sense of self-worth and is reflected in how they choose to treat and care for their bodies (Helman 2019).

Depression is one of the leading causes of illness and disability among adolescents, and suicide is the second leading cause of death in adolescents. Violence, poverty, humiliation and feeling devalued can increase the risk of developing mental health problems.

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Mental health and mental distress is an area that is worsening and accounts for the majority of the disease burden for young people. Around three quarters of all lifetime cases of mental health disorders begin before age 24 years (Duncanson, 2019).

Between 2009 and 2017 15- 24 year olds across the Wairarapa DHB had rates of mental distress similar to New Zealand rates (Duncanson, 2019). high psychological distress 9.4 % diagnosed depression 9.3% diagnosed anxiety disorder 8%

Māori were 63% more likely than non-Māori to be admitted to hospital for a mental disorder during 2011–2013. Psychotic related disorders were the most common disorders, followed by substance use disorders. The rate of admission for schizophrenia disorders was 4.2 times the non-Māori rate (Rangahau Hauora, 2015).

The number of people who have taken their own lives in New Zealand is the highest since records began, with 668 dying by suicide in 2018-2019. It was the fourth year in a row that number has increased. It was also the highest number of suspected suicide deaths since the Coroner's annual provisional suicide statistics were first recorded in 2007-08 (Chief Coroner, 2019).

The number of Māori deaths is also the highest since records began, with 142 deaths from July 2017 to June 2018 (Chief Coroner, 2019).

The highest number of suicides was within the 20-24-year-old group with 76 deaths.

Mental health service access rates in Wairarapa were consistently higher than national rates, particularly for 15–24 year olds between 2009 and 2017 (Duncanson, 2019).

Substance abuse

Drug use among 15–19 year olds is also an important global concern.

Comparisons between 2001, 2007 and 2012 in the youth 2000 survey indicate there has been a significant decline in the use of cigarettes, alcohol and marijuana reported by students.

In New Zealand 30% of males and 15% of females aged 15-17 have used drugs (MOH cited in Collaborative Trust, 2015) and out of those who have used 44.9% of males and 32.4% females are weekly users of cannabis.

Around 57% of young people under 18 years old had consumed alcohol in the past year, which was significantly lower than the rate in 2006 when three quarters of under-18 year olds had consumed alcohol in the past year. The percentage of 18–24 years who consumed alcohol in the past year was consistently higher than the rate of their younger peers at around 84-86% since 2011.

Globally, at least 1 in 10 adolescents aged 13 to 15 years uses tobacco, although there are areas where this figure is much higher. Cigarette smoking appears to be decreasing among younger adolescents in some high-income countries. (Clarke 2013).

Sexual behaviour

In New Zealand, secondary school students are delaying initiation of sexual behaviour when compared with their peers ten years ago.

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In 2012, the Youth2000 survey found that

11.2% of school students aged under 16 years and one-third (32.9%) of school students aged over 15 years were sexually active. (Duncanson, 2019).

18% of women aged 16–24 years had been pregnant in the previous five years. (Duncanson, 2019).

There has also been a strong downward trend in the rate of terminations of pregnancy for women aged 15–19 years since 2007.

Contraception use among sexually-active school students has shown little change over time; in 2012, 45.5% always used a condom, and 58.2% always used contraception.

Nutrition and physical activity

Many boys and girls in developing countries enter adolescence undernourished, making them more vulnerable to disease and early death. At the other end of the spectrum, the number of adolescents who are overweight or obese is increasing in low-, middle- and high-income countries.

Globally, in 2016, over one in six adolescents aged 10–19 years was overweight. Prevalence varied across WHO regions, from lower than 10% in the WHO South-East Asia region to over 30% in the WHO Region of the Americas (WHO 2011).

Violence

Interpersonal violence is the third leading cause of death in adolescents, globally, though its prominence varies substantially by world region. It causes nearly a third of all adolescent male deaths in low- and middle-income countries of the WHO Region of the Americas. Globally, nearly one in three adolescent girls aged 15 – 19 years (84 million) has been a victim of emotional, physical and/or sexual violence perpetrated by their husband or partner (WHO, 2011).

Wairarapa Youth Health Challenges

Challenges faced by Wairarapa youth that can affect their health and wellbeing include socioeconomic factors, perceived positive school climate, access to healthcare, exposure to violence, and risky health behaviours including suicide attempts (Crengle et al, 2013). There are significant number of Wairarapa Rangatahi who drive vehicles while unlicensed, binge drink substantial volumes of alcohol, engage in earlier sexual intercourse compared to other regions nationally, have high levels cigarette and marijuana use, and have limited knowledge about how to access services when required (WSCT, 2016).

Suicide and self harm

In the Wairarapa the provisional suicide rate was 17.8 deaths per 100,000 people, year to June 2018. This is the seventh highest DHB rate in New Zealand (Chief coroner, 2019).

Among Māori aged 15–24 years there was an average of nine hospitalisations per year for injury from self-harm during 2011–2013 (Rangahau Hauora, 2015).

Drug and alcohol use

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Ministry of Education data on school stand-downs and suspensions for drug and alcohol use show overall higher proportions of drug and alcohol related stand-downs and suspensions for school students in the Wairarapa compared to New Zealand as a whole. over the period 2009 to 2013 (Waldegrave 2015).

Wairarapa youth have a marginally higher percentage of young people had an alcoholic drink in the past year when compared with the national percentage. (Duncanson, 2019).

Tobacco use There has been a significant decrease in the proportion of Wairarapa Māori aged 15–17 years who smoke regularly, but no change in smoking rates among Māori aged 20–24 years. In 2013 48% in this age group were smoking cigarettes daily, compared to 27% of non-Māori (Rangahau Hauora, 2015).

Teenage pregnancy

While teenage pregnancy termination rates have tended to fall overall, during the period 2008 to 2014, Teenage birth rates have been higher in the Wairarapa DHB area than for all DHBs over the period 2010 to 2014 (Waldegrave 2015).

Sexually Transmitted Infections (STIs)

The gonorrhoea rate for Wairarapa is lower than the rate for New Zealand while the Wairarapa chlamydia rate is higher.

When gonorrhoea and chlamydia infection rates are combined the Wairarapa combined rate is slightly higher than the New Zealand combined rate (Waldegrave 2015).

Long term health issues

28% of Wairarapa Rangatahi described themselves as having a health issue that has lasted six months or more. This health condition has either caused difficulty or stopped them from everyday activities that other Rangatahi can usually do (23%), communicating or socialising (19%), or other activities (18%) (WSCT, 2016).

The long term impact of youth health challenges

Adolescence can be considered a sensitive phase, during which the quality of the physical, nutritional and social environments may change trajectories of health and development into later life.

The developmental science of adolescence is providing new insights into windows of opportunity during which intervention can have especially strong positive impacts on trajectories of health, education, social and economic success across the lifespan.

ACE studies

Understanding of the link between adverse childhood experiences (ACES) and adult health issues has been deepened by longitudinal research from the United States. These findings indicate strong links between adverse experiences during childhood and adolescence, and medical problems and unhealthy behaviours that occur later in life.

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The studies focused on key ACEs) and their lifelong impact on individuals (Felitti,1998). Adverse childhood events include psychological, physical and sexual abuse; violence against mother; and living with household members who were substance abusers, mentally ill or suicidal or who had been imprisoned; emotional and physical neglect, residential mobility and parental education.

The research found a strong relationship between the degree of exposure to ACEs and multiple risk factors for several of the leading causes of death in adults, including alcoholism, drug abuse, heart disease and suicide. Those with many ACEs were more likely to have many health risk factors later in life, however, these consequences of early adversity may not be seen for many years.

Adolescents who experienced early adversity are more likely than others their age to go on to use tobacco, alcohol and drugs and have unprotected sex, increasing the risk for pregnancy. They’re less likely to have good family and community support, may have on-going conflict with family and are at greater risk for mental health problems such as depression.

“If we wish to prevent poor adult health, and the associated spending, policy makers would be advised to take heed of the potentially long lasting effects of early childhood experiences.” (O’Neill, 2018)

Forgone health care

New Zealand secondary school students have high rates of forgone health care. (missed opportunities for health intervention). A study by Denny (2013) indicated one in six students (17%) had not seen a doctor or nurse when needed in the last 12 months.

In the past year 74% of Wairarapa Rangatahi have received healthcare and generally use a range of services (WSCT, 2016).

Another area that has significantly worsened over the last decade as shown by the Youth Survey Series includes access to a family doctor (Clark, 2014).

It is of concern that both students with health concerns and students from populations experiencing disparities in health outcomes were most at risk of forgone health care, as these issues are generally amenable to good quality primary care.

Female Maori and Pacific students and those living in neighbourhoods with high levels of deprivation were more likely to report forgone health care (Denny, 2013).

Students with chronic health problems, those engaging in health risk behaviours or experiencing symptoms of depression were more likely to report being unable to access health care when needed (Denny, 2013).

There are a number of factors that influence health care access and utilisation among adolescents, including individual characteristics such as age, gender and socioeconomic factors, availability and adolescent perceptions of their health care provider, and level of need or illness (Denny, 2013).

The challenge for the health sector is to configure services that address youth concerns and provide youth specific healthcare for all young people across Aotearoa. Adolescents who forgo health care are a vulnerable group at risk of physical and mental health problems (Denny, 2013).

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Youth Health Services

Young people access health services in a range of settings, including school-based clinics, general practices, community-based health centres and through mobile and out-reach clinics. They are known to ‘snack’ or ‘graze’ on services according to their present situation and needs.

In New Zealand, over 80% of secondary school students access health services in any given year. Of the 128 young people interviewed by Wairarapa Safer Community Council in the past year 74% of Rangatahi have received healthcare and generally use a range of services.

In New Zealand, the Ministry of Health has allocated DHBs funds to provide primary mental health services for youth (YPMHS) with the expectation that such services will deal with young people aged 12–19 years with high prevalence mental health conditions, such as mild-to- moderate anxiety, depression, alcohol and drug problems, and coexisting problems with medically unexplained symptoms. The DHBs have taken a variety of approaches to providing YPMHSs, including expanding the age range of existing primary mental health services, adapting existing primary mental health services for youth, expanding existing NGO or community-based services, and developing new services, for example psychologists in schools or NGO youth services, and funding youth specific services such as youth one stop shops.

Where youth access help for their health and wellbeing needs

NZ school students Wairarapa (Denny, 2013) Rangatahi (WSCT, 2016) General practitioners (GPs) or family doctors 93% 61% School health clinics 23% 5% After-hours or 24-hour accident and medical centres 16% 16% Hospital emergency departments 18% 15% Family planning or sexual health clinics 5% - Youth centres 2% 7% Drug and alcohol service - 2%. Kaumatua 5% School guidance counsellor 9% Friends 11% Teachers 30% Parents 77% Other family members (e.g. grandparent, aunts, uncles, 80% cousins)

Medical centres

“The quality of an adolescent’s initial contact with a GP influences the way they perceive the health system and their future patterns of utilising health services” (Bennett, 201 cited in Collaborative trust, 2011).

GP’s are ideally placed to respond to young people’s complex health problems by providing comprehensive health care, and acting as a first ‘port of call’ in the identification, treatment,

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follow up and referral of adolescent health problems. They are the gateway to the health system and can facilitate young people’s access to other services they require.

They are the most accessible primary health care provider for young people. Young people themselves perceive Doctors as one of the most credible sources of health information (Barber et al, 2001 cited in Collaborative trust, 2011).

However young people are often reluctant to visit doctors for fear of embarrassment in discussing sensitive issues such as sexuality, drug use and psychosocial problems. They are concerned about confidentiality and privacy and believe that GP’s treat only physical ailments. They also face administrative, psychological and financial barriers to accessing GP services.

Wairarapa Medical Centres

Enrolments

There are 8163 youth between 10-24 years enrolled in Medical centres across the Wairarapa (Tu Ora Compass, 2019).

The table below gives the number of enrolments across each medical centre in the Wairarapa and their ethnicity (Tu Ora Compass, 2019).

Enrolled Carterton Featherston Greytown Masterton Patients Medical Medical Centre Medical Centre Medical centre Aged 10- Centre 24 Total 1111 712 590 4216 Female 537 322 291 2092 Male 573 390 299 2124 Unknown 1 12 23 90 Asian 19 1475 481 2816 European 828 210 72 1150 Maori 225 1 13 141 Pacific 1 13 1 12 Other 38 0 0 0

Enrolled Kuripuni Martinborough Whaiora Whanui Patients Medical Centre Medical Centre Aged 10- 24 Total 233 441 860 Female 115 209 434 Male 118 232 426 Unknown Asian 5 22 18 European 181 309 349 Maori 40 111 438 Pacific 0 1 49 Other 7 7 0

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Presenting health issues

Medical centres do see a broad range of health concerns however all health professionals interviewed for this study rated mental health as the highest health concern for young people in the Wairarapa, followed closely by sexual health and injuries.

Privacy and confidentiality

Medical centres require young people to present at the clinic in the same manner as other patients. None of the medical centres have a specific space or provision to ensure youth privacy.

If the child is under 16 years old a health professional has an obligation to share information if requested by a parent. This may be in direct conflict to the child’s wishes not to share information with the parent.

All medical centres have a mandatory role to maintain confidentiality from parents for a person over the age of 16 years old, although billing processes can challenge this as many young people are enrolled as a whanau and the parent/caregiver receives the bill.

Cost

Medical centres have varying charges for patient consults. Most general practices offer zero fee visits for children aged 13 and under, and most non-VLCA practices offer cheaper visits for Community Services Card holders and their dependants.

Service Access

Medical practices across the Wairarapa have the same process for making appointments for all patients.

One medical centre reported an informal policy of triaging young people immediately by a nurse if possible when they presented at the clinic. They accepted ‘drop ins’ from youth and tried to see them as soon as possible.

Appointments are usually 15 minutes’ duration for all patients

Manaakitanga – Hospitality, Attitudes and Communication

Medical centres have the same policy and code of conduct for all patients regardless of their age. There are no specific policies around engagement or communication with young people.

One medical centre did point out they had a policy of employment diversity across their service to ensure their receptionists are reflective of the general population. This has had a distinct advantage to the practice with an increase in young people who make appointments.

Organisational kaupapa - Way of doing things

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Individual practitioners have a variety of skills and approaches to treating young people. The same procedures for assessment apply to all patients. There are no youth specific approaches reported by health professionals working with youth.

No medical centres conduct health assessments specifically for youth as part of their practice. The expectation is that school based clinics or Youth Kinex manage these if required.

Kotahitanga – Cross sector Collaboration and Collective Decision making

Two Medical Centres support local school based health clinics (Masterton Medical and Featherston Medical) with nurses, GPs, equipment and resources. One medical centre supports Youth Kinex with GP, Nurse and resources. (Masterton Medical).

All medical centres have access to a variety of specialists such as physios, Maori health team, Lab, Podiatry and Counsellors. Often these are on site and provide easy access for patients.

Professional training in youth health

Many nurses and GPs have undertaken training in particular youth heath issues such as sexual health and mental health. However there is no training for nurses, GPs or reception staff across the Wairarapa in specific youth development and needs.

Funding

There are a variety of funding sources that fund youth consultations.

Capitation: An allocated amount of money per enrolled patient is paid to the enrolling medical service based on historical demographic data e.g. ethnicity, age. When someone visits a practice they are not enrolled in they will be charged a higher co-payment. If they have a CSC the co-payment will be reduced and the balance of the fee will be “clawed back” from the practice of enrolment.

Casual enrolments

Enrolment is automatically maintained at the practice of choice as long as the patient is seen within three years. Even if they are not seen, the enrolment is maintained if they complete a new enrolment form confirming they wish to be enrolled. If they fill out an enrolment form at another practice, this becomes their practice of choice and the enrolment transfers. If they are seen at another practice they will be charged a higher fee and seen as a casual patient. Unless they confirm they want to be enrolled this should not happen. If they have a CSC a clawback will apply.

Claw back: All medical practices ‘claw back’ funding from the enrolled centre for seeing patients who present as casual patients at their service.

Sexual health: The DHB contracts Tu Ora to provide free sexual health and contraception services to young people. This funding is then allocated to practices according to the enrolled population under 21 years old for contraception and related consumables to enable a free service to young people aged under 19 years’ old

Package of care: A free consult for Maori but this currently at capacity in the Wairarapa

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Guided care: A further flexible funding pool, also determined through the national capitation formula. This is available for prevention and screening of long term health conditions, but is usually for older people.

ACC claims: An accredited Provider can claim for these. There are different allocations for each clinic

Services to Increase access funding: All practices are allocated funding (the amount is determined through the nationally agreed PHO Agreement) to provide access for groups who have traditionally been less likely to access services. This includes Maori, Pacific and people living in low decile areas. Most practices allocate this as packages of care and it is used at their discretion.

Youth specific funding

The DHB has a number of contracts with Tu Ora Compass Health. Tu Ora is the service provider, but in most instances sub-contracts the service to individuals or practices. These contracts include:

Sexual health (as above)

School based Health Services in Makoura and Kuranui colleges (and from 2020, Chanel College). This is a service with a nationally agreed service specification. The spec includes nurse clinics (according to the school roll) and HEADSS assessments. Tu Ora also use some of the funding to pay for GP clinics in the schools.

Masterton Medical Centre:

Masterton Medical funds a GP twice a week, each 3 hours long, at Youth Kinex for people aged 13-23.

They also provide a nurse and a GP to two local secondary schools (Rathkeale College and St Matthews Collegiate) at the school’s cost

They provide a GP to one other school health clinic (Makoura college) funded by Tu Ora Compass health.

Featherston Medical Centre

The practice provides GP support to the school based clinic at Kuranui funded by Tu Ora Compass health.

The GP also provided a whanau and students health clinic at the local primary school but now provides regular support to the school Principal as it was not widely utilised

Carterton Medical Centre:

The centre provided a youth clinic for 6 months during 2018 and supported the school based clinic at Kuranui. They no longer do this.

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Integrated models of health service for youth

“Accessible, acceptable, appropriate, effective and equitable youth services are the key principles for integrated care stipulated in the WHO’s framework for adolescent and young adult-friendly services” (WHO, 2001, 2012).

While there is no single universal definition for ‘integrated care services’, it is generally accepted that integrated care is a practice unit with clinical and non-clinical personnel working collaboratively to provide comprehensive, multidisciplinary care; ideally in one location. Primary health care and social services are organised and coordinated around the individual and his/her needs (Porter & Lee, 2013; World Health Organization [WHO], 2012; Hetrick et. al., 2017).

Integrated youth services are typically school-based services, community-based services (i.e. one-stop shop services) and services provided in general practice settings.

The key principles or core features of integrated youth services in community-based settings to inform and strengthen practice are:

· an emphasis on rapid access to care and early intervention · youth and family engagement · youth-friendly settings and services · evidence-informed approaches, and · partnerships and collaboration

Evidence supports the effectiveness of community based integrated youth services, including findings that young people respond better to youth specific services; there are improved mental health outcomes and that young people who would otherwise not access services engage with a youth specific service (Hetrick et. al., 2017; Halsall et. al., 2018).

Many young people may not otherwise have sought help from the mental health services, and with symptomatic and recovery success (Hetrick et. al., 2017).

Young people report high levels of satisfaction with these services (Hetrick et. al., 2017).

There are improved mental health outcomes for young people who received integrated care compared with usual care (Hetrick et. al., 2017).

Integrated services attract the traditionally under-serviced i.e. female, ethnic (Maori, Pacific (Hetrick et. al., 2017).

School health services

From 2008 funding has been provided for school nurses or school-based health services in the secondary schools attended by young people of highest need: decile 1 and 2 secondary schools, teen parent units and alternative education facilities. From 2013 this was extended to

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decile 3 schools, under the Prime Minister’s ‘Youth Mental Health Initiative’. There is considerable variability in the provision of health services in schools across New Zealand.

A significant proportion (12%) of secondary schools report no health services beyond the minimum requirement of first aid provision; this was more common among private schools than integrated or state-funded schools.

The other 88% of schools report some level of health service. The most common model of health service provision, in 56% of schools, was by visiting health professionals.

Other schools had on-site health professionals: 20% had a health professional (a school nurse) and 12% had a collaborative health team of health and other allied health professionals on site for most of the week.

Schools with higher levels of health service (an on-site school nurse or health team) were more likely to have more facilities, to be better integrated with the school, the community and local Primary Health Organisations, and to provide routine comprehensive health assessments (including HEEADSSS screening) and more comprehensive health services.

High quality school health services (those that have on-site staff well trained in youth health, with sufficient time to work with students and to perform tasks like routine HEEADSSS assessments) do impact positively on student health and wellbeing outcomes in areas such as depression, suicide risk, sexual health, alcohol misuse and school engagement.

There is also evidence that high quality school health services reduce the use of hospital A & E by students (Denny, 2014).

Wairarapa School health services

Schools serviced

There are school based services available to students at Makoura College, Kuranui College Wairarapa College, Rathkeale and St Matthews Collegiate. The Teen Parent Unit and Kura Kaupapa are serviced through the Makoura Health Clinic.

Chanel College and Solway College do not have a school based health clinic. Some initial discussions are in place with the Tu Ora Compass health and DHB to provide a service in 2020.

Presenting health issues

All school health professionals and students identified mental health as the most challenging health concern for youth. This includes but is not limited to, depression, anxiety, eating disorders, deliberate self-harm and abuse from others (physical, mental, sexual).

Sexual health followed closely behind as a concern for youth health.

Injuries and other general health issues such as skin issues e.g. eczema, infection, bites/stings, acne, weight loss/gain and respiratory-managing asthma and allergies (conditions associated with economic deprivation).

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Drug issues are mainly managed by the School Guidance Counsellor and referred to community services across the Wairarapa.

Privacy and confidentiality

All clinics have a self-referral system and operate a ‘drop in’ rather than appointments procedures.

Some schools have system where students must have teacher permission to leave class prior to attending the health clinic.

One school had concerns about the confidentiality of the record keeping and management as she is using the school data management system. School nurses usually use the medical centres’ patient management system which is secure. School nurses usually use a Patient Management System which is independent and secure, similar to the systems used by medical centres. However, notes can be shared with the local GP.

Cost

All schools have a free service to youth.

Funding

Funding for school clinics is based on the current Ministry of Health criteria administered by Tu Ora Compass Health and therefore is inequitable across the Wairarapa schools due to individual school decile ratings.

School based health services are funded by the Tu Ora Compass Health in 2 of 8 schools across the Wairarapa and includes the Teen Parent Unit and Kura Kaupapa. These are Makoura College and Kuranui College. Masterton Medical Centre and Featherston Medical Centre provide a GP to the two PHO funded schools. (Wairarapa College and Kuranui College)

Three additional colleges, Wairarapa College and St Matthews and Rathkeale College, provide their own nurse during school terms employed by the Boards of Trustees and Masterton medical centre respectively.

Medical supplies are funded through school Boards of Trustees, Medical Centres and Tu Ora Compass Health.

SIA (Services to improve access) This is specific funding for projects, programmes or a new service for targeted needs. Scripts are funded at school clinics. The pharmacy invoices Tu Ora Compass Health.

HEADSS assessments A percentage of funding is allocated by Tu Ora Compass for HEADSSS assessments for all year nines in two schools, the alternative education facilities across the Wairarapa and the Teen Parent Unit students.

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Service Access

All services are only available during school time and during the school term. One school nurse indicated she made home visits but rarely.

Most services are available part time ranging from two mornings to five days a week at a variety of times during the day.

Manaakitanga – Hospitality, Attitudes and Communication

All school health professionals demonstrated empathy and passion for young people. They talked about a positive, strengths based approach, the importance of rapport, taking time to get to know the student and caring about them. The author is deeply appreciative and in awe at their genuine commitment to the wellbeing of all Wairarapa youth.

Organisational kaupapa - way of doing things

HEADSSS assessments are a tool to understand adolescent behaviour, assess risk-taking behaviours and provide appropriate interventions. These are conducted with all year nines in two schools, the Teen Parent Unit and the Kura Kaupapa. They are long, complex and time consuming but provide important data that has the potential to assist schools and health services to understand and respond to collective needs. They also serve as a referral point for other health related services and provide the school and other services with important information about the students total wellbeing.

Consults can be as long as a young person needs and up to one hour in duration

Kotahitanga – Cross sector Collaboration and Collective decision making

All school nurses report excellent relationships with the school counsellor and school pastoral team.

Some schools have support from a GP and one has a psychiatrist available for case consults. Some schools have excellent support from the local medical practice but Wairarapa college has no support from any medical practice or GP.

Most report positive relationships with CAMHS although everyone was challenged by the long wait time for a referral.

Despite good intent there is only informal and sporadic networking or collegial support among school nurses and youth health professionals.

Professional training

Some Nurses have training in HEADSS assessments but not all

Individual health professionals have a variety of training in specific youth health issues such as sexual health, contraception, suicide prevention and management and self- harm but none are trained in holistic approaches to youth development or adolescent brain development.

Professionals are passionate, youth focussed and adopt positive strengths based approaches to youth health care.

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Youth participation

One school clinic has a student reference group twice a year as part of the school clinic contractual requirement. This is made up of representatives from all year levels and school personnel gaining feedback and suggestions for improvements in the service.

Individual School based health services

The following tables give an overview of the services that are available in the school health clinics.

Makoura College Health clinic

Presenting Mental health Health Family deprivation challenges Sexual health - contraception, StI’s, information, decision making Injuries in the winter due to sports Drug and alcohol comes through the GP not through the clinic Client base 737 consultations 243 individuals (DHB, July 2018 and June 2019) The clinic also services the Kura Kaupapa and the Teen Parent Unit. Funding Compass fund and provide a nurse 4 days a week during school hours and terms Compass fund a GP once a week who is employed by Masterton medical centre Hours 20 Hours a week during school hours and terms GP 4-5 hours per week Supporting A full time Guidance Counsellor is employed by the school Services A Youth GP from Masterton Medical provides individual consults to students and case management support to the nurse for between 4-5 hours per week Referrals are made to Family Works, CAMHS, psychologists, counsellors, Te Hauora, ‘To be heard’ nurses. Whaiora for smoke free, fitness, Family Start; South Wairarapa Community Trust for benefits and youth mentors Privacy and All students informed of confidentiality, unless concerns of safety then confidentiality someone is informed. All other information sharing is done with consent of student. Parents are not informed. All notes are recorded in Medtech a patient management system specifically for the school. The GP has access to Masterton medical centre Medtech patient management system to ensure continuous care. The nurse maintains close contact (phone and email) with Whaiora for shared students. For students enrolled in other medical centres there is either a conversation with nurse or email to students GP if they have been given permission. Referrals All year nines receive a HEADSS assessment during the year Students may self-refer for any reason. The guidance counsellor, Teachers and Whanau also refer students Location The clinic is based in a house separate to the rest of the school, housed alongside the School Guidance Counsellor Concerns HEADSSS is a great way to meet with students initially as they arrive at college. The HEADSSS framework is used as the base for all consultations.

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Although very useful HEADSS assessments are time consuming and referrals to other services is limited due to their limited capacity.

There is a gap in the service provision for dietary referrals for general wellbeing rather than severe illness.

Kuranui College Health clinic

Presenting Health Mental health - Students mostly present with a physical issue or challenges Environmental causes. Pressure with exams, fear overwhelm for the future

Sexual health - contraception, Sexually transmitted infections, information, decision making

Injuries in the winter due to sports

Drug and alcohol comes through the GC but also through the clinic

No smoking referrals of late

Skin issues- eczema, infection, bites/stings, acne; abuse-physical, mental, sexual; weight loss/gain; respiratory-managing asthma and allergies; (conditions associated with economic deprivation)

Client base 646 consultations

286 individuals

(DHB, July 2018 and June 2019)

Funding Compass health fund a nurse twice a week

Compass Health funds a Featherston Medical centre Doctor to attend once a week

A psychiatrist attends a clinicians meeting once a fortnight at his own cost

Cost No consultation cost to young people Scripts are paid for under SIA funding Students have to pay for specialists e.g. physio

Hours Two days a week during school hours

Supporting Services A full time Guidance counsellor is employed by the school and the nurse works closely with them

Referrals are made to GPs, Pathways, Family works, CAMHS, psychologists, counsellors, Te hauora, To be heard nurses, PIKI and Oranga Tamariki

Psychiatrist Dr Hill meets Dr Harsha Dias most fortnights as required for a clinicians meeting to triage and support the health team

referrals to GP practices for long term conditions

Privacy and There are some challenges with the waiting room mixed with the confidentiality Guidance counsellor.

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Results from the student reference group survey in 2019 indicate strong confidence in the privacy and confidentiality of the service.

During holidays if they need anything the nurse liaises with the medical centre or GP for a private referral. GPs at the local medical centres are constantly reminded not to send bills to student’s homes to ensure confidentiality

The Youth clinic GP sends patients notes to the local enrolled medical centre

Referrals Students refer themselves to the nurse or Guidance Counsellor or GP

Wherever possible the nurse triages student`s request for GP appointment as some do not need to see the GP to have their health issue addressed. Prior to school holidays of they need anything the nurse liaises with the medical centre or GP for a private referral

The nurse aims to see all year 9 students for a HEADSS assessment

Location On site in a private house separate to the rest of the school

Concerns As the school role has increased dramatically the service allocation has not, therefore demand exceeds capacity

HEADSS assessments are time consuming

The clinic has a student reference group twice a year as part of the school clinic contractual requirement. This is made up of representatives from all year levels and school personnel gaining feedback and suggestions for improvements.

Consultations and Individuals seen at Makoura and Kuranui college school based clinics (DHB, July 2018 and June 2019)

Consultations by Ethnicity Individuals Seen by Ethnicity 25 Asian, 10 Asian 550 European 232 European 564 Maori 192 Maori 67 Pacifica 30 Pacifica, 177 unknown 65 Unknown 1383 Total 529 Total

Consultations by gender Individuals by gender 1007 Female 331 Females 333 Male 182 Males

Consultations by age Reasons for visit 16 <12 137 Other 3 12 193 Sexual Health

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112 13 99 Accident/Injury 102 14 75 Dermatology 101 15 60 Mental Health 84 16 39 Respiratory 62 17 19 Chronic Care 28 18 28 Musculoskeletal 13 19+ 12 Ear, Nose, Throat (not injury) 11 Gastroenterology 11 Smoking 5 Sore Throat NOS 7 Opthalmological (not injury) 5 Gynaecological (not SH) 2 Neurology 1 Drug and Alcohol 1 Nutrition/weight management

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Wairarapa College health clinic

Presenting Mainly mental health – deliberate self-harm depression, anxiety, somatic Health issues challenges Sexual health – pregnancy tests and advice, contraception Injuries Family life challenges Students have poor health literacy and inconsistent help seeking behaviours Client base 2,333 consults in 2019. Some of these are repeat clients More females than male refer but there is a mix of ethnicities that refer Funding The Wairarapa College Board of Trustees employs and pays for a health clinic and nurse The nurse is ACC accredited so is able to claim for accepted referrals. The ACC claims help to support the service with medical supplies There is no external funding supporting this service Hours 5 days a week, during school terms between the hours of 8.45 – 3.15. The nurse does make home visits outside of these hours on occasion. The nurse has 40 minute appointments regularly. During holidays and weekends there is no school service. Supporting The health clinic compliments the full time Guidance Counsellor, the Services internal school Deans and guidance systems. There are good relationships with the guidance system The school has a contract with the local Physio who provides a clinic on Tuesday morning for a discounted fee to students. The nurse has a close relationship with a local pharmacy The nurse makes referrals to and consults with Changeability, STOP, Youth Kinex GP and ‘To be heard’ counsellors and CAMHs, The nurse has worked with Hutt hospital on long term chronic illness management. Privacy and All patient notes are filed in the school system KAMAR. There are concerns confidentiality about confidentiality of this information as KAMR is accessed by school staff. There is no exchange of patient notes with the patients local GP Students have to be released from class by a teacher to attend the clinic Referrals Students can drop in at any time during the school day They have to be released from class and most teachers support this to occur when requested The nurse follows up with regular check ins. Location The clinic is on site, not too close to classrooms, easily accessible Challenges Despite a strong need and various requests there is no GP service or support to the school There is sometimes some teacher reluctance to release students for a consult The nurse is isolated from other youth health expertise and professional network support

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Rathkeale College and St Matthews Collegiate

Presenting A broad range of issues are presented e.g. sexual health, boys with youth Health wounds infections, general colds, 1 mental health challenges Most mental health issues are managed by the Guidance Counsellor Client base Students from both Rathkeale and St Matthews. As this is a new service no statistics have been collated on gender, ethnicity or need in 2019 The nurse indicates that there are approximately 6 students per day but comments it is “only a new service" Funding The Trinity Schools Board fund Masterton Medical centre to supply a nurse for nine hours per week Masterton Medical provide a GP once a week. Casual patients are funded through the ‘claw back’ from the enrolled Medical Centre Hours The service started in August 2019 Rathkeale Monday and Friday 10.30 - 1.30 St Matthews Wednesday 1030 - 1.30 3hrs Supporting There is some case management sharing with the local GP at the youth Services clinic and there is a visiting GP attending the clinic once a week. Referrals to local GPs are made as required. Privacy and A request by one school to have names shared with the school has confidentiality been refused due to patient privacy constraints The nurse is able to access the Masterton Medical Medtech system for patients enrolled there but creates separate files for those who are not. Referrals Appointments are made through the office where a student gets sent a permission slip with ‘internal appointment’ on it. They are sent from the office to the clinic. Students can refer themselves but need permission to exit the class from the teacher. School vans are available for referrals to other services The nurse is able to provide photo evidence to Masterton medical centre for prescriptions and advice Medtech system ensures information is shared with the students local GP Location The clinic is situated in a private space in the school with access to a toilet and water and a separate entry and exit Challenges This is new service. Information has been shared with community in newsletters and student assemblies about the service but it is word of mouth that works best. Some parents expressed concern about the need to know if their children were attending the clinic. They were concerned about terminations. Education on the ‘Privacy Act’ and processes for referrals has alleviated this somewhat. Youth specific Training and implementation of HEADSS assessments are planned for training 2020 Training in specific health issues such as mental health and contraception has been competed No specific training in ‘youth’ development The nurse receives informal mentoring form the GP at the local health clinic

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Youth One Stop Shops

A number of community youth health organisations have been established in New Zealand over the past 15 years. These have been set up by passionate and motivated health professionals in response to a need for healthcare specifically targeted at New Zealand youth. Youth specific services have evolved in response to local demand as well as to opportunities for growth, supported by relationships with funders and other providers. As such each service has developed independently in its own setting although they are united by a common goal is to promote access to healthcare and social services for youth.

The population serviced by Youth One Stop Shops is aged predominantly between 10 and 25 years.

Approximately 137,000 occasions of service were provided in the previous year. (MOH, 2009)

The Youth One Stop Shops all receive significant proportions of their funding directly from the District Health Boards or through Primary Health Organisations that are themselves funded by the DHBs. Additional funding is provided through a multitude of other sources, ranging from private donors and City Councils to the Ministries of Social and Youth Development.

Youth One Stop Shops provide access to a range of services in youth-friendly settings, including health, social, education and/or employment services with the ability to refer to secondary or tertiary services as required. They employ Doctors, Nurses, Social Workers, Facilitators, Counsellors, Youth workers, Community Health Workers, Mentoring, Peer support, Clinical Psychologists, Therapeutic Group Facilitators and Youth Workers.

Some Youth One Stop Shops offer outreach, mobile and satellite services and/or evening clinics to increase access opportunities for young people.

Services are available at little or no cost to clients, are centrally located and provide a safe and welcoming environment. In some cases, transportation to assist access is provided.

Consideration is given to the young person’s needs in the wider context of their family and community/whanau, hapu and iwi. Services wrap around the client to ensure their individual needs are addressed in a seamless and coordinated way.

Services are delivered in a manner that is non-judgmental, culturally appropriate and respectful to young people. This promotes trust and the perception of confidentiality and safety for youth.

Services are holistic and strengths-based, focused on improving health and wellbeing and encourage long-term independence.

The integrated and youth-specific model of care attracts young people, particularly those who have higher need.

The top reasons young people use Youth One Stop Shops relate to cost, service flexibility and confidentiality, convenient location and perceptions of non-judgment, welcoming and safe staff who know about youth related issues.

Comprehensive, longitudinal health status measurement is complex and not routinely undertaken by any of the Youth One Stop Shops. Health measures are debated by the sector and there is no consensus on the best method for evaluating effectiveness. Measures of determinants of health are often used as proxy measure to reflect health status. Despite this

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lack of available evidence managers are strongly of the belief that their services are effective in improving the health and wellbeing of their clients. 89% of stakeholders surveyed and 94% of clients surveyed agreed.

Youth One Stop Shops in New Zealand.

Whangarei Youth Space Whangarei Rotovegas Rotorua Anamata Café for Youth Health Taupo Youth Services Trust Whanganui Directions Youth Health Centre Hastings and Napier Youth One Stop Shop Palmerston North Kapiti Youth Support Kapiti Coast Vibe Lower Hutt and Upper Hutt Evolve Wellington Korowai Youth Well-being Trust (298) Christchurch Youth Hub Trust Te Hurihanga o Rangatahi Christchurch Number 10 Invercargill

Youth Kinex Masterton

Youth Kinex was opened in May 2014 by Masterton Medical Centre in partnership with Compass Health and Connecting Communities. The idea behind this was to create a youth hub in a central location where youth specific services could be delivered. The purpose was to alleviate some of the barriers young people encounter when accessing healthcare, to provide timely, free and appropriate care in a confidential youth friendly environment. Currently this service is still emerging and has potential to grow into a fully integrated community youth hub.

Enrolments

The service is available for youth aged between 13 and 23 years old.

Total no of consultations (April 2018 - March 2019) 2170

Enrolments in other medical practices throughout the Wairarapa (a sample over a two month period 3/10/19- 28/11/19) 229 MML 8 Whaiora 7 Kuripuni 11 Carterton 6 Greytown 4 Feathy 3 Martinborough 10 other

Consultations by Ethnicity (April 2018 - March 2019) 1382 NZ European

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134 Other European 548 Maori, 49 Pacifica

Consultations by gender (April 2018 - March 2019) 1960 Female 210 Male

Consultations by age (April 2018 - March 2019) 13 22 14 39 15 105 16 191 17 257 18 382 19 337 20 293 21 272 22 169 23 70 24 26 24 + 7

Presenting youth health issues (Masterton Medical April 2018 - March 2019)

The predominant presenting issues relate to mental and sexual health although there are a large range of health issues seen at the clinic. The following is a breakdown of consults over a year.

819 GP visit (not specified) 0 Drugs and alcohol 330 GP mental health 102 Nurse consult (not specified) 431 GP sexual health 488 Nurse sexual health 0 Stop smoking

Privacy and confidentiality

The environment

The clinic has a small waiting room right off the front door. Despite music playing there is no privacy for anyone waiting.

Consult rooms are very close together and voices can be heard from both consult rooms.

The toilet is through the waiting room so everyone will see a person having to use it during a consult.

There is only one entry and exit to the building. One exit through the nurse’s consult room can be used if a Young person does not want to be seen exiting through the waiting room.

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Enrolment

All young people are required to complete an enrolment form as a casual patient where they are asked to provide details of their enrolled GP. The GP can then be informed of relevant information about the patient’s care. There is also an opportunity to refuse to share information with their GP. Many young people do not submit their GPs details and refuse permission to share information outside of the clinic.

Consult

The GP ensures the young person is aware of codes of confidentiality around sharing information and risk management.

Cost

There is no cost to young people for attending the clinic.

The clinic is away from the main centre of town but walking distance from most Masterton schools thus cost of travel is minimised.

Funding

Masterton Medical provide 6 hours GP plus nurse plus admin time per week including equipment and resources.

Tu Ora Compass Health PHO funds a mental health nurse 1 day per week offering up to 6 booked appointments. The nurse delivers the PIKI programme (expanded on later in the report).

Tu Ora Compass Health fund rental, and administration costs of the building.

Connecting communities manage the contract. This agreement is in place until 31st December 2019.

The clawback system is used to claim from young peoples enrolled medical centres if they present at the youth clinic, however some young people do not complete a casual enrolment form indicating their GP practice therefore the Youth Kinex cannot clawback from their GP.

Service access

The clinic is open 2 afternoons a week. Monday & Thursday from 2 - 5pm. The clinics operates on a drop in clinic. Wait times can be very long (up to 90 minutes). There is frequently insufficient time for all patients who wish to receive a health service. Demand exceeds supply.

Manaakitanga – Hospitality, Attitudes and Communication

The environment

The waiting room is bright, casual and full of colour. The music is youthful. The interior was designed and painted by the youth council.

There are a range of chairs and couches and beanbags to sit on.

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There a range of youth friendly posters and pamphlets around the room.

The consult

The GP takes the time the patient need to listen and respond accordingly. They use a strengths based, positive approach to all assessment and intervention.

Organisational kaupapa - way of doing things

Consults are up to 40 minutes long for a client as the GP takes time to understand and assess their health needs.

The GP uses the HEADSSS framework to understand the issues but does not have the time to conduct formal assessments.

Kotahitanga – Cross sector Collaboration and Collective decision making

Referrals can be made to Changeability CAMHS, specialist services, laboratory, Work and Income.

There is a need for social worker

The current Medtech patient management system used by most medical centres across the Wairarapa does not integrate, thus sharing case information with the patients enrolled GPs is difficult.

Professional Training

The GP is well experienced in all aspects of youth health.

Other services supporting youth health

The following is a list of organisations and services that provide youth health care across the Wairarapa. It is not an exhaustive list and the author apologises if they have missed any service.

Child, Adolescent and Family Mental Health Service (CAMHS)

Service The service provides mental health information, assessment, treatment and support options for children/Tamariki and young people /Rangatahi considered to have moderate to severe emotional, behavioural, and mental health issues. Location Masterton Referrals Appointments can be either at the CAMHS base or at an arranged meeting place in the community. Referrals may be made directly to CAMHS service by young people and their families Young people may be seen on their own or with their whanau/family. Age 0 – 19 yrs and their whanau/ families Cost Free 41 MLMckenzie Wairarapa youth health services DHB & Tu Ora Compass December 2019

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Piki

Service Piki’s vision is to enhance young people’s quality of life by equipping them with tools to overcome adversity and strengthen their wellbeing. It provides therapy and support options with a trained Mental Health Therapist, An emotional wellbeing app that helps keep youth progress on track Links to 24/7 support through phone and web services Peer support options Location Greater Wellington region. Age 18-25 years’ old Referral Self-referrals can be made directly through the Piki website. Youth can also be referred by a GP, other health providers and other agencies Cost No fees apply.

To be heard counselling

Service The aim is to improve access to health and social services to support mental wellbeing Location Counsellors across the Wairarapa Age All young people aged 12 to 25 years Community Services Card holders aged 25 years and over Māori 12 years and above Pacific Island people 12 years and above Referral The service can be accessed if a young person is enrolled or intends to enrol with a Compass Health doctor/practice, if they are experiencing a mild to moderate mental health issue Contact can be made through the family doctor, the Coordinator in the area directly, or through a community agency. Cost Free

Changeability (formerly Stopping Violence Services)

Service Services and programmes to empower individuals and families affected by violence and abuse to make positive changes and build respectful and trusting relationships. Location Masterton

Counselling Service Family Works Wairarapa 42 MLMckenzie Wairarapa youth health services DHB & Tu Ora Compass December 2019

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Service Family Works offers a range of counselling support for children/Tamariki, young people/Rangatahi and families and whanau who are facing complex challenges. Location Featherston

Skylight Trust Grief Counselling

Service Support for children, young people, families and adults who are experiencing a wide range of grief and loss: including family break-up, bereavement, bereavement through suicide, family member with a chronic illness, children with anger/anxiety/bullying issues, and any major life change involving loss.

Multi systemic therapy

Service MST is a community based programme to help families manage very challenging behaviours such as truancy, drug use, anti-social behaviour and offending. MST provides a therapist who works with the family and whānau for 2-5 months, meeting at least 2-3 days per week to support rapid progress towards changing behaviours. MST focuses on family and whānau goals, working in collaboration with the family whānau and ensures someone from the team is available 24 hours a day, 7 days a week for advice/support.

Te Hauora Runanga o Wairarapa

Service A community support service for Māori Health in the Wairarapa region. It grew from initiatives developed by Māori Health workers seeking to establish a more focussed approach to the delivery of Community health services. The service delivers Alcohol and Drug Counselling, Mental Health Support Services and Rongoa/Mirimiri Services, Rongoā, kuia and koroua service, Family Safety Team, Oranga Tamariki contracts, Kuia and koroua programmes, Detox, Peer support life skills, Parenting, Violence Free programmes, Youth justice wrap around, Smashed and Stoned Workshops and Te Mana to te Taiohi Groups. They are a Kaupapa Maori service delivering to all ethnicities. They work on a Whānau Ora model using Te Aka Matua model. Location Masterton Age All

King Street Artworks

Service A creative space for people who use, or have used mental health services and for their whanau and friends and for the whole community.

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Service Connecting Communities Wairarapa co-ordinate community based activities that enable community resilience and social well-being. The Council also supports projects that involve community and agency co-operation in environmental and other projects that will lead to greater individual and community wellbeing. Youth council: The Wairarapa Youth Council is made up of a group of young people who meet fortnightly to discuss and address youth related topics such as things to do, places to go, employment opportunities, training programmes, and anything else that relates to the Wairarapa and its young people. Youth café project Leadership camp East side Wairua programme: via schools who have referred Te Awhina youth group: 12-24 live in Mstn East, no membership, just turn up Financial capability Money mates programme Location Masterton

Featherston Community Centre

Service A community facility owned by the people of Featherston. They offer classes, activities and events for all ages as well as a warm and welcoming space for groups to meet.

Wairarapa Whanau Trust

Wairarapa Whanau Trust’s purpose is to coordinate social services in the Wairarapa region, allowing a more coordinated approach to community engagement, development and care, with specific focus on youth (12-24yrs).

The Trust aims to break down barriers to success for youth in the Wairarapa, and to build positive bridges with the community. This is achieved by providing youth with a safe place to belong, where they can learn new skills, and work with mentors from within the community.

Southern Wairarapa Safer Community Council

Service Holds the contracts for: Attendance, Life to the Max, Big Brother Big Sister, Safer Wairarapa, Youth Services and Alternative Education. It aims to get young people into education, training or work-based learning. Young people work with community-based providers who give guidance, support and encouragement to help them find the education, training or work-based learning that works. Youth Service offers guidance and practical support to young people.

Rangatahi to Rangatira

Service R2R is run by a group of Carterton’s young people, with support from Hurunui-o-Rangi Marae, Carterton District Council, and Wairarapa Safer Community Trust.

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R2R is a youth project that develops and encourages young people in Carterton to be involved in the community, be more aware of political, social, and environmental changes that are happening, and how to change the things they want Tuia Leadership Programme: Tuia is an intentional, long term, inter-generational approach to develop and enhance the way in which Rangatahi Māori (Māori young people) contribute to communities throughout New Zealand. Location Carterton Age Young people aged between 12 and 24 Online support Safer Teen Drivers You can help improve safety in Teenage Driving. A toolkit for parents of teen drivers Gambling Helpline – Youth Youth Gambling Helpline has younger counsellors who can help you talk through any challenges you may be having with your own or someone else's gambling. The Lowdown 24/7 email, text and online support for young people with depression or anxiety. SPARX Online tool for young people with mild to moderate depression. What's Up Youthline Youth helpline, counselling, support and youth development services. Just the Facts Website A new online resource of sexual health information designed with young people in mind. Just a Thought offers evidence-based Cognitive Behavioural Therapy (CBT) online and is designed for people with mild-to-moderate symptoms of anxiety and depression.

Factors impacting the effective delivery of health services for youth.

“Young people need a health service that is available at the right time, in the right place, and delivered by the right people. This will provide equity for young people to access services necessary for them to lead healthy lives” (Health professional.)

The following factors have been identified in the literature as vital to the effective provision of youth health services. A thematic analysis of Interviews and focus groups from the Wairarapa youth and health professionals provide voice to support these themes.

1. Privacy and confidentiality 2. Cost and funding 3. Access 4. Manaakitanga – Hospitality, Attitudes and Communication. 5. Organisational kaupapa - way of doing things 6. Youth health literacy 7. Kotahitanga – Cross sector Collaboration and Collective decision making 8. Professional training

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1. Privacy and confidentiality

Numerous studies have identified privacy and confidentiality as a major factor in young people’s health care. Adolescents who forgo health care due to confidentiality concerns are more likely to experience psychological distress, high rates of risk behaviours, and parent– teen communication issues (Denny, 2013).

Young people expressed concerns about GPs disclosing information to their parents and reception staff not protecting confidentiality.

28.2% New Zealand youth participants in the Youth 07 surveys were worried their care wouldn’t be kept private (Adolescent research group, 2008).

Among New Zealand students who had accessed health care, only 27% reported receiving private and confidential care (Denny, 2013).

Wairarapa health professionals reported that the medical centre billing structure and family enrolment scheme caused challenges to a young persons need for privacy.

“As many of the youth are part of a family enrolment, the parents get billed, so they will be aware of the appointment” (Health professional).

A small community creates further challenges to the privacy of young people.

“The Wairarapa has a small population living in small towns where there is a sense that everybody knows everybody else’s business. Masterton has three medical centres but the other towns only have one which means there is limited choice. Young people get very concerned about being seen and talked about (Health professional).

“Youth don’t want to come to a family medical centre where their neighbour or Aunty is sitting next to them in the waiting room making it awkward” (Health professional.

Young people were worried that their parents and whanau and their peers would judge them and know what they were doing.

“Kids are ruthless. If someone sees you going into the clinic they will take the piss out of you’ (Young person).

“Privacy is an issue. They see you and think you’re are just going there for condoms” (Young person).)

“You always see lots of people you know. This is a small town!” (Young person).

Health professionals reported that patients right to privacy created conflict for the delivery of consistent care for young people. They stressed the importance of sharing information across health services to enable consistency of care throughout the life course of a young person. They expressed concern about not getting information about consults from other services.

“We don’t get any notes for patients seen at the Youth clinic. How are we supposed to deal with them when they turn up to us and we don’t know what has happened to them” (Health professional).

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2. Cost of the service

Cost is one of the more common reasons for not accessing health care when needed. Most young people are students without income or on a low income. There are significant cost barriers for adolescents accessing health care from GPs and medical centres. Young people believe they cannot access a GP without payment and are unaware they are able to access services such as the youth clinic for free. They were also unaware of initiatives such as the free sexual health care.

14% of Rangatahi interviewed by the Wairarapa Safer community council indicated the cost was too high to go to a GP at a medical centre (WSCT, 2015).

“It’s expensive and you usually have to get your parents to pay and then they have to know about it” (young person referring to the cost of attending a medical centre).

“It’s expensive to go the medical centre. I have overdue bills and I am just not going back ‘cause I can’t pay them” (Young person).

In contrast to this the following comment sums up the difference between medical centres and school and the community youth clinic.

“It’s free and that is huge!” (Young person referring to the Youth clinic).

The cost of travel

Travel to and from a health service is also a significant contributor to the cost. When identifying barriers to young people accessing and receiving services, physical location, the rural factor, and transport constraints were most commonly identified.

10% of Rangatahi interviewed by the Wairarapa Safer community council had no transport (WSCT, 2016, Waldegrave, 2015).

The location of the service is paramount to young people and the subsequent cost of their care.

“We are a large geographical region but many of the services are based in Masterton. For some people this means travelling up to two hours to attend a service. Many young people have to rely on someone else for transport” (Health professional).

“It’s walkable from school. Not too central so everyone sees you” (Young person referring to Youth Kinex).

Sector funding and Enrolments

The way an organisation is funded can be an important factor for effective health service provision. Current health-related funding streams are decided on by the Ministry of Health and administered by the DHBs. The New Zealand primary care PHO/GP model of care expects an individual to enrol with a single health professional and then use this health professional for the majority of their primary care.

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Youth utilise health services in different ways from other sections of the population. Youth often choose to access services from a number of different Health professionals depending on the type of care required, personal preference, geographical access and convenience. Youth are sometimes transient and they often prefer to use different health professionals from their family for health issues which they feel are sensitive. Youth like to access care independently yet are often restricted by their transport options.

Any funding model needs to promote a holistic, population health approach to primary care and account for their “grazing” and the need for multiple services in the one place often required by youth.

The cost of a free service

Organisations in the Wairarapa identified funding restrictions as a key area which was not working well. Funding issues were identified as creating uncertainty and tensions between health professionals.

“A GP practice is a business and the onus should not be on them to pay for youth services. We need funding to run a Youth Health Clinic where a GP gets paid for the time regardless of how many patients come in. You cannot run a youth clinic out of the goodness of your heart” (Health professional).

Some organisations discussed the unfair targeting of funding, and the negative impacts of competition for funding on their core work. (Waldegrave, 2015) One Health professional expressed concern that patients were being taken away from their practice as a result of the ‘free’ youth clinic.

“Previously the youth did come to the Medical centre but now they go to Youth Kinex because it is free. There was never an issue before” (Health professional).

The cost of being ‘casual’

They also highlighted the increased cost to the young person when they became a casual patient at their family clinic as a result of attending another clinic.

“It is a problem. There needs to be openness where a non-enrolled patient can just turn up anywhere and not get charged the casual fee” (Health professional).

“A young woman who attended the centre with her mother found she was no longer enrolled at this clinic and subsequently would have been charged the higher rate as a casual patient. She did not want to inform her mother she had been to the Youth clinic. It put me in a very difficult position” (Health professional).

One solution cited by a health professional working in a medical centre was to run free youth clinics from their own practice using the free sexual health funding available.

“Every medical centre should run a free youth clinic once a week” (Health professional).

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GP’s have also cited problems with inadequate remuneration for longer consultations required for young people (Collaborative Trust, 2011).

Young people identified problems with some of the organisations that were funded to help them referring to changing staff, changing appointment times and not being able to get hold of staff when they felt they needed them. This was mirrored by Health professionals who felt services were often over-stretched, inadequately funded and under-paid (WSCT 2016).

3. Service Access.

Adolescents, by nature of their brain development, are impulsive. As the prefrontal cortex matures and the pathways between the prefrontal cortex and the limbic system becomes more efficient, they become better at reasoning, thinking logically, planning, solving problems and making good decisions. They need a lot of guidance from adults as they learn these skills. Having an immediate health service available where they can ‘drop in’ is an important biologically respectful factor in accessing health care. Appointment times and availability of the service were consistently cited as challenges to accessing a health service. Clinic opening hours and long waiting times can lead young people to forgo much needed health care.

“The current enrolment rules disadvantage youth as they are often transient e.g. move to University, travel, visit more convenient practices and then get de enrolled at their family practice” (Health professional).

Appointments

Young people had difficulty knowing how to contact, when to contact and who to contact with regards to health care. Wairarapa Rangatahi interviewed by the Wairarapa Safer community council (WSCT 2016) reported they were:

“unable to get in contact with the health professional” (11%)

“were unable to access health care when required” (27%)

“there was no suitable appointment time.”

“It takes ages and I just can’t be bothered waiting” (Young person).

Service availability

Varied opening times and service availability were a barrier to young peoples’ health care.

“It’s only open on this day and this day at this time. I can’t remember and its always too late when I do” (Young person).

“We need more school clinics. They are there all the time and easy to get to” (Young person).

One young person talked about the impact of a limited service in her school.

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Our school nurse is a ‘woman of mystery’. I have never seen her. We were all told she would be meeting with us individually for an assessment but it never happened. I am still waiting” (Young person).

Wairarapa health professionals supported this concern

“Services are open for short periods or restricted to certain days. As a drop-in clinic there is uncertainty to how long a visit will take. This makes it even more challenging to attend a service, particularly if travelling long distances” (Health professional).

‘Drop in’ service

One medical centre had begun an informal policy of allowing any young person who came to the clinic to be seen by a nurse immediately if possible.

School based health clinics and the youth health service have a ‘drop in’ policy where young people can present at any time the clinic is open and do not have to make an appointment.

“We are readily available to them. They are not forgotten” (School based Health professional).

“You can’t just pop into the medical centre like you can at Youth Kinex” (young person).

4. Manaakitanga

The concept of manaakitanga includes values of hospitality, kindness, generosity, integrity, trust and sincerity, support, showing respect, generosity and care for others. These are essential factors to young peoples’ health care.

Manaakitanga includes the way a young person is greeted when they arrive and the acknowledgement of who and where they come from. Young people’s lasting impression of a health professional is often determined when they walk in the door. The clinic environment can have a negative impact on the utilisation of the service.

Manaakitanga involves caring for young people as culturally located human beings through providing safe, nurturing environments. A health professional has an immediate responsibility and authority to care for the young person’s emotional, spiritual, physical and mental wellbeing.

Service provider communication

The health professional’s communication style and approach has a significant impact on the young person’s level of comfort and ease of communication when seeking health care.

Young people’s consistent articulation was for listening, support, non-judgemental attitudes and practical help from a health professional. They have reported concerns that health professionals have unsympathetic, authoritarian and judgemental attitudes towards them (Collaborative trust, 2011).

All youth participants in the Wairarapa social sector trials referred to the importance of being treated fairly and given respect, being consistent and patient, non-judgemental, and honest, showing youth they cared about them and listening to youth voice (Waldegrave 2015). 50 MLMckenzie Wairarapa youth health services DHB & Tu Ora Compass December 2019

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The young people called for an improvement in attitudinal approaches to them. They reported experiencing assumptions, judgements, being spoken down to and at times, a lack of respect. They wanted health professionals to be more honest and real. They certainly wanted to work on solutions but they needed to feel comfortable, accepted and respected first (WSCT 2016).

Young people report that the youth clinic ‘Youth Kinex’ and school based services provide a safe, friendly environment encompassing all the tenants of manaakitanga.

“There is no judgement – It’s just for youth. No one looks down at you. Everyone is the same as you” (Young person).

“I love the sense of welcoming. The wait is long but worth it” (Young person).

“The Doctor at Youth Kinex seems nicer. She is not so scary” (Young person).

“The staff were extremely helpful considering that I came in off the street. I cannot speak highly enough about them” (Young person writing on Facebook).

The waiting room

Young people are intimidated by a formal clinic and waiting room environment, appointment and booking procedures.

“You walk into the Doctors and feel intimidated “(Young person).

“The waiting room is scary” (Young person).

“The waiting room is so open and there’s no privacy” (Young person).

“The waiting room is boring. The music is shit and the magazines are ancient. The TV plays old peoples stuff. Why can’t we have a space for us? They do it for little kids” (Young person).

“Paint it so it doesn’t look so clinical. It feels so clinical. Its ugly and boring” (Young person referring to the medical centre).

“It looks like you are there to die when you walk in!” (Young person).

Reception

Young people referred to their initial reception as a significant factor when accessing a health service. Many talked about the environment in their local medical centre.

“There was an old lady there at the counter and she was really rude to me” (Young person).

10% of young people interviewed for Wairarapa safer community council indicated the Staff at the medical centres were ‘unfriendly’ and the Rangatahi were made to ‘feel uncomfortable’ (WSCT, 2016).

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One health professional talked about the need for a youth focussed space in their local medical centre.

“It would not be too hard to make a youth focused private waiting area just like they do for young children. I’ve seen it work elsewhere and it made a significant difference e.g. USB ports, music, paintings and art work (health professional).

Health professionals in school based health services discussed the importance of relationship and the need to provide a positive, friendly service.

“Greeting is important. We must be friendly and have a laugh. They need to feel like they are not a patient and that we are just having a conversation. It’s important to get the rapport, not be rushed” (School based Health professional).

" You have to build rapport. They won’t just bowl in. I have list of regulars. I know their names. They are on my radar and I always follow up. I often give them a hug" (School based Health professional).

5. Organisational Kaupapa

The kaupapa, theory and ideology of a youth health service should embrace youth-focused, youth-centred and strengths-based practice. These should be integrated into all areas and levels of the organisation, and drive all decision making and interaction with young people.

Youth friendly

Consulting with young people requires understanding of the unique emotional, psychological and cognitive changes in adolescence, effective engagement and a culturally responsive approach.

Some of the youth comments illustrate this concept

“At Youth Kinex they are more targeted to me. They come up with long term solutions not just your quick fix” (young person).

“Youth Kinex is more teenage based” (young person).

Assessments

“A psychosocial assessment of their functioning is at least as important as the physical exam” (Goldenring, 2004 cited in Collaborative trust, 2011).

Assessments that are holistic and strengths-based, focused on improving health and wellbeing and encourage long-term independence are required for young people.

Young people interviewed in the social sector trials recognised that they needed help to move forward on with their real issues. They considered helpers should get to know them before assuming a negative outlook. They wanted encouragement for positive change rather than continually going back over their past (Waldegrave, 2015).

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“I want to have a Doctor that really gets me and gets the problem sorted” (Young person).

A holistic view of health

A holistic approach to health considers the whole person and how he or she interacts with his or her environment and emphasises the connection of mind, body, and spirit.

Te Whare Tapa Whā is a well-known Māori model of holistic health. Te Whare Tapa Whā compares health to the four walls of a house where all four walls are necessary to ensure strength and symmetry (Durie, 1984). Te Whare Tapa Whā can be applied to any health issue (physical, spiritual, psychological or connections with family).

Looking after all aspects of wellbeing, Te Whare Tapa Whā consists of taha wairua(spiritual), taha hinengaro (mental and emotional), taha tinana(physical) and taha whānau(family) considerations. Together, all four are necessary and in balance, represent ‘best health’. Each taha is also intertwined with the other. Accordingly, if any one of these components is deficient this will negatively impact on a person’s health (Durie & Kingi, 1997).

One school based Health professional summed up a holistic approach

"I am not just a nurse dealing with injuries. I'm dealing with the whole person. I work holistically. You can’t just fix one thing. There is a whole picture that you have to put together to come to some solution" (School based Health professional).

Culturally appropriate service

When consideration is given to the young person’s needs in the wider context of their family and community/whanau, hapu and iwi and services wrap around the client to ensure their individual needs are addressed in a seamless and coordinated way, young people are more likely to utilise health services

Whakawhanaungatanga is the process of establishing links, making connections and relating to the people one meets by identifying in culturally appropriate ways, whakapapa linkages, past heritages, points of engagement, or other relationships. It embodies the centrality of extended family-like relationships and the “rights and responsibilities, commitments and obligations, and supports that are fundamental to the collective. Within this type of relationship, a young person is likely to engage and receive more effective treatment.

Health professionals talked about the need for their staff to reflect their patient population in gender, ethnicity and age. One talked about their organisations equity policy of employment and the difference that had made in their practice.

“We employed a young Maori girl who had just left school. It was bit of a risk as she did not have much experience but the way she communicated with the young people coming in made a significant difference to the practice. It was amazing!” (Health professional).

“Most people working with youth health in the Wairarapa are white female. We need a better gender balance to encourage male attendance as well as better Maori representation” (Health professional).

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6. Youth Health literacy

"The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make informed and appropriate health decisions is essential” (Healthy People, 2010).

Health literacy also includes the capacity of professionals and institutions to communicate effectively so that young people can make informed decisions and take appropriate actions to protect and promote their health.

Poor health literacy is very common. Over 50% of the adult NZ population are likely to have some difficulties with health literacy and they are:

· Less likely to use preventative services · Less likely to recognise the first signs of medical problems · Less likely to effectively manage their long-term condition · Less likely to communicate concerns to health professionals · More likely to be hospitalised due to a chronic condition · More likely to use emergency services · More vulnerable to workplace injury

Limited knowledge of what is available

It is evident that young people have limited health literacy or knowledge of services available.

26% of Wairarapa Rangatahi interviewed by the Wairarapa Safer Community council “didn’t know where to go” (WSCT, 2016).

27% said they “didn’t really know how to access services if needed” (WSCT 2016).

It was astounding to discover that none of the youth who had left school (18-24-year-old Work and Income clients’) knew anything about the Youth clinic or that they could get any free health care from a medical centre.

The level of youth knowledge about services available was identified by several health professionals as a barrier to them knowing about and therefore accessing the services in the first place (Waldegrave, 2015).

"There are challenges in communicating what we can do and how we do it. We need to get young people to understand and know about the service” (Health professional).

“Youth and whanau have little awareness and knowledge of the range of services available to them” (Health professional).

One school based clinic developed and disseminated a school leaver package of information on available health services and enrolment procedures for local medical centres. One medical centre also distributed a ‘summer survival’ pack for the youth clinic to ensure young people had information on what support is available to them.

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Attitude towards health care

Some young people indicated their own attitudes and knowledge of health issues were a barrier. Wairarapa Rangatahi interviewed by the Wairarapa Safer community stated they did not receive health care because they hoped “the problem would go away or get better” (49%).

“Some might not bother to get help ‘cause they are lazy. They think “She’ll be right. It’ll be fine. Let it pass by” (Young person).

90% of the youth interviewed by the Wairarapa Whanau Trust indicated they would not seek help due to their own feelings about shame particularly in relation to mental health issues.

A study that was part of the World Mental Health International College Student (WMH-ICS) found the most important barrier was preference to handle the problem alone (rated as “important” or “very important” by 56.4%), being too embarrassed to seek help (32.2%) (Duncanson, 2019).

Attitude towards health professionals

A number of young people indicated a specific attitude towards ‘Doctors’. They thought Doctors were only for ‘serious health issues’. Interestingly they did not see sexual health and mental health issues such as suicidality or depression as ‘serious’.

“I just want advice. It’s often not serious enough to go and pay for a Doctor. They are over qualified for what I need. Doctors are for serious things” (Young person).

“Mostly I think what I have is not good enough to go to a Doctor” (Young person).

Young people were intimidated by the medical language health professionals used

“They just talk in medical terms. I don’t understand the technical stuff they say. I just wish they would talk to us normally” (Young person).

“They have to make it palatable, not dumb it down but use language we understand” (Young person).

Some talked about a fear of Doctors

“Doctors are terrifying” (Young person).

Some were concerned about the treatment they would be advised

“I don’t want to go on any pills and that’s all they do” (Young person).

“They do a shit job and I just got put off. They didn’t even look at me and they didn’t see there was an issue” (Young person).

One young man with a long term health condition talked about finding a Doctor who really cared.

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“I got the best service I have ever had. He stopped looking at my notes and what every other Doctor had said. He researched more looking at the issue and talking with me. He really understood me and the underlying problem” (Young person).

Family influences

Family or parental constraints are a factor for some youth accessing services, and this is particularly so for services that require parental consent and a young person was unwilling to ask for this consent. Old fashioned, unhealthy, or entrenched attitudes, could be barriers to young people accessing services. Examples of this are attitudes towards teen pregnancy, and the social stigma associated with accessing mental health services. One health professional talked about the challenges of establishing a new clinic and the resistance from the parent community.

“The expectations of parents around confidentiality indicates they don’t get it. We need the ability to provide an environment that encourages privacy” (School based health professional).

“You get drilled into your head as a child that if you aren’t bleeding or dying you don’t go to a Doctor” (Young person).

There were clear concerns about not wanting to be judged, not wanting parents to know what they were up to and not wanting to hurt or embarrass them. There were also concerns that family/whānau could make things worse instead of supporting them (Waldegrave 2015).

Peer pressure, in particular negative peer attitudes about accessing health services including mental or sexual health support could also be barrier to youth accessing services. Others commented that parents were supportive

“My friends don’t influence me and my Mum knows I go ther.” (Young person referring to Youth Kinex).

Social influences such as economic deprivation also played a role in health care.

“The biggest challenge we have is that we have many young people surviving in difficult living situations. Increasing numbers of broken families; poverty, parents on drugs, parents on alcohol, death of parent from illness, accidents or suicide, young people with no fixed abode due to home situations, violence, gangs.... It’s overwhelming and there are minimal services to refer to, to address these needs. “(Health professional)

7. Kotahitanga- collective decision making

He whanau ko tahi tatau - We are all one family.

Kotahitanga involves collective decision making, collective action and solidarity, unity and togetherness. To address the growing number of issues and improve the level of health and wellbeing of Rangatahi a coordinated, collaborative approach is required.

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“The environments in which Rangatahi move in must recognise the importance of family, culture, educational institutions and communities in helping to shape happy and healthy young people “(WSCT, 2015).

The youth health workforce is small, highly specialised and is geographically widespread. Professional isolation of youth health professionals is an issue that can impact on individuals and services, sharing of resources and ideas, collegial support and governance and peer review processes (Ministry of Health, 2009).

Cross sector collaboration

Health professionals reported that networking was important to: gain knowledge about work practices; maintain relationships; ensure ongoing collaboration; ensure that duplication of services does not occur; and facilitate holding agencies to account to ensure transparency (Waldegrave, 2015).

Wairarapa Health professionals emphasised the good working relationships that they considered to exist among health services and other organisations in the Wairarapa.

Cross-agency networking and relationships are working well, and close and positive working relationships and collaboration between organisations are widely discussed. There is a shared commitment to addressing issues (Waldegrave, 2015).

Networking and cohesion across agencies were also frequently discussed as something working poorly. Communication between agencies can be difficult due to time and work commitments. (Waldegrave, 2015). Time constraints were discussed by multiple organisation respondents who argued that time limited the ability of agencies to work together (Waldegrave, 2015).

“Youth services in the Wairarapa are fragmented and there is considerable variation in how the different sectors engage with, and follow-up with youth; and within localities (schools, health services and the community) (Health professional).

“Our community is not really addressing these issues. Keeping our young people safe is all of our jobs”(Health professional).

Equitable distribution of service

“Everything goes to Masterton. The rest of the Wairarapa misses out. Our youth are disadvantaged as a result” (Health professional).

Sharing information across services

Some talked about the challenges of networking and information sharing between medical centres and the local school and youth clinics.

“There is a problem with sharing information between practices and the schools and youth clinic” (Health professional).

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“We don’t get any notes for patients seen at the Youth Kinex” (Health professional).

Managing transitions

Professionals reported concern about the transition between school and youth services to an adult medical practice and he impact this would have on the continued health care.

“How does a youth health centre link up with other medical centres? How do they get continuous care?” (Health professional).

“How does the school and youth clinic transition young people to a medical practice once they have turned 24?” (Health professional).

Young people also cited this as a barrier to continued care

“What do we do once we have finished school? I don’t understand all the technical words and how to do it or where to go.” (Young person).

8. Education and training of health professionals

Health professional’s confidence, knowledge and skills in communicating, identifying, and treating adolescent health issues is an important factor in the provision of effective health care. The social sector trials health professionals indicated relationships with clients, having youth friendly staff, and continuity of staff were considered important (Waldegrave, 2015).

Inadequate training in consultation skills and managing psychosocial problems in adolescents have been cited as barriers for health professionals (Collaborative trust, 2011).

Nationally almost all of the health professionals working in or visiting schools have had some level of training in youth health (Denny 2014).

58% had attended a study day on youth health,

9% had completed some postgraduate papers in youth health

7.5% had completed a postgraduate certificate or diploma in youth health

25% had received more general postgraduate training in child and youth health.

73%) have also had training in sexual health, either from Family Planning or other training institutions

Clearly one of the most important factors in the provision of an effective health service is the passion of the health professionals. This was evident when asking health professionals why they provided support to youth and school clinics.

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"We did it because we were asked to do it. We see there is a need and it is part of being a community organisation. There is clearly a need and we have to step up" (Health professional).

“It’s supporting our patients in a manner that is perhaps more accessible, comfortable, convenient for them” (Health professional).

“We did this because it is supporting a passion and interest of our employees. As a business we need to think about retaining staff and that involves supporting their interests and talents” (Health professional).

Although many had undergone training in youth health issues they wanted a greater understanding of youth development and their needs.

“There is no specific youth focussed training and we would love it” (Health professional).

The term ‘Youth’ One last interesting comment made by a group of young people was using the word ‘youth’. They want a ’youth friendly’ environment but do not want to be labelled as such.

“As soon as you put the word ‘youth’ in front of something no one will go. It’s a stigma. People think its lame. You don’t want to go somewhere your mum will tell you to!” (young person).

Summary of Youth Health Service provision across the Wairarapa

The youth health sector needs a comprehensive strategy that incorporates kaupapa, theory and ideology that embraces youth-focused, youth-centred and strengths-based practice.

Young people want to be involved in the planning implementation and delivery of services that they will use. They want to be involved in designing the environment, be engaged as staff members and to be seen as positive contributing members of the community.

Young people:

They need understanding of what health care services are available to them and how they can access free health care.

Young people want a private, confidential health service where they can drop in and receive the health care they need, when they need it, in their own communities.

They want a service where they can access all different types of support to develop their health, wellbeing, employability skills and social connections.

They need mental health services integrated with, and disguised as other services and timely access to sexual and reproductive health care.

Young people want to get health care in an environment that is welcoming, physically appealing and youth friendly.

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Young people want professionals to be welcoming, use informal communication styles, and use a variety of ways to establish rapport with them.

Health professionals

Health professionals want equitable, biologically respectful funding models to provide free health care for all young people regardless of what setting they are in.

Health professionals need training in youth specific health care. They need understanding of adolescent brain development and behaviour and strategies to meet their needs. They also need support to develop cultural competency.

Health professionals want opportunities to share best practice and network. They want support and access to specialist health professionals to share case management and support young people for further intervention.

They want systems and processes that make it easy to share information with other relevant professionals in the life of the young person. They want to provide continuous care for all young people regardless of the service the youth chooses to use

They need the time and skills to assess and intervene in a holistic manner.

Opportunities for cross sector collaboration are also important.

Strengths and gaps in the provision of youth services across the Wairarapa

Medical Centres

Privacy and confidentiality: Young people report that privacy and confidentiality issues are barrier to their utilisation of local medical centres. They are worried that their parents and whanau, community and their peers will judge them and know what they were doing when they attend a medical centre.

Young people expressed concerns about GPs disclosing information to their parents and reception staff not protecting confidentiality.

Cost and funding: Cost is a major barrier for young people accessing health care in local medical centres across the Wairarapa. Young people believe they cannot access a GP without payment and are unaware they are able to access services such as the Youth clinics for free. Many were also unaware of initiatives such as the free sexual health care.

The location of the service is paramount to young people. Transport issues place a further cost and barrier to accessing effective health care. This is particularly important for those who have left school. They need services in their own communities.

Health professionals report that funding and enrolment constraints conflict with adolescent health seeking behaviour across a variety of services and negatively impacts competition for funding on their core work.

Access: Young people are intimidated by appointment and booking procedures.

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Manaakitanga – Hospitality, Attitudes and Communication: Young people report that medical centres are not youth friendly and the waiting room and reception is intimidating. They have reported concerns that health professionals have unsympathetic, authoritarian and judgemental attitudes towards them.

Organisational kaupapa - way of doing things; There are no reported youth specific policies, and practices across medical centres.

There is a need to improve the cultural capability of the services.

Youth health literacy: Health professional have made attempts to improve the knowledge of young people about how to enrol in a medical centre.

Young people have limited health literacy or knowledge of services available. They have difficulty knowing how to contact, when to contact and who to contact with regards to health care

Some young people indicated their own attitudes and knowledge of health issues are a barrier to receiving health care.

A number of young people indicated a specific attitude towards ‘Doctors’. They thought Doctors were only for ‘serious health issues’.

School based health services

Privacy and confidentiality: Young people trust the health professionals in schools to maintain privacy and confidentiality.

Having a health service on a school site can sometimes be a barrier for young people worried about peers and teachers’ attitudes and assumptions.

Cost and funding: All Young people are appreciative of the free access to health care in school based services and believe this is an important

Access: Varied opening times and service availability were a concern for young people

Manaakitanga – Hospitality, Attitudes and Communication: Young people believe health professionals in school based clinics are friendly, welcoming, and provide them with the care they need.

Organisational kaupapa - way of doing things: Young people report that school based health services provide a holistic, youth focussed service

School based health professionals report a strong focus on holistic health and being youth friendly in all their approaches

Youth health literacy: Young people have varied health literacy. Some have limited help seeking behaviours and their own attitudes towards health can act as a barrier to receiving appropriate health care. This is particularly true for those with mental health issues and those who have left school.

Kotahitanga – Cross sector Collaboration and Collective decision making: Some health professionals working across school based services are isolated professionally and need support for complex cases particularly in relation to mental health.

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Wairarapa Health professionals emphasised the good working relationships that they considered to exist among health services and other organisations in the Wairarapa.

Professional training: There is varied training in consultation skills and managing psychosocial problems in adolescents.

Youth Kinex

Privacy and confidentiality: The current venue hinders confidentiality of the service. It is small and the current configuration does not allow for privacy

Cost and funding: Some health professionals report concerns that the free clinic may impact on current enrolments in local medical centres

All Young people are deeply appreciative of the free access to health care in school based services and believe this is an important to receiving the health care they need

Access: Both health professionals and young people report the service is woefully under resourced and the limited availability of the service hinders their health care.

Although the majority of young people are either educated, live, or are employed in Masterton, there is limited access to youth friendly health services for young people out of school in the South Wairarapa.

Manaakitanga – Hospitality, Attitudes and Communication: Young people report that the youth clinic ‘Youth Kinex’ provides a safe, friendly environment encompassing all the tenets of manaakitanga.

Organisational kaupapa - way of doing things: Applying a comprehensive youth friendly approach is hindered by the lack of capacity of the service. There is not enough time available and too many young people requiring support to take the time needed to provide comprehensive, holistic youth health care.

Youth health literacy: Many young people who have left school are not aware of the availability of the service

Kotahitanga – Cross sector Collaboration and Collective decision making: There is a huge opportunity to extend the services available to include all aspects of youth health and wellbeing. This will require coordination and cross sector collaboration.

Professional training: Professionals are experienced and trained to provide youth health services

Recommendations for the effective provision of a Wairarapa youth health service

One young person summed up the recommendations succinctly.

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“Everyone is different. We are all individual. Don’t put money into just one thing. Don’t narrow it down and think that’s it sorted.” (Young person)

The following is a series of recommendations based on:

· Feedback from stakeholders including young people and health professionals across the Wairarapa · Best practice principles identified by Youth One Stop Shops (Gibson-Rothman, 2017). · Examples of innovative best practice already existing across the Wairarapa health sector · Recommendations made in the Wairarapa District Health Board ‘Life to go’ strategy 2005 · It is hoped these recommendations will be combined with those of the DHB Mental Health and Addictions report (2018)

Robust Governance

1. Develop a District Health Board Youth Health Plan

Develop a Youth Health Plan and incorporate it into the overall District Health Board strategy. Develop specific measurable actions that are implemented, resourced and monitored and evaluated.

Each District Health Board is required to have a youth health plan as part of their responsibilities for the health of their catchment population. Kaupapa, theory and ideology should embrace youth-focused, youth-centred and strengths-based practice. These should be integrated into all areas and levels of the organisation, and drive all decision making and interaction with young people. Young people have specific health needs and evidence on ACE studies strongly suggest that intervention at a vulnerable and early age determine help seeking behaviour and lifelong health.

Although the 2005 DHB health strategy incorporates many of the above aspects there is an opportunity to update and formally embed a current youth health strategy into the governance of the organisation.

2. Create a vision for youth health across the Wairarapa

Develop a strategy that incorporates the principles of effective youth health.

· Holistic service: that support young people to thrive physically, mentally, socially and spiritually. · For young people: designed and delivered specifically for the youth age range. It would recognise that young people have specific health needs and requirements that differ from the wider population. · Equal outcomes for Rangatahi: The youth health service should recognise Māori as tangata whenua and their right to equitable health care and outcomes. It should have specific policies, plans and procedures to support the health and wellbeing of Māori. · Bigger picture: The youth health service should contribute to the bigger picture of the health and wellbeing of young people in New Zealand.

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3. Establish a cross sector, collaborative steering group

Create a Youth health steering group governed by a partnership of local organisations

“To address the growing number of issues and improve the level of health and wellbeing of Rangatahi requires a coordinated, collaborative approach. The environments in which Rangatahi move in must recognise the importance of family, culture, educational institutions and communities in helping to shape happy and healthy young people.” (DHB, 2015)

The governing body of the service should steer the services and ensure robust governance policies and procedures throughout. As many of the young people have complex social, emotional and health needs they would benefit from holistic services and an environment that supports integration and collaborative practice across service delivery boundaries (including primary care) to ensure ‘any door is the right door’

This may include, but not be limited to the Education, Health, Iwi, Community development, Not For Profit and Government sector. Organisations could be approached such as Compass Health, District Councils, Wairarapa DHB, Maori Health Directorate, Iwi, Connecting Communities, REAP, YETE, the Whakaoriori and South Wairarapa Kahui ako (Schools community of learning).

4. Commit to Youth participation.

Create a Youth Advisory Group to provide governance over the implementation of the DHB youth health plan.

Youth participation in the planning and delivery of services is a fundamental principle that should be applied to the implementation of a DHB youth strategy. Youth health services need to be acceptable to young people to increase their engagement with services. Youth should be involved in planning, implementation and delivery of services. They should also be involved in designing the environment, be engaged as staff members and their feedback should be incorporated in services.

5. Develop a Fair, Flexible Youth Centred Funding Model

Develop a flexible funding model for youth regardless of what health service they access across the Wairarapa. The funding should be allocated to the young person regardless of what service they choose to access and fair and equitable across all health services.

The New Zealand primary care PHO/GP model of care expects an individual to enrol with a single health professional and then use this health professional for the majority of their primary care. The current funding model is not biologically respectful to youth. Young people are developmentally transient as they learn, train, work and live in a variety of different areas. They are known to ‘snack’ or ‘graze’ on services according to their present situation and needs.

Medical centres who have young people present as a casual are faced with complex funding issues where they have to spend time ‘clawing back’ from the patients enrolled service.

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6. Implement a coordinated Patient management systems and reporting

Implement a patient management system that is consolidated and supported so that the function provides:

· valuable information · consistent information across providers · mechanisms for feedback · automated reporting from clinical management IT systems · supports transitions from school and youth based clinics to a general practice.

Reporting on outcomes for youth across medical centres, school based and the youth clinic is inconsistent and cumbersome. It is difficult to share information across services to ensure consistency of care.

There is a need for early electronic flagging of clients as they turn 24 years to prompt transition planning, guide choices for clients on appropriate services and facilitating contact between clients and providers if support is needed.

Robust workforce development

7. Establish a Wairarapa Youth Health Service Specialist team

Create a specialist Youth Health team that are mobile and can support all school, practices and the youth clinic. These would be dedicated professionals who are trained in youth health and development.

There are pockets of collaborative practice, shared case management and informal networking across the youth health sector with experienced health professionals, however the majority of Nurses, Doctors and health professionally are isolated professionally and geographically.

The Youth Health Service Specialist team would:

· Synthesise common health issues across the region and advocate for services to address them · Create opportunities to share best practice on how to address youth health issues · Share expertise, case management and provide supervision for health professionals working with high risk young people · Support nurses in all school and youth clinics · Convene regular network meetings with all health professional who are working with youth. · Visit colleges on a regular basis that don’t have school-based health care. · Support youth events and areas where there are high density youth e.g. Castlepoint, Riversdale at holiday time.

8. Train health professionals to provide best practice health care

Develop and implement a training programme for health professionals in youth development, adolescent brain development and their behaviour, social, emotional development, health needs and holistic assessments. 65 MLMckenzie Wairarapa youth health services DHB & Tu Ora Compass December 2019

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There is evidence of huge passion, good will and interest in providing quality health services to young people across the sector. Every person interviewed for this report displayed a commitment far beyond their job descriptions to understand young people and help.

Many have received training in specific health issues e.g. sexual health, self-harm, suicide risk assessment, however there was little evidence of training in ‘youth’ as a whole. As anyone working with youth will know, their needs are complex, their developmental needs are specific and best practice in youth health care is challenging.

It is vital that all professionals that come into contact with young people have an understanding of their needs. Staff at reception, and health professionals would benefit from an understanding of the barriers and enablers to effective youth engagement, assessment and intervention.

Improve youth and whanau ‘health literacy’

9. Increase health literacy and knowledge about services through promotion and increased publicity

Develop and distribute a Wairarapa wide health education information pack

The youth health service should contribute to the bigger picture of the health and wellbeing of young people in New Zealand.

Young people and their whanau need

· better education on the short and long term consequences of ‘forgone care’ · better education on the consequence of risky behaviours such as drug and alcohol use, risky sexual behaviour, driving and the impact of toxic stress · increased knowledge of what services are available · simple instructions on how to access services · improved understanding of current health issues

Some of the solutions are already in place but need more consistency and coverage for all young people

Develop and distribute a comprehensive School leavers pack to all schools.

Kuranui health clinic develop a pack of handouts that is provided to all school leavers across the region. The aim of this pack is to increase knowledge of youth health issues and available services for young people and improve access through increased knowledge of enrolment procedures. The pack contains information on available local services and instructions on how to enrol in a local medical centre.

Create a health Survival pack across all medical centres

As a social enterprise Masterton Medical applies “commercial strategies to maximize improvements in financial, social and environmental well-being.” (health professional)

Currently Masterton Medical provide a ‘Summer survival pack’ available to all young people who attend the Youth Kinex service. This pack is funded by Masterton Medical and contains information on on-line and other available health services, sexual health information, and contains takeaways such as lip balm, sunscreen and condoms. They plan also to include a guide on how to enrol in a medical centre and it is branded with the organisations logo. 66 MLMckenzie Wairarapa youth health services DHB & Tu Ora Compass December 2019

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Making this pack ‘youth friendly’ and freely accessible to all young people would provide young people with information on health issues, helps to improve access to health services through an improved knowledge of how to enrol and increases potential new enrolments through branding awareness.

10. Investigate educational partnerships with schools that improve youth health literacy.

Develop a collaborative partnership with the Whakaoriori and South Wairarapa Kahui Ako (Communities of Learning) to improve their wellbeing and health literacy.

Schools are struggling to educate and manage the complex health issues they are presented with each day. Health professionals can improve health literacy by supporting educational programmes that are linked to the NZ health and PE curriculum in schools. This support must align with educational curriculum requirements and be flexible enough to suit individual schools’ timetables and curriculum restraints.

Youth Friendly Medical Centres

11. Incorporate best practice for youth health care across all medical centres

Integrate kaupapa, theory and ideology that embraces youth-focused, youth-centred and strengths-based practice into all areas and levels of the organisation, and drive all decision making and interaction with young people.

This would require a review of

· Waiting rooms and reception areas to ensure they are ‘youth friendly’. · Communication on the availability of free youth health care for those under 21 years old e.g. sexual health. · Confidentiality policy’s clearly and regularly explained to young people and staff · Holistic assessments to understand the young person in their entire context. These should use non-judgemental, strengths-based and youth appropriate language. · Enrolment processes for youth that support flexible and allow them to access a variety of health services across the Wairarapa.

Equitable School based services

12. Provide a fully resourced, equitable school based health service to every school in the Wairarapa.

A fully resourced school based service would have:

· Regular access to and support from a GP or health practitioner. · Health professionals who are trained and resourced to complete a HEADSS assessment for targeted students. · Regular networking and professional development opportunities for staff working across the sector. · A social worker to work collaboratively with the Guidance counsellor and Health professionals

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School based services address many of the barriers to effective youth health service provision. They resolve transport barriers, play an important role in de-stigmatising service access, are immediate, free, private and have a youth friendly kaupapa. One young person summed up by saying:

“We know what works. School health clinics are full. Kids use them. Make them great so we can all benefit.”

Some New Zealand regions are trialling mental health support in primary care settings. These Health coaches are skilled in counselling skills such as brief therapy and acceptance commitment therapy(ACT).

Youth Health Hubs.

13. Expand Youth Kinex to become a hub for holistic youth health care across the Wairarapa

It is clear that Youth Kinex provides a vital service to youth across the Wairarapa, particularly to those who have left school. Demand currently outweighs supply and the current venue is a woefully inadequate space.

Youth Kinex needs to include more privacy, waiting space, increase availability, hours and days it is open and increase and broaden the services to include mental health, social connections, careers advice and other aspects of wellbeing/hauora.

Locate and inhabit a new facility.

The venue would be a centrally located youth friendly place, big enough for groups of young people to meet regularly and professionals to convene.

The venue would be configured to maintain confidentiality with break out, consult rooms and meeting spaces

The venue would allow for expansion of complimentary services

Develop partnerships with community organisations to provide holistic health care for young people

The hub could serve as a base for the Youth health specialist team and support school based clinics across the Wairarapa

This service could hold enrolments and manage the administration for all youth using school based health clinics and Youth Kinex

A collaborative partnership and cohabitation with the Youth Council ‘wellbeing café’ would increase foot traffic and destigmatise help seeking as well as involve young people in the provision of health services.

A collaborative partnership with YETE (Youth, Education, Training and Employment’ providing job clubs and careers services could also encourage young people to access health care.

14. South Wairarapa Community centre and medical centre

Support the development of a Youth health hub in Featherston

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The Featherston Medical Centre is moving alongside the new Featherston Community Centre. This new premise could serve as a base for youth health service provision in the South Wairarapa, replicating the model developed at Youth Kinex.

Organisations such as the Featherston Medical Centre, Featherston Community Centre, Fab Feathy community development and Wairarapa Whanau Trust have indicated willingness to work collaboratively to establish a South Wairarapa youth health hub.

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References

Clark, T. C., Fleming, T., Bullen, P., Denny, S., Crengle, S., Dyson, B., Fortune, S., Lucassen, M., Peiris-John, R., Robinson, E., Rossen, F., Sheridan, J., Teevale, & T., Utter, J. (2013). Youth’12 Overview: The health and wellbeing of New Zealand secondary school students in 2012. Auckland, New Zealand: The University of Auckland.

Collaborative Trust. (2011) Youth Health Manual. Enhancing the skills of primary care practitioners in caring for all young New Zealanders.

Davis, R., Davis-Tana, S., Vea, T. Porirua. (July 2019). Youth Insights Report. An Integrated Youth Model of Care. Prepared for Gerardine Clifford-Lidstone, General Manager Child, Youth &Localities. Capital & Coast District Health Board.

Deane, K., Dutton, H. & Kerekere, E. (2019) Ngā Tikanga Whanaketanga – He Arotake Tuhinga. A Review of Aotearoa New Zealand Youth Development Research. Auckland, NZ: University of Auckland

Denny S., Grant S., Galbreath R., Clark, T.C., Fleming, T., Bullen, P., Dyson, B., Crengle, S., Fortune, S., Peiris-John, R., Utter, J., Robinson, E., Rossen, F., Sheridan, J., & Teevale, T. (2014). Health Services in New Zealand Secondary Schools and the Associated Health Outcomes for Students. Auckland, New Zealand: University of Auckland

Denny, S Farrant, B., Cosgriff, G., Mo Harte RN, Cameron, T., Johnson, T., McNair, V., Utter, J., Crengle, S., Fleming, F., Ameratunga, S., Sheridan, J., & Robinson, J. (2013) Forgone Health care among secondary school students in New Zealand. Journal of primary health care. Volume 5. Number 1. March 2013

Duncanson, D., Oben, G., Adams, J., Richardson, G., Wicken, A. & Smith, L. (November 2019) Health and wellbeing of under-25 year olds in Hutt Valley, Capital & Coast and Wairarapa Draft 2019 report, New Zealand Child and Youth Epidemiology Service, Department of Women’s and Children’s Health, University of Otago.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14 (4), 245-258.

Patton, G., Olsson, C., Skirbekk, V., Saffery, V., Wlodek,M., Azzopardi, P., Stonawski, M., Rasmussen, B., E.; Francis, E., Bhutta, Z., Kassebaum, N., Mokdad, M., Murray, C., Prentice, A., Reavley, NP., Sweeny, P., & Sawyer, S. Adolescence and the next generation. https://www.nature.com/articles/nature25759

Gibson-Rothman, L. (April 2017). Youth one stop shops in New Zealand: A framework for recommended practice. Working Together fund.

Gluckman, Sir Peter (FRS). (26 Aug 2010). It is Hard to be a Teenager: Keynote address to alumni and friends of the University of Auckland. Wellington.

Helman, S, Dr. (2019). Proposal to Improve Youth Health Services in the Wairarapa.

Masterton and Carterton District Councils (June 2016) Wairarapa Rangatahi Development Strategy 2016 – 2021.

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Ministry of Health. (2009) Synopsis Report. Evaluation of Youth One Stop Shops Version 1.1. New Zealand.

Ministry of Youth Development (2009). Keepin’ it real. A resource for involving young people in decision-making. New Zealand.

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Noel, H., Denny, S., Farrant, B., Rossen, F., Teevale, T., Clark, T., Fortune, S. (2013). Clustering of adolescent health concerns: A latent class analysis of school students in New Zealand. Journal of Paediatrics and Child Health, 49(11), 935-941.

O’Neill, K. (2019) Another way to look at teens. Positive youth development. Brainwave Review, Issue 29, Summer 2019

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O’Neill, K. and Lisa Busch, L. (2012) Adult health... What’s childhood got to do with it? Brainwave Trust Aotearoa 2018. First published Brainwave Trust Newsletter 17, Summer 2012

Steinberg, L. (2016). Adolescence (11th ed.). New York, NY: McGraw-Hill Education

Te Rōpū Rangahau Hauora a Eru Pōmare, (2015) Wairarapa District Health Board Māori Health Profile. University of Otago, Wellington. Ministry of Health.

Wright, S. (2017) It’s not their hormones. It’s their brains. Brainwave Trust Newsletter 20, Winter 2014. Updated December 2017.

Waldegrave, C; King, P. (2015) Overall Synthesis Combined Summary Report for the Wairarapa Social Sector Trial (SST): Snapshots and Mapping. Family Centre Social Policy Research Unit. Wairarapa Social Sector Trial 31 August 2015.

Wairarapa Safer Community Trust. (2016) Rangatahi Health and Wellbeing Report. Wairarapa Safer Community Trust.

Wairarapa District Health Board. (12 Dec 2018) Wairarapa mental health and addiction service review report Version 1.0 Status Final Draft Report. Wairarapa District Health Board.

World Health Organization (2011) Young People: Health Risks and Solutions Fact Sheet No 345 cited at http://www.who.int/mediacentre/factsheets/fs345/en/

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3DHB WRDHB Revised delivery plan (calendar years) 2019 2020 2021

Quarter Three Quarter Four Quarter One Quarter Two Quarter Three Quarter Four Quarter One Quarter Two Quarter Three Quarter Four

Community Health Fax Decommissioning (3D)

Telehealth Programme (3D) Electronic Patient Observations POC Electronic Patient Observations (3D)

Hospital and Single Clinical Portal (3D) Specialist Services WebPAS Enhancements inc NCAMP (WR) NCAMP (3D) Single PAS (3D) MHAIDS Programme of Work (3D) Trendcare and CCDM/Variance (3D)

CostPro Upgrade (WR) Unified Communications / PABX and Call Centre Replacement (3D) Corporate and Workplace Digital Workplace Programme of Work (3D) Systems Exchange Online Accelerated Rollout 3DHB Payroll / HRIS (3D)

Windows 10 Upgrade Completion (3D) Workflow engine (3D) Wide Area Network Upgrade (3D)

NetScaler replacement (3D) API (3D) ICT Systems SQL Upgrades (3D) Disaster Recovery and Backups (3D) Cyclic Software Upgrades (3D) including BadgerNet Intune MDM

Standard Service Support (3D) ICT Services Security Remediation (3D)

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3DHB Covid 19 Work

March April May June

2nd 9th 16th 23rd 30th 6th 13th 20th 27th 4th 11th 18th 25th 1st 8th 15th 22nd 29th

COVID-19 RPH Electronic Case Management Community Health Covid-19 – HV Meals on Wheels

Cardiology W@H Radiology W@H BAU

Unsigned Prescriptions Hospital and Covid-19 AIMS Changes Specialist Services Covid-19 Whiteboards

Covid-19 – Enabling Virtual Patient Visits Covid-19 Hospital at Home Discovery (moves into Telehealth)

Corporate and Zoom Enablement Zoom Improvement Workplace Systems Covid-19 – Logistics – Network & Service Delivery

ICT Services Covid-19 Incident and Remediation (3D)

Projects on Hold 2019 2020 2021

Quarter Three Quarter Four Quarter One Quarter Two Quarter Three Quarter Four Quarter One Quarter Two Quarter Three Quarter Four

Community Health Electronic Referrals (3D) Recommence Q3

Hospital and eWhiteboards and Dashboards CI (3D) Specialist Services

Corporate and Business Intelligence Improvements (WR) Workplace Systems

ICT Systems

ICT Services

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