Community & Public Health Advisory Committee

‘Aakina to ora, hei oranga mauroa’ – Mahaki Albert, Tumu Tikanga CM Health Look after yourself to preserve health and wellbeing

COUNTIES MANUKAU DISTRICT HEALTH BOARD COMMUNITY AND PUBLIC HEALTH ADVISORY COMMITTEE (CPHAC) Wednesday, 27 January 2021

Venue: Room 103, Ko Awatea, Middlemore Hospital; 100 Hospital Road, Otahuhu; Auckland Time: 9.00am

Committee Members CMDHB Management Colleen Brown – Committee Co-Chair Fepulea’i Margie Apa – Chief Executive Pierre Tohe – Committee Co-Chair Aroha Haggie – Director, Funding & Health Equity Barry Bublitz – Mana Whenua Dr Gary Jackson – Director, Population Health Dianne Glenn – CMDHB Board Member Dr Campbell Brebner – Chief Medical Advisor, Primary & Katrina Bungard – CMDHB Board Member Integrated Care) Lana Perese – CMDHB Board Member Jessica Ibrahim –Executive Advisor to the CE Paul Young – CMDHB Board Member Vicky Tafau – Secretariat Apulu Reece Autagavaia – CMDHB Board Member Robert Clark – Mana Whenua Board Observers Tipa Mahuta – CMDHB Board Member Brittany Stanley-Wishart Tori Ngataki

AGENDA: PART I – Items to be considered in this public meeting

1. AGENDA ORDER AND TIMING Page No.

2. GOVERNANCE 9.00am 2.1 Apologies 002 2.2 Register of Interests 2.2.1 Does any member have an interest they have not previously disclosed? 003 2.2.2 Does any member have an interest that may give rise to a conflict of interest with 005 a matter on the agenda? 2.3 Confirmation of Public Minutes of the Community & Public Health Advisory Committee 006 Meeting – 16 December 2020 2.4 Action Items Register 016 2.5 CPHAC Draft Workplan 2021 018

3. UPDATES 9.30am 3.1 Asian Health Status & Population Growth (Kitty Ko, Asian Health Gain Advisor, Population 019 10.00am Health) 10.30am 3.2 Localities Update (Penny Magud, General Manager Locality Services) 041 3.3 Faster Cancer Treatment Reporting Data (Aroha Haggie, Director Funding & Health 045 10.50am Equity)

11.05am Morning Tea

11.35am 3.4 South Auckland Social Wellbeing Board; 5-Year Strategy (2020 – 2025) and 2-Year Action 048 Plan (Ann Wilkie, Programme Director) 3.5 Metrics that Matter; 6 Month Summary to December 2020 (Paul Hewitt, Senior Planning Advisor; Zizi Jasim, Planning Advisor) – to be included

4. INFORMATION PAPER 4.1 Action Item from ARF: Implications of Covid-19 on Primary Care 070

11.50am 5. RESOLUTION TO EXCLUDE THE PUBLIC 080

Counties Manukau District Health Board – Community & Public Health Advisory Committee

CPHAC BOARD MEMBER ATTENDANCE SCHEDULE 2021

Name 27 Jan Feb 10 Mar 21 April May 2 June 14 July 25 Aug Sept 6 Oct 17 Nov

Colleen Brown (Co-Chair)

Pierre Tohe (Co-Chair)

Barry Bublitz

Dianne Glenn

Katrina Bungard

Lana Perese

Paul Young No Meeting No Meeting No Meeting No Apulu Reece Autagavaia

Robert Clark

Tipa Mahuta

Brittany Stanley-Wishart

Tori Ngataki

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

002 CPHAC MEMBERS DISCLOSURE OF INTERESTS 16 December 2020 Member Disclosure of Interest Colleen Brown  Chair, Disability Connect (Auckland Metropolitan Area) (CPHAC Co-Chair)  Member, Advisory Committee for Disability Programme Manukau Institute of Technology  Member, NZ Down Syndrome Association  Husband, Determination Referee for Department of Building and Housing  Chair, Rawiri Residents Association  Director and Shareholder, Travers Brown Trustee Limited  Board Member, NZ Neighbourhood Support  District Representative, Neighbourhood Support NZ Board Pierre Tohe  Senior Executive, Tainui Group Holdings (CPHAC Co-Chair)  Trustee, Taniwha Marae Barry Bublitz  Director, International Indigenous Council for Healing Our Spirits Worldwide  Patron - Management Team, Te Mauri Pimatisiwin (A Journal of Aboriginal and Indigenous Community Health)  Chair - Māori Research Review Committee  Chair, Wikitoria King Whānau Trust  Chair, Eva Newa Wallace Whānau Trust  Secretary, Mataitai Farm Trust  Turuki Health Care – Employee  Co – Chair Mana Whenua Kei Tamaki Makaurau Board  Co-Chair Kaitiaki Roopu: Whakangako te Mauri o te Tangata Dianne Glenn  Member, NZ Institute of Directors  Life Member, Business and Professional Women Franklin  Member, UN Women Aotearoa/NZ  Life Member, Friends of Auckland Botanic Gardens and Chair of the Friends Trust  Life Member, Ambury Park Centre for Riding Therapy Inc.  Member, National Council of Women of New Zealand  Justice of the Peace  Member, Pacific Women’s Watch (NZ)  Member, Auckland Disabled Women’s Group  Life Member of Business and Professional Women NZ  Interviewer, The Donald Beasley Research Institute for the monitoring of the United Nations Convention on the Rights of Persons with Disabilities.  Member, Lottery Individuals with Disabilities Committee  Member, Expert Advisory Group to the Retirement Commissioner working on retirement income Katrina Bungard  Deputy Chairperson MECOSS – Manukau East Council of Social Services.  Elected Member, Howick Local Board  Deputy Chair, Amputee Society Auckland/Northland

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

003  Member of Parafed Disability Sports  Member of NZ National Party Lana Perese  Director & Shareholder, Malatest International & Consulting  Director, Emerge Aotearoa Limited Trust  Trustee, Emerge Aotearoa Housing Trust  Director, Vaka Tautua  Director, Malologa Trust  Director & Shareholder, Perese Wood Investments Limited Paul Young  Councillor, Auckland Council  Director, Paul Young International Ltd Apulu Reece Autagavaia  Member, Pacific Lawyers’ Association  Member, Labour Party  Trustee, Epiphany Pacific Trust  Trustee, The Good The Bad Trust  Member, Otara-Papatoetoe Local Board  Member, Pacific Advisory Group for Mapu Maia – Problem Gambling Foundation  Board of Trustees Member, Holy Cross School  Member of the Cadastral Surveyors Board  Assessor of the Creative Communities Scheme South & East Auckland Robert Clark  Chair Manawhenua I Tamaki Makaurau Health Board  Member of Te Whakakitenga (Waikato/Tainui Tribal Parliament)  Depty Chair Waikato Tainui Appointments Committee  Depty Chair Huakina Marae Forum  Ngati Tiipa Lands/ Te Kotahitanga Marae Trustee  Chair Counties Maori Rugby  Crown appointed Tangata Kaitiaki for Waikato Awa and West Coast Harbours  Cultural Advisor for Counties Manukau Police  Deputy Chair of Te Hiku O te Ika Tipa Mahuta  Deputy Chair, Te Whakakitenga o Waikato  Councillor, Waikato Regional Council Brittany Stanley-Wishart  Deputy Chair, Pasifika Students in Health in NZ (charity that receives funding from CM Health for its biennial conference) Tori Ngataki  Board member, Ngāti Tamaoho Trust 2016 to 2020 (restanding)  Board member, Second Natures Trust 2016 to 2021  Marae Rep, Te Whakakitenga o Waikato Inc 2017 to 2021 (restanding)  Director, Keep it Māori Ltd (social enterprise) 2019

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

004 COMMUNITY and PUBLIC HEALTH ADVISORY COMMITTEE MEMBERS’ REGISTER OF DISCLOSURE OF SPECIFIC INTERESTS

Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 16 November 2020

Director having interest Interest in Particulars of interest Disclosure date Board Action Pierre Tohe Public Excluded Agenda of 8 Mr Tohe does work for 8 April 2020 That PierreTohe’s specific interest is April 2020 Waikato/Tainui. noted and the Committee agreed that he may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making, if applicable. Lana Perese Integrated Primary Mental Malatest International, the 9 September 2020 That Lana Perese’s specific interest is Health & Addiction Services company Ms Perese is a noted and the Committee agreed (IPMHAS) Director and Shareholder for, that she may remain in the room are evaluating IPMHAS. Also, and participate in any deliberations Ms Perese is a Board Director of the Committee but is not for Vaka Tautua which is one of permitted to participate in any the providers in the Pacific decision making, if applicable. Collaborative and potentially one of the Awhi Ora providers

Counties Manukau District Health Board –Community & Public Health Advisory Committee 27 January 2021

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Minutes of Counties Manukau District Health Board Community and Public Health Advisory Committee Held on Wednesday, 4 November, 2020 at 9.00am – 11.30pm Room 101, Ko Awatea, 100 Hospital Road, Middlemore Hospital, Otahuhu, Auckland

PART I – Items considered in Public Meeting

BOARD MEMBERS PRESENT

Colleen Brown (Co-Chair) Dianne Glenn Katrina Bungard Lana Perese Paul Young Apulu Reece Autagavaia Robert Clark (Mana Whenua) Brittany Stanley-Wishart (Board Observer)

ALSO PRESENT

Fepulea’i Margie Apa (CEO, CM Health) Dr Gary Jackson (Director, Population Health) Aroha Haggie (Director, Funding & Health Equity) Dr Christine McIntosh (acting Chief Medical Officer, Primary & Integrated Care), standing in for the seconded Dr Campbell Brebner) Jessica Ibrahim (Executive Advisor to the CE) Vicky Tafau (Secretariat) (Staff members who attended for a particular item are named at the start of the minute for that item)

PUBLIC AND MEDIA REPRESENTATIVES PRESENT

No media representatives were in attendance.

WELCOME

The meeting commenced at 9.00am with a welcome from Colleen Brown.

1. AGENDA ORDER AND TIMING

Items were taken as per the agenda.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

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2. GOVERNANCE

2.1 Apologies

Apologies were received from Pierre Tohe, Barry Bublitz and Tori Ngataki and Robert Clark, Margie Apa and Aroha Haggie for lateness.

2.2 Register of Interests

Disclosure of Interests – no amendments to note. Disclosure of Specific Interests – no disclosures to note.

2.3 Confirmation of the Minutes of the joint Hospital Advisory Committee/Community and Public Health Advisory Committee/Disability Advisory Committee meeting held on 4 November 2020.

Resolution (Moved: Colleen Brown/Seconded: Dianne Glenn)

That the minutes of the Community and Public Health Advisory Committee meeting held on 4 November 2020 be approved.

Carried

2.4 Action Items Register/Response to Action Items

Ms Tafau to put all provider presentations into the Resource Centre.

CPHAC were happy with Action Item progress. The Kootuitui response was noted.

2.5 CPHAC Work Plan 2021

CPHAC asked for regular Oral Health updates to be added to the work plan.

Conversation ensued around Oral Health service delivery in practices around Counties Manukau and peoples’ negative experiences and how that might follow that up.

In terms of what is happening in the Prevention space, Dr Jackson suggested asking ARDS and CADS to present to the committee around explaining their customer feedback process.

Auditing of contracts to also be put on the work plan.

3. UPDATES

3.1 Mana Kidz Update to CPHAC (Phil Light, acting General Manager-Integrated Child Youth; Dr Philippa Anderson, Public Health Physician and Claudelle Pillay, Immunisation Nurse Leader)

Mana Kidz is a comprehensive school based, nurse-led child health programme delivered in 88 schools across the Counties Manukau region. There are approximately 34,000 tamariki consented onto the programme. 59 schools have a nurse and whaanau support worker in school each day and 29 schools have a nurse in school once a week. To supplement schools, Mana Kidz run an 0800 line where schools and whaanau can ring if they have any child health concerns, the aim of this line is to connect whaanau with the appropriate team or service where applicable. The comprehensive child health programme has three arms; rheumatic fever prevention through sore throat management, skin infection management and child health assessment and management.

Dr Anderson gave a broad overview of the information provided in the report and note the following points: Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

007

 Mana Kidz has established more rigorous follow ups for patients.  Nurse practitioners are working with the teams to assist in increasing access for whaanau.  A lot of work has gone into providing training for nasal pharyngeal swabbing.  Asked CPHAC to note the amount of research that is underway with the programme. Looking at piloting COVID testing within schools, potentially for the entire whaanau.  Mana Kidz is a valuable workforce in terms of past responses, eg Measles in 2019, COVID in 2020.  RH Fever – in the May 2019 budget $12M was allocated for 4 years. The bulk of that funding was for a co-design piece. This has now been contracted. ThinkPlace are partnering with local Maaori & Pacific re innovative approaches to Rh Fever prevention and treatment.

CPHAC advised that they would like to receive a copy of the ThinkPlace report to the Ministry of Health. Dr Anderson told CPHAC that the hope is that the information will flow both ways; CM Health influencing ThinkPlace and ThinkPlace sharing data and information with CM Health. The budget will also be divided between the region to support programmes that are being implemented. Annie Ualesi has been engaged by Think Place and a Maori contractor from the Heart Foundation.

Apulu Reece Autagavaia is hoping that the funding will assist in resolving the racism issues that were raised within the Rh Fever programmes dealing with whaanau. CPHAC was advised that work is being done in KidzFirst around implicit racism within the service.

ThinkPlace have been clear that they wish to work with CM Health.

Action Invite MoH to provide their big picture thinking around Rh Fever in Counties Manukau and regionally. CPHAC would like Think Place to present around the ideas they have been coming up with and how they’ll be implemented. June 2021.

Colleen is interested in how whaanau manage the purchasing of medication. Dr Anderson advised that the medication is free.

The premise of the programme is that if we can deal with the Strep throats it will prevent the Rh Fever. The focus of the programme is on the Group A Strep Throats and Dr Anderson is pleased with the way this is working. There is recognition that there is more work needed locally in the health promotion space around Group A Strep Throat and Rh Fever. Alliance Health+ has been funded to undertake this work.

In regard to the Impetigo Programme; if a child has impetigo then comprehensive hygiene information is provided to the whaanau. Clean, Cut, Cover is the information provided. Packs are given to take home. Various programmes are working with whaanau to ensure that homes either have washing machines or have access to washing machines. Laundromat use is quite common for many homes.

Ms Pillay advised that there has been much improvement with impetigo over the years and this has been corroborated by CM Health nursing staff.

It was reiterated to CPHAC that Ms Haggie will be bringing an Immunisations Review to CPHAC in 2021.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

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3.2 Women’s Health in the Community Update (Dr Christine McIntosh, acting Chief Medical Advisor, Primary & Integrated Care)

Dr McIntosh took CPHAC through the presentation, highlighting the benefits of various forms of contraception.

Hormonal contraception has very low amounts of side-effects. It is essential that providers in the community have the correct information to provide to women in order for them to make fully informed decisions around contraception.

Contraception also assists women with unplanned pregnancies; health issues, alcohol consumption, etc. A planned pregnancy ensures that the woman can be in the best health possible when planning to get pregnant. Through POAC women can be referred to a practice that does provide contraception services.

CM Health offers free LARC free for women who are Maaori or Pacific, quintile 5, CSC holders or are engaged in secondary mental health services or CADS. Unintended birth is associated with poor health and social outcomes for women. Reduced birth interval and >5 births carry increased risks for mama and pepe. 48.6% of post-natal women reported having no antenatal discussion about contraception.

Removing financial barriers is key for women who are Maaori or Pacific, Quintile 5, CSC holders or women involved with secondary mental health services or CADS.

Dr McIntosh noted that access to the morning after pill has also improved.

Primary Care and midwives take responsibility for providing contraception information antenataly so that women can be prepared. Best Start Pregnancy Tool has the dissemination of this information built in.

Birthing Hubs will also be included in discussions around contraception information dissemination.

Apulu Reece Autagavaia noted that if all women are well, all of the time, unintended pregnancies wouldn’t be such an issue. Social and cultural norms associated with whaanau, includes the value of whaanau. The tension about cultural norms and well being can be difficult to navigate.

Dr McIntosh advised CPHAC that abnormal uterine bleeding is a prevalent problem in our community (leads to anaemia) which can lead to uterine cancers. This is compounded by obesity, so high rates for Pacific particularly and also Maaori. GPs need to understand the issue, get good background information and potentially take a biopsy. Treatment offered is likely to be the mirena. This treatment reduces periods almost totally, reduces anaemia and reduces the risk of cells turning cancerous. So, communication/information is crucial. Additional funding has been received to ensure more work can be done in the community to assist women with Abnormal Uterine Bleeding. The funding provided will go a long way to addressing the equity gap.

Action Dr McIntosh is to return to CPHAC in 2021 to provide detailed information in regard to HPV in CM Health and a presentation regarding the Best Start Pregnancy Tool.

5. RESOLUTION TO EXCLUDE THE PUBLIC

Resolution (Moved: Paul Young /Seconded: Robert Clark)

That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000:

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

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The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items Reason for passing this resolution in Ground(s) under Clause 32 for to be considered relation to each item passing this resolution 2.1 Confirmation of Public That the public conduct of the whole Confirmation of Minutes Excluded Minutes 4 or the relevant part of the proceedings As per the resolution from the public November 2020. of the meeting would be likely to section of the minutes, as per the result in the disclosure of information NZPH&D Act. for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i)) of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)] 3.1 Strategic Discussion That the public conduct of the whole Commercial Activities or the relevant part of the proceedings The disclosure of information would of the meeting would be likely to not be in the public interest because result in the disclosure of information of the greater need to enable the for which good reason for withholding Board to carry out, without prejudice would exist, under section 6, 7 or 9 or disadvantage, commercial (except section 9(3)(g)(i)) of the activities. Official Information Act 1982. [Official Information Act 1982 [NZPH&D Act 2000 Schedule 3, S32(a)] S9(2)(i)]

Carried

This first part of the meeting concluded at 10.30am.

SIGNED AS A CORRECT RECORD OF THE COUNTIES MANUKAU DISTRICT HEALTH BOARD COMMUNITY AND PUBLIC HEALTH ADVISORY COMMITTEE MEETING OF 16 DECEMBER 2020.

______Colleen Brown Committee Co-Chair

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

010

PART I – Items considered in Public Meeting

BOARD MEMBERS PRESENT

Colleen Brown (Co-Chair) Dianne Glenn Katrina Bungard Lana Perese Paul Young Apulu Reece Autagavaia Robert Clark (Mana Whenua) Brittany Stanley-Wishart (Board Observer)

ALSO PRESENT

PUBLIC AND MEDIA REPRESENTATIVES PRESENT

No media representatives were in attendance.

WELCOME

The meeting commenced at 9.00am with a welcome from Colleen Brown.

1. AGENDA ORDER AND TIMING

Items were taken as per the agenda.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

011

2. GOVERNANCE

2.1 Apologies

Apologies were received from Pierre Tohe, Barry Bublitz and Tori Ngataki and Robert Clark, Margie Apa and Aroha Haggie for lateness.

2.2 Register of Interests

Disclosure of Interests – no amendments to note. Disclosure of Specific Interests – no disclosures to note.

2.3 Confirmation of the Minutes of the joint Hospital Advisory Committee/Community and Public Health Advisory Committee/Disability Advisory Committee meeting held on 4 November 2020.

Resolution (Moved: Colleen Brown/Seconded: Dianne Glenn)

That the minutes of the Community and Public Health Advisory Committee meeting held on 4 November 2020 be approved.

Carried

2.4 Action Items Register/Response to Action Items

Ms Tafau to put all provider presentations into the Resource Centre.

CPHAC were happy with Action Item progress. The Kootuitui response was noted.

2.5 CPHAC Work Plan 2021

CPHAC asked for regular Oral Health updates to be added to the work plan.

Conversation ensued around Oral Health service delivery in practices around Counties Manukau and peoples’ negative experiences and how that might follow that up.

In terms of what is happening in the Prevention space, Dr Jackson suggested asking ARDS and CADS to present to the committee around explaining their customer feedback process.

Auditing of contracts to also be put on the work plan.

3. UPDATES

3.1 Mana Kidz Update to CPHAC (Phil Light, acting General Manager-Integrated Child Youth; Dr Philippa Anderson, Public Health Physician and Claudelle Pillay, Immunisation Nurse Leader)

012

ThinkPlace have been clear that they wish to work with CM Health.

Colleen is interested in how whaanau manage the purchasing of medication. Dr Anderson advised that the medication is free.

Ms Pillay advised that there has been much improvement with impetigo over the years and this has been corroborated by CM Health nursing staff.

It was reiterated to CPHAC that Ms Haggie will be bringing an Immunisations Review to CPHAC in 2021.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

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3.2 Women’s Health in the Community Update (Dr Christine McIntosh, acting Chief Medical Advisor, Primary & Integrated Care)

Dr McIntosh took CPHAC through the presentation, highlighting the benefits of various forms of contraception.

Removing financial barriers is key for women who are Maaori or Pacific, Quintile 5, CSC holders or women involved with secondary mental health services or CADS.

Dr McIntosh noted that access to the morning after pill has also improved.

Birthing Hubs will also be included in discussions around contraception information dissemination.

Action Dr McIntosh is to return to CPHAC in 2021 to provide detailed information in regard to HPV in CM Health and a presentation regarding the Best Start Pregnancy Tool.

5. RESOLUTION TO EXCLUDE THE PUBLIC

Resolution (Moved: Paul Young /Seconded: Robert Clark)

That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000:

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

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The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

Carried

This first part of the meeting concluded at 10.30am.

SIGNED AS A CORRECT RECORD OF THE COUNTIES MANUKAU DISTRICT HEALTH BOARD COMMUNITY AND PUBLIC HEALTH ADVISORY COMMITTEE MEETING OF 16 DECEMBER 2020.

______Colleen Brown Committee Co-Chair

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

015 Items once ticked complete and included on the Register for the next meeting, can then be removed the following month. Community & Public Health Advisory Committee Meeting – Action Items/Resolution Register – 16 December 2020

COMPLETE DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES  Standing Items Locality Updates: Provide updates for Locality Hubs in 27 January Penny Magud general until established enough to provide individual 2021 deep dives. ARPHS – six-monthly update. 2 June and Doone Winnard 17 November 2021 Quarterly Non-Financial Summary: Quarterly report. 27 January Paul Hewitt Agenda Item 3.5 Metrics that Matter 2021 20/21 Metro Auckland SLM Improvement Plan – 10 March 2021 Robin van Ausdall quarterly report.

26.9.2018 3.1 4.3 Healthy Families New Zealand: Update to CPHAC in 6 TBC Phil Light Have not been able to confirm for months’ time. HFNZ have issued an invitation to host December. Will try for early 2021. CPHAC at Amersham Way, Manukau. 1.7.2020 4.1 Utilisation of Auckland Regional HealthPathways: 2 June 2021 Catherine Turner CPHAC asked Auckland Regional HealthPathways to return in a years’ time. CPHAC would like to be updated on how well has equity been ‘baked in’ and include progress on links to Disability. 9.9.2020 4.1 Mental Health: The team were asked to report back to 10 March Charles Tutagalevao, CPHAC in three months’ time providing strategic Ian Soosay, Pam analysis on how the work we do works in with the rest Hewlett of the country. Include information around future demand. 4.11.2020 3.1 Covid Testing Strategy: CM Health Board wish to be TBC TBC kept up to date with where this strategy is at, due to workforce at places like hotels and Americold type workplaces, are likely to be South Auckland residents. 4.11.2020 3.2 Faster Cancer Treatment: reporting data to be 27 January Aroha Haggie  provided to CPHAC.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

016 Items once ticked complete and included on the Register for the next meeting, can then be removed the following month.

COMPLETE DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES  4.11.2020 3.2 Immunisation Rates Early 2021 Aroha Haggie ELT’s work programme has a deep dive on Immunisations to pick apart what is happening there. Ms Haggie will come back to the committee as soon as they can with the plan of where they need to focus 16.12.2020 3.1 Rheumatic Fever Funding: Invite MoH to provide their 2 June big picture thinking around Rh Fever in Counties Manukau and regionally. CPHAC would like Think Place to present around the ideas they have been coming up with and how they’ll be implemented. June 2021. 16.12.2020 3.2 Women’s Health in the Community: Dr McIntosh is to return to CPHAC in 2021 to provide detailed information in regard to HPV in CM Health and a presentation regarding the Best Start Pregnancy Tool.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

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DRAFT CPHAC Committee Work Plan 2021

Meeting Date Strategic Deep Dive Operational Deep Dive Standing Items External / Regional Presentations Public Excluded

Localities Update Intesectoral Collaboration (Penny Magud) Asian Health: Health Status & Population 27 January SWB – 5 Yr Strategy & 2 Yr Action Plan Growth (Kitty Ko) (Ann Wilkie) Metrics that Matter (Paul Hewitt & Zizi Jasim)

Primary & Integrated Care Mental Health - Provide analysis on how the Community Workforce & Capacity work we do works in with the rest of the National Hauora Coalition – Current State & (Matt Hannant & Campbell Brebner) country. Include information around future SLM Improvement Plan Quarterly Report Funder Report/Dashboard (Timing TBC) 10 March Future Planning demand. (Kate Dowson (Fran Voykovich) (Dr Rawiri Jansen, Simon Royal) Te Ranga Ora Update (Charles Tutagalevao, Ian Soosay, Pam (Matt Hannant) Hewlett) Pacific Health – Fanau Ola Update incl Nurses presenting Patient Stories Q3 Non-Financial Summary Report Mental Health & Addiction: Treaty of Waitangi Audit Results (TBC) (Doana Fatuleai) 21 April TBC Suicide Prevention/Postvention (Sharon McCook) (Paul Hewitt & Zizi Jasim) progress report Winter Plan – Focus on Vaccinations (Fran Voykovich)

Health Pathways – Innovations & Learnings Funder Report/Dashboard (Timing TBC) from 2020 and how well has equity been (Fran Voykovich) Provider Development ARPHS 6-Monthly Update to CPHAC 2 June ‘baked in’. Include progress on links to (Aroha Haggie/Funder GMs) Jane McEntee Disability. Budget 21/22 Funder Discussion (Campbell Brebner, Catherine Turner) (Aroha Haggie, Steve Murray)

Consumer Council re Engagement in the Localities Update What is happening in the Prevention space? Community (Penny Magud) ARDS & CADS re their customer feedback Renee Greaves Contract Auditing 14 July process. (?) SLM Improvement Plan Quarterly Report (Gary Jackson) Te Ranga Ora Progress Update (Kate Dowson) (Earnest Pidakala, Matt Hannant) Annual Report Alcohol Harm Minimisation – Strategy Refresh (Paul Hewitt & Zizi Jasim) (Gary Jackson) Weight Reduction Service Funder Report/Dashboard (Timing TBC) 25 August (Gary Jackson) Q4 Non-Financial Summary Report (Fran Voykovich) Women’s Health: Best Start Pregnancy Tool TBC (Dr McIntosh) (Paul Hewitt & Zizi Jasim)

Southern Corridor Progress Update on Women’s Health (Alan Greenslade) Funding Arrangements to ensure Improved 6 October Primary Birthing Units Health Outcomes for Vulnerable Whaanau (Mary Burr/Sarah Tout) Startwell Nurses – How has 2021 been for (Aroha Haggie) vulnerable mothers/whaanau?

SLM Improvement Plan Quarterly Report (Kate Dowson Smokefree 2021/Vaping Area Update ARPHS 6-Monthly Update to CPHAC Funder Report/Dashboard (Timing TBC) 17 November (Basil Fernandes) Q1 Non-Financial Summary Report Jane McEntee (Fran Voykovich) TBC (Paul Hewitt & Zizi Jasim)

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021 018 Hello, Kia Ora, Talofa Lava, Namaste, Nǐ hǎo, Pagbati, An-young-ha-se-yo, Jom reab suar, Xin Chao

Asian Health Asian Health Status & Population Growth January 2021

Kitty Ko Asian Health Gain Advisor Directorate of Population Health

Date: 019 Asian population in Counties Manukau & Who are Asian people?

The New Zealand health and disability sector classifies ethnicity data according to the Ministry of Health protocols. The term ‘Asian’ used in the New Zealand Census and related data sets, refers to people with origins in the Asian continent, from China in the north to Indonesia in the south and from Afghanistan in the West to Japan in the East. This differs from the definition used in other countries such as the United Kingdom or the USA.

Reference: Counties Manukau Health (2020). Annual Plan 2020/21. Auckland. Counties Manukau Health. Retrieved from https://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Annual-reports-and-plans/2020-21-CM-Health-Annual-Plan- incorporating-2020-21-Statement-of-Perform....pdf 020 Asian populations in Counties Manukau

CM Health localities by prioritised ethnic groups, ER population 2018 NZ Euro/ NZ Euro/ Maaori Pacific Asian Total Maaori Pacific Asian Total Other Other Eastern 9,300 6,700 68,200 71,200 155,700 Eastern 6% 4% 44% 46% 100% Franklin 14,600 3,400 6,800 55,900 82,500 Franklin 18% 4% 8% 68% 100% Manukau 48,400 50,000 63,300 49,600 210,300 Manukau 23% 24% 30% 24% 100% Maangere/Ootara 19,600 65,200 18,600 10,000 112,300 M/O 17% 58% 17% 9% 100% Total 92,360 125,440 158,040 191,170 567,010 Total 16% 22% 28% 34% 100%

CM Health Asian subgroups, 2018 The largest Asian sub-groups in Chinese Filipino Indian Korean Other Total Counties Manukau in 2018 Asian Asian were Indian (~half) and % of CM Health Chinese (~a third). The highest 32% 6% 48% 3% 11% 100% Asian pop numbers resided in Eastern % of CM locality (Howick, Pakuranga) 9% 2% 13% 1% 3% 28% population and Manukau locality Estimated ER (Papatoetoe, Manurewa, 51,030 11,340 73,710 5,670 17,010 158,040 count Papakura)

Reference: Lees J., Lee M. & Winnard D .(2021) Demographic Profile: 2018 Census, Population of Counties Manukau. Auckland: Counties Manukau Health. In publication. 021 Life expectancy

• Life expectancy of Asian people is consistently greater than both the overall life expectancy and the average life expectancy of NZ European/Other ethnic groups.

• When we look deeper into the drivers of life expectancy, we see diversity of health status within the many Asian ethnicity subgroups.

• As the ‘healthy migrant effect’ typically reduces over 5-7 years of New Zealand residency, to sustain this relatively high life expectancy, we are focused on early ill-health prevention and effective Reference: management of long term conditions in Counties Manukau Health (2020). Annual Report 2019. Auckland. Counties Manukau Health. our Indian and Chinese communities. Retrieved from https://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and- planning/Annual-reports-and-plans/2019_CM_Health_Annual_Report.pdf

022 Diabetes prevalence by ethnicity in Auckland metro in 2018

• Pacific, Indian and Māori populations have the highest diabetes prevalence in the Auckland metro region. Based on longitudinal laboratory results, the crude diabetes prevalences for people aged 15 and over were 15.1%, 12.0% and 8.6% for Pacific, Indian and Māori populations in metro Auckland in 2018.

• By age 70, 19% of the adult population of metro Auckland in 2018 had developed laboratory- confirmed diabetes. This varied significantly by ethnicity, with European/Other at 12% compared with Indian at 44% and Pacific at Reference: 50%. Chan, W. C., Lee, M. (AW) & Papaconstantinou, D. (2020). Understanding the heterogeneity of the diabetes population in Metro Auckland in 2018. Auckland: Counties Manukau Health. Retrieved from https://countiesmanukau.health.nz/assets/About-CMH/Reports-and- planning/Diabetes/2020_Understanding_the_Heterogeneity_of_the_diabetes_pop.pdf

023 Diabetes prevalence by ethnicity and NZDep2013 quintile in metro Auckland in 2018

• Pacific people living in the most socioeconomic deprived areas have the highest diabetes prevalence.

• Pacific and Indian people living in the least socioeconomic deprived areas in Auckland metro still have almost twice the age standardised diabetes prevalence than the New Zealand European and Other group living in the most socioeconomic deprived areas.

Reference: Chan, W. C., Lee, M. (AW) & Papaconstantinou, D. (2020). Understanding the heterogeneity of the diabetes population in Metro Auckland in 2018. Auckland: Counties Manukau Health. Retrieved from https://countiesmanukau.health.nz/assets/About-CMH/Reports-and- planning/Diabetes/2020_Understanding_the_Heterogeneity_of_the_diabetes_pop.pdf

024 Number of poorly controlled diabetes by ethnicity and by DHB in 2019

There are over 6,000 Indian people with diabetes living in CM Health. While more likely to have controlled diabetes than Maaori and Pacific people with diabetes there are still ~16% with very poorly controlled diabetes

Reference: Chan, W. C. & Lee, M. (AW) (2020). Update on Diabetes prevalence in 2019 based on laboratory results in the Auckland Metropolitan Region (from TestSafe). Auckland: Counties Manukau Health. Retrieved from https://countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Diabetes/2020-09- Updates_on_diabetes_prevalence_in_2019.pdf

025 Access to prevention services by ethnicity

Reference: Draft Counties Manukau Health Annual Report 2020.

026 Access to prevention services by ethnicity

Asian data is not reported here?

Reference: Draft Counties Manukau Health Annual Report 2020.

027 Access to early detection and management services by ethnicity

Asian data is not reported here?

Reference: Draft Counties Manukau Health Annual Report 2020.

028 Barriers to access services

Systemic barriers Cultural barriers Practical barriers Lack of interpreter services or Lack of English language Intense stigmatisation around culturally / linguistically appropriate proficiency mental illness that exists among health information many Asian cultures Inadequate knowledge and Lack of bilingual health professionals, awareness of existing Religious beliefs, and cultural incompatible Western health health services differences in the presentation treatment models as well as treatment of mental illness Lack of cultural competence in health care

Reference: Ko, S. W. K. (2013). A Review of Asian Mental Health Service Development in Auckland, New Zealand (Unpublished master’s dissertation). University of Auckland, Auckland, New Zealand.

029 Barriers to access services

Reference: Cen, D. (2017). Project report for preventing barriers to Immunisation for Asian population in the Counties Manukau region. Auckland: Counties Manukau Health . 030 Making health decisions by ethnicity and age group

Half of the young participants stated their parents made health decisions for them instead of them making own health decisions even these young people were already in their early 20s.

A Chinese elderly also said family member made health decisions for him/her; again this is very common among Asian cultures for adult children make decision for their elderly parents.

The above show the cultural differences when accessing, approaching and utilising health services; thus, a specific approach to engage with Asian communities is needed in health promotion and Reference: delivering health services. Azhaara, A. (2017). POPULATION HEALTH 302 ORGANISATION PROJECT REPORT - Oral Health in Young People. Auckland: Counties Manukau Health.

031 Factors affecting health decisions by ethnicity and age group

Cost was a major factor affecting health decisions for young participants; while language and transport were barriers for elderly Chinese.

For adults who were parents, time, priority and cost were the factors affecting health decisions as they needed to work and look after their families; they often put their own health to the last on their priority list.

The above shows different age groups within Asian communities need different approaches when accessing, approaching and utilising Reference: health services. Azhaara, A. (2017). POPULATION HEALTH 302 ORGANISATION PROJECT REPORT - Oral Health in Young People. Auckland: Counties Manukau Health.

032 Asian Health Gain Advisor role

Evaluation, Reporting Build Relationships & Communication To establish & grow collaborative and Support the Planning Team in building positive relationships planning & performance reporting in a manner that enhances visibility at executive & service delivery levels across the district Leadership Provide advice, promote and facilitate Regional Planning Asian health gain by influencing local ownership and commitment to Asian Health Gain Liaison & Networking integrated & collaborative approaches Be a visible advocate for the health & Advisor wellbeing of the diverse Asian communities living in Counties Manukau

Local Strategic & Annual Planning Service Development Provide advice, encouragement & Advice & Support support to Locality Leadership Groups Work closely with subject matter in development of Asian health gain experts to build their understanding of activities Asian health needs and challenge CM Health’s performance and opportunities to improve

033 Asian Health Gain Advisor role

CM Health Asian Health & Wellbeing Community Network currently has over 230 members; across DHBs, PHOs, NGOs and community organisations including students and individuals who are interested in Asian Health.

Members include Chinese, Indian, Filipino, Korean, Vietnamese, Cambodian, Japanese, South Asian, and others, etc.

034 Asian Health Gain Advisor role

Asian cultural celebrations & Asian Health Action Roadmap

035 Asian Health Gain Advisor role

Share learning and influencing Asian info and resources for cancer & patients and families Requests from frontline clinicians

Queries for accessing services Asian in CM Health speaking support Cultural

advice Chinese and needed Vietnamese lawyers Asian speaking therapists

Cultural input for Cultural input into diagnosing and updating CM developing treatment Health’s policies & plan for Asian mental procedures health service users

036 Communities in Action (Community Flu Fighters Programme in Asian communities)

• A total of 945 individuals received the vaccines in 2020. • 568 from Chinese organisations, 85 from Indian, 148 from Korean, 9 from Korean Positive Ageing Charitable Trust Takanini School Road Gurdwara Sri Cambodian, and 135 from ethnically Kalgidhar Sahib Temple diverse organisations. Transport, language, time, priorities, mistrust, and lack of support are barriers to the elderly Asian population accessing influenza vaccinations via the traditional access points of G.P practices or community pharmacies.

Influenza immunisation rates can be improved by offering vaccinations where elderly Asian people socialise as social connectedness is fundamental to Asian culture and Botany and Flat Bush Ethnic Association Wat Khemaraphirataram Cambodian Temple “community is where the heart is”. 037 Communities in Action (Community Flu Fighters Programme in Asian communities)

038 Well-done Asian Communities!

039 Questions & Answers

Source: https://elearning.tki.org.nz/Media/Images/Equity-vs-equality

040 Counties Manukau District Health Board Community & Public Health Advisory Committee Locality Community Health Services - Community Hubs Update

Recommendation

It is recommended that the Community & Public Health Advisory Committee:

Receive the update on the Locality Community Health Service Community Hubs.

Note this report is being simultaneously submitted to the 267 January Executive Leadership Team meeting.

Prepared and submitted by: Penelope Magud General Manager Locality Services on behalf of Margie Apa, CEO, Counties Manukau Health.

Executive Summary

This paper details the developments that have occurred to date in regards to the utilization of the 4 Community Hubs and details the developments approved to be implemented over the next 6 months.

Background

Counties Manukau Health (CM Health) has for several years been progressing a programme of work which is progressively integrating and extending the role of Primary Care and Community Health Services within the District’s health and social care system.

Grow Community Hubs is a key investment strategy for CM Health, with the intention to deliver more outpatient/ambulatory services closer to patients’ homes in Primary Care and locality based Community Hubs. This is part of a broader health service delivery network connecting general practice, community care, specialist services, Middlemore Hospital and Manukau Health Park.

The plan is for Community Hubs to offer a core suite of services, beyond the scope of general practice, as well as specific services appropriate to the needs of the locality population. The hubs will provide the necessary community infrastructure to enable provision of extended services in the locality community areas and enable an expanded range of services to be delivered in the community from a ‘neutral space’ where a range of professionals can work from, and patients can be referred to, in a model that complements established GP-patient relationships and enhances CM Health provision of more accessible ambulatory care.

Locality Community Health Service manages 4 Community Hubs in Mangere, Otara, Botany and Pukekohe as well as the integrated Mental Health and Community Health facility at Awhinatia in Takinini.

The service is still currently delivering District Nursing Services from Building 38 Western Campus, Middlemore, however plans are being developed to ensure that these clinics transfer to the hubs at Mangere and Otara.

Services can be and are delivered directly or coordinated virtually from these 5 community sites.

As Community Hubs are primarily about services, rather than facilities, they are located and organised differently in each locality taking into account pre-existing local services, service mobility needs, operating models and optimal service location.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

041 As Community Hubs are further developed they will be an integral part of an integrated continuum connecting health and social services across home, community, NGOs, general practice and hospital settings. They will be supported by an effective information and communication system.

Community Hub Developments to date:

Mangere Hub Mangere Hub is in Waddon Place; it currently has 7 clinic rooms which over quarter 1 & 2 of the 20/21 financial year has had in excess of 4,500 clinic attendances at the following clinics:  Acute Allied Health Clinics  Cardiology  Child Development  Contraception clinic  Diabetes  Endocrinology  Gastroenterology  General Medicine  Neurology  Ophthalmology Diabetes  Pediatric Medicine  Podiatry  Psychological Medicine  Renal Medicine  Respiratory Medicine  Rheumatology  Stroke

Otara Hub Otara Hub is located at 112 Braids Road, Otara. This is a property which is owned by Ngati Tamahoo and until November 2020 CM Health held a license to occupy 6 clinic rooms. The hub currently operates out of 6 Clinic rooms which over quarter 1 & 2 if the 20/21 financial year has provided 1301 allied health or nurse led clinics for Otara domiciled patients in the following clinical areas:  Cardiology  District Nursing clinics (DN clinic volumes are not included in the figure above)  Diabetes  Allied Health clinics  Maternity  Child development  Retinal Screening  Outreach Cervical Screening

Ngati Tamaoho own the building and CM Health has recently negotiated a 5-year lease of the whole property. This will enable CM Health to expand clinic space from 6 to 11 clinics, as well as create a staffing hub for community health staff & space to provide virtual telehealth.

Eastern Hub (Botany Superclinic) 14 clinic rooms providing in excess of 13,000 clinic attendances. Currently functioning at 94% utilization Monday to Friday 8.30 – 4.30, this is an increase from 23% in February 2017 22% of all patients attending clinics in the Eastern Hub are not Eastern Locality domiciled. District Nursing clinics 7 days per week Retinal Screening Clinics 6 days per week Primary Care provide evening cervical screening clinics

Integrated care model being developed,

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

042  The locality Community Health, Mental Health and Primary Health staff are aware of the range of clinics that are run from the hub and identify the opportunity for consultation or joint visits for their patients.  The Nurse Clinic Coordinator has aligned clinics for patients to reduce the need for patients to come to the hub multiple times in a week.  Clinic Coordinator and Hub Nurses have spent time with clinicians providing education on how the hub staff can support the clinics in the provision of patient education and health care. This has led to clinicians involving the hub nurse’s consultations to enable patients’ needs to be better supported within the community system e.g. referral to complex care, DN referral or additional health education.  The hub has introduced a more comprehensive review of those patients who DNA to help identify barriers to attendance rather than just focusing on the process.

CM Health own the Unit Title for Unit A, with Care Group (Formerly East Care owning the unit titles for B & C), Care group have submitted a formal letter of interest to the Board to purchase Unit A

Pukekohe Hospital – Outpatients  Infusion clinic provided in partnership with Medicine has commenced 1 day per week, providing blood transfusion and venous sections to 4 local patients that would normally be admitted to Middlemore Medical Assessment Unit weekly  Clinic Coordinator Registered Nurse has been recruited to, to oversee the coordination of the clinics, ensure clinicians are appropriately supported in line with the other hubs & Manukau Health Park Modules  Locality Leadership Group submitted a report to Board Chair & CEO in regards to local needs & short, medium & long term recommendations of what needs to be delivered & developed locally  Pukekohe Hospital Outpatients has the capacity to provide 6000 outpatient clinics per annum Monday to Friday. The current facilities are 99% utilized providing 5,986 outpatient clinic appointments per annum. This includes private Local Midwife Clinics, as well as regional services such as Wheelchair Services, Starship Diabetes services, CADS services  5% of patients attending clinics at Pukekohe Hospital are not domiciled in the Franklin Locality. These patients are domiciled in Manukau locality, typically in the Karaka, Drury region.

Approved Developments to occur in the next 6 months

Locality Community Health Services are working with all divisions to confirm the clinics that should be delivered within each of the hubs as well as the staffing level, competency and equipment that is required to support new locality based community hub services/clinics.

Mangere  10 additional clinic rooms – 100 additional clinics per week Monday to Friday with the opportunity to look at providing further evening and weekend clinics, particularly with District Nursing clinics relocating to Mangere hub and being required to operate 7 days per week with some evening clinics too.  District Nursing clinics to move from Building 38 to Mangere Hub  Establishment of a community base for staff – Including Community Health multidisciplinary nursing & allied health teams as well as children’s services

Otara  5 additional clinic rooms; group therapy area – 60 additional clinics or group sessions per week Monday to Friday. Like Mangere there is the opportunity to look at providing further evening & weekend clinics, particularly as all District Nursing clinics will be provided in the hubs and away from western Campus. These clinics will be operational 7 days per week with some evening clinics too.  Re-establish District Nursing clinics across the week and extend to cover evenings & weekends  Establishment of a community base for staff – including Community Health multidisciplinary nursing & allied health teams and Public Health Nursing

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

043 Franklin  12 additional clinic and procedure rooms (e.g. physician and nurse provider outpatient clinics; patient tele-health rooms; infusions & minor surgical procedure rooms; nurse support/preparation area; patient toileting facilities).  Ongoing development of the Community Ward to provide a medical pathway to support admission avoidance & earlier transitions of care from Middlemore Hospital

Awhinatia (Manukau)  As a CM Health community based multi service site the plan is to ensure retinal screening has the ability to provide clinics from this site. The service is currently working through contractual issues with the clinic where screening is currently provided from.  Opportunity to review what clinics could also be provided from the Awhinatia site as part of an integrated model of care with Mental Health and Locality Community Health Services.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

044 Counties Manukau District Health Board Community and Public Health Advisory Committee Faster Cancer Treatment Reporting Data

Recommendation

It is recommended that the Community and Public Health Advisory Committee:

Receive the Faster Cancer Treatment Reporting Data paper.

Note this paper was endorsed by the Executive Leadership Team on 15 December to go forward to the Community & Public Health Advisory Committee for their information.

Note that the information provides an update of FCT performance and related activity noting that the focus of FCT is predominantly at the hospital for diagnosis and treatment.

Note that FCT performance for October 2020 is 88% in terms of the hospital based specialist treatment being delivered within 62 days.

Note that since May 2020, the monthly performance remains at or above 85%. Covid19 contingency plans are in place to maintain cancer services across various levels of alert status.

Note that there is potential benefit from further work to address joint Primary Care and Hospital actions to ensure that Equity considerations are adequately incorporated, and FCT can sustainably meet the target of 90%.

Note the actions identified in the paper in relation to continued development of FCT performance.

Prepared and submitted by: Aroha Haggie Director Funding & Health Equity

Glossary

ADHB Auckland District Health Board CNC Cancer Nurse Coordinator CTT Cancer Tracking Team DNA Did Not Attend ED Emergency Department FCT Faster Cancer Treatment FSA First Specialist Assessment GP General Practitioner MOH Ministry of Health NCN Northern Cancer Network

Purpose

The purpose of this paper is to provide an update on Faster Cancer Treatment (FCT) reporting data in line with action 3.2 from the 4 November 2020 Meeting of the Community and Public Health Advisory Committee.

Background

FCT has a current target of 90% of patients to receive their first cancer treatment (or other management) within 62 days of being referred with a high suspicion of cancer and a need to be seen within two weeks. Counties Manukau District Health Board- Community & Public Health Advisory Committee 27 January 2021

045 The current reporting of FCT data is mandated by MOH for 13 tumour streams and the focus is on hospital patient flow performance. Not all cancer care is included in the FCT reporting. Rather FCT reporting is restricted to measuring the timing of care where clear pathways are in place – 62-day pathways.

Hospital based cancer treatment

The FCT target and current reporting is focused on hospital based cancer patient flows, with performance recorded against all tumour streams. Actual volume of treatment numbers are not reported as part of FCT. One of the key challenges across all the tumour streams is to ensure that FCT is a core priority of all clinical teams and support staff involved in the patient pathway. In the past 12 months services have refocused on the need to meet the FCT target and are ensuring patients are continuously facilitated, predominantly by the CNC and CTT.

For the month of October the achieved level of FCT was 88%. In terms of patient numbers this means that 30 of 34 eligible patients were treated within 62 days. If 1 additional patient had passed this would have achieved the 90% target. Of the four patients who breached: two patients were delayed in medical oncology at ADHB and two other patients faced delays due to in-house capacity constraint.

A key component of all FCT activity is developing collegial relationships across all services and also externally with regional NCN colleagues and specifically with ADHB as the tertiary provider of treatment. This includes engagement with regional meetings and data evaluation to establish consistency in application of the business rules to standardise the comparison of performance against the target and monitor the various cancer pathways. Recently senior managers and clinicians from the organisation’s cancer service participated in a regional review of the gynaecological endometrial cancer pathway to improve FCT performance. The cancer service intends to progressively engage in similar regional reviews for other tumour streams.

Community/Primary Care

Currently, the FCT reporting data excludes any primary care related information. However there are steps being taken to capture information that will allow better monitoring of how patients are being detected and progressed through the system of care. Cancer screening data, such as for Breast and Bowel cancers are also reported separately and do not form part of FCT reporting. From a population health perspective,

Counties Manukau District Health Board- Community & Public Health Advisory Committee 27 January 2021

046 the Cancer Steering Group does ‘deep dives’ into specific tumour streams (2-3 times a year). This provides an in-depth analysis of cancer registrations, treatments, and mortality for that tumour stream, as well as ethnicity-based volumes so that a reasonable view of equity and outcome for each deep dive can be developed.

FCT is largely predicated on the specific grading of each patient by hospital specialists for an FSA appointment. The hospital based grading of patients for FSA is however dependent on the supplied information from the GP.

Equity

Equity considerations are an important part of the funding of services. Utilisation by ethnicity indicates that in particular tumour streams, there is lower achievement of FCT performance for Maori and Pacific patients. This is difficult to measure on a month by month basis as the volumes in each group are small. In the 12 month period Nov 2019 – Oct 2020 FCT performance has been 85% for both Maori and 85% Pacific patients.

FCT HeatMap Report Includes patients with first treatment period 01 Nov 2019 To 31 Oct 2020 Period 01 Nov 2019 To 31 Oct Performance Trends last 6 months 2020 62-day target: passes and Patients Passed 62 day 62 day Sep 2020 Oct 2020 Variance May 2020 - Jul Aug 2020-Oct Variance capacity breaches 62 Days compliance compliance 2020 2020 Ethnicity % Trend Asian 33 27 81.8% 100.0% 85.7% -14.3% 100.0% 90.9% -9.1% European 186 170 91.4% 100.0% 81.8% -18.2% 90.2% 92.1% 1.9% Indian 18 18 100.0% 100.0% 100.0% 0.0% 100.0% 100.0% 0.0% Maori 65 55 84.6% 100.0% 100.0% 0.0% 81.3% 100.0% 18.8% Other 6 6 100.0% 0.0% 100.0% #DIV/0! 100.0% 100.0% 0.0% Pacific Islander 68 58 85.3% 100.0% 83.3% -16.7% 84.6% 94.4% 9.8% Total 376 334 88.8% 100.0% 88.2% -11.8% 89.2% 94.7% 5.5%

Discussion

In the Counties Manukau district, there is a growing and aging population, with an expected increase in incidence for all cancer types. Volumes requiring specialised treatments such as chemotherapy and radiotherapy are also projected to increase. There will be increased capacity constraint, particularly in Breast, Gynaecology and Head & Neck tumour streams. Patients require upfront outpatient and diagnostic services to reach a diagnosis or be excluded from the FCT pathway. This creates the need for additional outpatients, radiological and biopsy procedures.

The decline in FCT performance against the target for Maori and Pacific patients is particularly worrying. Delays to treatment impose ill health onto the community and a poorer outcome for individual patients. Reportedly, Maori and Pacific patients have trouble engaging with services, demonstrate significantly higher outpatient DNA rates in existing models of care and frequently have comorbid conditions affecting management. This is not always evident as patients that delay due to comorbidity or patient choice are excluded from the FCT target. In the case of delays caused by patient choice it is important to understand the barriers that prevent individuals from engaging in timely access to services. Hence, while the FCT target focus is predominantly at the hospital for diagnosis and treatment, there are areas that would potentially benefit from further collegial work with Primary Care.

A community focus can be taken to assist hospital FCT performance, as follows:

 Deeper review of the barriers for patients presenting to GP - current data suggests that a significant number of patients (mainly Maaori & Pacific) present to ED with subsequent diagnosis of late stage cancer. It would be worth exploring what the gaps are, and how these result in patients not being referred earlier or obtaining an earlier diagnosis.

 Potential of developing Marae based services and like-opportunities that may improve the experience of Maaori patients with a suspicion / diagnosis of cancer. Counties Manukau District Health Board- Community & Public Health Advisory Committee 27 January 2021

047

 Developing information sets for primary care referrals so that the decision making around cancer suspicion could be better prioritised  Exploring the use of basic diagnostic tests in primary care to support referrals (e.g. pipelle procedures undertaken in primary care; to decongest the volume of patients on a suspicion of cancer pathway as patients with a negative pipelle are more likely to not have a cancer).

Counties Manukau District Health Board- Community & Public Health Advisory Committee 27 January 2021

048 Appendix 1. 5-year strategy & 2-year work plan

South Auckland Social Wellbeing Board 5-Year Strategy (2020 – 2025) and 2-Year Action Plan

S 049

Contents

The South Auckland Social Wellbeing Board 3

Purpose of this document 4

Introduction – the next 5 years 5

What we know 6-8 Our Strategic Aspirations and Success Factors 9 Prevention, crisis and resilience building in an end-to-end system 10 The 5 Year Strategy 11 Why are we doing this 12-13

Executing the Strategy - the 2 Year Action Plan 14 Accountabilities 15 2020/2021 Work Programme 16

Our commitment to innovate and disrupt 17

Infrastructure 18

Appendices – descriptions of new initiatives 19-21

050

The South Auckland Social Wellbeing Board (as at June 2020)

Independent Advisor to Accident Counties Chair the Chair Compensation Council: Manukau DHB Sandra Lewis Holden Corporation: Gael Surgenor Margie Apa Alofivae (State Services Neil Phillips Commission)

Department of Kainga Ora Ministry of Ministry of Ministry of Corrections Karen Education Health Justice Alistair Riach Hitchcock Isabel Evans Clare Perry Julia Lynch

Ministry of Ministry of NZ Police Oranga Te Puni Pacific Peoples Social John Tims Tamariki Kokiri Sina Glynis Martin Aiolupotea- Mark Sandland Mariassouce aiono Goldsmith

051

Purpose of this document

Engage Others Achieve Mandate Ensure Commitment in the diversity, equity challenge and to do what it takes to make a difference to break down the barriers & disrupt opportunties in our community for our children & whānau the system where required

As a Board we are committed to breaking Our community is diverse and vibrant with We need agency mandate at all levels to down the barriers and disrupting the strong cultural values. We need to leverage enable our local leaders to do what it takes parts of the system that aren‘t working the strengths and work better together at all to make a difference for our communities levels to achieve sustainable future change optimally for our community

052

Introduction

The next 5 years – building on the work to date Building resilient communities through greater collective impact The development of this 5 year strategy and 2 year action plan is intended to create a shared medium term The SASWB’s member agencies have collectively been on a journey of mindset change, contributing to the vision, and to identify the actions required to achieve the 5 year goals. There is a deliberate shift to a “next design of different ways of working that use evidence and insights to achieve greater collective impact. phase” view for the SASWB, building on the cross-cutting themes from learnings to date. The 2 year action There is still more work to do to integrate the culture change throughout the member organisations, and plan is aligned to the confirmed 2 year funding path, including the Joint Venture for Family Violence and Sexual this will be a key piece of work in the 2 year action plan. Violence (JV) funding for early years family violence initiatives. Agencies have achieved a significant shift on the spectrum from networking / co-ordination as a group, Factors impacting our community in the next 5 years where information was exchanged for mutual benefit, to an advanced level of co-operation and The Board has identified a number of factors that will impact our local environment, and therefore the role collaboration where there is now some common planning, formal communication flows and some and function of the SASWB over the short-medium term, including: resource sharing and concessions. The SASWB is on the cusp of being able to achieve greater collective impact and an end to end system; a system that will support and enable communities to build social • An increased agency focus on relationships with Iwi and NGOs, and enabling communities to take active capital, whānau resilience and long term intergenerational change. The key elements required to achieve roles this are highlighted in Figure 1, and work on these elements form the foundation of the Board’s 5 year • A strong focus on partnerships, prevention and participation, however, at the same time, strategy. acknowledgement of an increase in intensive support models that are currently operating within single agency silos Figure 1: Key elements to achieve greater collective • Agencies’ operating models are evolving, building on learnings from the COVID response, and include Impact and an end-to-end a general shift by the majority of agencies from central to local / regional decision making system • The COVID recovery response. There will be a significant impact in South Auckland, particularly on unemployment, housing, financial security and the resulting psychological distress and trauma. There is an exacerbation of existing stressors for already at risk families, but also a population cohort who have

never required support before now accessing support. The Board considers it has a role to play in

supporting South Auckland’s COVID recovery phase • The social housing building programme (volume and density) will have an impact on the ability of existing infrastructure and supporting services including schools to meet the needs of a growing and potentially There is more work to be done to make a long-term difference through evidence-based disruption vulnerable population. Long term sustainability continues to be a key driver of the SASWB’s strategy. Embedding the collaborative way of working into core business, and formalising iwi and community There is a consensus that the impact of these factors in the medium term will benefit from enhanced partnerships will enhance our ability to respond to the consistent theme across all SASWB prototypes; that collaboration, a specific focus on communities of greatest need, and a wellbeing strength based approach. there is a high complexity of underlying stressors for a large proportion of South Auckland families, and Our journey to date and the shift to the next phase systems are currently disproportionately accessible to those that do not require them the most. Since its inception in 2016, the SASWB has applied a whānau-centred early support and prevention approach The strategy and action plan will reinforce the test and learn approach but will also incorporate an intent to improving long term outcomes for children. The original ‘5 intervention settings’ have evolved over time, to act on its mandate to disrupt where necessary to achieve outcomes for whānau. There will be support to testing initiatives across the spectrum of prevention, crisis and building whānau resilience. We recognise for agencies to identify and implement core business improvements that are gained from improved the unique features of our community, the local nuances and the need to understand the complexities and collaboration; inform system level change; and to break down organisational barriers and silos. growing inequity for our Māori and Pasifika populations. The ongoing refinement of the PBI infrastructure, We will continue to support and work in partnership with other PBIs and across Tāmaki Makaurau to governance and management arrangements, and the backbone function over time, has enabled the SASWB create an environment that supports and enables protective factors in communities; share learnings; and to test and learn rapidly, and therefore respond in a timely way, to community needs as a collective, when present national themes for system level change. required. 053

What we know: There are many opportunities to make a real difference for children and whānau

• Agency commitment, passion and investment in South Auckland • Shift to a focus on wellbeing rather than deficits • Effective collaborative / local infrastructure established through building of • Embed learnings and performanceimprovement Our 5 year strategy trusted relationships and mindset evolution over time – and a recognition opportunities into agencies / system builds on our strengths, that this takes time • Systematise established trusted relationships across agencies and the opportunities • Deep understanding of South Auckland community, the complexities of its • Iwi / community voice at the table we have identified, that unique population groups & challenges • Build community relationships and partnerships that ‘live’ will continue to • A willingness to challenge the status quo and tackle what is often considered

strengthen the as “too hard” the Treaty partnership approach effectiveness of the • An Independent Board Chairperson • Better define whānau SASWB’s collaborative • Ability to incorporate strategic and operational insights • Springboard off COVID-19 operating model enhancements Strengths

way of working to • Relationships functioning well with proven deliverables Opportunities • Align with other Auckland regional initiatives for impact (APO, achieve improved • Diversity across agencies ASSLG, Regional Public Sector Lead) outcomes for children • An agile backbone function / Implementation Office • Connect and share learnings with other PBIs and NGOs and whānau. • Focus on achieving a whānau-centred approach • Resource investment in Auckland region • A common purpose driven by shared culture and vision & ability to • Increase visibility of learnings in Wellington influence and challenge each other • Mandate for disruption

The 2 year Action Plan • A testing / learning framework underpinning design and delivery specifically incorporates mitigation strategies to • Funding uncertainty – resulting in lack of staff security / consistency • Risk aversion & organisational inertia address known • Decision making at local level being impacted by centre • Scale and complexity of South Auckland – risk of being put in • Different governance arrangements across agencies, and a lack of weaknesses and threats the “too hard” basket regional autonomy for some who then cannot fully participate in SASWB that limit our ability to • Reprioritisation of collaborative resources back into agencies

activity and/or local decision making achieve our goals. at discretion of individual agencies • National barriers – national policy influencing local ability to exercise discretion and therefore a tendency to err on the side of caution locally • The need to continue to prove ‘legitimacy’ to ensure • Ability to navigate complexity of Manawhenua and Matawaka in South Threats longevity Weaknesses Auckland • Pace of change limiting communication / real engagement • Ability to respond to the complexity within the Pasifika community with communities • Currently a government agency focus only with no Iwi / Māori / • Limitations on local mandate and flexibility from centre community input at governance level

054

What we know: We need to work differently to be able to respond to the diverse and complex needs of our community

Strong cultural values and unique needs Access to support is impacted by size and inequity

11% of NZ’s total Māori 569,000 people Our population is increasing 16% Māori popn resides in CM = 11% of NZ’s population by at least 1-2% every year

21% Pasifika 37% of NZ’s total Māori (36%) and Pacific (32%) 22% of our population are children Pasifika popn populations aged <15 years ismuch resides in CM = 13% of all children in NZ

Counties Counties Manukau higher than other ethnic groups 27% Asian

AsNZ’of % a s 20% of NZ’s Asian 205,000 people (36%) live in the 1 in 2 children live in the most 40% of total CM population popn resides in CM most socially deprived areas socially deprived areas is born overseas

It is complex, but we need to do better…

On average, we receive more Almost 20,000 people in South 4,220 ‘unique’ children 55% of students in Counties Manukau than 60 Police 111 calls every Auckland receive Job Seeker aged 0-4 years were present were attending school regularly in T2, day relating to family harm Income Support (43% of the at one or more family harm 2019 (c.f. 59% for all of Auckland) total for Auckland) call outs in a 12 month 1 in 10* adults receive period. The weekly volumes A further 18,500 people receive care for a diagnosed On average, 175 ROCs are increased over lockdown. mental health condition other income support received by OT every week (Fig 2)

Almost 70,000 people live Over 2,500 families are waiting 1,086 school age children We have the highest number of child protection with one or more for housing on the Social are not attending school referrals nationally with over 1,000 per year long term health conditions Housing Register

* This rate is potentially impacted by lower than expected access rates for some populations 055

What we know: The South Auckland community is diverse and vibrant, with strong cultural values... these strengths are core to building resilient communities

83% of those of Māori descent identified with one or Younger age groups consist of higher proportions of Māori, Pacific and Asian peoples more iwi 20-30% of Māori, Asian and Pacific people were in households that included other family householders compared with 6% of NZ European/Other groups

147 Howick has the highest proportion (49%) of the population born overseas in the entire Auckland region. Ōtara-Papatoetoe also has a high proportion (42%) different ethnicities 18% of those who had been born overseas had been living in New Zealand <5 years

Nearly two-thirds of people in Māngere-Ōtāhuhu identify as Pacific (61%), alongside almost half of the people in Ōtara-Papatoetoe (46%) and one-third of the people in 2013 Census Manurewa (33%) One in four people in Papakura (28%) and Manurewa (25%) identify as Māori Nearly half of the Asian population in CM Health identified themselves as Indian (46%) and a third as Chinese (34%). Approximately half (51%) of the Pacific population identified as Samoan, nearly a quarter as Tongan The Middle Eastern, Latin American, African (MELAA) group represents 1.4% of the (23%) and just over a fifth (21%) as Cook Island Māori. CM population; 64% of this group identified as Middle Eastern

056

Our strategic aspirations and success factors

In 5 years time, we will be able to say.... We will know we’ve succeeded when....

Children and whānau are leading the development of Our systems are able to flex up and flex down and 1 their own “one plan” and they trust us to support them 1 respond to the goals and aspirations of whānau

There is an agreed definition of partnership and thereis We are working in partnership with Iwi 2 2 mutual trust and confidence

Agencies initiate collaborative working because it Collaboration across government and non-government improves whānau outcomes, and adds value to the way organisations is the way of working 3 3 that they are able to respond to whānau

Multi-disciplinary working is seen as a professional Our frontline workers want to work in a multi- development opportunity and pathway. Trusted disciplinary environment 4 4 relationships are not dependent on individuals.

NGOs are enabled to take the lead in supporting NGOs are funded in a way that enables them to walk communities of greatest need and whānau to build alongside whānau and feel supported by agencies when 5 long term resilience 5 they require their support

057

A system view of prevention, crisis and resilience building as an end-to-end process is fundamental to being able to achieve our aspirations

PREVENTION

CRISIS CRISIS CRISIS

RESILIENCE

Start Well ECE Play 30 School alert School alert School alert School psychological response MDCAT MDCAT MDCAT Papakura One Plan Kaiarahi FGC and New Mums prevention opportunities Current 2018/19 work Currentprogramme 2018/19

058

South Auckland Social Wellbeing Board 5-Year Strategy

Te Tiriti o Waitangi Why Kāwanatanga Tino rangatiratanga Oritetanga Wairuatanga Why we do what Decision making Partnerships Equity Spirituality & Values we do Child & Youth Wellbeing Strategy aspiration “That NZ is the best place in the world for children and young people”

South Auckland Social Wellbeing Board Vision All children in South Auckland are healthy, learning, nurtured, connected to their communities and culture, and building a positive foundation for the future What What we need Goal 1: Whānau wellbeing & resilience Goal 2: Iwi partnership & participation Goal 3: Collaboration Goal 4: Equitable access to do Mana motuhake Rangatiratanga Manaaki ki te tangata Tomonga Matatika Children & whānau determine Iwi partnerships & participation A collaborative way of working is Diverse communities of greatest need including their own journey at all levels embedded as core business Māori and Pasifika are supported and enabled

Achieve equitable whānau-centred Embed an end to end collaborative Establish iwi leadership in governance and commissioning that enables whānau voice, way of working across prevention, local community partnerships and Iwi and NGO leadership crisis and resilience building

Key Pillars How Resilient communities built on self determined need and strengths; that flourish within environments that support and enable protective factors How we will do it Devolved funding models that promote equity and facilitate a one-plan approach

A flexible system of proportionate universalism that reflects the diversity of Counties Manukau

Workforce capability and a ‘can do’ culture that responds to communities

Collaborative ways of working including NGO leadership focused on whānau defined aspirations 059

Why are we doing this: We know we can do better for our community

We know there is consistency in the type and complexity level of stressors impacting at-risk families in our community, irrespective of entry point or agency lens. This level of complexity can mean that whānau have limited bandwith to take proactive action to seek / access support.

An existing population of already 1 stressed becoming more stressed COVID has

resulted in: A large cohort of ‘new’ people seeking Impacts of COVID 2 support

”Hidden” impacts from delayed access 3 to support and care during lockdown

060

Why are we doing this: We know we can do better for our community

Our whānau, community, and frontline staff have told us that we need to build trusted relationships, and what can be achieved when these relationships are built

061

New pieces of New Prevention In progress JV = Joint Venture Executing the strategy: The 2-Year Action Plan work Opportunities

PILLARS

Workforce capability and a ‘can Resilient communities built on Devolved funding models A flexible system of proportionate Collaborative way of working incl do’ culture that responds to ACTION AREAS self determined need and strengths based on need universalism NGO leadership communities • Progress development of a • Test a devolved funding • Design and test an integrated IHV / • Design and test a multi-disciplinary Papakura Marae community partnership model approach across all funders MDCAT model - building on Papakura “intensive case management” • Prototype Papakura Marae “One with existing contracts / Marae Family Start and Well Child function -- drawing on / streamlining Hub Plan, One System Kaiārahi” funding services existing agency ICM resources (commence 1 July 2020) JV • Complete 2.5 years of the 5 year • Design and test a prevention • Design and test an integrated Social Start Well cohort opportunity for at risk mums and new- Work / Health model for a cohort of Early years • School alert psychological response borns referred from SAM. Integrating children requiring FGC intervention. resiience • Finalise E&I school alert analysis to Intensive Home Visiting and MDCAT Aligned with OT Intensive Intervention inform expansion JV learnings to test a / Edge of Care Model flex up / flex down model JV JV • Supporting the COVID recovery • Finalise implementation of MDCAT • Test site for elements of the ICR response by enhancing the CM with Multi-agency Hub including the new integrated Multi- MDCAT to respond to increased information system (Whetu) Disciplinary Hub psychosocial distress (TBC)

• Establish an Iwi partnership at • Test a collective commissioning • Establish and embed Change • Continue to build relationships with Partnerships governance and management levels approach building on the NGO Champions within agencies relevant agency initiatives and Coalition programmes • Establish cross organisation training schedule Workforce • Scope and test transdisciplinary working

Evidence & Extract and present cross-cutting themes to inform future design and system change Insights

Board & SMG Take a future focus, and commit to resourcing agreed work programme, break down barriers, and influence internal agency system change

062

Executing the strategy: Accountabilities

Lead Participating Implementation Action Area Agency agencies Lead

OT, MSD, NZP, CMDHB, • Prototype Papakura Marae “One Plan, One System Kaiārahi” (commence 1 July 2020) NZ Police TBC KA, Corrections

OT, MSD, NZP, CMDHB, • Progress development of Papakura community partnership model Papakura SG Jaymee Wells Marae

KA, TSI, Corrections, MOJ

• Test a devolved funding approach across all funders with existing contracts / funding TBC TBC TBC

Papakura • Design and test an integrated IHV / MDCAT model building on Papakura Marae Family Start and Well Childservices OT, CMDHB OT, MSD, CMDHB TBC

• Design and test a multi-agency “intensive case management” function -- drawing on / streamlining existing agency ICM resources TBC TBC TBC

• Complete 2.5 years of the 5 year Start Well cohort CMDHB, OT MSD, OT, CMDHB Rochelle Bastion

• Progress school alert psychological response MOE, NZ MOE, NZP, DHB Ishani Gupta • Finalise E&I school alert analysis to inform expansion Police

• Design and test an integrated Social Work / Health model for a cohort of children requiring FGC intervention. Aligned with OT OT, CMDHB OT, CMDHB Ishani Gupta Intensive Intervention / Edge of Care Model

• Design and test a prevention opportunity for Mums and new-borns referred from SAM. Integrate Start Well nurse and FSM Social Early Years Resilience OT, CMDHB OT, CMDHB, Corrections Ishani Gupta Worker into the collaborative way of working

OT, MSD, NZP, CMDHB, • Finalise implementation of MDCAT with Multi-agency Hub Hub SG Peter Anderson KA, Corrections • Test site for elements of ICR model including new integrated information system (Whetu) NZ Police / JV TBC agency hub - CMDHB / • Supporting the COVID recovery response by enhancing the CM MDCAT to respond to increased psychosocial distress(TBC) TBC TBC (CMDHB?)

Multi MOH

• Continue to build relationships with relevant agency initiatives and programmes that support and enable SASWB work ALL ALL IO

• Test a collective commissioning approach building on the NGO Coalition JV TBC TBC

Partnerships • Establish an Iwi partnership at governance and management levels TPK ALL Katrina Taupo

• Establish and embed Change Champions within agencies SMG TBC TBC

• Establish cross-agency / NGO training schedule TBC TBC Seema Kotecha

Workforce • Scope and test transdisciplinary roles

063

Executing the strategy: 2020/2021 Work Programme

Planned deliverables Papakura Marae Hub Early Years Intervention Multi-agency hub Partnerships Workforce

• Commence System Navigator • Progress Start Well 5-year cohort • Transitioned to full operations • (Refer Intensive Case Management • Workshop to design • Progress community partnership • Completion of E&I output for School with confirmed agency initiative) Change Champion roles / model Alert to inform next steps participation • Scoping Collective functions Q1 • Scope integrated IHV / MDCAT • Design and planning for school • Appoint Operations Manager Commissioning approach • Stocktake workforce model psychological response (permanent) building on NGO Coalition training Sept 2020 • Initial workshop for Intensive Case • Scope and design FGC intervention • Identify lead for COVID recovery • Strategic Māori advisors develop • Scope the transdisciplinary management prototype model Psychosocial Mental Wellbeing Plan an engagement strategy with iwi role and how this could be & commence planning (TBC) and Māori shared across organisations • Implement integrated IHV / MDCAT • Commence implementation of school • Participate in planning of Whetu • Implementing Collective • Commenced prototype psychological response testing Commissioning implementation of Change • Detailed design and planning for • Implementation planning and • COVID recovery Psychosocial • Strategic Māori advisors Champions within 1-2 Q2 Intensive Case Management commence delivery FGC intervention response in place (TBC) implement the engagement plan organisations Dec 2020 prototype • Scope integrated IHV / MDCAT with iwi and Māori intervention for new mums

• Scope devolved funding approach • Implementation planning integrated • Whetu test site • Strategic Māori advisors co-design • Share learnings of Change across all funders (existing contracts) IHV / MDCAT intervention for new an iwi partnership plan Champions to roll out Q3 • Implement Intensive Case mums further Management prototype • Some shared training Mar 2021 sessions in place

• Complete System Navigator • Implemented school psychological • COVID recovery Psychosocial • Learnings from Collective • A workforce capability plan prototype and share learnings response with learnings response fully implemented – Commissioning being collated • Learnings from IHV / MDCAT • FGC initiative underway informing learnings to share(TBC) • Strengthened iwi partnerships Q4 prototype to inform system design Intensive Intervention / Edge of Care • Multi-disciplinary hub • Commence devolved funding model implementation and delivery Jun 2021 model implementation • Commenced IHV MDCAT learnings shared • Community partnership model intervention for new mums aligned with strengthened iwi partnership

064

Executing the strategy: Our commitment to innovate and disrupt

Principle driven design Innovate and disrupt Act on learnings

1. Achieve equitable access for our community Local 2. Incorporate whānau voice into design and Innovate delivery Agencies are committed to 3. Promote leaderful practice that places translating enhancements into core respectful and trusted relationships at the business and adapting local heart processes and operational policy 4. Promote Iwi, community and NGO Test where the evidence demonstrates leadership benefits. 5. Optimise and enhance existing services not duplicate or create new services National 6. Enable flexible approaches that reduce The SASWB will work with central fragmentation and duplication and enable Evidence agencies to establish formal thriving whānau mechanisms to proactively present 7. Responsibility to respond to issues arising in our community in a timely manner e.g. cross cutting themes and evidence COVID Stop Act to the centre to inform national 8. Evidence & Insights, and the Theories of system change and policy settings. Change underpin the design, and informs decision making X 065

Executing the strategy: Infrastructure

Governance and management arrangements Backbone function: The SASWB Implementation Office The existing governance and management arrangements outlined in Figure 3 Over time, as the collaborative way of working becomes part of the local system’s core below will be strengthened by the establishment of formal iwi and community business, the Implementation Office’s function and structure will evolve. However, it is partnerships, a key element of the 2 year action plan. expected that over the next 2 years, it will continue in its current form, hosted by the Counties Manukau District Health Board, and housed in the Multi-Agency Hub - Te Taanga Strong connections to central government will be maintained through the Lead Manawa. Agency, MSD. Resources currently funded by the SASWB include: Figure 3: Governance and management arrangements (as at June 2020) • 0.5FTE Programme Director • 1FTE Programme Manager • 1FTE Evidence and Insights Lead • 1FTE Evidence and Insights Analyst • 1FTE Project Manager

Additional resource-in-kind is outlined below: Role Agency FTE Board participation All Strategic Management Group All Operational Management Groups Various depending on initiative focus areas Implementation Office: Project Resource Ministry of Social Development 0.4 FTE Start Well Project Lead Counties Manukau Health Child and Maternal Health 0.2 FTE Interim Operations manager – Multi Strategic Māori Advisors Group Oranga Tamariki 1.0 FTE Disciplinary Hub (3 months) Strategic Māori advisors from each agency came together in 2019 with the SME Māori Te Puni Kokiri 0.4 FTE mandate to progress Iwi and Māori participation and leadership across the Start Well Social Worker Oranga Tamariki- Partnering for Outcomes 1.0 FTE Implementation Office Advisor NZ Police 0.5 FTE SASWB. It has taken an approach to explore opportunities across the north, DHB Support CMDHB 0.2 FTE south, east and western parts of Tamaki ki te tonga, South Auckland, starting with Papakura in the south. The Group’s work plan will support and enable the A key piece of work for the Implementation Office over 2020-2021 will be to work with Board’s achievement of the goals. central government to strengthen and present the case nationally for system level change based on the evidence of the SASWB work and the PBI Success Framework.

066

Appendices Brief descriptions of new work areas

Note: Many of these are in early scoping phase and therefore information is limited

067

Papakura Marae: A “One-plan, one-system Kaiārahi” in Supporting the COVID recovery response by enhancing the CM conjunction with the Papakura MDCAT MDCAT to respond to increased psychosocial distress TBC Prevention opportunity JV Facilitating the provision of the right support at the right time, to Utilising the family harm platform to identify and respond to the At risk mums and new-borns make safe and keep safe. Objectives: increased psychosocial distress as a result of COVID impacts. • To identify the core requirements for a “one plan” way The SASWB has the infrastructure in place to respond in a collective An opportunity to engage earlier with a cohort of mothers and babies identified in at-risk situations, through police call outs for of working at a locality level, (and also what is specific to way that is aligned with the Ministry of Health’s “COVID-19: Papakura) Psychosocial and Mental Wellbeing Plan” which has outlined the family harm. need for the system to work together to address the issues. • To identify the system blockages and enablers of a “one Test a flex up / flex down model which integrates learnings from plan” way of working This will require an enhancement of the CM MDCAT team with Intensive Home Visiting, MDCAT and SAM unborn alert referrals, • To identify the elements of the trusted relationships that psychological / Mental health resource to contribute to the utilising a multi-disciplinary needs assessment to determine the required, in order to systematise them rather than relying early identification of need and the upskilling of other agencies most appropriate pathway for support on individual / personal relationships to understand psychological distress and the support required. • To identify how frontline staff and/or BAU processes can be Objectives: enabled within existing legislation and policy, to support Objective: To reduce the immediate / future impact of cumulative harm whānau in a timely manner • To support the local COVID-19 recovery response using on children. • To utilise evidence and insights to recommend operating existing platforms and infrastructure To build on cross cutting learnings to date model improvement opportunities (across the system) that • To evidence the type and volume of need in the community To test the reallocation of existing Social Work resource will enable us to make safe and keep safe through which will inform local design of community-based responses through “Family Success Matters” to higher intensity /lower appropriate and timely response to whānau, irrespective • To build greater understanding of conditions and support case load of where they are in their journey (from crisis through to requirements which can then be embedded across agencies. To input into a greater understanding of what proportionate resilience) universalism means for South Auckland • To apply a “Who’s Plan is it anyway” approach. To test a flex up / flex down model School psychological response JV Building on learnings from the Family Harm School Alert initiative, Papakura Marae: Integrated IHV / MDCAT model building there is recognition that there is a need to: Prevention opportunity on Family Start and Well Child services JV Integrated Social Work / Health model for a cohort of children Support teachers to identify psychological distress as a result of A collaborative approach across Family Start and Well Child children being exposed to family harm / violence particularly in at risk of poor outcomes, identified at FGC intervention. service provision that is Māori / marae led supported by learnings the younger age group and prevent longer term impact An opportunity to build on Intensive Home Visiting learnings and of Start Well align a collaborative response with OT Intensive Intervention / Support children from primary school to secondary school Edge of Care Model Objectives: who have been exposed to family harm / violence with an To reduce the immediate / future impact of cumulative harm evidence- based intervention. on children. Objectives: Objectives: To build on learnings from Start Well and MDCAT To identify existing supports / services already in place that • To input into a greater understanding of what proportionate To test the reallocation of existing Family Start resource could be repurposed universalism means for South Auckland to higher intensity / lower case load To identify and test a tool / programme that will prevent the • To test Play30 in a non ECE setting and older age group To input into a greater understanding of what proportionate long-term effects and risk of poor long term outcomes for • To test a flex up / flex down model universalism means for South Auckland children exposed to family harm / violence. To test a flex up / flex down model

068

Change Champions – embedding learnings and performance improvement Multi-agency “intensive case management” function -- drawing opportunities back into agencies on / streamlining existing agency ICM resources Identifying senior level “change champions” (part funded by SASWB) within A proposal to test a collaborative Intensive Case Management agencies who have dedicated time and resource to champion nmulti- model that brings together existing Intensive Case Management agency, multi-disciplinary working by: resources from agencies into one place acknowledging that the • Working closely with the SASWB and other partner agencies, focussed stressors are the same and require a collaborative approach to on leading, enabling and influencing individual agency participation in address these. No one agency can deliver all. collaborative activities A possible opportunity is to build on the agency co-location and • Identifying and championing improvement opportunities within their the one plan Kaiārahi that is already underway at Papakura respective organisation, where collective working identifies Marae. opportunities to optimise their operating models and therefore outcomes for whānau Objectives: • Contributing to future thinking through the SASWB Senior Management • To test the ability to achieve better integration and Group efficiencies from one collaborative service vs multiple They would be responsible for: agencies working with one whānau to address the same underlying stressors • Embedding learnings into agencies and leveraging these for the benefit of their own agency • To test an end to end approach where one “thing” walks • Connecting appropriate agency services with multi-agency initiatives alongside whānau through multiple agencies/ services • Identifying and accessing the right skill sets, expertise and experience and through crisis and resilience building. to support multi-agency activity • Participating in SMG Workforce development – embedding a culture of collaborative way of working and “can do” attitude at all levels of organisations

Key pieces of work will be: • Establish a cross agency / system training schedule – drawing on existing training programmes / learning opportunities which upskill staff on the shared vision, purpose and ways of working. Share case studies wider and utilise existing staff working in collaborative models to present and share learnings. • Building collaborative working / multi-agency roles into a desirable career pathway – ‘legitimising’ / creating transdisciplinary roles

069 Information Paper Counties Manukau District Health Board Audit Risk and Finance Committee ARF Action Item #221 - Implications of Covid-19 on Primary Care

Recommendation

It is recommended that the Audit Risk & Finance Committee:

Receive this information paper on the implications of Covid-19 pandemic on the Primary Care Sector as requested Action Item #221 of the ARF Committee.

Note this paper was endorsed by the Executive Leadership Team on 3 November to go forward to the Audit Risk & Finance Committee.

Note Primary Care, and in particular the Maaori and Pacific providers, have played a critical part of the Covid- 19 response, and responded extremely well at very short notice to provide Covid-19 services to the community.

Note that, in common with other parts of the health system and the wider economy, Covid-19 has had a significant impact on Primary Care and the way patients access services.

Note work is ongoing to understand these impacts, access the longer time implications, and develop strategies for remediation.

Prepared and submitted by: Dr. Christine McIntosh, Acting Chief Medical Advisor Primary & Integrated Care and Matt Hannant, General Manager Primary Care and Health of Older People, Funding and Health Equity.

Glossary

PC Primary Care General Practice UC/UCC Urgent Care IPC Infection Prevention Control PPE Personal Protective Equipment PHO Primary Healthcare Organisation CTC Community Testing Clinic CBAC Community Based Assessment Clinic

Purpose

At the Audit Risk and Finance Committee Action Item #221: Mr Gosche queried whether we are looking at the pressures that our GPs and Pharmacies are facing, particularly as some have found Covid-19 to be the tipping point for them possibly having to close down their practices. This is the response to this information request.

Executive Summary

As a result of the Covid-19 pandemic Primary Care General Practice, Urgent Care and Pharmacy have been required to immediately adapt their model of service delivery to the Counties Manukau Population, and sustain an ongoing flexibility as the pandemic unfolds.

Levels 3 and 4 present a financial sustainability concern for Urgent Care and Pharmacy, and unlike other parts of Primary Care Urgent Care did not receive additional financial support from the Ministry. Capitation

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

070 provides some buffering to General Practice from higher level lockdowns although the sector has stated this is insufficient. General Practice has also expressed disappointment with the withdrawal of a planned second tranche of sustainability funding by the Ministry.

Covid-19 has potentially exacerbated structural funding issues within Primary Care. The sector has long advocated for a comprehensive review of the funding formula, which arguably has not kept pace with health needs or complexity within communities. During trilateral discussions between the Sector, Ministry and DHBs there is consensus that a funding review is required, and a joint funding bid was prepared for Budget 20 that looked to mitigate to the extent possible these issues. That bid was not successful but rather overtaken by events.

Some Primary Care organisations who have been very actively involved in the response will have experienced significant additional revenues. Furthermore, large corporate model Primary Care has been able to flex and cope better than small practices and there needs to be a consideration about whether the conditions of the pandemic may open up further opportunity for acquisition of practices by large corporates and whether this is strategically wanted for the CM Health population.

The physical environment and model of service delivery changes required to safely manage IPC and PPE in all alert levels is requiring a lot of energy. The security of supply of PPE, pre-contact screening of patients, vigilance for IPC measures, are all contributing to the workload and the time taken in all aspects of primary healthcare provision has been increased substantially. It just takes longer to get everything done. Moving to virtual consults can help considerably but access, particularly for more vulnerable populations needs special attention.

Maaori and Pacific providers have underpinned the Covid-19 response for the entire community including testing and other support to the community. The capacity and capability of these providers has been leveraged to the fullest extent including working in partnership with Mana Whenua and the local communities they serve. The configuration of these services to support the pandemic response for everyone has meant that our Maaori specific resources and services have been at times diminished for our Maaori whaanau who already experience significant inequities.

The significant concerns in Primary Care are about the widening of health inequities as a result of the pandemic. System Level Measures and Health Targets already show that many are falling away from the targets and it is concerning that it is disproportionately affecting Maaori. The reasons are likely to be multifactorial and urgent attention is required to understand how to reverse the apparent trend. Some PHO’s report that quality initiatives have needed to be deferred and there has been little capacity to engage in new programmes of work.

The workforce is reported to be tired and stressed. PHO’s report a concern about accrued annual leave and the Summer break may create a vulnerability in Covid-19 responsiveness both from Primary Care provision and staffing pop-up Covid-19 testing. In addition, it is felt that many near retirement doctors and nurses are likely to retire earlier that they would have otherwise retired, compounding a concern that already exists for GP and Primary Care nursing workforce in CM Health.

Communication to the Primary Care sector has been very important and it is worth noting that pharmacy felt they were not getting enough information compared to Primary Care and Urgent Care. There is an opportunity to check uptake of Medinz and HealthPathways for pharmacy and ensure content is relevant to pharmacy.

Your Health Summary (a shared electronic primary healthcare record) has been considered an integral part of the pandemic preparedness for continuity of care for patients in Primary Care. However, uptake has been slow which is potentially jeopardising the project and ultimately the safety and quality of the care if patients need to seek healthcare away from their usual provider.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

071 Background

As a result of the Covid-19 pandemic Primary Care General Practice, Urgent Care and Pharmacy have been required to immediately adapt the way they work. On March 21 2020 the Royal NZ College of General Practitioners (RNZCGP) requested all General Practices in the country to immediately adopt virtual triage for all patient contacts and aim to provide at least 70% of consultations by virtual means starting two days later on 23 March 2020. The Covid-19 emergency was considered significant enough to strongly encourage General Practice to change their model of service delivery immediately. The weeks in Level 4 lockdown followed by lower levels, then again a Level 3 lockdown in August, and the ongoing concern about community outbreak has consolidated changes in service delivery by some Primary Care providers.

At the Audit Risk and Finance Committee meeting in September (Action Item #221) Mr Gosche queried whether we are looking at the pressures that our GPs and Pharmacies are facing, particularly as some have found Covid-19 to be the tipping point for them possibly having to close down their practices. This is the response to this information request.

In compiling this information paper about the Covid-19 pandemic response and implications for Primary Care, Urgent Care and Community Pharmacy in CM Health area, information from key stakeholders has been sought. We have received responses from all of the Clinical Directors of the 5 PHO’s with practices in Counties Manukau Health (Alliance Health Plus, ProCare, East Health, National Hauora Coalition and Tamaki Care), GP’s in practice, and pharmacy lead Primary Care CM Health. Only one verbal response was received from an Urgent Care. Data was provided by PHO’s and the Primary Care division. Finally, we have considered information from two university groups doing research specific to the Covid-19 NZ Primary Care response.

This report is broadly grouped into key themes and divided into Primary, Urgent Care and Pharmacy.

Financial Implications

Primary Care and Urgent Care

 Clinic closures: There are very few clinics that have had to permanently close as a result of the Covid-19 pandemic financial impact, although many clinics have seen a considerable drop in co-payments. The clinics that closed did so during the first (level 4) lockdown, and most were part of a corporate provider group and closed as part of a rationalisation process.  Primary Care capitation based funding is keeping most practices financially sustained although changes have been made in many practices to reduce costs e.g. reducing staffing levels and limiting opening hours.  Payment for Covid-19 assessment and swabbing. The criteria and resulting payments have varied over the course of the pandemic and resulted in some non-payment due to incorrect completion of the e- notification form which determines payment. There has been frustration and an expressed loss of trust in the DHB system by some practice owners and clinicians as a result, and tolerance is low given the financial pressures in practices.  Practices very rapidly adapted to virtual consults however they are reporting that many pateints still prefer face-to face, and are less willing to pay the co-payments for healthcare provided by telehealth, despite it taking at least the same length of time and input by the clinicians. Practices are seeing a delay in payment and increased work to chase non-payment.  Everything is taking longer to do in Primary Care, even in Level 1, adding to workload and resulting in less efficiency e.g. IPC and PPE, double handling of patients with telephone as well as in-person consults and work force tied up with ‘red stream1’ and Covid-19 swabbing.  Unexpected, unplanned practice shut-down ordered by the Public Health Service due to close contact with Covid-19 cases has occurred in a small number (fewer than 10) Auckland practices. Tamaki Care reported 12 temporary clinic closures across their network including CM Health. The financial implications

1 The aim of green, amber and red streaming is to triage and manage patients as they flow through General Practice in a way that keeps patients and staff safe, with infection control restrictions and service provision that relates to the probability of exposure to infection. Anyone with a cough, cold, runny nose, sore throat, fever (even if only a sniffle) could potentially have COVID 19 and is therefore categorised in the ‘Red Stream’. Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

072 are significant if this occurs. There is a feeling of helplessness because of the unpredictability of shutdown despite adhering to all PPE/IPC guidance and an apparent inconsistency of restrictions imposed has caused frustration for practices.  The Tamaki Care network (Total Health Care PHO) reports that having shared clinical and data systems provided good insight and predictability into the effect of changing Covid-19-alert levels, and the necessary actions to support operations and sustainability. They were able to flex to manage clinic closures and demand.  Urgent Care does not receive capitation funding and much of their revenue is generated by ACC claims. Level 4 lockdown and to a lesser degree Level 3 lockdown dramatically reduced Urgent Care attendance (see Figure 1), particularly because injury related attendance was very low. Immediately prior to lockdown attendance was high. Urgent Care did not receive sustainability funding from the Ministry, unlike pharmacy and General Practice.  Ministry of Health Covid-19 National funding to support Covid-19: late March $15M workload and the switch to virtual health, $22M paid early in the national lockdown and a further $3.4M to support digitally enabled healthcare paid to PHO’s on the 14 September 2020. (Practices receive the higher of these two amounts: either a minimum $1000 payment; or 90 cents per each high-needs patient and 30 cents for every other patient. Practices where 50 per cent or more of patients are high needs, receive an additional $2000 payment. A planned second tranche of funding was not provided.  Covid-19 has potentially exacerbated structural funding issues within Primary Care. The sector has long advocated for a comprehensive review of the funding formula, which arguably has not kept pace with health needs or complexity within communities. During trilateral discussions between the Sector, Ministry and DHBs there is consensus that a funding review is required, and a joint funding bid was prepared for Budget 20 that looked to mitigate to the extent possible these issues. That bid was not successful but rather overtaken by events.

Pharmacy

 Some pharmacies have reported that their pharmacy has had reduced income and increased expenses through this year because of Covid-19. Some implemented free deliveries to maintain service. However, increased repeats during the late March to end of August period had net effect of pharmacies no worse off or slightly better off.  Some pharmacies are reporting significant effects on their business from Covid-19 with potential consequences for the viability of their business with further lockdowns.  The current environment of some pharmacies discounting e.g. Chemist Warehouse, Zoom, Countdown, has created a competitive environment that is unsustainable, which had already meant pharmacies were suffering from a business perspective and it would not take much more to make some unviable.  Pharmacies that have been most affected are the ones with a next door GP clinic which was required to shut down due to Covid-19 close contact.  Retail sales are generally down, including for cough-cold products.  However, it was noted that there are too many pharmacies in CM Health already, and it is difficult for small pharmacies to continue to exist. Yet we keep getting applications for new pharmacies.  Ministry of Health Covid-19 funding: Pharmacy received an early payment which helped to pay for their reconfigurations of pharmacies to minimise contact with patients for the first lockdown. They feel frustrated because $18m has been allocated for pharmacies but the barriers to accessing this money are believed to be excessive, and possibly no money will be given out.

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

073 44000

42000

40000 UCL 38000

36000

LCL 34000

32000

30000 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20

UCC UCL Average LCL

Figure 1. Urgent Care Centre attendance through the Level 4 lockdown till end of June. 95% confidence interval for upper and lower limits (Counties Manukau located Urgent Care: ETHC Bairds Road, Takanini Care A&M,Eastcare, Otahuhu White Cross, ETHC Mangere, ETHC Dawson Road, ETHC Browns Road, Counties Care A&M, Franklin)

Figure 2. ProCare GP Consult volume spanning pre-covid-19 level 4 lockdown until end of September.

Managing Covid-19 Infection Prevention Control and Swabbing Activity

General

 Staff anxiety for managing self, patients is widespread.  Concern about coming to work because of their or a family member’s vulnerability to Covid-19.

Primary Care and Urgent Care

 Practices have needed to adapt by making physical changes to the environment e.g. Perspex screens at reception, locking the practice doors to screen patients prior to entry (Level 3 and 4) waiting room chairs physically distanced, and requires reorientation of the practice for managing patient flow through ‘red’ and ‘green’ streaming, and in many practices implementing shifts to avoid all staff exposed to a case. A high level of vigilance, putting on and taking off PPE and cleaning, additional staff time and increases the Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

074 time burden of all activities, not just Covid-19 related care.

Pharmacy

 Having to reconfigure the pharmacy at short notice to protect patients and staff. Getting Perspex screens, keeping patients out of the pharmacy, finding new ways to do vaccinations to reduce the risk of getting Covid-19.  Being front-line at a time of uncertainty and a feeling of high risk compounded by stress of having patients who had been for Covid-19 testing coming into the pharmacy for a prescription afterwards.

60000

50000 5883

40000 13335

30000 3103 31001 9355 20000 2610 5191 1559 18286 2435 5046 10000 1568 1162 11157 160 9485 8230 1885 0 426 3601 1002 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20

CTC/CBAC Other Facility - GP Other Facility - UCC

Figure 3. Covid-19 testing by facility for CMH domiciled population.

Workforce

Primary Care and Urgent Care

 The overall morale in General Practice is low at the moment. People are feeling burnt out and tired and the stress levels are probably at a greater level than in the general population.  There has been reduction in nursing and GP FTE in some clinics to manage costs.  Locum GP/nurse cover and staff on short-term contracts have been most affected so far, although there are some permanent GPs that have also reduced their hours.  One PHO noted that Covid-19 related work was paid higher than PC can pay admin and nursing staff and therefore staff chose to work for the Covid-19 pandemic response.  One area of concern relates to the need for Primary Care staff to take leave. With the reduction in travel opportunities staff have taken little holiday in general and many are planning on substantial breaks in future. Accommodating this will present a service challenge and this may present a particular risk over the summer holiday’s period.  A few PHO Clinical Directors think that significant number of older GPs and nurses that will retire earlier than they may have otherwise have planned, once they see out the pandemic out of loyalty to their patients and not wanting to let their colleagues down. There is a concern about compounding workforce issues in Primary Care.  Staff members that have mild respiratory symptoms and are required to stand down whilst awaiting swab results from their own Covid-19 testing. This is creating additional burden.

Pharmacy  Considerable stress before and during the lockdowns from a huge increase in demand as patients stockpiled and vastly increased numbers of prescriptions were received in a very short timeframe. This resulted in long hours and huge work pressure that resulted in very stressed staff for some time after lockdown.  Difficulty getting to work during Level 3 regional lockdown for staff who live outside regional border Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

075 leading to long waits to get across border and sorting out the paperwork to assist with border crossing.

Quality and Performance

 There has been a significant impact of Covid-19 on overall performance for National Health Targets and our Screening, Immunisation and Clinical/LTC indicators. PHO’s recognise the issue but are struggling to get practices to engage in improvement related activities right now as they simply do not have the time or mental capacity to engage.  PHO’s report deferring quality initiatives during the pandemic because of lack of capacity in the practices.

93.5 93.0 92.5 UCL 92.0 91.5 91.0 LCL 90.5 90.0 89.5 89.0 88.5 Jul-20 Jan-20 Jun-20 Oct-19 Apr-20 Feb-20 Sep-20 Dec-19 Aug-20 Nov-19 Mar-20 May-20

8M % UCL Average LCL

Figure 4. System level measure: Fully immunised at 8 months of age. (UCL and LCL at 95%CI) CM Health 8 Month Immunisations Performance by Ethnicity - 12 Months to Sept. 2020 100% 95% 90% 91% 85% 80% 75% Percentage 01/10/2019 01/11/2019 01/12/2019 01/01/2020 01/02/2020 01/03/2020 01/04/2020 01/05/2020 01/06/2020 01/07/2020 01/08/2020 01/09/2020

01/10/20 01/11/20 01/12/20 01/01/20 01/02/20 01/03/20 01/04/20 01/05/20 01/06/20 01/07/20 01/08/20 01/09/20 19 19 19 20 20 20 20 20 20 20 20 20 Maaori 84% 86% 86% 85% 84% 84% 85% 85% 82% 80% 76% 79% Pacific 95% 95% 94% 93% 93% 93% 92% 91% 91% 91% 92% 92% Asian 99% 98% 99% 97% 98% 98% 98% 98% 98% 99% 98% 98% Other 91% 92% 91% 92% 92% 92% 92% 91% 90% 89% 90% 92% Total 93% 93% 93% 92% 92% 92% 92% 92% 91% 90% 90% 91% Target 0.95 0.95 0.95 0.95 0.95 0.95 0.95 0.95 0.95 0.95 0.95 0.95

Figure 5. Infants fully immunised at 8 months of age (Target 95%).

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

076

Figure 6. Fully vaccinated at 8 months of age by PHO. Target 95%

Equity

Primary Care and Urgent Care

 Moving to virtual consults provides advantages to many patients however there is a concern about this being a significant barrier to access for some patients who either do not have access (lack of credit on phone) or know how to use the technology, or find communication unsatisfactory by teleconsult.  Capacity and capability to provide screening, preventative care and long-term condition care during the Covid-19 pandemic has been variable and there is a trend downwards in some measures. Further exploration is required to understand whether this is due to data upload or other factors and an examination of the measures by ethnicity to identify widening disparity. For example a concerning drop has occurred for Maaori infants fully immunised at 8 months of age (see figure 5).  Maaori providers have made substantial contribution during the lockdowns to mobilise resources and staff to successfully meet the needs of the whole community. This has reduced workforce capacity in other areas of Primary Care and at times this has diminished resources and services for Maaori whaanau who already experience significant inequities.  The providers, with their Pacific staff and connections to the community, were invaluable in ensuring our response was targeted and culturally appropriate. This was particularly the case when Churches started to allow and then request pop up stations to swab their congregations. This was a vital part of the response.  A key challenge we have identified, and are now addressing, is how we can assist in building greater capacity and resilience amongst our front line providers (Maaori and Pacific) who are critical during Covid surge model. In addition we are working with the providers to see how we can be better connected in lead up and during response to optimise the response.  Mental health consults have risen and GP’s report large burden of mental health issues in the community, and limited capacity in the system to support patients (see figure 7).  Patients have temporarily moved into CM Health area due to the Covid-19 pandemic. This creates an issue to access to care when they cannot see their regular GP and/or they cannot access CM Health/PHO programmes of care due to being non-CM Health PHO domiciled patient.

Figure 7. CVD risk assessment. Target 90%

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

077 Communication

 Two platforms for communication have been important during the Covid-19 response; Medinz and Auckland Regional HealthPathways. Medinz has provided an ability to provide rapid communication to Primary Care and Urgent Care providers as well as pharmacy. HealthPathways provided the platform for comprehensive up to date information to support not only Covid-19 related care but a wide range of Covid-19 impacted care.  PHO leads did not report a concern about communication.  Pharmacy did report a concern about ability to find information. There is an opportunity to check pharmacy knowledge about HealthPathways and Medinz and to consider pharmacy specific information for both of these platforms.  Your Health Summary is a secure database that holds a summary of your Primary Care health record. The purpose of Your Health Summary is to make sure patients can be provided with the very best care if you need to see a doctor outside of your usual General Practice.  Youth Health Summary has been considered an integral part of the pandemic preparedness for continuity of care for patients in Primary Care however, uptake has been slow which is potentially jeopardising the project.

Figure 8. Quick Covid-19 NZ Primary Care Survey (NZ wide)

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

078 What could be helpful?

 Good timely information to guide practice.  It would be useful to have a fast track process for testing of health care professionals.  The community healthcare workforce does appreciate recognition of the work they are doing to support the population during extraordinary times.  Administration burden in Primary Care continues to grow and anything that can be done to reduce this will be greatly appreciated.

Discussion

The information received for this report indicates that there is not an immediate vulnerability in the Primary Care Urgent Care and Pharmacy sector to financial unsustainability but there is a concern in the short term due to the unpredictability of lockdowns, and in the long term a perception that near retirement GP’s and nurses are likely to retire as soon as possible which may compound a workforce shortage already occurring in CM Health area.

The Primary Care workforce is reported to be stressed and tired creating a vulnerability. . Consideration should be given to the accrued leave throughout the year in Primary Care meaning that staff are likely to take leave over the Christmas and Summer period and the risk this may pose to capacity if a community outbreak occurs at this time. Forward planning is essential to ensure that this holiday period is adequately covered so that workforce can have a break. Your Health Summary is a project which is enabling the sharing of a health summary record across Primary Care providers. This is an essential component of preparedness for further outbreaks as it enables patients to receive continuity of care when their own practice or GP is unavailable.

Maaori and Pacific providers have underpinned the Covid-19 response for the entire community including testing and other support to the community. The skills and knowledge and connection to the community of this workforce is essential to the success of the Covid response thus far. It should be noted that there has been limited capacity to deal with preventative healthcare and there is a concern that there is a widening of disparity of health outcomes for Maaori. Consideration should be top of mind on the pandemic effects on Primary Care effectiveness of care for more vulnerable populations, and what financial and workforce support is required. Please note that some primary care programmes of care are likely to have underspend due to lack of capacity not a lack of need.

We recommend that consideration of the benefits and risks of a corporate model of Primary Care provision in the Counties Manukau population and that if financial sustainability of smaller practices becomes an issue that there may be uptake of these practices by the large corporates. During the Covid-19 response the corporate model has demonstrated comparative strength and agility to flex in the face of Covid-19 pandemic and establish their own virtual consult platform. It is timely to consider what the Board’s view is of the corporate model for the Counties Manukau population and to consider what the opportunities are for DHB provision of Primary Care services if the situation of financial sustainability of practices and pharmacy changes especially in the context of the Health and Disability System review recommendations e.g. DHB Primary Care ownership and provision, particularly in areas of market failure. A national research project funded by Health Research Council and Ministry of Health on different models of ownership and care will provide further insights to inform decision making.

Communication is key to the community providers. Feedback suggests that there is an opportunity to check pharmacy knowledge about Health Pathways and Medinz and to consider pharmacy specific information for both of these platforms.

Thank you for the request for information on how well the Primary Care sector is coping during the pandemic. The providers who have given feedback were appreciative of being asked for their perspectives and have willingly provided information and data. What the Covid-19 response has shown us is that the Primary Care sector can work collaboratively and effectively around a common goal. At the same time as maintaining the Covid-19 response, the challenge is to support the ongoing delivery of all of the other health services that the community require and the Primary Care division are actively considering the best ways forward. Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

079 Counties Manukau District Health Board

5.0 Resolution to Exclude the Public

Resolution: That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000:

The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of Reason for passing this Ground(s) under Clause 32 for items to be considered resolution in relation to each passing this resolution item 2.1 Confirmation of That the public conduct of the Confirmation of Minutes Public Excl Minutes of whole or the relevant part of the As per the resolution from the CPHAC Meeting proceedings of the meeting public section of the minutes, as 16.12.2020 would be likely to result in the per the NZPH&D Act. 2.2 Public Excl Action disclosure of information for Items Register which good reason for withholding would exist, under 3.1 Covid Vaccination section 6, 7 or 9 (except section Planning 9(3)(g)(i)) of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32(a)]

Counties Manukau District Health Board – Community & Public Health Advisory Committee 27 January 2021

080