HDAC Agenda 27 November 2018

Distribution

Committee Members  Karen Naylor, Chair  Diane Anderson, Deputy Chair  Dot McKinnon  Adrian Broad  Barbara Cameron ID ENTRAL  Ann Chapman M C  Brendan Duffy  Michael Feyen DISTRICT HEALTH BOARD  Nadarajah Manoharan  Oriana Paewai  Barbara Robson  Vicki Beagley  Anne Kolbe  John Waldon

Management Team  Kathryn Cook, Chief Executive A g e n d a  Scott Ambridge, GM, Enable New Zealand  Keyur Anjaria, GM, People & Culture  Judith Catherwood, GM, Quality & Innovation  Ken Clark, Chief Medical Officer  Celina Eves, ED, Nursing & Midwifery Health & Disability  Chiquita Hansen, CEO, Central PHO  Craig Johnston, GM, Strategy, Planning & Advisory Committee Performance  Steve Miller, Chief Digital Officer  Gabrielle Scott, ED, Allied Health  Stephanie Turner, GM, Māori  Neil Wanden, GM, Finance & Corporate Services  David Sapsford, CE, Acute & Elective Specialist Part 1 Services  Lyn Horgan, OE, Acute & Elective Specialist Services  Claire Hardie, CE, Cancer Screening, Treatment & Support Date: 27 November 2018  Cushla Lucas, OE, Cancer Screening, Treatment & Support  Syed Zaman, CE, Healthy Aging & Rehabilitation  Andrew Nwosu, OE, Healthy Aging & Rehabilitation  Marcel Westerlund, CE, Mental Health & Addictions Time: 9:00 am  Vanessa Caldwell, OE, Mental Health & Addictions  Dave Ayling, CE, Primary, Public, Community Health Place: MidCentral District Health Board  Debbie Davies, OE, Primary, Public, Community Health Boardroom  Jeff Brown, CE, Healthy Women, Children & Youth Gate 2 Heretaunga Street  Sarah Fenwick, OE, Healthy Women, Children & Palmerston North Youth  Jill Matthews, MAGS  Carolyn Donaldson, Committee Secretary  Megan Doran, Committee Secretary  Communications Department  External Auditor  Board Records

Ministry of Health  Nicola Holden, Account Manager

Public Copies: www.midcentraldhb.govt.nz/orderpaper

Contact Details Telephone 06-3508967

Next Meeting Date: 5 February 2019 Deadline for Agenda Items: 23 January 2019

MIDCENTRAL DISTRICT HEALTH BOARD

Health & Disability Advisory Committee Meeting

27 November 2018

Part 1

O r d e r

1. ADMINISTRATIVE MATTERS 9am

1.1 Apologies

Committee Members Ann Chapman and Anne Kolbe

1.2 Welcome

1.3 Late Items

1.4 Conflicts and/or Register of Interests Update

Pages: 9-11

1.5 Minutes of the Previous Meeting

Pages: 12-21 Documentation: minutes of the Health & Disability Advisory Committee meeting held on 16 October 2018 Recommendation: that the minutes of the previous meeting be approved as a true and correct record.

1.6 Matters Arising from the Minutes

Page: 22 Documentation: schedule of matters arising dated 9 November 2018 Recommendation: that the matters arising be noted.

2. PERFORMANCE 9.10am

2.1 Uru Kiriora – Primary, Public and Community Health Cluster Report & Presentation

Pages: 23-36 Documentation: report from the Clinical Executive and Operations Executive dated 7 November 2018 Recommendation: that the Committee: • endorse the progress made by the Uru Kiriora - Primary, Public and Community Health Cluster in 2018/19 • note the focus on primary care enrolment • note the uptake in extending access to primary care services, and planned consumer engagement regarding Health Care Home • note the progress being made in the Pharmacy Business Improvement Programme

Dr Dave Ayling and Deborah Davies, Clinical and Operations Executives will provide a 15 minute presentation.

2.2 Uru Whakamauora – Healthy Ageing & Rehabilitation Cluster Report

Pages: 37-48 Documentation: report from the Clinical Executive and Operations Executive dated 20 November 2018 Recommendation: that the Committee: • endorse the progress made by the Uru Whakamauora- Healthy Ageing and Rehabilitation cluster to date • note the range of improvement initiatives focusing on improving care outcomes and patient experience for older people who may be living with frailty • note the opportunities for revenue from the Non Acute Rehabilitation (NAR) contract

2.3 Pā Harakeke - Healthy Women, Children & Youth Report

Pages: 49-59 Documentation: report from the Clinical Executive and Operations Executive dated 20 November 2018 Recommendation: that the Committee: • endorse the progress made by the Healthy Women Children and Youth Cluster Service to date. • note the information regarding upcoming Midwifery strikes • note the Mokopuna Ora Collective work and Child Health Forum initiatives • note the work to ensure achievement of elective targets • note the dates of the cluster plan workshop, to which is there is an open offer for the board to attend

2.4 Uru Mātai Matengau – Cancer Screening, Treatment & Support Cluster Report

Pages: 60-69 Documentation: report from the Clinical Executive and Operations Executive dated 12 November 2018 Recommendation: that the Committee: • endorse the progress made by the Uru Mātai Matengau - Cancer Screening, Treatment & Support Cluster in 2018/19 • note progress in developing a business case for the replacement of the linear accelerators

2.5 Uru Arotau – Acute & Elective Specialist Services Cluster Report

Pages: 70-85 Documentation: report from the Clinical Executive and Operations Executive dated 12 November 2018 Recommendation: that the Committee: • endorse the progress made by Uru Arotau – Acute & Elective Specialist Services Cluster in 2018/19. • note the quality improvement programmes of work continue to be progressed, namely Takatū, Medimorph which includes Frailty and Transfer of Care. • note the final phase of the Emergency Department renovations. • note the Acute & Elective Specialist Services Cluster Business Improvement Programme.

2.6 Uru Rauhī – Mental Health & Addictions Cluster Report

Pages: 86-154 Documentation: report from the Clinical Executive and Operations Executive dated 14 November 2018 Recommendation: that the Committee endorse the progress made by Uru Rauhī, Mental Health & Addiction Services Cluster in 2018/19.

2.7 Paiaka Whaiora – Hauora Māori Cluster Update

Pages: 155-162 Documentation: report from General Manager, Māori dated 15 November 2018 Recommendation: that the Committee:  note the Hauora Māori Cluster Update  note the plan and approach to the Hauora Māori Cluster establishment

2.8 2018/19 Regional Services Plan Implementation Update

Pages: 163-165 Documentation: report from Manager, DHB Planning and Accountability dated 15 November 2018 Recommendation: that the Committee note the update on progress with the 2018/19 Regional Service Plan

REFRESHEMENT BREAK 11.00am

3. STRATEGIC PLANNING 11.15am

3.1 Population and Health Profile Update, with an Equity Lens

Pages: 166-188 Documentation: report from Manager, DHB Planning and Accountability and Public Health Physician and Maori Health Practice Leader dated 14 November 2018 Recommendation: that the Committee: • note the 2018 profile of the population and health status for the district • endorse the findings being used in future planning

3.2 Palmerston North Health and Wellbeing Plan Presentation

Pages: 189-199 Documentation: report from Project Manager dated 7 November 2018 Recommendation: that the Committee endorse the approach that is being taken for the Palmerston North Health and Wellbeing Plan.

Craig Johnston, General Manager and Angela Rainham, Project Manager will provide a 10 minute presentation. 6

3.3 Development of a Strategy for Pharmacy in MidCentral and a Moratorium on Community Pharmacy Contracts

Pages: 200-208 Documentation: report from Portfolio Manager, Clinical Services dated 20 November 2018 Recommendation: that the Committee: • note that as of the 1st of October 2018, all 32 MidCentral Community Pharmacies have signed the new national Integrated Community Pharmacy Services Agreement. • note that the DHB is drafting a Strategy for Pharmacy in MidCentral for pharmacy services and that once the draft strategy is formalised, an engagement phase with wider stakeholders and the community will proceed. • note that the DHBs have received legal advice that neither the Commerce Act 1986 nor administrative law prevents a DHB from adopting a policy under which the DHB chooses which licensed pharmacies receive a contract or chooses the types of pharmacy services covered by an individual contract. • endorse for the Board’s consideration a proposal to impose a moratorium on issuing new contracts for community pharmacy providers from the 18th of December 2018, until the adoption of a policy on contracting pharmacy services within MidCentral in 2019.

4. QUALITY IMPROVEMENT 11.55am

4.1 Clinical Governance and Quality Improvement Report

Pages: 209-267 Documentation: report from Acting Manager, Quality Improvement and Assurance dated 5 November 2018 Recommendation: • that the content of the clinical governance and quality improvement report be noted • the Quality Agenda - Clinical Governance Framework be endorsed • progress in delivering improvements in Clinical Governance and Quality Improvement be endorsed.

4.2 Choosing Wisely Progress Report

Pages: 268-274 Documentation: report from Clinical Lead and Programme Manager dated 19 November 2018 Recommendation: • that the content of the report be noted • the progress with Choosing Wisely in MidCentral district be endorsed.

4.3 Transport Services Return from Wellington

Pages: 275-279 Documentation: report from Senior Portfolio Manager, Health of Older People dated 9 November 2018 Recommendation: that the Committee: • note the commentary around transport services • note the activity currently underway to improve information and services

4.4 Air Ambulance Helicopter Service Arrangements

Pages: 280-290 Documentation: report from General Manager, Strategy, Planning & Performance dated 7 November 2018 Recommendation: that the Committee note this update on changes occurring to Air Ambulance Helicopter Services

5. POLICY & GOVERNANCE 12.30pm

5.1 Committee’s Work Programme 2018/19

Pages: 291-296 Documentation: report from General Manager, Quality and Innovation dated 15 November 2018 Recommendation: that the Committee endorse the progress being made in the delivery of the 2018/19 work programme.

6. LATE ITEMS

7. DATE OF NEXT MEETING

5 February 2019, Boardroom MidCentral District Health Board, Gate 2 Heretaunga Street, Palmerston North 8

8. EXCLUSION OF PUBLIC

Recommendation: that the public be excluded from this meeting in accordance with the Official Information Act 1992, section 9 for the following items for the reasons stated: Item Reason Reference • Potential & Actual Serious To protect personal privacy 9(2)(a) Adverse Events July - October 2018

9 Register of Interests: Summary, November 2018 Name Date Company/Organisation Nature of Interest Anderson, Diane 1.7.16 Nil Broad, Adrian 24.6.14 Manawatu Horowhenua Tararua Trust Manager Diabetes Trust 9.12.13 Palmerston North City Council Councillor Cameron, Barbara 25.4.13 Manawatu District Council Councillor Member & Deputy Chair, Manawatu District Licensing Committee 1.11.16 Oranga Tamaki Ministry of Children Member, Community Response Forum 27.2.18 Sport Manawatu Board Member Chapman, Ann 17.12.13 Otaki Mail Part Owner 18.5.12 Otaki Community Health Trust Member 21.12.07 Gen-i Son is employee 29.4.16 Central Region’s Technical Advisory Grandson is a contractor to TAS Service Duffy, Brendan 3.8.17 MITO Board Member 3.8.17 Local Government Commission Commissioner 3.8.17 Electra Trust Trustee 3.8.17 Environmental Legal Assistance Fund, Deputy Chair Ministry for the Environment 3.8.17 Business Kapiti Horowhenua Inc (BKH) Chairperson 3.8.17 Life to the Max, Horowhenua Chair Feyen, Michael 5.12.16 Horowhenua District Council Mayor Manoharan, 9.12.13 Surgical Educators of the Royal Educator Nadarajah Australasian College of Surgeons 9.12.13 Private Otorhinolaryngology Practice, Owner Palmerston North 9.7.17 Aroha Ultimate Care Wife is an employee (facility manager) McKinnon, Dot 5.12.16 Whanganui DHB Chairperson Cousin of Whanganui DHB General Manager 9.2.17 NZ DHB Chairs’ National Executive Member 9.2.17 Health Practitioners Disciplinary Member Tribunal 9.2.17 Health Sector Relationship Agreement Member Committee 9.2.17 Four Regions Trust (formerly known Chair as Powerco Trust) 9.2.17 Whanganui Eyecare and Medical Trust Husband is Chair 21.3.17 Moore Law & Associates Legal Executive, Director and Shareholder 4.7.17 20 DHBs (Central Region’s Technical Member, National Health Workforce Advisory Service) Strategy 21.3.17 Chardonnay Properties Limited Part Owner 19.12.17 ERSG Board Member 19.12.17 Regional Governance Group Chair Naylor, Karen 6.12.10 MidCentral DHB Employee 22.9.15 New Zealand Nurses’ Organisation Member & Workplace Delegate Board Member 9.10.16 Palmerston North City Council Councillor Paewai, Oriana 1.5.10 Rangitane o Tamaki nui a Rua CEO 1.5.10 Te Runanga o Raukawa Governance Member Group 1.5.10 Manawhenua Hauora Chair Member, Child Health Tamariki Ora District Group 13.6.17 Te Whiti ki te Uru Co-ordinating Chair 13.6.17 Tararua Hauora Services Charitable Trustee Trust 13.6.17 Central Primary Health Organisation Member, Alliance Leadership Team (Central PHO Board) 13.6.17 Feilding Health Care Member, Clinical Governance Group 13.6.17 Manawatu District Council Member, Nga Manu Taiko, a standing committee of the Council 13.6.17 Te Ohu Auahi Mutunga (TOAM) Member, Governance Board 13.6.17 Before School Checks (B4SC) Member Collective 13.6.17 Nga Kaitiaki o Ngati Kauwhata Inc Committee Member 13.6.17 Te Tihi o Ruahine Whanau Ora Alliance Member 10 30.8.18 Cancer Society Manawatu Board Member Robson, Barbara 19.7.16 Kind Hearts Trust Board Member 10.12.01 Federation of Women’s Health Co-convenor Councils Aotearoa NZ (Inc) 31.5.10 Medicines Review Committee Consumer Representative Feb 13 Ministry of Health Member, Consumer Reference Group – National Workforce Strategy Project (MoH & HWNZ) 11.10.16 Ernst & Young Daughter is an employee – Business Advisor Committee Members Beagley, Vicki 5.10.15 Massey University Employee – Research Office 5.10.15 Arohanui Hospice Husband, John Freebairn, is the Chairperson 5.10.15 Supportlinks/Enable New Zealand Son receives respite care 11.10.16 Palmerston North City Council Member, District Licensing Committee Hartevelt, Tony 14.8.16 Otaki Family Medicine Ltd Independent Director 14.8.16 Merck Sharpe & Dohme (Merck) (NZ Elder son is NZ market access operations for Global Pharmaceutical manager Company) 14.8.16 Fairfax Media Young son is news director for Stuff.co.nz Kirkcaldie, Ewen 1.8.08 PDF Rutherfords Ltd Director Kolbe, Anne 22.7.16 Kolbe Medical Services Ltd Director and Joint Owner 22.7.16 Communio, NZ Senior Consultant & Contractor 22.7.16 Whanganui DHB Member, Risk & Audit Committee 22.7.16 Health Research Council of NZ Husband chairs the clinical trials advisory committee 22.7.16 Auckland University Holds an adjunct appointment (Associate Professor level) Husband is an employee (Professor of Medicine, FMHS) 22.7.16 Australian Medical Council Husband is a member of the Medical School Advisory Committee, and leads the Medical Specialties Advisory Committee Accreditation Team 22.7.16 Royal Australasian College of Husband is a member of the College’s Physicians governance working party, and chairs the revalidation working party 22.7.16 EXCITE International Board Member, and Chair of Advisory Council 22.7.16 Medicare Benefits Schedule Review Senior Advisor/Government taskforce Taskforce (Australia) to review the Medicare Benefits Schedule 22.7.16 Institute of Environmental Science & Daughter an employee – forensic Research (ESR) scientist 28.8.18 Tairawhiti DHB Consultant (strategic services) 13.3.17 Siggins Miller, Australia Senior Advisor & Associate Management Cook, Kathryn 4.5.15 Aspen Pharma Sister is an employee 1.7.16 Central Region’s Technical Advisory Director Services Ambridge, Scott 20.8.10 Nil Anjaria, Keyur 17.7.17 MidCentral DHB Wife is a user of the Needs Assessment & Service Co-ordination Service Ayling, David 23.5.18 Youth One Stop Shop Clinical Director 23.5.18 MASH Trust Trustee 23.5.18 City Doctors/White Cross Shareholding (Value less than $10k) 23.5.18 Central PHO Member, Alliance Leadership Team Brown, Jeff Caldwell, Vanessa 7.5.18 Nil Catherwood, Judith 1.5.18 Nil Clark, Kenneth 3.8.10 Dr Kenneth Clark Ltd Private gynaecology practice, Palmerston North 2015 Central PHO TCPHO rust Board Member Davies, Deborah 18.5.18 Central PHO Member, Alliance Leadership Team 18.5.18 MidCentral DHB Daughter is an employee and works within hospital services. 11 Eves, Celina 14.5.18 Celina Eves Limited Owner – personal consulting company, UK 14.5.18 Iolanthe Midwifery Trust Trustee – midwifery charity in UK Fenwick, Sarah 13.8.18 Nil Hansen, Chiquita 9.2.16 MidCentral DHB Employed by MDHB and seconded to Central PHO 8/10ths 9.2.16 Central PHO CEO Hardie, Claire 13.8.18 Royal Australian & NZ College of Member Radiologists 13.8.18 Palmerston North Hospital Regional Trustee Cancer Treatment Trust Inc 13.8.18 NZ Breast Cancer Foundation Member, Medical Advisory Committee Horgan, Lyn 1.5.17 Coronial Services Sister is Coroner based in Wellington 18.5.18 Central PHO Member, Alliance Leadership Team Lucas, Cushla 1.5.18 Nil Johnston, Craig 19.2.16 Central PHO Member, Alliance Leadership Team 19.4.16 MidCentral DHB Son is an employee and works within hospital services Miller, Steve 18.4.17 Puriri Trust & Puriri Farm Partnerships Director. Farming business. Nwosu, Andrew 10.8.18 AB Therapy Services Director. UK health consulting company. Sapsford, David 18.5.18 Nil Scott, Gabrielle 19.8.16 MidCentral DHB Son is a casual employee and works within various hospital services Turner, Stephanie 17.2.16 Waingawa Ltd Director. Farming business. Wanden, Neil 16.2.16 Opus International Wife is a major shareholder Westerlund, Marcel 18.5.18 Nil Zaman, Syed 1.5.18 Nil Matthews, Jill 1.3.16 Nil Amoore, Anne 23.8.04 Nil Russell, Greig 3.10.16 City Doctors Minority shareholder 3.10.16 NZ Medical Council Member, Education Committee Downing, Eileen 2.9.10 Nil Andrews, David Smith, Jo 27.8.10 Nil Nepia-Tule, 1.9.10 Nil Claudine Bradnock, Barb 26.8.10 Nil Jermey, David 31.8.17 Central PHO Member, Alliance Leadership Team Carey, Steve 31.5.18 Ministry of Health Brother-in-law an employee within management 31.5.18 MidCentral DHB Wife is an employee within hospital services Ayres, Vivienne 26.8.10 Nil Channing, Chris 27.8.10 Nil Els, Johan 28.10.16 Nil Tanner, Steve 16.2.16 Nil Brogden, Greg 16.2.16 Nil Purdy, Darryl 13.10.17 Ross Intermediate Trustee 12.10.17 Graham Wastney Family Trust Trustee 13.10.17 Spotless Facility Services Limited Brother-in-law an employee (not at MDHB site) 13.10.17 Setpoint Solutions Limited Brother-in-law an employee (but not for MDHB) 13.10.17 Crossroads Church Attendee Manderson, John 16.2.16 Nil

MIDCENTRAL DISTRICT HEALTH BOARD

Minutes of the Health & Disability Advisory Committee meeting held on 16 October 2018 at 9.00am at MidCentral District Heath Board, Board Room, Gate 2, Heretaunga Street, Palmerston North

PART 1

PRESENT

Karen Naylor (Chair) Brendan Duffy Diane Anderson (Deputy Chair) Oriana Paewai Dot McKinnon Barbara Robson Adrian Broad Barbara Cameron Ann Chapman Michael Feyen

IN ATTENDANCE

Kathryn Cook, Chief Executive Claire Hardie, Acting Clinical Executive, Cancer Screening Treatment & Support Cushla Lucas, Operations Executive, Cancer Screening, Treatment & Support Dave Ayling, Clinical Executive, Primary, Public, Community Health Debbie Davies, Operations Executive, Primary, Public, Community Health Gabrielle Scott, Executive Director, Allied Health Jeff Brown, Clinical Executive, Women & Children’s Health (part meeting) Judith Catherwood, General Manager, Quality & Innovation Lyn Horgan, Operations Executive, Acute and Elective Services Marcel Westerlund, Clinical Executive, Mental Health & Addictions Sarah Fenwick, Operations Executive, Women & Children’s Health Stephanie Turner, General Manager, Maori & Pacific Vanessa Caldwell, Operations Executive, Mental Health & Addictions Andrew Nwosu, Operations Executive, Healthy Ageing & Rehabilitation Syed Zaman, Clinical Executive, Healthy Ageing & Rehabilitation Scott Ambridge, General Manager, Enable New Zealand (part meeting) Dr Richard Isaccs, Medical Oncologist (part meeting) Aaron Phillips, Charge Radiologist Therapist (part meeting) Erin Snaith, Outpatient Charge Nurse (part meeting) Denise Mallon, Manager, Breast Screen, Coast to Coast (part meeting) Alllanah Kilfoyle, Consultant Haematologist (part meeting) Dee Hunter, Clinical Trials Nurse (part meeting) John Manderson, Programme Manager, Business Improvement (part meeting) Barbara Ruby, Acting Manager, Quality & Clinical Risk (part meeting) Daniel Collins, Project Coordinator, Quality and Clinical Risk (part meeting) Barb Bradnock, Senior Portfolio Manager, Strategy, Planning & Performance (part meeting) Jo Smith, Senior Portfolio Manager, Strategy, Planning & Performance Jill Matthews, Manager, Administration & Governance Services Megan Doran, Committee Secretary Dale Wicken, Communications Officer

Public: 3 Media: 1

Unconfirmed Minutes 13

Opening the meeting, the Chairperson welcomed Andrew Nwosu, Operations Executive, Healthy Ageing & Rehabilitation.

1. ADMINISTRATIVE MATTERS

1.1 Apologies

Apologies were received from Committee Members Anne Kolbe, Vicki Beagley and Nadarajah Manoharan.

1.1 Late Items

There were no late items.

1.2 Conflicts and/or Register of Interests Update

There were no conflicts of interest or updates to the register of interest.

1.3 Minutes of the Previous Meeting

It was resolved:

that the minutes of the previous meeting be approved as a true and correct record, subject to item 4.1, bullet point 13 being amended to read, “Tararua Adult Mental Health Services”. (Moved Adrian Broad; seconded Brendan Duffy)

1.4 Matters Arising

There were no matters arising from the minutes.

2. PERFORMANCE

2.1 Uru Mātai Matengau – Cancer Screening, Treatment Support Cluster Report and Presentation

Dr Claire Hardie, Clinical Executive presented to the Committee an overview of the aims and work of the Uru Mātai Matengau cluster. It was noted that a copy of the presentation would be available on the Governance SharedNet site.

Vanessa Caldwell and Marcel Westerlund entered the meeting.

Achieving equitable outcomes for Māori was a key focus of the service and the Cluster was engaging closely with Pae Ora and other key stakeholders.

It was noted that a business case was being developed for the replacement of the services’ four linear accelerators. This would include the potential siting of a linac in both Taranaki and Hawke’s Bay.

The use of cannabinoids in cancer treatment was questioned. The service advised there was no medical evidence to support the use of cannabinoids at this time but this could be considered in the future if evidence became available.

The services’ partnering with community groups and trusts, such as the Oncology & Radiation Trust, was supported.

Unconfirmed Minutes 14

Barb Bradnock entered the meeting.

The rollout of the bowel screening programme was raised and concern was expressed that the current restructuring within the Ministry of Health may impact progress.

Smoking cessation was discussed, including the effectiveness of current investment. The addictive nature of smoking was noted, as was the need for an inter-sectoral approach. The Committee was advised that the incidence of smoking within the district was reducing, however there was inequities amongst population groups: non-Māori - <10 percent, Māori – around 30 percent. Management advised that the Primary, Public & Community Health cluster would be focusing on this and engaging with all clusters. This work would include reviewing current investment.

In respect of breastscreening coverage rates, it was suggested public messaging include the level of radiation involved noting that this was much less than a normal xray.

Members of the Uru Mātai Matengau cluster left the meeting.

It was resolved that the Committee:

• endorse the progress made by the Uru Mātai Matengau - Cancer Screening, Treatment & Support Cluster in 2018/19 • note that procurement of the Treatment Planning System is underway • note the cluster presentation at the October HDAC meeting • note the intention to expand the regional model of service to include outreach linac sites subject to planning and development of a business case.

2.2 Uru Kiri Ora – Primary, Public and Community Health Cluster Report

The Clinical Executive introduced this report.

2.2.1 Child & Adolescent Oral Health Service

The Committee noted the workplace culture review being undertaken within the Child & Adolescent Oral Health Service.

The non-retention of last year’s new graduates was raised, and the impact this had on the service’s workforce. It was hoped that this situation would not reoccur.

The issue of connectivity was noted, and it was suggested management contact Bay of Plenty DHB who had put in place solutions in this regard for its rural areas.

It was noted that limited progress had been made in reducing the level of arrears, and that the DNA rates were no longer being reported to the Committee. It was questioned whether these impacted on the Services’ ability to reduce the level of arrears.

2.2.2 PHC Nursing Integration

The Committee congratulated Mandy Bevan, Charge Nurse.

2.2.3 Primary Health

PHO enrolment rates were discussed and management advised 1,500 unenrolled youth had been identified. Members questioned whether there was capacity amongst general

Unconfirmed Minutes 15

practices to take on these young people. Management advised there were practices who were actively enrolling new patients and the DHB was also trying to increase providers’ understanding of which practices had open books.

The introduction of triaging within Health Care Homes was noted and it was suggested that there had been no socialization of this with the community. It was questioned whether the time freed up by triaging enabled the Health Care Home to take on new clients. Management advised that rather than just increasing outputs, it was important this was balanced with dedicating resources to system development.

Vaping as an alternative to smoking was discussed. Management advised that for some people this was a more palatable option than other smoking cessation tools available, such as nicotine gum. It was noted that the long term impact of vaping was unknown.

Jeff Brown and Sarah Fenwick entered the meeting.

MidCentral DHB’s participation in recent health-related expos was noted, however it was considered it could increase its presence at these events.

Information on school-based health services was sought and management undertook to provide this for the Committee’s next meeting:

• percentage of the district’s schools receiving this service • percentage of students being able to access this service.

Management advised that the possibility of extending the school-based service to intermediate schools had been raised with the Ministry of Health.

Management advised that details of the rollout of the St John’s Urgent Community Care Service had yet to be finalised. It was likely this would be provided in main centres, such as Palmerston North.

2.2.4 Per and Poly Fluorinated Alkyl Substances (PFAS)

It was noted that national communication around this matter could be improved.

It was resolved that the Committee:

• endorse the progress made by the Uru Kiriora - Primary, Public and Community Health Cluster in 2018/19 • note the progress being made in the scaling of the Primary Health Care Nursing Integration • note the progress being made in the Health Care Home programme throughout the district • note the progress being made in the Pharmacy Business Improvement Programme

Ken Clark entered the meeting.

2.3 Uru Arotau – Acute and Electives Specialist Services Cluster Report

The Operational Executive introduced this report, and tendered the Clinical Executive’s apologies as he was on leave.

Unconfirmed Minutes 16

The work being done to recruit radiologists up to staff establishment levels was noted. It was questioned whether the current shortage would impact on timely diagnosis, eg achievement of the Faster Cancer Treatment targets.

Management advised the shortage of radiologists was an international and national concern. This specialty was in crisis. There was evidence that artificial intelligence may in time take over much of the role of radiology. Some radiologists were choosing remote service arrangements from their own homes. MidCentral DHB’ strategies included supporting current radiology staff, forging relationships with community providers, teleradiology, and other professionals groups, such as obstetricians and Emergency Department, providing specific medical imaging services.

Management advised that the Theatre Dashboard was nearing completion, with fewer data issues being experienced.

The enormous amount of work being done across the organisation was noted. While this was supported, members questioned whether staff were experiencing change fatigue. The issue of bullying was also raised. Management advised there were mixed emotions amongst staff, with a lot of excitement, pressure and anxiety. It was noted that culture change took time and it was important that the organization was mindful of the impact on staff. Programmes such as Speaking Up for Safety, Promoting Professional Accountability and the Quality & Safety Walkrounds would support staff in raising issues.

The Operations Executive advised that the appointment of MidCentral’s first Emergency Department was pending. She further advised an agreement with a private provider had been signed for outsourcing surgical work. This would assist the service in implementing the new theatre grid.

It was resolved that the Committee:

• endorse the progress made by Uru Arotau – Acute & Elective Specialist Services Cluster in 2018/19. • note that a Teleradiology Service is in place supporting the delivery of medical imaging services. • note that due to Radiology staffing levels that we will support our current three Registrars until December 2018 at which time they will transfer to CCDHB and MidCentral DHB will return to providing placements and training for Radiology Registrars once we have sufficient Radiologists on staff. • note the new facility arrangements for the provision of self-managed renal patients and endorse the focus on increased home care. • note the work being done to establish an Acute & Elective Specialist Services Cluster Alliance Group. • note the Acute & Elective Specialist Services Cluster Business Improvement Programme is in place.

2.4 Pā Harakeke – Health Women Children and Youth Cluster Report

The Operations and Clinical Executives presented this report.

Management advised the Cluster had established an action plan to enable it to achieve ESPIs.

Unconfirmed Minutes 17

The impact of the new birthing unit on the hospital’s midwifery workforce and environment was questioned. Management advised that currently 20 percent of births at the unit were being transferred to the hospital. This impacted on workload, as did the hospital’s new induction to labour policy. It was noted that the midwifery shortage was a national issue. Work was being done through the Health Workforce Advisory Group. Sourcing midwifes from overseas continued. The importance of “growing our own” midwifery workforce was noted.

The paediatric continence service was discussed, particularly the issues being faced and the intersectoral approach being taken.

The concept of a one-stop shop for kids was discussed. Management advised that the development of this would be challenging with the current financial constraints.

It was resolved that the Committee:

• endorse the progress made by the Healthy Women Children and Youth Cluster Service in 2018/19. • note the consumer engagement underway to improve breast feeding levels • note the intersectorial work being done in the area of paediatric continence • note that an action plan is being developed to support the achievement of elective targets.

Barb Ruby, Daniel Collins and John Manderson entered the meeting.

3. DISABILITY

3.1 Disability Support Services

The Executive Director, Allied Health and General Manager, Enable New Zealand spoke to this report.

The Committee supported the development of a Disability Strategy for the DHB. The timing of this work was discussed, particularly given Mana Whaikaha had just been launched. Management advised that the strategy would require engagement with a wide range of consumers across all age groups, not just the 1,600 involved in Mana Whaikaha. Engagement with local government and other key stakeholders would also be essential. A New Zealand Disability Strategy was in place and this would be used as the guiding document.

The Committee requested that the next disability update include a diagram of the Mana Whaikaha structure.

It was resolved that the Committee:

• note the Disability Support Services report • endorse the new timeframe for the development of MidCentral District Health Board’s disability strategy.

Scott Ambridge left the meeting.

2. PEFORMANCE CONTINUED

2.5 Uru Rauhi – Mental Health and Addictions Cluster Report

The Clinical and Operations Executive presented the report.

Unconfirmed Minutes 18

The work being undertaken in Tararua was noted. Management advised the Tararua service would be moving into new accommodation in November.

In respect of the SAC 1 and 2 patient safety indicators, management clarified that the reviews were instituted immediately. Once the Coroner’s report had been received, the incident would be revisited based on the Coroner’s findings. The General Manager, Quality & Innovation advised that a report regarding previous SAC events would be provided for the Committee’s next meeting.

A profile of the Acute Care Team, including details of staffing and activity, was requested and it was agreed this would be provided for the Committee’s next meeting. The profile to also update the Committee on progress with planned initiatives previously reported.

The Committee noted that there had been a steep increase in the number of “crisis” calls. The Clinical Executive advised that two-thirds of these clients presented after- hours, and at least 50 per cent did not present with a mental health disorder.

The data regarding referrals and discharges by district was discussed. The Committee noted the higher rates in Horowhenua and the reason for this was questioned. The Clinical Executive advised this was a complex area, involving a wide range of issues such as economic factors, unemployment, housing and drugs. Unfortunately, there was also a high suicide rate in the area.

The recent River Inspires symposium was raised. This was considered to be a great success of inter-sectoral work. It had been driven by the NGO workforce group, supported by the DHB.

MidCentral DHB’s performance against the national mental health and addiction indicators was discussed. Members questioned whether more capacity and resources was required to enable an improvement in performance. The Chief Executive advised this was an incredibly challenging area and the DHB was looking forward to the report of the current Government Inquiry. Significant investment in mental wellbeing was required.

It was resolved that the Committee:

• endorse the progress made by Uru Rauhī, Mental Health & Addiction Services Cluster in 2018/19.

2.6 Uru Whakamauora – Healthy Ageing and Rehabilitation Cluster Report

The Clinical and Operations Executives presented the report.

The reduction in the number of complaints regarding aged residential care facilities was noted. It was further noted that some families were reluctant to lay a complaint as they feared their family member would be victimised. This may mean the total number of complaints was understated.

The number of DNAs for outpatient appointments was discussed. Management advised that in addition to reminding clients of their appointments, work into the reasons why people were not attending was required so other initiatives could be put in place. Management further advised that an outpatient improvement programme would be

Unconfirmed Minutes 19

commencing shortly and work into the reasons why people were not attending would be taken forward in that programme.

The DHB’s oversight of the standard of care within the aged residential care sector was raised. Management advised there were processes in place nationally and locally to advise the DHB of any incidents. Regular reporting also occurred.

The issue of social isolation was noted and it was agreed this required a community partnership response.

The importance of engaging with community groups, such as Federated Farmers and Rural Support Network was noted.

It was resolved that the Committee:

• endorse the progress made by the Uru Whakamauora - Healthy Ageing and Rehabilitation Cluster in 2018/19 • note the integration of Mental Health and Older People Needs Assessment and Service Co-ordination initiatives underway (NASC). • note as a consequence of the Excellence in Home Care Recommissioning Project, around 400 clients receiving community support migrated to new providers.

4. QUALITY IMPROVEMENT

4.1 Business Improvement

The proposed name change for this programme was supported as it better reflected the approach being taken. Management advised there were new definitions included in the report which outlined the type of savings created which management hoped would provide clarity to the Committee.

It was resolved that the Committee:

• endorse the progress and approach of the Business Improvement Programme • endorse the retitling of the programme to ”Improving Value Programme” in keeping with the focus on improving outcomes and the value of the investment in our people and our population.

Marcel Westerlund and Ken Clark left the meeting.

4.2 Quality Account

The value of the Quality Account on an ongoing basis was discussed. The Committee considered there was value in this type of report particularly of communicating this to the community. It was suggested the report could be simplified. It was also suggested that it reflect a stronger consumer and clinician voice.

The Committee requested that the DHB use proactive media to promote the messages in the account both internally and externally.

The General Manager, Quality & Innovation advised she would seek input from the Consumer Council regarding the value of the report. This approach was supported.

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The Committee expressed it thanks to all involved in the Quality Account’s development.

It was resolved that the Committee:

• endorse the draft Quality Account 2017/18 • provide feedback on the value of the Quality Account in an annual reporting format, given all the content is reported to HDAC in other formats throughout the year.

5. POLICY & GOVERNANCE

5.1 Committee’s Work Programme, 2018/19

The Committee’s work programme was noted.

The structuring and size of the Committee’s meeting agenda was raised. The frequency of reports from each Cluster was discussed and it was agreed these should continue to be six-weekly. It was further agreed that additional time be taken for meetings to enable all agenda items to be fully considered. Time was set aside for additional workshops and presentations which could be utilised.

It was noted that a report on the Speaking Up for Safety programme had been requested by another Committee. Members agreed that the Health & Disability Advisory Committee should also receive this information. Management undertook to see how this could be arranged.

The General Manager, Quality & Innovation advised a function to celebrate Palmerston North Hospital’s 125th anniversary was planned for around 2pm on Tuesday 27th November. It was planned that the HDAC meeting that day would end at 1pm, followed by lunch.

It was also planned that the Choosing Wisely presentation be provided at the Committee’s next meeting.

It was resolved that the Committee:

endorse the progress being made in the delivery of the 2018/19 work programme.

6. LATE ITEMS

There were no late items.

7. DATE OF NEXT MEETING

27 November 2018 at 9.00am.

The meeting closed at 12.25 pm.

Confirmed this 27th day of November 2018

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……………………………………………………… Chairperson

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Health & Disability Advisory Committee • Schedule of Matters Arising, 2018/19 as at 9 November 2018

Updates • In October 2018, the Committee endorsed the Quality Account for the Board’s approval. The Board approved this document.

OPEN ITEMS Matter Raised Scheduled Responsibility OPTIMISE dashboard & baseline (final) Oct 17 FRAC July 18 L Horgan VRM & HOC Update June 17 L Horgan & N Wanden Child, Adolescent & Oral Health Service July 18 Bd March 19 D Davies Plan BSCC Equity Plan for MDHB Oct 18 Nov 18 C Lucas ISM – Paiaka Whaiora: (inc information re Nov 18 Feb 19 J Catherwood & S Turner reporting lines, functions, comparison with status quo & graphical illustration) Linac x 4 Business Case Oct 18 March 19 C Lucas COMPLETED ITEMS Helicopter Service Briefing Bd Nov 18 Nov 18 C Johnston School based services: % of district’s Oct 18 Nov 18 D Davies school who receive this services; % of students who have access to this service Profile of ACT including staffing, activities, Oct 18 Nov 18 V Caldwell and progress with planned initiatives previously reported Health shuttles MDHB & CCDHB – closer May 18 Bd Nov 18 C Johnston connections Choosing wisely presentation April 18 BD Oct 18 J Catherwood Elective services – briefing re elective June 18 July 18 L Horgan surgery thresholds (ESPI 5) and how this process works Measurement of referral changes for after May 18 Bd July 18 C Hansen hours care SAC/complaints: final report for 17/18 July 18 Sep 18 J Catherwood Francis Group programme of work: • presentation March 18 Sep 18 J Catherwood & L Horgan • cost & CBA March 18 Sep 18 J Catherwood Alliancing arrangements for clusters July 18 Oct 18 J Catherwood & C Johnston Child, Adolescent & Oral Health Services – Sep 18 Oct 18 D Davies clarification re dental chair utilisation & workforce PN Airport Water Contamination 10.9.18 Oct 18 D Davies Mental Health • Service user & clinician feedback on July 18 Sep 18 V Caldwell video conferencing • Marama real time feedback July 18 Sep 18 V Caldwell

I:\CEO\ADMINCS\HDSAC\Draft Reports awaiting sign-off\Part 1\Nov 18\1.6 2018-19 HDSAC Matters Arising-9 Nov 18.docx 23

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Author Dr David Ayling, Clinical Executive Deborah Davies, Operations Executive

Endorsed by Kathryn Cook, CEO

Date 7 November 2018

Subject Uru Kiriora Primary Public and Community Health Cluster Report

RECOMMENDATION It is recommended that the committee: • endorse the progress made by the Uru Kiriora - Primary, Public and Community Health Cluster in 2018/19 • note the focus on primary care enrolment • note the uptake in extending access to primary care services, and planned consumer engagement regarding Health Care Home • note the progress being made in the Pharmacy Business Improvement Programme

Strategic Alignment

Operational performance for the Uru Kiriora - Primary, Public, and Community Health Cluster is aligned to the District Health Board (DHB) Strategy, in particular to the four strategic imperatives that are the fundamental focus for MidCentral District Health Board, with an overarching emphasis on quality.

Glossary ACC Accident Compensation Corporation CPHO Central Primary Health Organisation CSC Community Service Card DHB District Health Board ED Emergency Department ELT Executive Leadership Team

Primary, Public and COPY TO: Community Health MidCentral DHB Heretaunga Street PO Box 2056 Palmerton North 4440 Phone +64 350 8074 24

IFHC Integrated Family Health Centre IS Information systems MDHB MidCentral District Health Board MoH Ministry of Health MSD Ministry of Social Development NES National Enrolment System NGO Non-Government Organisation OIS Outreach Immunisation Service PFAS Per-and Poly-Fluorinated Alkyl Substances PHC Primary Health Care PHO Primary Health Organisation PPC Primary Public and Community PPU Planning and Performance Unit SBHS School Based Health Service SBIS School Based Immunisation Programme VLCA Very Low Cost Access WINZ Work and Income New Zealand

1. PURPOSE

The purpose of this report is to set out the Cluster’s performance against plans, budget and targets, and to advise any current and emerging matters.

2. SERVICE OVERVIEW

The Primary Public Community Health Cluster is responsible for the planning, funding and provision of:

• Primary and community based services via a range of contracted partners • Public health services spanning health promotion, protection, regulation, and clinical care delivery • Specialist sexual health services • Child and adolescent dental services for 0-18 year olds across the district • Community based nursing services including District Nursing and Primary Health Care (PHC) nursing in partnership with Primary Care and the Central Primary Health Organisation (PHO)

Services in the Cluster are structured into the following four service groups:

• Child Adolescent Oral Health • District Nursing • Primary and Community Health Care • Public Health (including Sexual Health)

3. CLUSTER AIM AND PRIORITIES

The Primary, Public, Community Health cluster focus will be broad encompassing determinants of health/spanning generations/health and social care/other sectors and will have a clear intersect with each locality plan. Key aspirational goals and priorities include; strengthening intersectoral partnerships, the development of cross organisational locality based teams, and enablement of a supported capable Primary, Public and Community Health Care Workforce.

A Cluster Health and Wellbeing Services Plan is being developed which will set out its aims and priorities. The cluster overview will be presented at the November meeting.

4. 2018/19 PLANNING INITIATIVES

In 2018/19 the Primary, Public and Community Health Cluster will contribute to the delivery of the District Health Board’s (DHB’s) Annual and Operational Business Plans. Key initiatives for the Cluster, grouped by MidCentral District Health Board (MDHB) strategic priorities, are:

Initiative Rating & Trend MDHB Strategic Priority: Reduce health inequities 1. Improve access to general practice and locality based community health teams  2. Increase enrolment with Central PHO  3. Strengthen utilisation of other workforce in primary health care settings  4. Participate in collaborative efforts that supports the health and wellbeing of children  and young people 5. Identify the potential for and implications of extending school based health services  to all secondary schools in the region. 6. Improve immunisation coverage rates across priority age groups, per the  immunisation schedule. MDHB Strategic Priority: Minimise the impact of long term conditions 7. Improve early detection and management of risks for cardiovascular disease  8. Improve delivery of equitable quality services for people at high risk of or living  with Diabetes and reduce variation in practice 9. Increase access to community clinical pharmacists in health care delivery team  MDHB Strategic Priority: Develop our communities 10. Strengthen integrated model of public, primary, and community health care  services. Rating & Trend Legend G On track, A Behind plan – R Behind plan – major D No completed as progressing as remedial action risks and exception planned planned plan in place report required  Improved from last  Regressed from last  No change from last report report report

The cluster is on track with the annual and operational plan initiatives with updates provided on the following:

• Access to general practice and locality based teams- Further updated metrics on health care home will be provided at end of quarter two. See 7.2 and 7.5 for further detail.

• Enrolment - see 7.2

• Immunisation - see section 6.

• Increasing health and well-being of young people and School-based Health Service expansion - The expansion of School Based Health Service (SBHS) to all decile four schools inclusive of two additional schools (Awatapu College and Dannevirke High School; alongside the two already being supported (Otaki College and Hato Paora) will bring total service coverage to 18 schools/alternate education/teen parent units (out of a total of 30 for district). The model of care for the service is currently being reviewed (see 5.1 below for further detail). The proposed commencement date is February 2019 with planning on track. Meetings have been scheduled with the school principals and the role description for the SBHS Registered Nurses will be revised in line with the service specifications and model of care.

With this increase, approximately 3900 students will be included in SBHS supported Colleges/units from January 2019 (based on the 2018 education count numbers). This will bring coverage to 43 percent of the college populations supported by SBHS services in 2019. (Decile one to four inclusive).

• Increased access to Clinical Pharmacists- recruitment is complete with all expected to be in post by early December. See 10.1 for further detail.

5. KEY ACHIEVEMENTS IN THE MONTH

5.1. PHC Nursing Integration

The Primary Health Care Nursing Integration project is collaboration between MidCentral District Health Board and the Central Primary Health Organisation, in partnership with General Practice teams and the District Nursing Service to improve patient care.

The initial aim was to integrate and align the MDHB PHC nursing workforce with two Integrated Family Health Centres, beginning with District Nursing alignment. The addition of equity as a driver and awareness of local variations in service provision and community need resulted in broader engagement with GPTs including Māori Health providers, with four GPTs and District Nursing the initial co-design partners.

Following initial evaluation of the project, endorsement was gained to further scale focused on both increasing the number of GP teams aligned with the District Nursing Service (DNS), and across wider PHC nursing teams. The care capacity and demand plan for the District Nursing Service has been finalised, aimed at improved visibility of capacity constraints to the wider organisation given that approximately 50 percent of referrals come to the DNS from MidCentral inpatient/outpatient services. Alert messages related to variances are being developed. The next stage will be alignment with the processes of the Hospital/Integrated Operations Centre.

In increasing equitable access further progress has been achieved with Otaki Integrated Family Health Centre (IFHC) confirming a shift in the District Nursing clinic site into the building aligned with the general practice and Central PHO services. This will enable the project to begin to progress at this site. Discussions are planned with The Palms IFHC in the next month, congruent with the phase three aims of increasing the number of General Practices involved, also offering the opportunity to align the interface with the new Practice Patient Management System (PMS) Indice.

A plan has been agreed to implement a limited number of devices to test a mobility solution capable of integrating the workflow across DHB community nursing and GPteams. This continues to significantly delay progress of implementation of the total shared care model, being primarily related to the timing of the digital strategy mobilisation.

When considering the electronic transfer of information between services, a number of forms for the District Nursing Service and Public Health Nurses have been adapted and provided to the Central PHO for integration with Indici. This is critical to ensure that DHB community services are enabled to interact effectively with the new PMS as it is implemented. 28

Focus continues with Public Health Nursing leadership and wider stakeholders to develop the model of care for the expansion of the School Based Health Service. Initial scoping has been undertaken and is being used to inform the model. Key principles must include: youth friendly services; improving access to assessments and referrals; assessment and nursing services; health promotion activities; support for pregnancy, and ensuring students know who their GP team is and where they can go for primary care outside of educational facility hours. There is also the opportunity to enhance quality improvement, professional development of staff and piloting of innovation and the stakeholder group is keen to see active youth voice and participation. Draft core model of care elements will be work-shopped with stakeholders in November in preparation for the February commencement.

5.2. Pharmacy

Nationally, on 1 October 2018, the Integrated Community Pharmacy Services Agreement came into effect. MidCentral DHB had a 100 percent signing rate prior to the cut-off date of 14 September 2018. The new contract is a key step in enabling us to deliver on the aspirations of the Pharmacy Action Plan and the DHB’s priority for health services to be delivered closer to home, and to reduce inequity by providing additional support to the at risk populations. Maintaining access to health services is critically important and MidCentral DHB highly values the distributed community pharmacy network that delivers services to our population. We recognise the ability of community pharmacy to advance national health objectives is dependent on its sustainability.

5.3. Public Health

Sustainability Update

Government planning priorities for 2018/19 include a focus on waste disposal. Public Health has been working closely with a small team to develop the MidCentral Sustainability Policy and Business Case. Following a presentation to the Executive Leadership Team (ELT) the policy was approved.

Earlier this year we were approached by a student looking for a practicum placement for his requirements towards his Masters in Public Health at Massey University. This was seen as an ideal opportunity for further work in this area to be completed. The substantive goal of the practicum with PHS was to undertake a stocktake of existing environmental sustainability initiatives within the Palmerston North Hospital. Another specific focus was to explore opportunities for improving sustainability through better waste management by introducing or expanding recycling within the hospital.

Outcomes: It was very pleasing to find that MDHB is doing more than people may assume. As an organisation we are: • enjoying considerable energy and carbon savings through the work of Warren Crawley, an engineer working with Spotless Services • recycling PVC infusion and irrigation bags, oxygen face masks and tubing, which are being sent to Matta Products for recycling into rubber play and industrial mats • recycling aluminium anaesthetic bottles: these are collected free of charge, with 50 bottles being equivalent to one bicycle frame 29

• many enthusiastic individuals from all parts of the hospital (and Horowhenua Health Centre) are busy recycling and taking home plastics etc • recycling of Supplier support for programmes: e.g. Baxters with PVC and Aluminium.

Options identified for expanding sustainability initiatives include: • introduction of recycling programme for high volume items (milk bottles, glass, and kimguard) • improved water management • procurement and packaging of medical supplies • review of use of anaesthetics: types of gases and mode of delivery • reduction in vehicle usage and staff flights.

The business case includes provision for a Sustainability Officer to support and build on what is already being achieved. Development of the position description is underway.

5.4. Smoke free/ Auhi Kore Policy

This policy was due to come to the committee for endorsement, however due to a delay with the consultation process this will be presented at the next committee meeting.

6. AREAS OFF TRACK AND REMEDIAL PLANS

6.1. Smoking Cessation

The quarter one result at 84 percent is a two percent reduction on the previous quarter. For Māori there was a corresponding decrease from 83 to 81 percent. A similar two percent reduction occurred for the national result this quarter. A total of 280 SBA’s are necessary to complete each week across the district to reach the 90 percent target. Currently approximately 30 percent of practices have reached target, 30 percent are within the 70-90 percent range, and the remainder are below 70 percent. Central PHO continues to engage with general practice teams regarding the provision of smoking brief advice and referral to quit services. Quit coaches are available for clinics at GP Teams.

Central PHO is working in collaboration with TOAM, MCPG, Te Tihi and Public Health to develop further strategies and activity to improve the quit rate across the MidCentral region.

6.2. Immunisation

The table below shows the three month coverage rates, for the three months ending 19 October 2018, against a target of 95 percent.

Of note:

The overall three-month coverage rate at milestone age eight months remains at 91 percent. However target has been achieved with the coverage rate improved to 95 percent for the October month with Māori at 92 percent. The decliner/opt-off rate continues to vary with no distinct trend associated with GP enrolment.

The Immunisation Stakeholder Group consisting of representatives across the sector, has a work programme in place to support achievement of the childhood targets and to increase the uptake of both influenza and pertussis vaccination in pregnant women. Work streams include: working with Lead Maternity Carers (LMCs); timely enrolment of all new-borns; monitoring and maintaining equity of coverage; timely follow up of delayed immunisations; monitoring and responding to the decliner rate; follow-up of non-responders – referral to Outreach Immunisation Services (OIS); ongoing communication and awareness raising. Work is progressing across all of the work streams. Specific work conducted since the last update includes, immunisation coordinator visits to general practices, developing an understanding of demographic characteristics associated with decliners and delayers for the Quarter One period of 2018/19, timing of referral to OIS, and ongoing monitoring compared with national trends.

6.3. Children and Adolescent Oral Health Service

Chair utilisation has increased marginally in the past month and follow up on clinical meetings continues with all staff. Arrears for 0-18 year olds in October are 5,264 compared to 5,577 in August, a decrease of 293. The focus for addressing arrears continues to be on the number of children waiting the longest. In regards to the number of children/adolescents waiting the longest, this was 292 in October compared to 286 in August. There has been a significant improvement since July 2017 when the number was 1969.

The Service Plan development is underway with a draft expected to be discussed with the Leadership team in November.

Questionnaire module (Titanium): This electronic health record system operational in the district for over 18 months continues to provide service level challenges. Activation of the risk assessment module has been further delayed by previously undetected compatibility issues with current service applications. These are being worked between Titanium Solutions and Information Systems (IS), with a dedicated IS lead managing this process for the service. Resolution is expected to enable activation in late November.

Individual staff interviews were completed in October for the workplace culture review being undertaken. The report and recommendations are expected in mid- November 2018.

7. KEY ISSUES AND INITIATIVES IN COMING MONTHS

7.1. PFAS Update

Recently, Palmerston North Airport Company identified a number of residential and industrial sites near the airport’s northern boundary where there is a possibility of Per-and-Poly-Fluorinated Alkyl Substances (PFAS) contamination, arising from past use of the firefighting foam. Levels of the chemicals exceeding the interim drinking water guidelines in surface water samples at these sites.

Following consultation with private bore owners, ground water samples were taken from 12 properties predominantly located to the north and west of the Airport, who have some reliance on bores for drinking water.

All 12 samples complied with interim drinking water guidelines (set at 70 parts per trillion). Eleven samples failed to detect any trace of per- and poly-fluoroalkyl substances (PFAS) at concentrations above the limits of reporting (1 part per trillion).

A groundwater sample from one private bore indicated the presence of perfluorooctane sulfonic acid (PFOS) at 1.2 parts per trillion (just above the limit of reporting), but 58 times lower than the interim drinking water guideline value (70 parts per trillion).

Owners/occupiers of the properties concerned have been notified of their results.

Soil values detected on site were all below the human health screening values for industrial/commercial land-use.

Sediment sampling from streams detected PFAS in the northern stream and southern drain but not in Mangaone Stream flowing through the city. Sediment is material that settles in the bottom of drains and streams.

Surface water was also sampled. This is water that collects on the surface of the ground in drains, streams and lakes as opposed to groundwater that travels through aquifers below ground. Surface water sampling did detect PFAS including in the Mangaone stream, however at low concentrations. PFAS was also detected at ground water sampling sites on airport land.

Further testing is now planned in the northern stream and southern drain, and Mangaone stream adjacent to the airport, to understand whether eels and other aquatic life have been impacted. MidCentral DHB Public Health Services advises that swimming in potentially affected waterways is not considered to pose a significant health risk.

7.2. Health Care Home

Following on from recent engagement between the Consumer Council and the Central PHO Clinical Board, a series of fora will be facilitated late January 2019 focussed on a shared understanding of the new ways of accessing General Practice Teams; easy access to broad interdisciplinary team members; patient portal; virtual consultation; and telephone triage as examples. Further metrics will be provided at the completion of quarter two for the participating practices.

7.3. Primary Care Enrolment Programme

Current estimates indicate that there are approximately 13,382 people living in our district who are not enrolled with a GP team. This equates to approximately seven percent of the total MDHB population. Evidence shows that people experience better health outcomes when they a longitudinal relationship with a primary care provider. Māori enrolment continues to be lower than non Māori currently at 86 percent.

MDHB and Central Primary Health Organisation (CPHO) have been working together to develop a programme to increase enrolment numbers across the district. Following a look into other models around New Zealand, MDHB and CPHO will implement a one year pilot Primary Care Enrolment Programme. The new programme will see the existing New Born Enrolment Programme expanded to cover the entire lifespan and will engage with the unenrolled population and encourage and assist them to enrol with a General Practice Team. The programme will initially employ a new coordinator for twenty hours a week with potential to increase capacity if there is more demand than anticipated. The role will focus on identifying people presenting to MidCentral services that are not currently enrolled with a General Practitioner Team, with an initial focus on the Emergency Department. Processes will actively engage and support enrolment. The role will be key in liaising across hospital services including outpatients, General Practice Teams, Central PHO, community providers, Public Health Nurses, key government agency partners and Non-Government Organisations (NGO’s). The programme will initially be funded for one year and its effectiveness will be evaluated prior to the end of the pilot.

The project team is in the process of finalising a number of resources to support the programme, which includes:

• development of a ‘Keeping Healthy in MidCentral’ pamphlet to be used by key Government Agency partners i.e. Work and Income New Zealand (WINZ), Housing NZ, Education, real estate firms, I Site etc. where families may present when new to the district. • TV messaging for Emergency Waiting Room – we are currently working with the group creating the TV based messaging for use in the Emergency Department (ED) waiting room. • a revised business card for ED to give out to patients who present who require support enrolling. • small and relevant Frequently Asked Questions one pager. • small questionnaire will be implemented to determine reasons/barriers for enrolment. • better use of existing data - An example of this is the Planning and Performance Unit (PPU) providing the NEP daily updates of patients who present to ED without a GP Team for follow up. • the development of a clear communications campaign to both ensure GP Teams are aware of the new programme, and to provide information for individuals and whanau. The new National Enrolment System (NES) is scheduled to go live in February 2019 and will make it simpler and faster to check an individual’s enrolment status.

The Committee will continue to receive regular updates on enrolment data as part of this clusters dashboard.

7.4. Extending Access to Primary Care Services from 1 December 2018 – Free Under 14’s and Community Service Cards Changes

Free Under 14’s

All General practices in the region are adopting the free under 14’s. Currently children under the age of 13 are eligible for free visits at their enrolled general practice, are not charged the regular five dollar prescription fee and have access to zero fees after-hours care. This also applies to injury related visits covered by Accident Compensation Corporation (ACC). From 1 December 2018 zero fees will be extended to all children aged under 14. The Ministry of Health (MoH) will be providing additional funding to DHBs to cover this increase in access coverage.

Community Services Card Changes

From December 2018 low-cost visits are being introduced for Community Service Card (CSC) holders and their dependent children. General practices can choose whether or not to provide low-cost visits to community service card holders. We anticipate that most practices across MidCentral will opt to provide low-cost visits to CSC holders as those practices that opt in will receive an additional subsidy from the Government through increased Capitation funding, the modelling for which is based on CSC data provided by Ministry of Social Development (MSD). The CSC initiative will apply to visits to an individual’s regular general practice where they are enrolled and will bring the cost of visits in line with the cost at Very Low Cost Access (VLCA) practices, currently capped at $18.50 per visit. The CSC initiative will not apply to CSC card holders enrolled at VLCA practices as they are already paying a reduced fee, or after hours visits or visits to practices the card holder is not enrolled with. The implementation of the CSC initiative will take a phased approach and Central PHO is currently working with practices to determine the individual practice’s preferred opt-in dates. To date all but two of the Central PHO IFHCs / General Practices have indicated that they intend to adopt the CSC initiative. City Doctors White Cross has indicated that nationally all White Cross practices will not be adopting the CSC initiative at this time. Dr. Short’s practice in Dannevirke has also indicated that they will not be adopting the CSC initiative at this time.

BCG Vaccination

Bacillus Calmette-Guérin (BCG) vaccinations have progressed well over the month. Vaccinations have been completed on 63 children under six months and on 55 children aged between six months and five years. Attendance at clinics in Palmerston North has been excellent, unfortunately at the Horowhenua clinic there have been a number of DNAs. These families are being actively contacted both prior to the clinic and after if not attending to offer a further appointment. It is anticipated that we will have completed vaccinating the backlog by June 2019.

HPV School Based Immunisation Programme (SBIP) has recommenced following the vaccine shortage. MDHB’s Public Health Service is on track with their schedule. General Practice has been notified by the Ministry that they can order now ten doses every two weeks. Guidance as to who should receive these doses was given in the notification. 34

8. SCORECARD

A DHB-wide scorecard covering the full continuum of care is being developed for each cluster. This is expected to be developed over 12 months, and as information collection systems allow.

As at End of October 2018

Customer Patient

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) CP41 - Complaints 100.0% 100.0% 95.0% 5.0% 100.0% 95.0% 5.0% responded to within 15 PHO Enrolment Total 93.0% 93.0% 93.0% 0.0% 93.0% 93.0% 0.0%

PHO Enrolment Maori 86.0% 86.0% 90.0% (4.0%) 86.0% 90.0% (4.0%)

PHO Quit Smoking 86.0% 85.7% 90.0% (4.3%) 85.9% 90.0% (4.1%) Advice PHO Infant Primary 91.0% 91.2% 95.0% (3.8%) 91.1% 95.0% (4.0%) Immunisation PHO Cervical Screening 75.0% 75.0% 80.0% (5.0%) 75.0% 80.0% (5.0%)

Organisational Health and Learning

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) OH01 - Staff Stability 99.4% 100.0% 99.0% 1.0% 99.6% 99.0% 0.6%

OH02 - Staff Turnover 0.00% 1.16% 1.00% (0.16%) 0.29% 1.00% 0.71%

OH03 - Sick Leave Rate 2.41% 3.12% 3.20% (0.08%) 4.29% 3.20% 1.09%

OH06n - Number of 31 28 0 28 28 0 28 employees with an

Legend * Non-financial KPI results for Dec- Achieved 2017 to date are subject to data-quality and completeness checks relating to Partial Achievement the WebPAS transition. Not Achieved

8.1. Performance as at end of October 2018

The number of employees with leave balances over two years has reduced consistently over the past 3 months. Active planning with individuals is in place. Cervical screening coverage rate remains static, with a range of initiatives underway to improve this.

8.2. Contracted Service Delivery

A number of Primary, Public and Community Health services are provided under contract by community and Non-Government Organisation (NGO) providers. Responsibility for these contracts is being progressively transferred to the Cluster.

9. FINANCIAL POSITION

9.1. Financial Position as at end of October 2018

$000 Oct-17 Oct-18 Oct-17 Year to date Actual Actual Budget Variance Actual Actual Budget Variance

Revenue 465 669 671 (1) 2,123 2,733 2,653 81 Pass Through Revenue Net Revenue 465 669 671 (1) 2,123 2,733 2,653 81

Expenditure Personnel 1,108 1,181 1,108 (73) 4,370 4,261 4,369 108 Outsourced Personnel 0 2 0 (2) 8 4 1 (3) Sub-Total Personnel 1,108 1,183 1,108 (75) 4,378 4,265 4,370 105

Other Outsourced Services 19 103 96 (7) 77 387 313 (74) Clinic al Supplies 160 177 161 (16) 638 637 656 20 Infrastructure & Non-Clinical 123 109 157 48 644 589 640 51

Total Expenditure 1,410 1,573 1,522 (51) 5,737 5,878 5,979 101

Provider Payments 0 5,281 5,281 0 0 21,288 21,779 491 Corporate Servic es 94 71 72 1 375 291 290 (1)

Net Expenditure (1,040) (6,255) (6,204) (51) (3,988) (24,724) (25,395) 672

FTE Medic al 4.0 4.2 3.9 (0.3) 4.0 3.9 3.9 0.0 Nursing 80.7 71.4 76.4 5.0 81.9 70.6 75.1 4.4 Allied Health 68.2 65.2 71.4 6.1 69.3 66.1 69.1 3.0 Support 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Ma na ge me nt / A dmin 16.5 16.8 14.6 (2.3) 16.5 16.7 14.6 (2.2) 169.4 157.7 166.2 8.6 171.6 157.4 162.6 5.3

Favourable to Budget Unfavourable to Budget but within 5% Unfavourable to Budget outside 5%

The Primary, Public, and Community Health result for the month was net expenditure of $6.255m, which was an adverse variance to Budget of $0.051m.

Revenue Revenue was on budget.

Year-to-date net revenue is $0.081m favourable to budget and is forecast to be $0.051m favourable to budget at year end. Work is presently underway to maximise the District Nursing ACC revenue to increase this favourable result.

Expenditure Total Personnel was $0.075m adverse to the Budget. Medical was $0.042m adverse to the budget primarily due to the recoding of the costs to the cluster. Allied Health was $0.046m adverse to the Budget due to the DHB wide accrual for the MECA back-pay this month.

Year-to-date total expenditure is $0.591m favourable to budget and is forecast to be $0.693m favourable to budget at year end, primarily in provider payments.

10. BUSINESS IMPROVEMENT PROGRAMME

10.1 Pharmacy Programme

The Hospital to Community Pharmacist Pilot is now into its second quarter and is showing strong results. Q2 outlined the prevention of 16 moderate to major harm events, a reduction of 42.5 bed days and estimated marginal cost savings of $66,316. For the project to-date, they have outlined the prevention of 36 moderate to major harm events, a reduction of 67.5 bed days and estimated marginal cost savings of $136,592. This clearly shows the clinical and financial benefits of having dedicated pharmacists supporting patient care and flow.

The recruitment of dedicated Population Health and Primary Care Support Pharmacist roles is complete with all expected to be in post by early December. The recruitment panel consisted of MDHB and CPHO members to further embed the partnership approach to the Primary Care Support Pharmacy team. The Pharmacy Programme Board has confirmed the FTE to population/IFHC allocation of resources based on an equity matrix, which was developed to ensure that resources target those most in need.

• The Population Health Pharmacist role is to understand trends in prescriber and dispensing data for the population of MidCentral and design best practice guidelines to influence prescriber and patient behaviours.

• The Primary Care Support Pharmacists will be working as allocated to complete complex medication reviews and medicine therapeutic assessments. The aim is to ensure individual patients medications are appropriate and address inequity issues at an IFHC level through patient audits. The additional recruits will complement the already established small Central PHO clinical pharmacy team.

11. RECOMMENDATION

It is recommended that the Committee: • endorse the progress made by the Uru Kiriora - Primary, Public and Community Health Cluster in 2018/19 • note the focus on primary care enrolment • note the uptake in extending access to primary care services, and planned consumer engagement regarding Health Care Home • note the progress being made in the Pharmacy Business Improvement Programme

Deborah Davies Dr David Ayling Operations Executive Clinical Executive

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Author Dr Syed Zaman, Clinical Executive Andrew Nwosu, Operations Executive

Endorsed by Kathryn Cook, Chief Executive

Date 20 November 2018

Subject Uru Whakamauora Healthy Ageing and Rehabilitation Cluster Report

RECOMMENDATION It is recommended that the committee: • Endorse the progress made by the Uru Whakamauora- Healthy Ageing and Rehabilitation cluster to date • Note the range of improvement initiatives focusing on improving care outcomes and patient experience for older people who may be living with frailty • Note the opportunities for revenue from the Non Acute Rehabilitation (NAR) contract

Strategic Alignment Operational performance for the Healthy Ageing and Rehabilitation Cluster is aligned to the DHB’s Strategy, in particular to the four strategic imperatives that are the fundamental focus for MidCentral District Health Board, with an overarching emphasis on quality. Glossary ACC Accident Compensation Corporation ARC Aged Residential Care ACE Acute Care of the Elderly CF Calderdale Framework CCDM Care Capacity and Demand Management DHB District Health Board Uru Whakamauora COPY TO: Healthy Ageing and Rehabilitation MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone: +64 (6) 3569 169 38

DNA Did Not Attend ELT Executive Leadership Team HAR Healthy Ageing and Rehabilitation HOC Hospitals Operations Centre HOP Health of Older Person HR Human Resources MDHB MidCentral District Health Board NAR Non Acute Rehabilitation NGO Non-Government Organisation OPAL Older Persons Assessment and Liaison PPPR Personal Protection and Property Rights STAR Specialist Treatment Assessment and Rehabilitation Services UTI Urinary Tract Infection NASC Needs Assessment Service Coordination

1. PURPOSE

The purpose of this report is to set out the Cluster’s performance against plans, budget and targets, and to advise any current and emerging matters.

2. SERVICE OVERVIEW

The Healthy Ageing and Rehabilitation Cluster is responsible for the planning, funding and provision of specialist services for people over the age of 65 years (55 years for Māori) and those between the ages of 16-64 with a physical disability, with a focus on assessment, treatment and rehabilitation. Services in the Cluster are currently structured into the following groups:

• Elder Health • Rehabilitation • Therapy Services • NASC Services

We are working toward a more integrated and connected system with contracted community providers, to provide services, which will emerge over the coming months.

3. CLUSTER AIMS AND PRIORITIES

A key aim of the Healthy Ageing and Rehabilitation (HAR) Cluster is to put people at the centre of all we do. By embedding an ethos of inclusivity and shared decision making around the treatment and care for people who may be disabled, living with frailty or have chronic or long term needs, we will enable them, their Whānau and carers, to live well, maintaining independence, and promoting both dignity and quality of life.

Our aspirational goals and priorities are:

• Joined up care. • More choice and control for older people with regard to their own health. • Implementation of effective multidisciplinary community teams including contracted providers. • Development of clinical and non-clinical staff across the sector around the needs of older people. • Better patient and resident flow through our health system.

A Cluster Health and Wellbeing Plan is being developed which will set out in full our aims and priorities.

4. 2018/19 PLANNING INITIATIVES

In 2018/19 the HAR Cluster will contribute to the delivery of the District Health Board’s Annual and Operational Business Plans. Key initiatives for the Cluster, grouped by MidCentral District Health Board’s (MDHB) Strategic priorities, are:

Rating & Initiative Trend MDHB Strategic Priority: Develop our communities 1. Increase registration of older people into the patient portal  2. Increase enrolment of older people in the community falls and fracture prevention  and the in-home strength and balance programmes 3. Align local and national development of Future Models of Care for Home and  Community and Support Services MDHB Strategic Priority: Address the needs of targeted priority populations 4. Align the Kauri HOP team configuration and scale to the Horowhenua & Tararua  HOP team, rebuilding the infrastructure ready for an ageing population 5. Implement Early Supported Discharge Programme  MDHB Strategic Priority: Reduce health inequities 6. Increase access to community rehabilitation for all people across the district  7. Improve access to options for appropriate response to demand for acute services  8. An Interface Geriatrics service to enable early specialist assessment at the front  door is finalised 9. Design an Acute Care of the Elderly (ACE) Unit to support specialist assessment  and intervention for those requiring hospitalisation 10. Improve options for people living in the community or transitioning to the  community experiencing disjointed care 11. Co-design a specialist sub regional rehabilitation service for people with a disability  aged 16 to 65 Rating & Trend Legend G On track, A Behind plan – R Behind plan – major D No completed as progressing as remedial action risks and exception planned planned plan in place report required  Improved from last  Regressed from last  No change from last report report report

The Cluster is on track with the annual and operational plan initiatives.

5. KEY ACHIEVEMENTS IN THE MONTH

5.1. Older People with Frailty

Work continues in conjunction with Francis Health in relation to the Older People with Frailty work stream. The OPAL business case, which proposes specialist geriatric care in a dedicated unit, is progressing well with ELT sign off on 14 November. Therapy teams led by physiotherapy and occupational therapy coordinators have commenced rapid cycle testing of a multidisciplinary approach to streamline the referral process using a trusted assessor methodology. This commenced on 8 October and involves reviewing referrals that have been sent to both services to see which one can take a lead to follow up with the person rather than both services visiting them at home.

Further rapid cycle testing is planned around how liaison can be improved between the Kauri Health Care Health of the Older Person (HOP) teams and the Palmerston 41

North inpatient wards. Outcomes from this work will be critical in defining next steps for supporting effective transfers of care and enhancing the patient journey out of hospital.

5.2. Community care

In October, an Aged Residential Care (ARC) induction pack was sent to all 36 ARC facilities. The pack collates a range of information on MDHB services that enable better navigation of ARC supporting services. The document is a service improvement initiative between ARC and the DHB, and feedback has been incredibly positive.

We are leading an initiative to design a toolkit around Personal Protection and Property Rights (PPPR) to support older people who are no longer able to speak for themselves and have no one to advocate on their behalf when they need access to permanent aged residential care.

Older people living with frailty and waiting for PPPR orders can sometimes become deconditioned. There is work ongoing with relevant stakeholders to identify best practice that benefits individuals. One such initiative was the ‘Take 5, Get up Get Moving’ programme, which our Clinical Executive presented information to the public and staff.

The National Framework for Home and Community Support Services (HCSS) consultation closes on 30 of November 2018. The aim of the consultation is around designing patient centric services that better support an ageing population, and reflect equity by increased responsiveness to Maori need. Any organisations as part of the health and social sector are able to make submissions on the framework.

5.3. Community Rehabilitation

The current NAR contract expires on 30 November 2018, ACC have changed the contract to enable them move from hospital based rehabilitation to one that is more supportive of community based rehabilitation, the variation to this contract allows for a 1.36% price increase effective from 1st of December 2018 ($9.85 per day). Following discussions, we have agreed to provision the Non Acute Rehabilitation contract using a “case mixed community rehabilitation” model of service delivery for patients within the MDHB catchment area by 1st July 2019.

5.4. STAR 2

September/October Bed utilisation rates were 82 and 78 percent respectively with reduced wait times. These reduced utilisation rates feed into the whole system bed modelling assumptions as well as create opportunities to reduce annual leave backlogs.

The Care Capacity Demand Management (CCDM) plan continues on track and we are working with the Human Resources department (HR) to implement the calculations moving forward.

Falls and incidents continued a downwards trend with only eight falls across the two months. This is significantly reduced compared to earlier in the year where we experienced 10 – 13 falls a month.

Annual leave balances over two years have reduced with a number of staff having support to reduce their balance at the end of October 2018. These staff will have the ‘over two-year component’ significantly reduced by mid-January 2019.

One on one hours (a type of specialing) for September and October were 1,414 (562 hours September and 852 hours October). This represents higher than usual activity for this time of year and is directly attributable to a high risk patient who is a falls and absconding risk waiting on the PPPR process.

Digital Hospital Operations (Miya Patient Flow) was launched in STAR 2 at the end of October as part of the phase three end user acceptance phase. This has improved the visibility of patient’s journey and has helped with multi-disciplinary discharge planning processes.

5.5 STAR 4

Average length of stay on our Star 4 wards is trending down but still higher than previous years, patient complexity often differs from our Star 2 patient cohorts, we are in the process of reviewing our Star 4 bed utilisation, case mix, and patient reported outcomes to understand this better and see where we can improve.

25.00 STAR 4 ATR Cumulative ALOS 20.00

15.00 2016/17

LOS Days LOS 10.00 2017/18 2018/19 5.00

0.00 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Weeks of year

6. AREAS OFF TRACK AND REMEDIAL PLANS

No issues of note this period.

7. KEY ISSUES OR INITIATIVES IN COMING MONTHS

• There is continued recruitment to vacancies. An offer was accepted for a Consultant Geriatrician with a start date in January 2019. • Continued progress with our Health of Older Person (HOP) teams, OPAL Unit, Interface Geriatrics and Early Supported Discharge initiatives as part of the Older People with Frailty Work stream. • Finalisation of the Excellence in Homecare partnering agreements with Home and Community Support Providers are due around February. Activity to finalise these are underway. • Dementia New Zealand and the New Zealand Dementia Cooperative are holding a regional Knowledge Exchange forum in Palmerston North on 14 November 2018. This forum will provide education, share knowledge, and continue to raise awareness about dementia. • MDHB has recently invested in four staff in a Train the Trainer programme to understand and implement Advance Care Planning (ACP) in everyday practice across the district. Current planning is underway to ensure we maximise the use of these ‘superusers’ to support the organisation. • Allied Health champions have been actively working with the Hospital Operations Centre (HOC) development team and User Acceptance testing has entered the stabilization phase (late October) in STAR 2. Nursing, Medical and Allied Health staff will use the system for a period of two weeks prior to ‘go live’ period. • In November, selected participants who have completed the Foundation training for the Calderdale Framework (CF) will attend facilitator training. Facilitators will support implementation of the Framework by undertaking a project to implement the CF within their service and participate in regular network meetings.

8. SCORECARD

A DHB-wide scorecard covering the full continuum of care is being developed for each cluster. This is expected to be developed over 12 months, and as information collection systems allow.

As at End of October 2018

Customer Patient

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) CP21 - Acute 0.0% 1.3% 7.5% (6.2%) 0.8% 7.5% (6.7%) readmissions within 28 CP25r - Occurrence 4.6 1.5 3.5 (2.0) 1.8 3.5 (1.7) Rate of Medication CP26r - Occurrence 4.6 7.7 5.0 2.7 7.5 5.0 2.5 Rate of Patient Falls CP28p - Hospital 1.20% 2.86% 0.50% 2.36% 3.89% 0.50% 3.39% acquired UTI rate (%) CP30p - Inpatients 0.46% 0.62% 0.50% 0.12% 0.39% 0.50% (0.11%) developing Pressure CP41 - Complaints 100.0% 100.0% 95.0% 5.0% 100.0% 95.0% 5.0% responded to within 15 Internal Process and Operations

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) IP02 - ED stays less 50.0% 100.0% 95.0% 5.0% 71.4% 95.0% (23.6%) than 6 hours IP03a - Average LoS: 15.14 15.50 4.00 11.50 16.29 4.00 12.29 Acute Inpatient IP07 - Bed Day Usage 88.3% 73.1% 85.0% (11.9%) 92.4% 85.0% 7.4% (by Health Specialty) IP18 - Outpatient 7.3% 5.9% 6.0% (0.1%) 6.3% 6.0% 0.3% appointment DNAs IP18ma - Outpatient 15.8% 20.0% 6.0% 14.0% 19.0% 6.0% 13.0% appointment DNAs, IP18nm - Outpatient 6.1% 4.5% 6.0% (1.5%) 4.8% 6.0% (1.2%) appointment DNAs, Non- IP18-16 - Outpatient 0.0% 0.0% 6.0% (6.0%) 0.0% 6.0% (6.0%) appointment DNAs, 5-16 IP18-64 - Outpatient 12.5% 13.0% 6.0% 7.0% 12.3% 6.0% 6.3% appointment DNAs, 17- IP18-65 - Outpatient 5.7% 3.6% 6.0% (2.4%) 4.3% 6.0% (1.7%) appointment DNAs, 65+ IP22 - Hospitalised 100.0% 80.0% 95.0% (15.0%) 92.9% 95.0% (2.1%) smokers provided with IP28 - One to One 574 854 0 854 1,680 0 1,680 Hours Organisational Health and Learning

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) OH01 - Staff Stability 99.7% 100.0% 99.0% 1.0% 99.8% 99.0% 0.8%

OH02 - Staff Turnover 0.00% 0.31% 1.00% 0.69% 0.54% 1.00% 0.46%

OH03 - Sick Leave Rate 3.25% 2.78% 3.20% (0.43%) 3.23% 3.20% 0.03%

OH06n - Number of 25 23 0 23 23 0 23 employees with an

Legend * Non-financial KPI results for Dec- Achieved 2017 through Sep-2018 are subject to data-quality and completeness checks Partial Achievement relating to the WebPAS transition. Not Achieved

Performance as at October 2018 – Actions on Variance

• The number of falls continues to reduce, all falls are closely monitored and reviewed; there are no particular areas of concern, and prevention through promoting safe mobility remains a strong focus. • Hospital-acquired urinary tract infection (UTI) rates are included in a current programme of work promoting fundamentals of care; central to this is ensuring sufficient hydration, which is an important preventer of UTI’s. • Acute length of stay was above target due to the case complexity and issues arising from the PPPR process. • We had a number of skin integrity episodes on STAR 2 and 4 wards, we continue to monitor these with regular audits, and reinforce good practice with the new integrated risk care plan. • We are continuing to work on improving our outpatient Did Not Attend (DNA) rates using strategies such as contacting clients by phone/ text to remind them of appointments and will be considering other means to ensure our approaches are equitable. • Leave plans are in development for all staff with balances over two years. Leave balances are monitored on a regular basis and existing leave plans updated as required.

Contracted Service Delivery

A number of Healthy Ageing and Rehabilitation Cluster services are provided under contract by community and Non-Government Organisation (NGO) providers. Responsibility for these contracts is being progressively transferred to the Cluster. Key contracts are Aged Residential Care, Home and Community Support, respite and day services and mobility promotion.

9. FINANCIAL POSITION

9.1. Financial Position as at October 2018

$000 Oct-17 Oct-18 Oct-17 Year to date Actual Actual Budget Variance Actual Actual Budget Variance

Revenue 568 431 465 (34) 2,069 1,922 1,864 58 Pass Through Revenue 0 0 0 0 0 0 0 0 Net Revenue 568 431 465 (34) 2,069 1,922 1,864 58

Expenditure Personnel 1,009 1,140 1,100 (40) 3,983 4,231 4,441 209 Outsourced Personnel 15 14 6 (8) 44 38 23 (15) Sub-Total Personnel 1,023 1,154 1,105 (48) 4,026 4,270 4,464 194

Other Outsourced Services 57 66 55 (11) 263 230 220 (10) Clinic al Supplies 107 125 103 (22) 486 481 418 (62) Infrastructure & Non-Clinical 72 67 73 6 301 267 297 30

Total Expenditure 1,259 1,412 1,336 (76) 5,076 5,247 5,399 152

Provider Payments 0 6,945 6,945 0 0 27,130 27,158 28 Corporate Servic es 118 76 76 0 477 303 303 0

Net Expenditure (809) (8,001) (7,892) (109) (3,485) (30,758) (30,996) 238

FTE Medic al 13.8 12.7 14.3 1.6 13.4 13.5 14.1 0.6 Nursing 60.8 62.0 68.0 5.9 60.1 61.6 66.3 4.7 Allied Health 57.0 59.2 62.9 3.8 57.0 59.0 62.9 3.9 Support 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Ma na ge me nt / A dmin 12.8 12.3 8.5 (3.7) 13.3 11.5 8.5 (2.9) 144.3 146.1 153.7 7.6 143.7 145.6 151.8 6.2

Favourable to Budget Unfavourable to Budget but within 5% Unfavourable to Budget outside 5% FT E Below Budget FTE Higher than Budget but within 5% FTE Higher than Budget

Healthy Ageing was $109k adverse to budget for October.

Net Revenue was $34k adverse due to ACC. Invoicing is still behind and we have taken a conservative position on our assumptions for ACC revenue.

Personnel was adverse to budget by $48k. There was a provision taken up for Allied Health back pay at 3 percent, which was budgeted for in September, this contributed $103k. This was offset by vacancies within Allied Health, Medical & Nursing.

Outsourced services were adverse to budget by $11k due to lymphodema costs, this represented a catch up on Septembers under charge.

Clinical supplies were $22k adverse to orthotics, which has been seeing an increase in demand.

9.3 Year to Date Financial Position

Healthy Ageing is $258k favourable to budget at October YTD.

Revenue is $58k favourable to budget which is due to non-acute ACC revenue and relates mostly to 2017/18 where we revenue billed in this period was greater than our conservative estimate.

Personnel is $194k favourable to budget, this is due to vacancies within the service across all staff types but particular within the Allied Health space as recruitment proves to be difficult. Nursing is under budget due to lower utilisation rates in STAR 2 making it possible to run lower than anticipated rosters.

Clinical supplies is adverse to budget by $62k. This is due to Orthotics $23k, this service is becoming a more common form of treatment and delays in Orthopaedic surgery are also driving additional demand. Specialist referrals for this service will be reviewed by the Clinical Executive to ensure appropriate use. Other supply costs like blood, dressings and patient consumables have also added $17k to the deficit, with another $12k coming from transport costs.

Infrastructure costs are favourable to budget by $30k due to lower bed days which generates savings in food and laundry charges.

10. BUSINESS IMPROVEMENT PROGRAMME

A comprehensive programme of work has been developed to focus on providing integrated care for older people with frailty, looking at interactions between acute, primary, community and social care services and older people living with multiple co-morbidities, to maintain their health and wellbeing in their own home for longer. This targeted approach is designed to improve both the quality of life of older people and build a strong workforce going forward. The connected programmes below will as a whole improve quality of life for older people and reduce dependence on costly hospital based services.

The programmes of work are:

• Acute Care of Older People • Early Supported Discharge • Rapid Response • Expanded HOP team • Ortho-geriatrics / surgical liaison • Community Rehabilitation

This programme will be scoped in the first quarter of 2018/19 and aims to be implemented during the year.

11. RECOMMENDATION

It is recommended that the Committee: • endorse the progress made by the Uru Whakamauora- Healthy Ageing and Rehabilitation cluster to date • note the range of improvement initiatives focusing on improving care outcomes and patient experience for older people who may be living with frailty • Note the opportunities for revenue from the Non Acute Rehabilitation (NAR) contract

Andrew Nwosu Dr Syed Zaman Operations Executive Clinical Executive

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Author Dr Jeff Brown, Clinical Executive Sarah Fenwick, Operations Executive

Endorsed by Kathryn Cook, Chief Executive

Date 20 November 2018

Subject Pā Harakeke Healthy Women Children and Youth Report

RECOMMENDATION It is recommended that the Committee: • endorse the progress made by the Healthy Women Children and Youth Cluster Service to date. • note the information regarding upcoming Midwifery strikes • note the Mokopuna Ora Collective work and Child Health Forum initiatives • note the work to ensure achievement of elective targets • note the dates of the cluster plan workshop, to which is there is an open offer for the board to attend

Strategic Alignment Operational performance for the Healthy Women Children and Youth Cluster is aligned to the DHB’s Strategy, in particular to the four strategic imperatives that are the fundamental focus for MidCentral District Health Board (MDHB), with an overarching emphasis on quality.

Glossary

ACC Accident Compensation Corporation CALM Computer Assisted Learning for the Mind CPAC Clinical Priority Assessment Criteria

COPY TO: Pa Harakeke Healthy Women Children and Youth MidCentral DHB Heretaunga Street PO Box 2056 Palmerton North 4440 Phone +64 350 8074 50

DHB District Health Board DNA Did Not Attend ESPI Elective Services Patient Flow Indicators FSA Funded Specialist Appointment FTE Full Time Equivalent GP General Practitioner LMC Lead Maternity Carer LPS Life Preserving Services MCIS Maternity Clinical Information System MDHB MidCentral District Health Board MERAS Midwifery Employee Representation & Advisory Service MSD Ministry of Social Development O&G Obstetrics and Gynaecology P2A Paediatric to Adult RMO Resident Medical Officer RN Registered Nurse SMO Senior Medical Officer SUDI Sudden Unexplained Death in Infancy

1. PURPOSE

The purpose of this report is to set out the Cluster’s performance against plans, budget and targets, and to advise any current and emerging matters.

It is for the Committee’s information and comment, on the progress and direction of travel for the Cluster.

2. SERVICE OVERVIEW

The Healthy Women Children and Youth Cluster is responsible for the planning, funding, commissioning and provision of:

• Primary and secondary maternity care, secondary obstetrics and gynaecology services – including antenatal day unit, inpatients, outpatient clinics, community midwifery services and lactation services • Family centred care to neonates, children and young people - up to their sixteenth birthday as inpatients and until end of school for ongoing ambulatory care

Services in the cluster are structured into the following service groups:

• Maternity services, including hospital obstetrics and gynaecology services; and primary maternity services • Neonatal services • Child health services, including community and specialist services • Child development services • Youth health services

The service is working toward an integrated system with more community providers being connected into the Cluster over time. This will be reflected in all aspects of the report.

3. CLUSTER AIM AND PRIORITIES

The Cluster’s aspirational goals and priorities are to improve the health and wellbeing of women and children, with a focus on the first 1000 days.

A Cluster Health and Wellbeing Service Plan will be developed that will align with the District Health Board (DHB) strategy, recognise the challenges, aspirations and priorities for the population group, to ensure a focus on equity with the recognition that early intervention is essential and improves long term outcomes. A first draft will be available in the first quarter of 2019.

4. ANNUAL PLAN INITIATIVES

In 2018/19 the Cluster will contribute to the delivery of the DHB’s Annual Plan.

Initiative Rating & Trend MDHB Strategic Priority: Reduce health inequities

1. Improve breastfeeding rates with a particular focus on supporting Māori  and Pacific women and those living in high deprivation areas. 2. Strengthen continuity of care and integrity of handover information  between LMC, Well Child Providers, and GP Teams 3. Children and families are safe from harm  4. Participate in collaborative effort that supports the health and wellbeing of  children and young people MDHB Strategic Priority: Address the needs of targeted priority populations 5. Improve the capacity of child health services to better meet the needs of  children with learning and behaviour difficulties MDHB Strategic Priority: Achieve quality and excellence by design  6. Reduction in intervention rates (caesarean section & perineal trauma)  7. Enhance efficiency in service delivery and improve gynaecological service  model of care, including urodynamics and ultrasound scanning 8. Implementation of the national gestational diabetes guidelines including  realignment of the antenatal diabetes service. Rating & Trend Legend G On track, A Behind plan – R Behind plan – D Not completed as progressing as remedial action major risks and planned planned plan in place exception report required  Improved from  Regressed from  No change from last report last report last report

5. KEY ACHIEVEMENTS IN THE MONTH

5.1. Enabling Good Lives

The Ministry of Health trial in our DHB of a new approach to disability services commenced 1 October 2018. Along with Oranga Tamariki, Education, Enable, disability and support services, our DHB Paediatricians will be meeting to co-design a new model of integrated care while responding to requests for support. For children under eight years there will be no need for a diagnosis before early intervention is provided. For other children and young people up to 18 years the aim is for an integrated approach when more than one agency is involved. The group first met on 18 October 2018 to discuss responsibilities, pathways, consent, technology, and commenced fortnightly triage, assessment and support meetings on 1 November 2018.

5.2. Mokopuna Ora Collective

In 2014 MidCentral District Health Board (MDHB) implemented a Keeping Babies Safe Programme (Pēpi Haumaru) which was delivered via the Health Care Development Team. The components of this programme included safe sleeping environments, shaken baby prevention programme, reducing smoke exposure, alongside a Pēpi-pod programme.

In October 2018 the MDHB received additional funding from the Ministry of Health via the Crown Funding Agreement to support the National Sudden Unexplained Death in Infancy (SUDI) Prevention Programme. Rather than duplicate the same programme the sector supported the additional funding going towards an organised wahakura programme. This would develop the capacity of weavers to weave and teach whānau and health professionals how to weave wahakura, and distribute wahakura to whānau who urgently require a safe sleep space.

To date a variety of hui and a symposium have taken place to introduce the kaupapa to the MDHB district and these have been very well received.

A facebook page Mokopuna ora (https://www.facebook.com/healthandwellbeingmamaandpepi/), and email address ([email protected]) have been created to support communication and promotion of the kaupapa.

The collective is supported by Pēpi Haumaru, which now sits with the Child Health Community Team. Given the fast pace of the programme some existing funding is going to be utilised to support a Mokopuna Ora Coordinator and recruitment is well underway. Monitoring and evaluation of the outcomes of the programme will be undertaken to ensure positive impact.

5.3. Child Health Forums

The Child Health Forums began in 2008 and have been delivered twice annually since then. The Forum is developed and facilitated by the MDHB Child Health Community Team. The most recent event on 19 September 2018 attracted over 100 professionals from General Practice Teams, Well Child/Tamariki Ora Providers, Public Health, Social Service providers, the Education sector and Secondary hospital services. Topics covered included:

• Paediatric Respiratory Presentations in General Practice. • Fussy Easting • Food Allergies • The Computer Assisted Learning for the Mind (CALM) Project

The programme at each forum always features a Paediatrician presenting on a topical issue along with speakers in any other relevant areas of interest and includes presentations from a selection of our intersectoral partners including Ministry of Social Development (MSD), Police and social service providers. Feedback and evaluations following each forum continually indicate that this is a valuable learning opportunity along with creating awareness about new initiatives or programmes of work for professionals working with children and family in our community.

6. AREAS OFF TRACK AND REMEDIAL PLANS

6.1. Midwifery Shortage Update

The DHB continues to experience a shortage of midwives within the secondary environment. As advised previously, one year contracts have been offered to Registered Nurses (RNs) as a temporary solution. There have been no incidents to date. The high headcount of new RNs in the maternity service is requiring resource to support and up skill them. The skill mix is challenging to ensure there is adequate oversight of nurses on the maternity ward after hours.

6.2. Maternity Clinical Information System

The Maternity Clinical Information System (MCIS) has been in place now for nearly four years. The Ministry of Health and CleverMed visited MidCentral on 16 October 2018 and has committed to working with the team to improve the experience. A further three visits are scheduled before the end of the year and an agreed plan of work will be formulated for 2019.

6.3. Senior Medical Officer Vacancy Obstetrics and Gynaecology

Women’s Health had two Senior Medical Officer (SMO) vacancies until 17 September 2018 and these impacted on service delivery as there have been additional on call requirements. This has led to gynaecology elective targets not being met and an action plan is being developed to resolve this.

One SMO has returned from long term Accident Compensation Corporation (ACC) leave as of 17 September 2018. An SMO has been recruited and will commence 29 January 2019. Locum cover from November–January has also been sourced. Locum cover which was being used every other weekend has ceased and an additional long-term locum will finish in December.

6.4. Gynaecology Elective Services Patient Flow Indicators (ESPI)

ESPI 2: A total of 21 patients waiting for an FSA had been waiting greater than four months. These patients have subsequently all been seen.

ESPI 5: Forty patients have been given a commitment to treatment but have not been treated within the required four month timeframe. This is due to SMO sick leave and the recruitment process.

The service has been allocated additional theatre sessions as they arise, and a list per week allocated as part of the hospital theatre agreement with Crest commenced 2 November 2018. Current lists are being reviewed to confirm the need for surgery with some patients being brought back to clinic, some have already had their surgery and two have moved out of the area.

The service is investigating the triage and accepting of patients for FSAs and the Clinical Priority Assessment Criteria (CPAC) scoring threshold to ensure a timely and sustainable FSA and theatre waiting lists into the future. Locum cover commenced 7 November 2018 and should support the achievement of ESPI 2.

7. KEY ISSUES AND INITIATIVES IN COMING MONTHS

7.1 Midwifery Strikes

Midwifery Employee Representation & Advisory Service (MERAS) has announced the intention for their midwives to strike. Strikes announcements have been confirmed from 22 November 2018 every day until 5 December 2018. Strikes will be for a two hour period twice a day (one day shift, one night shift). Life Preserving Services (LPS) are being agreed on a daily basis 14 days in advance. MERAS are committed to ensuring that the strike does not impact on the care of women and babies or affect Midwifery Education. Daily conference calls with the National Coordinator, daily planning meetings are being undertaken, business continuity planning is being agreed and contingencies are being put in place. Communication will be released by MidCentral Communications Department to internal and external stakeholders and consumers on 16 November 2018.

7.2 Healthy Women Children and Youth Cluster Wellbeing Plan Planning Event

Three workshops are being held on 23 November 2018 to engage staff about the vision and plan for the cluster for the next five years. The cluster leadership team are working with our enabler colleagues in Strategy, Planning and Performance to coordinate the event and ensure that all staff are able to share their views on the direction of travel for the cluster. This is the beginning of the cluster health and wellbeing plan work. Further events are planned for February 2019 to engage consumers and external stakeholder.

7.3 Antenatal Clinic Review

The antenatal clinic review commenced on 29 October 2018 with good representation from community and antenatal clinic midwifery, obstetrics, consumer, Lead Maternity Carers (LMCs) and the quality team. The focus of the inaugural meeting was to identify what currently works well and recognise areas requiring improvement in the community midwifery team and the antenatal clinic. The outcomes of the discussions are being themed to allow terms of reference for the project to be finalised.

7.4 Hysteroscopy

Hysteroscopy is still being held in theatre. A project to relocate into the clinic setting is near completion with the first hysteroscopy procedure due to commence in clinic in December 2018.

8 SCORECARD AS AT OCTOBER 2018

A DHB-wide scorecard covering the full continuum of care is being developed for each cluster. This is expected to be developed over 12 months, and as information collection systems allow. Meantime, the scorecard is being used for hospital-based care together with other key measures and data available for the Cluster, national health targets that are applicable, and serious adverse events. It has not yet been possible to break down the results to a specific women’s result and specific children’s result, the data team are working to try and facilitate this for the cluster.

Customer Patient

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) CP21 - Acute 8.4% 10.0% 7.5% 2.5% 8.5% 7.5% 1.0% readmissions within 28 CP25r - Occurrence 6.3 0.8 3.5 (2.7) 2.8 3.5 (0.7) Rate of Medication CP26r - Occurrence 0.0 0.0 5.0 (5.0) 0.2 5.0 (4.8) Rate of Patient Falls CP28p - Hospital 0.21% 0.00% 0.50% (0.50%) 0.05% 0.50% (0.45%) acquired UTI rate (%) CP30p - Inpatients 0.00% 0.00% 0.50% (0.50%) 0.02% 0.50% (0.48%) developing Pressure CP31 - LSCS rate 26.1% 0.0% 25.0% (25.0%) 24.9% 25.0% (0.1%)

CP41 - Complaints 100.0% 100.0% 95.0% 5.0% 100.0% 95.0% 5.0% responded to within 15 Internal Process and Operations

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) IP00d - ED 137 97 0 97 539 0 539 Presentations (by IP00ma - ED 45 29 0 29 163 0 163 Presentations, Maori (by IP00nm - ED 92 68 0 68 376 0 376 Presentations, Non- IP00-04 - ED 75 48 0 48 334 0 334 Presentations 0-4 years IP00-16 - ED 29 27 0 27 106 0 106 Presentations 5-16 IP00-64 - ED 32 22 0 22 96 0 96 Presentations 17-64 IP00-65 - ED 1 0 0 0 3 0 3 Presentations 65+ years IP02 - ED stays less 80.3% 82.5% 95.0% (12.5%) 81.4% 95.0% (13.6%) than 6 hours IP03a - Average LoS: 2.03 2.43 4.00 (1.57) 2.45 4.00 (1.55) Acute Inpatient IP03e - Average LoS: 1.20 1.40 4.00 (2.60) 1.45 4.00 (2.55) Elective Inpatient IP07 - Bed Day Usage 56.0% 52.1% 85.0% (32.9%) 62.2% 85.0% (22.8%) (by Health Specialty) IP18 - Outpatient 8.7% 8.7% 6.0% 2.7% 9.0% 6.0% 3.0% appointment DNAs IP18c - Colposcopy 15.6% 17.1% 15.0% 2.1% 16.0% 15.0% 1.0% Outpatient appointment IP18ma - Outpatient 12.9% 15.8% 6.0% 9.8% 16.2% 6.0% 10.2% appointment DNAs, IP18nm - Outpatient 7.7% 7.0% 6.0% 1.0% 7.4% 6.0% 1.4% appointment DNAs, Non- IP18-04 - Outpatient 8.8% 7.0% 6.0% 1.0% 7.6% 6.0% 1.6% appointment DNAs, 0-4 IP18-16 - Outpatient 8.4% 6.4% 6.0% 0.4% 8.7% 6.0% 2.7% appointment DNAs, 5-16 IP18-64 - Outpatient 9.0% 9.9% 6.0% 3.9% 10.0% 6.0% 4.0% appointment DNAs, 17- IP18-65 - Outpatient 5.9% 6.1% 6.0% 0.1% 3.8% 6.0% (2.2%) appointment DNAs, 65+ IP22 - Hospitalised 83.3% 87.2% 95.0% (7.8%) 89.1% 95.0% (5.9%) smokers provided with IP28 - One to One 653 582 0 582 3,527 0 3,527 Hours Organisational Health and Learning

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) OH01 - Staff Stability 99.5% 100.0% 99.0% 1.0% 99.6% 99.0% 0.6%

OH02 - Staff Turnover 0.00% 0.52% 1.00% 0.48% 0.52% 1.00% 0.48%

OH03 - Sick Leave Rate 3.14% 2.48% 3.20% (0.72%) 3.51% 3.20% 0.31%

OH06n - Number of 36 36 0 36 36 0 36 employees with an

Legend * Non-financial KPI results for Dec- Achieved 2017 through Sep-2018 are subject to data-quality and completeness checks Partial Achievement relating to the WebPAS transition. Not Achieved

8.2 Performance as at October 2018

• Further understanding and breakdown of the ED Data is being sought to determine the issues. • The DNA rate across the cluster remains variable. There is a robust process in place to ensure referral details are accurate and text and phone call reminders are made to clients. Patients are given a second opportunity to attend and then discharged back to their General Practitioner (GP). The Maori population are over represented in the DNA rates with the rate for Maori being 15.8 to 40 percent in colposcopy. Work with the Pae Ora team is underway to progress improvements. • Smoking cessation screening has improved as below with further work to occur.

WH Smoking Cessation 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18

• Sick leave rates have improved this month. • Plans in place for staff with annual leave over 2 years are taking some time to be realised but every effort is being made to reduce this.

9 FINANCIAL POSITION

9.2 Financial Position as at end of October 2018

$000 Oct-17 Oct-18 Oct-17 Year to date Actual Actual Budget Variance Actual Actual Budget Variance

Revenue 247 410 454 (45) 653 1,503 1,721 (218) Pass Through Revenue Net Revenue 247 410 454 (45) 653 1,503 1,721 (218)

Expenditure Personnel 1,644 1,854 1,827 (28) 6,543 7,112 7,401 289 Outsourced Personnel 6 11 2 (8) 37 113 10 (103) Sub-Total Personnel 1,650 1,865 1,829 (36) 6,580 7,225 7,411 186

Other Outsourced Services 63 128 124 (4) 249 571 428 (143) Clinic al Supplies 236 226 240 14 1,030 963 976 13 Infrastructure & Non-Clinical 84 106 104 (2) 389 406 422 16

Total Expenditure 2,033 2,325 2,296 (28) 8,248 9,165 9,237 72

Provider Payments 0 538 539 1 0 2,154 2,157 4 Corporate Servic es 532 7 7 0 2,121 29 29 0

Net Expenditure (2,319) (2,460) (2,389) (72) (9,717) (9,845) (9,702) (143)

FTE Medic al 41.9 44.9 46.0 1.1 41.4 43.1 45.6 2.4 Nursing 119.1 123.9 131.5 7.6 121.1 122.9 130.6 7.7 Allied Health 11.7 14.5 16.5 2.1 11.3 14.2 16.5 2.3 Support 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Ma na ge me nt / A dmin 16.3 17.7 16.1 (1.7) 16.6 17.4 16.0 (1.3) 189.1 201.0 210.1 9.1 190.4 197.6 208.7 11.1

Favourable to Budget Unfavourable to Budget but within 5% Unfavourable to Budget outside 5%

The Healthy Women, Children & Youth result for the month was net expenditure of $2.460m, which was $0.072m adverse variance to the Budget.

Revenue Total Revenue was $0.045m adverse to the Budget mainly due to $0.020m of Women’s elective revenue not being achieved, and lower Non-Resident revenue than anticipated.

Elective Caesarean procedures are impacting on the ability to undertake Gynecology elective surgery so an additional Gynecology list was introduced and has reduced the elective underachievement by over 50 percent compared to September. A second list is starting at CREST in November.

Year-to-date net revenue was $0.218m adverse to budget. Additional lists at CREST and in-house are aiming to recover most of the underachieved elective revenue, however the underachievement in colposcopy revenue is due to a reduction in demand. Net revenue is forecast to be $0.174m adverse to budget at year end.

Expenditure Total Personnel was $0.036m adverse to the Budget. Total Medical costs were $0.027m adverse to the Budget plus an additional $0.010m in Locum costs, both providing cover for a vacancy. The replacement consultant is due in January 2019.

Nursing was $0.031m favourable mainly due to reduced demand in the Maternity / Delivery which has seen staff sent to other wards to work, and vacancies in the Child Community Health team.

Clinical Supplies were $0.014m favourable to the Budget due to lower blood and flight costs this month.

Year-to-date total expenditure was $0.072m favourable to budget primarily in personnel. Total expenditure is forecast to be $0.127m favourable to budget at year end. Provider payments are forecast to be on budget.

Year-to-date net expenditure was $0.143m adverse to budget. Net expenditure is forecast to be $0.068m adverse to budget at year end. This includes $0.140m of adverse lab costs which are offset by favourable variances in other clusters and is neutral DHB wide.

10 BUSINESS IMPROVEMENT PROGRAMME

There are no specific Business Improvement Programme within Healthy Women Children and Youth currently.

There are however links with the programmes of work related to the whole of system; including reviewing contracts, Clinical Nurse Specialist review and bed management review.

11 RECOMMENDATION

It is recommended that the Committee: • endorse the progress made by the Healthy Women Children and Youth Cluster Service to date. • note the information regarding upcoming Midwifery strikes • note the Mokopuna Ora Collective work and Child Health Forum initiatives • note the work to ensure achievement of elective targets • note the dates of the cluster plan workshop, to which is there is an open offer for the board to attend

Sarah Fenwick Dr Jeff Brown Operations Executive Clinical Executive 60

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Author Dr Claire Hardie, Clinical Executive Cushla Lucas, Operations Executive

Endorsed by Kathryn Cook, Chief Executive

Date 12 November 2018

Subject Uru Mātai Matengau Cancer Screening, Treatment & Support Cluster Report

RECOMMENDATION It is recommended that the Committee: • endorse the progress made by the Uru Mātai Matengau - Cancer Screening, Treatment & Support Cluster in 2018/19 • note progress in developing a business case for the replacement of the linear accelerators

Strategic Alignment Operational performance for the Uru Mātai Matengau - Cancer Screening, Treatment and Support Cluster is aligned to the DHB’s Strategy, in particular to the four strategic imperatives, with an overarching emphasis on quality.

COPY TO: Cancer Screening, Treatment and Support MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 356 9169 61

Glossary

BCFNZ Breast Cancer Foundation New Zealand CCN Central Cancer Network DHB District Health Board DNA Did Not Attend ED Emergency Department FCT Faster Cancer Treatment HBDHB Hawkes Bay District Health Board HDAC Health and Disability Advisory Committee LOS Length of Stay MDHB MidCentral District Health Board RCTS Regional Cancer Treatment Service TPS Treatment Planning System UTI Urinary Tract Infection

1. PURPOSE

The purpose of this report is to set out the Cluster’s performance against plans, budget and targets, and to advise any current and emerging matters.

2. SERVICE OVERVIEW

The Cancer Screening, Treatment and Support Cluster is responsible for the planning, funding and provision of cancer services across the continuum of care. The cluster also has a regional responsibility for non-surgical cancer treatment.

The populations served are: • All people with, or suspected of, or surviving a cancer diagnosis. • Eligible populations of cancer screening programmes. • All peoples (local / regional) for non-malignant haematological conditions. • All peoples accessing palliative care services. • Non-surgical cancer treatment for the Taranaki, Whanganui, Hawkes Bay and Wairarapa regions.

Services in the Cluster are structured into the following four service groups: • Prevention and Early Detection (screening) programmes. • Diagnostic and Treatment Services. • Support Services. • Palliative Care Services.

We are working toward a more integrated system and connections with community providers, which are contracted by the DHB to provide services, will be developed over time. This will be reflected in all aspects of the report.

3. CLUSTER AIM AND PRIORITIES

Overall the cluster aims to decrease cancer incidence through effective population health strategies however, for those people who do develop a cancer diagnosis, the cluster’s aspirational goals are for all people to experience better and more equitable outcomes.

A Cluster plan is being developed which will set out its aims and priorities.

4. 2018/19 PLANNING INITIATIVES

In 2018/19 the Cancer Screening, Treatment and Support Cluster will contribute to the delivery of the DHB’s Annual and Operational Business Plans. Key initiatives for the Cluster, grouped by MDHB’s Strategic priorities, are:

Rating & Initiative Trend MDHB Strategic Priority: Reduce health inequities 1. Improve access, timeliness and quality of cancer treatment and support services  2. Implement system improvements to minimise Faster Cancer Treatment breaches  due to reasons of clinical considerations’ or ‘patient choice’ for Māori 3. More women participate in cancer screening  4. Implement recommendations from audit against Supportive Care Framework  MDHB Strategic Priority: Address the needs of targeted priority populations 5. Ensure application of prostate cancer decision support tool to improve the referral  pathway across primary and secondary services 6. Implement actions regarding cancer services to achieve Regional Services Plan  7. Achieve cancer treatment timeliness indicators  Rating & Trend Legend G On track, A Behind plan – R Behind plan – major D No completed as progressing as remedial action risks and exception planned planned plan in place report required Improved from last Regressed from last No change from last    report report report

The Cluster is generally on track with the annual and operational plan initiatives with updates provided on the following:

• Inequities persist for screening and are noted under the areas off track below. • MDHB continues to work regionally, under the CCN, in the delivery of the Regional Services Plan. An update regarding regional activities is included under Key Issues and Initiatives in coming months.

4. KEY ACHIEVEMENTS IN THE MONTH

4.1 Partnership with Breast Cancer Foundation

Improvements in breast cancer survivorship have led to significant growth in the number of patients requiring on-going care. Treatment completion can be an uncertain time for patients who are often faced with a range of potential physical issues and uncertainty about the future. Traditional models of follow-up are generally brief outpatient appointments which are disease focused and intent on detecting recurrence rather than providing holistically for survivorship needs.

The BCFNZ has approached MDHB to work in partnership to optimise and support survivor well-being for low-risk breast cancer patients. The proposed service, fully funded by the BCFNZ, is based on supported self-management principles and reduces reliance on clinic attendance.

BCFNZ have employed a specialist breast nurse to lead this work, who will contact the women at home via phone, email or telehealth solutions. This nurse will be able to access hospital systems, provide clinical notes and communications, check on test results and prescriptions and ensure tests have been ordered as necessary, as well as being able to refer directly to social and psychological support agencies.

The model is a partnership and patients remain under the clinical responsibility of their specialist at MDHB but have the MDHB/BCFNZ survivorship service as their primary support. There will be close communication between the BCFNZ staff and the secondary or primary care teams.

The detailed proposal is under development and a memorandum of understanding has been agreed. The plan is to pilot the service with a cohort of women at various stages since their breast cancer treatment completion, who will play a role in co- design of the survivorship service. The BCFNZ will also work with local Maori women to design services that work to reduce inequities as well as providing support for the individual.

4.2 Treatment Planning System Replacement

The TPS has been ordered and training will occur the week beginning 19 November 2018. A date for the building work has also confirmed and will be completed in early January 2019.

4.3 Acute Oncology Service

The Acute Oncology pilot continues and is currently being evaluated. Given the positive feedback to date the service has continued beyond the pilot timeframe and will be available on an on-going basis while the evaluation is undertaken.

5. AREAS OFF TRACK AND REMEDIAL PLANS

5.1 Addressing BreastScreen Inequities

A Pro-Equity and Wellness Plan has been developed as a collaborative effort between Pae Ora, the local Independent Service Provider and BreastScreen Coast to Coast. The Plan is a three year strategy spanning 2019 -2021 focussing on: • Enhancing flexibility and relevance for service delivery to improve access to breast screening for priority women. • Developing initiatives to increase health literacy and health promotion about breast screening among priority women, whānau and health care providers. • Improving information management strategies and processes to identify priority women eligible for the screening programme in a timely manner. • Strengthening workforce capacity and capability to respond effectively to the needs of priority women to increase equitable participation in breast screening.

This Plan is in draft and out for consultation.

5.2 Linac Reliability

Linac breakdowns have caused significant disruption in September and October with 84 hours of downtime. This has continued into November with, at times, three of the four linacs out of service. As a result patients have experienced multiple changes of appointment which has impacted negatively on their working lives and personal plans.

6. KEY ISSUES AND INITIATIVES IN COMING MONTHS

6.1 Linac Procurement Programme

The procurement process for the replacement programme of the linacs continues to make good progress. A paper was presented to the Finance, Risk and Audit Committee at the November meeting and the business case, for the first two linacs, is on track for consideration in the New Year.

HealthAlliance has previously established a Panel of Suppliers for linacs and entered into Panel Procurement Agreements. The Panel and the Panel Procurement Agreements provide overarching terms and conditions with specific requirements and pricing to be determined via a secondary procurement process by DHBs.

In the last three months the evaluation criteria to inform the secondary procurement process has been finalised. The clinical team has also undertaken a discovery process to explore the market and hA panel, given it has been some time since a different vendor and vendor partnership has been considered. Site visits are planned this month to Cancer Centres working in a similar way to the RCTS including those that manage outreach sites and sites that utilise the hA panel suppliers’ equipment and software.

Once these visits are completed a secondary procurement process will be undertaken to contract with a vendor for the supply of the MDHB linacs and ongoing support for the next 5 to 10 years to ensure a long term relationship. This will ensure a strong partnership is established to enable the RCTS to deliver sustainable and forward focused Radiation Oncology services throughout that lifetime.

6.2 Regional Cancer Services

Ernst & Young, who are leading the development of a single system of care for the Central Region have commenced engagement sessions and will hold a workshop with Cancer Cluster leadership and clinicians in Palmerston North in November.

6.3 Regional Radiation Oncology

Following the cluster presentation at the August HDAC meeting there was media interest in the opportunity to take radiation treatment into the communities at Hawkes Bay and Taranaki DHBs. The proposal has been well received and an email of support sent from the Chief Executive of the Prostate Cancer Foundation. This has been provided below for the Committees interest

I refer to a recent report on Stuff regarding the replacement of linear accelerators at Palmerston North and the possibility of re-deploying units to other centres such as Taranaki and Hawkes Bay. As reported, I understand you are preparing a business case for this option.

I write in support of this proposal as we are well aware that a number of men make their prostate cancer treatment decisions based on convenience, rather than what might be the best treatment option for them, due to the inconvenience of having to be away from their home, business, farm, etc. for an extended period. Having the option of radiotherapy in both those regional centres will benefit patients, both in their primary treatment and also in subsequent radiation treatment that may be required.

Please note our support of this proposal when preparing your business case. I have copied in our President who resides in Hawkes Bay and is well aware of the benefits this would provide for prostate cancer patients in his region.

HBDHB have also commenced a discovery process to understand the facility requirements of any future site. As part of this process the RCTS has been assisting a Hawkes Bay architectural team regarding the specifications for linac bunkers and associated facilities.

6.3 BowelScreen Implementation

Local preparations continue. Nationally, the project to address recommendations relating to the National Screening Solution design is taking longer than expected. Acknowledging that access to the national information system is a key dependency for all DHBs awaiting confirmation of go-live dates a formal update is expected from the National Screening Unit in the next few weeks.

7. SCORECARD - October 2018

Customer Patient

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) CP21 - Acute readmissions within 28 days 16.8% 9.0% 7.5% 1.5% 11.0% 7.5% 3.5%

CP25r - Occurrence Rate of Medication Errors 0.0 2.6 3.5 (0.9) 3.8 3.5 0.3

CP26r - Occurrence Rate of Patient Falls 0.0 0.0 5.0 (5.0) 2.2 5.0 (2.8)

CP28p - Hospital acquired UTI rate (%) (provisional) 0.00% 0.00% 0.50% (0.50%) 0.00% 0.50% (0.50%)

CP30p - Inpatients developing Pressure Ulcers (%) 0.28% 0.00% 0.50% (0.50%) 0.16% 0.50% (0.34%)

CP36 - FCT: 62 days or less to first treatment (%) 100.0% 100.0% 85.0% 15.0% 100.0% 85.0% 15.0%

CP41 - Complaints responded to within 15 days (%) 0.0% 0.0% 95.0% (95.0%) 100.0% 95.0% 5.0%

Internal Process and Operations

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) IP00d - ED Presentations (by Destination) 32 26 0 26 119 0 119

IP02 - ED stays less than 6 hours 84.4% 76.9% 95.0% (18.1%) 73.1% 95.0% (21.9%)

IP03a - Average LoS: Acute Inpatient 6.55 6.07 4.00 2.07 6.91 4.00 2.91

IP03e - Average LoS: Elective Inpatient 4.70 3.89 4.00 (0.11) 4.94 4.00 0.94

IP07 - Bed Day Usage (by Health Specialty) 62.0% 65.4% 85.0% (19.6%) 79.5% 85.0% (5.5%)

IP18 - Outpatient appointment DNAs 0.7% 0.9% 6.0% (5.1%) 0.7% 6.0% (5.3%)

IP22 - Hospitalised smokers provided with help to quit 100.0% 100.0% 95.0% 5.0% 92.5% 95.0% (2.5%)

IP28 - One to One Hours 128 36 0 36 449 0 449

Organisational Health and Learning

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) OH01 - Staff Stability 99.4% 100.0% 99.0% 1.0% 99.4% 99.0% 0.4%

OH02 - Staff Turnover 0.00% 2.33% 1.00% (1.33%) 1.00% 1.00% (0.00%)

OH03 - Sick Leave Rate 2.66% 3.61% 3.20% 0.41% 2.97% 3.20% (0.23%)

OH06n - Number of employees with an Annual Leave 19 21 0 21 21 0 21 balance in excess of two years

Legend Achieved

Partial Achievement

Not Achieved

7.1 Performance as at October 2018

• Work continues to set cancer specific targets. In the interim all identified cases exceeding the generic targets are reviewed individually; there are no current trends or incidents of concern.

• The focus on Shorter Stays continues. Six patients waited in excess of six hours in October with all presenting outside of hours or at weekends. The pathway for acutely unwell patients is operational and education sessions are now updated.

• Staff turnover is above target with four staff leaving in October; year to date the cluster remains on target. All staff left to pursue other interests.

• Sick leave above target noted; no issues of note.

• Leave plans are in development for all staff with balances over two years with significant leave being taken over the Holiday Season. While the number of staff above the threshold has increased between September and October the number of hours of leave owed has decreased.

7.2 Contracted Service Delivery

Some services are provided under contract by external providers. Responsibility for these contracts is being progressively transferred to the Cluster. There are no issues of note with contracted providers this month.

8. FINANCIAL POSITION

8.1 Financial Position as at end October 2018

$000 Oct-17 Oct-18 Oct-17 Year to date Actual Actual Budget Variance Actual Actual Budget Variance

Revenue 1,312 1,566 1,269 296 5,385 5,588 5,468 120 Pass Through Revenue (483) (683) (534) (149) (2,201) (2,562) (2,170) (392) Net Revenue 828 883 735 148 3,184 3,025 3,298 (273)

Expenditure Personnel 1,563 1,704 1,616 (88) 6,106 6,392 6,559 167 Outsourced Personnel 2 0 3 3 42 39 14 (24) Sub-Total Personnel 1,564 1,704 1,619 (85) 6,149 6,430 6,573 143

Other Outsourced Services 520 531 515 (16) 2,235 2,379 2,186 (193) Clinic al Supplies 484 422 499 77 2,009 2,081 2,045 (37) Infrastructure & Non-Clinical 115 120 113 (6) 760 419 464 44

Total Expenditure 2,684 2,777 2,746 (30) 11,153 11,310 11,268 (42)

Provider Payments 0 252 417 165 0 1,499 1,670 171 Corporate Servic es 364 160 160 0 1,400 644 642 (2)

Net Expenditure (3,876) (2,307) (2,589) 282 (15,736) (10,428) (10,281) (147)

FTE Medic al 35.8 37.3 37.1 (0.2) 35.0 36.0 36.9 0.9 Nursing 52.6 51.6 53.0 1.4 51.8 50.9 52.3 1.4 Allied Health 60.2 60.7 60.5 (0.2) 59.1 59.4 60.5 1.1 Support 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Ma na ge me nt / A dmin 30.0 28.6 30.6 2.0 29.9 29.0 30.6 1.6 178.5 178.1 181.2 3.0 175.8 175.3 180.3 5.0

Favourable to Budget Unfavourable to Budget but within 5% Unfavourable to Budget outside 5%

The Cancer Screening, Treatment and Support result for October was net expenditure of $2.307m, which was a favourable variance to Budget of $0.282m.

Revenue

Net revenue was $0.148m favourable for the month. Year-to-date net revenue is $0.273m adverse to budget. IDF revenue in the first quarter was below budget however the IDF forecast, based on 2017/18 activity, indicates that this will be recovered by year end. In accordance with this forecast, October IDF revenue was $0.016m favourable to budget.

Expenditure

Total Personnel was $0.085m adverse due to some one-off payments in medical staffing due to changes in role and job sizing, as well as costs due to overtime associated with the linac breakdowns. Clinical Supplies were $0.077m favourable. Provider Payments were $0.165m favourable due to wash up of contract payments.

Year-to-date total expenditure was $0.042m adverse to budget. This is primarily a result of a one off payment to HBDHB not accrued for the 2017/18 year.

Year-to-date net expenditure is $0.147m adverse to budget due to adverse revenue in July through September; this is forecast for full recovery by year end.

8.2 Business Improvement Programme

The cluster has no specific projects under the Business Improvement Programme.

9. RECOMMENDATION

It is recommended that the Committee: • endorse the progress made by the Uru Mātai Matengau - Cancer Screening, Treatment & Support Cluster in 2018/19 • note progress in developing a business case for the replacement of the linear accelerators

Cushla Lucas Claire Hardie Operations Executive Clinical Executive 70

For:

Decision X Endorsement X Noting

To Health & Disability Advisory Committee

Author Lyn Horgan, Operations Executive Dr David Sapsford, Clinical Executive

Endorsed by Kathryn Cook, Chief Executive

Date 12 November 2018

Subject Uru Arotau Acute & Elective Specialist Services Cluster Report

RECOMMENDATION It is recommended that the committee: • endorse the progress made by Uru Arotau – Acute & Elective Specialist Services Cluster in 2018/19. • note the quality improvement programmes of work continue to be progressed, namely Takatū, Medimorph which includes Frailty and Transfer of Care. • note the final phase of the Emergency Department renovations. • note the Acute & Elective Specialist Services Cluster Business Improvement Programme.

Strategic Alignment

Operational performance for Uru Arotau – Acute & Elective Specialist Services (AESS) Cluster is aligned to the DHB’s Strategy, in particular to the four strategic imperatives that are the fundamental focus for MidCentral District Health Board (MDHB), with an overarching emphasis on quality.

COPY TO: Operations Executive Acute & Elective Specialist Services MidCentral Health PO Box 2056, Palmerston North Central Palmerston North 4440 Phone +64 (6) 350 8825 71

Glossary

AESS Acute & Elective Specialist Services ALOS Average Length of Stay CCDHB Capital & Coast District Health Board CHF Congestive Heart Failure CME Continuing Medical Education COPD Chronic Obstructive Pulmonary Disease CT Computed Tomography CWD Cost Weighted Discharge DHB District Health Board DNA Did Not Attend DOSA Day of Surgery Admissions ED Emergency Department ENT Ear Nose and Throat ERCP Endoscopic Retrograde Cholangio-Pancreatography ESPI Elective Services Patient Flow Indicator FSA First Specialist Assessment FTE Full Time Equivalent ICU Intensive Care Unit IDF Inter District Flow IFHC Integrated Family Health Centre MAPU Medical Assessment and Planning Unit MCH MidCentral Health MDHB MidCentral District Health Board MECA Multi Employer Collective Agreement MoH Ministry of Health MRT Medical Radiation Technologist NASO National Ambulance Sector Office NZNO New Zealand Nurses Organisation RIS Regional Information System RMO Registered Medical Officer SCU Self Care Unit SMF Self Managed Facility SMO Senior Medical Office SSIED Shorter Stays in Emergency Department WebPAS Web Patient Administration System

1. PURPOSE

The purpose of this report is to set out the Cluster’s performance against plans, budget and targets, and to advise any current and emerging matters. This report against the 2018/19 Annual Plan covers the months of September and October 2018.

2. SERVICE OVERVIEW

The AESS cluster is responsible for the planning, funding and provision of:

• Medical services and subspecialties • Surgical services and subspecialties • Anaesthetics and Intensive Care Unit • Medical/Surgical inpatient wards • Medical imaging and hospital pharmacy • Emergency services.

We are working toward an integrated system and there will be more arrangements for specialist services in the community. This will be reflected in all aspects of the report.

3. CLUSTER’S AIM AND PRIORITIES

Overall the Cluster aims to move to a re-designed hospital that provides acute and elective care based on people's needs, evidenced based care, equitable outcomes, and standardised transitions of care across the system. A hospital that provides treatment and services that are not possible to be delivered elsewhere in the system, for example; IFHCs, people’s homes.

A cluster health and wellbeing plan is being developed which will set out its aims and priorities. This will be completed by March 2019.

4. 2018/19 PLANNING INITIATIVES

In 2018/19 the AESS Cluster will contribute to the delivery of the DHB’s Annual and Operational Business Plans. Key initiatives for the Cluster, grouped by MDHB’s Strategic priorities, are:

Initiative Rating & Trend MDHB Strategic Priority: Reduce health inequities 1. Identify the steps required to better meet the needs of the sub regional population, in particular the capability and capacity of the renal department at MDHB to meet A  these needs as set out in the Renal Project Plan. MDHB Strategic Priority: Strengthen our financial position 2. Achieve annual target volume of elective surgery discharges A  3. Improve the patient journey and flow through the hospital for medical patients, and A  shorten stays in ED through the Medimorph programme of work. 4. Reduce acute bed day utilisation through the Medimorph programme of work. G  5. Reduce average length of stay for acute inpatient events through the Medimorph G  programme of work. 6. Reduce projected budget deficit through the Business Improvement Programme.  73

MDHB Strategic Priority: Minimise the impact of long-term conditions 7. A better pathway for cardiac intervention – rapid diagnosis and intervention of G  cardiac conditions/events through the National STEMI Pathway. 8. Improved prevention and management of diabetes and diabetes complications G  across the district* 9. Improved prevention and management of COPD and CHF across the system as part G  of the Long Term Conditions Programme. MDHB Strategic Priority: Address our acute care demand 10. Improve the alignment of theatre capacity and demand G  11. Utilise real-time data to effectively manage resources and improve visibility of G  patient flow across the organisation *implementation of the MidCentral Provider Diabetes Specialist Services Reconfiguration Implementation Plan Rating & Trend Legend G On track, A Behind plan – R Behind plan – major D No completed as progressing as remedial action risks and exception planned planned plan in place report required  Improved from last  Regressed from last  No change from last report report report

The Cluster is on track with the annual and operational plan initiatives with updates provided below.

5. KEY ACHIEVEMENTS IN THE MONTH

5.1 Medical Imaging – Teleradiology

The Teleradiology Service continues to assist with reducing the reporting times and supporting the Radiologists workflow within Medical Imaging with approximately 250 examinations sent off site daily for reporting.

There are still some minor technical process issues with the sending of images that is to be resolved. The service is confident that this will be completed by the end of November. The teleradiology provider is very responsive to feedback and monitoring of reporting timeframes.

5.2 Theatre Capacity and Demand

The new theatre grid was implemented from November. This optimises the use of our available theatre capacity. It has been implemented together with the outsourcing and outplacing of surgery at CREST hospital. Outsourced ENT procedures started in late October, and outplaced lists for Ophthalmology, General Surgery, Gynaecology, Dental and Urology (Paediatrics) commenced in November.

5.3 Improved Patient Flow and Shorter Stays

Shorter Stays in the Emergency Department (SSIED) has not been achieved for September at 79 per cent and October at 82 per cent. Although this was a decrease of seven and six per cent respectively compared to similar months in 2017, presentations to ED increased by four and five per cent (106 presentation increase in September and 188 in October) compared to the same periods in 2017. The daily presentation average for September 2018 was 126, compared to 122 in September 2017 and October 2018 was 122 compared to 116 in October 2017. However, acute admissions through ED (1,013 in September and 960 in October) were both lower than the monthly average for last year (1,024). 74

A SSIED Health Target Action Plan is being developed and sets out the actions to deliver improved performance within the Takatū, Medimorph which includes Frailty and Transfer of Care programmes to enable achievement of this target. The plan is currently with clusters to capture all actions to improve performance within each cluster.

The ED’s actual result is down to 82 per cent and has been below 90 per cent since December last year. Previously the ED result was 94-95 per cent. This lower result and timing fits with the building work where at times ED have been down to two cubicles and they are using consultation rooms for triage rooms.

Graph 1: ED Presentations July 2016/17 –October 2018/19

ED Presentations 4500

4000 2018/19 2016/17 3500 2017/18

3000 Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

Graph 2: Acute Admissions July 2016/17 – October 2018/19

Acute Admissions 1300 1200 1100 2018/19 1000 2016/17 900 2017/18 800 700 Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

Emergency Department Renovations

In November 2017, renovation work commenced in the Emergency Department and was expected to be completed within seven months. The purpose of the project was to improve the patient experience when first presenting to the department and to enhance the capacity and capability of the use of the sub-acute area. This would be achieved with the introduction of designated triage areas for ambulance patients and those who self-present to the waiting area, enabling private consultation without the risk of breaching confidentiality. In addition the sub-acute area would be enhanced increasing its potential for use. 75

As previously reported due to unforeseen seismic and firewall safety requirements identified during the building work the completion of the project was delayed. However, by the end of October the sub-acute area and ambulance triage areas have been completed, the reception area has been relocated and the final touches to the new relatives’ room and isolation room are almost ready. The work has now entered its final phase with the building of the three waiting area triage rooms and the decoration of the waiting room. It is anticipated that the work will be completed during the week before Christmas.

The Francis Group improvement work continues with Medimorph (General Medicine) and Takatū (Emergency Services). Overall these two programmes are governed through the Timely Care Steering Group which oversees and supports the work. Indications as noted below continue to be promising regarding overall acute length of stay and in particular the progress in supporting the older adult population.

The quality improvement programmes of work continue to be progressed, namely Takatū, Medimorph which includes Frailty and Transfer of Care.

Takatū – Emergency Department Performance

Table 1: ED Presentations, Inpatient Admission Rate and ED Length of Stay - July to October 2017 versus July to October 2018

• The ED continues to see 7 patients more per day than the same quarter last year. • Significantly, the ED managed the growth in demand without increasing inpatient admission rates which are down 10 per cent on the same quarter last year. • Despite this increased demand and challenging staffing vacancies, the department has managed to achieve a 34 minute reduction in length of stay while also undertaking work to further improve quality and performance. • Work is underway to implement the Zone (previously called Pod) Model in November. This allows for the fast tracking of patients through the department and greater team-based working. • The introduction of board rounds between ED senior medical and nursing has been achieved. • Consultation with the inpatient specialist services, to implement care pathways and streamline admission processes, is ongoing. Meetings have been held with Intensive Care, Mental Health, Gynaecology, General Surgery and General Medicine. • Preliminary work has begun on a Workforce Development plan.

Medimorph – Acute Medicine Performance

Table 2: Acute Medical Occupancy, Acute Medical Admissions and General Medicine Bed Day Savings - July to October 2017 versus July to October 2018

• Several improvement efforts have resulted in significant reductions to the number of beds occupied by general medicine patients within the hospital and the average length of stay (ALOS). • Significant improvements have been achieved in reducing “stranded patients” (those staying more than six days) by 26 per cent as shown in diagram 3 above. • These patients represent a significant proportion of resourced beds and overall costs to hospitals.

Medimorph - General Medicine and Patient Flow

Table 3: General Medicine Occupancy, General Medicine Length of Stay and General Medicine Stranded Patients - July to October 2017 versus July to October 2018

• Bed Day savings aggregate to 1,445 less days our patients are staying in hospital. • The improvements have contributed to an overall reduction in occupied hospital beds of 4.7 per cent compared to the same quarter last year. • General Medicine length of stay has decreased by 14 per cent, 4.3 days compared to 5 days this time last year.

6. AREAS OFF TRACK AND REMEDIAL PLANS

6.1 Electives

The preliminary report year to date to October has MDHB behind against the Elective Initiative CWDs by 536 against plan.

The year-to-date deficit is compounded due to the under delivery in July of 163.5 and conferences that were held throughout October in ENT, Orthopaedics, Anaesthetics and General Surgery.

Outsourced and outplaced procedures began in late October and November. The use of this additional capacity will allow us to fulfil the target and earn all available revenue by year end and achieve our discharges.

Against the Elective Initiative Discharges, MDHB was behind by 15 discharges for October against a plan of 731 and behind year to date by 27 discharges.

Against the Health Target, MDHB is behind by 33 discharges for October and 87 year to date against a target of 2,770.

Elective Services Patient Flow Indicators (ESPIs)

Please note: Gynaecology ESPIs will be reported in the Healthy Women, Child and Youth Cluster report.

ESPI 2: Total patients waiting for an FSA was 1,099 of which 89 have been waiting greater than four months. The patients waiting are predominantly in Orthopaedics (49) Respiratory (16) Endocrinology (11), with the remainder spread over other specialties.

There is an overall reduction in the number of patients not yet booked for an FSA >4 months with a strong emphasis on getting patient booked at 3 months and seen before they get to 4 months.

ESPI 5: 56 patients have been given a commitment to treatment but have not been treated within the required four month timeframe; Orthopaedic Service (20), General Surgery (18) and ENT (9). The remaining patients are scattered amongst the other surgical sub-specialities.

MDHB applied to the Ministry of Health (MoH) for dispensation for non-compliance of ESPI 2 and ESPI 5 in ENT, Orthopaedics and Gynaecology. This dispensation was to the end of October however we have sought an extension on this until December as it was contingent on the implementation of the new theatre grid and outsourced ENT procedures and outplaced lists which is now in place.

We have adopted a number of strategies to recover ESPI and Health Target discharge performance and manage any clinical risk.

• Successful negotiations completed with Crest Hospital for the provision of outplaced elective surgical services and outsourced elective surgical services will ensure ESPI 5 compliance. 78

• Our new theatre grid was implemented from November. This optimises the use of our available theatre capacity. • MDHB has experienced reduced workforce capacity in a number of specialities particularly Gynaecology however ongoing active recruitment continues in these areas. • We have interim locum arrangements in Gynaecology, Respiratory and Rheumatology with successful permanent recruitment into these roles commencing in the New Year. • Additional clinics for First Specialist Assessments. • We have appointed a Clinical Co-ordinator to work alongside our Elective Surgery Booking Co-ordinators. • We are ensuring patients are kept well informed of any delays. • We are managing clinical risk by ensuring patients have access to a clinical assessment/advice if required. The Clinical Co-ordinator also provides appropriate clinical oversight of the patients on the waiting lists and supports the Elective Surgery Booking Co-ordinators. • We have a Production Plan to achieve best outcomes and efficiencies around the utilisation of all theatre resources. • Ensure patients are booked in order of acuity.

MDHB will be ESPI compliant by the end of December 2018 and will achieve the Health Target discharges by year end.

6.2 Theatre Dashboard and Non ESPI Report

The finalisation of the theatre dashboard and Non ESPI Report remains delayed until the New Year whilst cleansing of the data in WebPAS occurs.

7. KEY ISSUES AND INITIATIVES IN COMING MONTHS

7.1 Renal Service Facility

The Renal Self-Managed facility (SMF) was re-located to the old Star 3 unit following the closure of the Ruahine Street facility on 21 September 2018.

The New Renal Self Care Unit (SCU) has capacity for 8 patients (compared to 6 previously). Nursing FTE has been increased to facilitate an improved home training programme and combined with the new facility this will enable the concurrent training of 4 home haemodialysis patients at a time. This dedicated FTE (1.0) and existing staff with home training experience will double the number of patients training to dialyse at home.

Strategies to improve the home dialysis patient numbers and reduce the demand for incentre dialysis are a key focus for the renal service.

In addition to the improvement of the home haemodialysis training programme consideration is currently being given to the establishment of a community based dialysis facility. This would be used by those patients able to self-manage their dialysis but for social reasons are unable to do this at home. This includes housing where dialysis is unable to be installed e.g. rental properties and homes where there is insufficient space to accommodate dialysis machines.

A community based facility would not need to be staffed, the patients would remain under the care of the renal service and be managed under the home haemodialysis service as do those patient who dialyse at home.

Home based supervision by non-nursing staff for patients who are able but anxious about dialysing at home alone is also being considered. A support programme involving Massey senior psychology students to identify individual patient barriers is also part of the focus on increasing home dialysis numbers. Communication and a programme of strategies to address these barriers would enable home haemodialysis for a number of patients who would otherwise remain in the incentre unit.

These initiatives will assist in determining the number of chairs required when the incentre renal unit is re-located in 2019. This re-location will facilitate the expansion of the Gastroenterology department to accommodate the national bowel screening programme. A small project group is working on modelling the incentre unit to confirm the number of chairs required when the incentre unit is relocated – the location is yet to be determined.

Currently the renal unit has a very high number of patients dialysing incentre. This number is influenced by patients re-locating from other DHBs, patients returning from home dialysis to incentre due to illness and/or infection.

8. HEALTH AND WELLBEING PLAN

Early work has begun within the AESS cluster to establish our Health and Wellbeing Plan.

• This plan will give effect to the MDHB Strategy • Best meet the needs of our communities by ensuring we deliver the most effective and efficent health service arrangements that we can for our population. • Investing in the future to ensure know where and when we need to invest in infrastructure, programs, services and resources to meet the health care needs of communities across the district. • Strengthening health service improvements in our health system so we can find new, more effective ways to deliver better, safer care and treat more patients, sooner. • Intergrating care across health ands social service system which will create a sealmess journey for consumers. • Reducing Inequalities by identifying targeted approaches to improve health outcomes for at risk and disadvantaged populations.

9. AIR AMBULANCE ARRANGEMENTS FOR THE CENTRAL REGION

On the 1 November 2018 DHBs across the Central Region will engage with the National Ambulance Sector Office (NASO) with the introduction of the new air ambulance helicopter service. As MDHB does not have its own service, the impact of this introduction will be negligible. MDHB will continue to liaise through the Capital and Coast DHB flight retrieval service for urgent transfers as per our current arrangement.

10. STAFFING MATTERS

The Cluster is fully recruited for House Officers for the quarter beginning September. Recruitment for the Registrar changeover in December is also positive.

Active recruitment and retention of Radiologists continues. From December 2018 there will be 3.1 FTE Radiologists in the department and 5.6 FTE vacancies. One Radiologist has dropped 0.1 FTE for November. A full time permanent Radiologist has been given a job offer which would commence from February.

An interventional Radiologist that recently resigned is returning to work for two weeks at the beginning of December. Another locum that previously worked at MCH is looking to work some hours each week from February including some minor interventional procedures.

Additional MRT FTE has been recruited so that tasks previously carried out by Radiologists can be delegated. Some examples of this are prioritisation of referrals under the guidance of a Radiologist and exploring the potential for MRTs to provide basic fluoroscopic examinations.

Recruitment into Medical Services is positive. The following permanent SMOs will commence in January in:

• Rheumatology • Infectious Disease and General Medicine • Full time General Medicine

Dr John Caplin, from the UK, joins the Cardiology team for a one year period replacing Dr Dave Mundell.

The Diabetes and Endocrinology Service has successfully recruited a SMO from the UK who is expected to commence in May 2019. This is 0.5 Diabetes and Endocrinology and 0.5 General Medicine position.

The General Medicine Service will be recruited by late January 2019 to allow the new General Medicine medical roster to commence once the recently recruited SMOs arrive. This roster will support improved patient flow, reduced length of stay, establish an SMO led team in the Medical Assessment and Planning Unit and provide improved GP to SMO contact to alleviate unnecessary presentations to the Emergency Department.

11. SCORECARD

A DHB-wide scorecard covering the full continuum of care is being developed for each cluster. This is expected to be developed over 12 months, and as information collection systems allow.

AESS Cluster Scorecard for October 2018

Customer Patient

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) CP21 - Acute readmissions within 11.3% 10.0% 7.5% 2.5% 11.0% 7.5% 3.5% 28 days CP25r - Occurrence Rate of 2.6 3.7 3.5 0.2 2.9 3.5 (0.6) Medication Errors CP26r - Occurrence Rate of 3.0 3.1 5.0 (1.9) 2.9 5.0 (2.1) Patient Falls CP28p - Hospital acquired UTI 0.56% 0.30% 0.50% (0.20%) 0.43% 0.50% (0.07%) rate (%) (provisional) CP30p - Inpatients developing 0.14% 0.35% 0.50% (0.15%) 0.20% 0.50% (0.30%) Pressure Ulcers (%) CP41 - Complaints responded to 100.0% 100.0% 95.0% 5.0% 100.0% 95.0% 5.0% within 15 days (%) Internal Process and Operations

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) IP00a - ED Presentations 3,778 3,796 0 3,796 15,780 0 15,780 Hospital-wide IP00d - ED Presentations (by 3,607 3,664 0 3,664 15,104 0 15,104 Destination) IP00ma - ED Presentations, 682 651 0 651 2,846 0 2,846 Maori (by Destination) IP00nm - ED Presentations, Non- 2,925 3,013 0 3,013 12,258 0 12,258 Maori (by Destination) IP00-04 - ED Presentations 0-4 262 240 0 240 1,229 0 1,229 years old (by Destination) IP00-16 - ED Presentations 5-16 318 279 0 279 1,396 0 1,396 years old (by Destination) IP00-64 - ED Presentations 17- 2,031 2,109 0 2,109 8,426 0 8,426 64 years old (by Destination) IP00-65 - ED Presentations 65+ 996 1,036 0 1,036 4,053 0 4,053 years old (by Destination) IP02 - ED stays less than 6 78.5% 81.2% 95.0% (13.8%) 80.2% 95.0% (14.8%) hours IP03a - Average LoS: Acute 4.10 4.36 4.00 0.36 4.20 4.00 0.20 Inpatient (excluding Day Case) IP03e - Average LoS: Elective 2.77 2.53 4.00 (1.47) 3.41 4.00 (0.59) Inpatient (excluding Day Case) IP07 - Bed Day Usage (by Health 91.7% 79.1% 85.0% (5.9%) 89.6% 85.0% 4.6% Specialty) IP18 - Outpatient appointment 6.6% 5.5% 6.0% (0.5%) 6.5% 6.0% 0.5% DNAs IP18ma - Outpatient appointment 12.5% 11.8% 6.0% 5.8% 12.2% 6.0% 6.2% DNAs, Maori IP18nm - Outpatient appointment 5.4% 4.3% 6.0% (1.7%) 5.3% 6.0% (0.7%) DNAs, Non-Maori IP22 - Hospitalised smokers 82.4% 77.4% 95.0% (17.6%) 78.5% 95.0% (16.5%) provided with help to quit IP28 - One to One Hours 3,549 3,073 0 3,073 14,604 0 14,604

Organisational Health and Learning

Description Previous Month Month Month YTD YTD YTD Variance KPI Trend Month Actual Target Variance Actual Target (13 month) OH01 - Staff Stability 99.5% 99.9% 99.0% 0.9% 99.5% 99.0% 0.5%

OH02 - Staff Turnover 0.56% 0.50% 1.00% 0.50% 0.55% 1.00% 0.45%

OH03 - Sick Leave Rate 3.05% 3.40% 3.20% 0.20% 3.56% 3.20% 0.36%

OH06n - Number of employees 145 130 0 130 130 0 130 with an Annual Leave balance in

Legend * Non-financial KPI results for Dec- Achieved 2017 to date are subject to data-quality and completeness checks relating to Partial Achievement the WebPAS transition. Not Achieved

11.1 Performance as at October 2018

Corrective Actions

• Acute Readmission Rate: The Clinical Executive along with Dr Greig Russell, Principal Medical Information Officer, is continuing to review this data to enable us to put in place any corrective actions. • SSIED – please refer to Section 5.4 • ALOS: Elective ALOS has shown a reduction of 0.24 days compared to the previous month. A more focussed effort on identifying the estimated day of discharge on the patient whiteboards may have contributed to this improved reduction. Acute ALOS has increased slightly from 4.10 days to 4.36 days. • Outpatient appointment DNAs: A focussed work programme is planned for outpatient appointments which will support addressing this measure. There has been an improvement on the previous month of 6.6 per cent to 5.5 per cent. • Hospitalised Smokers: The unfavourable result is driven by the adult inpatient wards and the Emergency Department. There has been a slight improvement from last month. All of these areas have action plans in place to improve this result. • Sick Leave Rate: The sick leave rate is reducing since August’s seasonal winter illnesses. • Leave plans are either in place/or development for all staff with balances greater than two years.

12. FINANCIAL POSITION

12.1 Financial Position as at October 2018

$000 Oct-17 Oct-18 Oct-17 Year to date Actual Actual Budget Variance Actual Actual Budget Variance

Revenue 1,460 1,822 1,694 128 3,965 5,445 6,605 (1,159) Pass Through Revenue (389) (272) (367) 95 (1,476) (1,091) (1,490) 399 Net Revenue 1,072 1,550 1,327 223 2,489 4,354 5,114 (760)

Expenditure Personnel 7,610 8,285 8,088 (196) 30,822 32,684 32,493 (192) Outsourced Personnel 165 202 82 (121) 780 848 332 (516) Sub-Total Personnel 7,775 8,487 8,170 (317) 31,602 33,533 32,825 (708)

Other Outsourced Services 785 882 752 (130) 3,247 3,006 2,987 (20) Clinic al Supplies 2,659 2,735 2,669 (66) 10,687 11,247 10,903 (344) Infrastructure & Non-Clinica 394 376 404 28 1,700 1,572 1,642 70

Total Expenditure 11,613 12,480 11,995 (485) 47,236 49,358 48,357 (1,001)

Provider Payments 0 16 22 6 0 (60) 87 147 Corporate Servic es 395 726 725 (2) 1,622 2,895 2,898 4

Net Expenditure (10,936) (11,671) (11,414) (257) (46,369) (47,839) (46,228) (1,611)

FTE Medic al 208.5 207.5 219.3 11.9 204.3 205.3 217.7 12.4 Nursing 490.8 506.0 505.1 (0.8) 492.5 505.1 496.4 (8.6) Allied Health 101.7 105.5 107.9 2.4 101.1 104.4 107.8 3.3 Ma na ge me nt / A dmin 101.0 106.4 97.6 (8.8) 100.4 108.0 97.5 (10.5) 902.0 925.3 930.0 4.6 898.3 922.8 919.4 (3.4) Favourable to Budget Unfavourable to Budget but within 5% Unfavourable to Budget outside 5% FTE Below Budget FTE Higher than Budget but within 5% FTE Higher than Budget 83

Acute & Elective was adverse to budget by $257k in October.

Due to the school holidays falling in October and a large amount of CME for international conferences being taken amongst SMOs (General Surgery, Orthopaedics, Urology, Anaesthetics and ENT) the Elective shortfall continued in October. With the new theatre grid implemented from November together with the outsourcing and outplacing of surgery at our private hospital, we have revised our production to ensure elective targets are met by year end.

Net Revenue was favourable to budget by $223k. The Elective Revenue shortfall for September was $420k, CME leave was high for October. This month sees recognition of the IDF inflow delivery over target for the months of July to October which resulted in additional revenue of $650k.

Personnel was adverse to budget by $317k. $58k of this variance was in the ED and related to being an SMO accident leave and having to cover the vacancy internally. There was an overspend in Anaesthetics which related to RMOs on CME leave and internal cover at additional rates which amounted to $27k. RMOs as a whole were $73k over for October, this is partly due to higher scaled RMOs than were anticipated and additional overtime primarily related to call backs. General Surgery will be implementing a night shift in December which should reduce the amount of call backs. There was a provision taken up for Allied Health back pay at 3 per cent which was budgeted for in September, this contributed $107k to the personnel overspend. There was also a $121k overspend on Locums in Surgical and Medicine to cover vacancies.

Outsourced services were $130k adverse to budget which related to outsourced radiology and the use of Everlight, this service is being utilised due to Radiologist vacancies. The October charge contains a wash up to reflect YTD usage; however Radiologist vacancies YTD offset Everlight outsourcing charges by $180k.

Clinical supplies were $66k adverse to budget and we continue to review our use of high cost consumables each month. There was $104k of service contracts in Medical Imaging that came to bear, majority of which related to prior periods. Renal costs were $42k over budget within pharmaceuticals due to higher than anticipated patient volumes. Transfer costs were $27k overspent, primarily within the ED service due to demand. The above was offset with an SSU charge that was reversed from last month of $130k.

Infrastructure costs were $28k favorable to budget due to reduced spend on meals and laundry as bed day numbers reduced in October.

The AESS cluster has adopted a number of strategies to recover our financial performance to ensure the cluster meets budget by year end.

• Achieve elective revenue however any underachievement will be offset by additional IDF revenue. • General Surgery moves to a Registrar night roster in December which will see a reduction in additional duties/call backs. • Review of all locum usage. General Medicine will be recruited by end January/early February. • In house compounding for Avastins which will reduce current costs. • Review our use of high cost consumables each month. 84

• Implementation of our summer bed plan within the adult inpatient services. We have worked with our clinical teams to flex beds down over summer based on summer occupancy as we have done over previous years and supports as many of our staff as possible to take annual leave over the summer period.

12.2 Business Improvement Programme

The Acute and Electives Specialist Services Cluster is involved in the System Flow Business Improvement Programme, which includes the three sub-programmes of Long-term Conditions, Timely Care and Frailty and Transitional Care.

The overarching objective is right care, right time, right place.

The current focus has been the completion of a summer bed plan which is currently being implemented within the adult inpatient services. This plan is to flex beds down over summer based on summer occupancy. The next area of focus is a whole of hospital inpatient flow model to inform ward and service configuration changes to reflect changes in service delivery models and patient flow. The purpose of the model is to better inform how we plan and deliver acute and elective care going forward to support our improvement efforts in:

• Admission avoidance • Improve flow, reduce avoidable delays and improve timely care across the hospital • Supporting older people to stay healthier and longer in the community, whilst also enhancing hospital services for older people with frailty when they need it • Timely and safe transfer of care back to community and their home.

The goal is to sustainably move to exemplar benchmarking status through reductions in length of stay and occupancy to reduce our overall hospital bed usage.

The outcome is safe, patient/whanau centred, efficient and future focused health services.

Mahi Tahi – Better Together Programme

The Mahi Tahi – Better Together programme is under way on Ward 26. Training for the staff commenced from Monday 5 November until Friday 9 November. This training will be supported by the Service Manager for Inpatient Services, Pae Ora, the Nurse Educator, Charge Nurse and the nursing Project Lead. There will be a ‘Frequently asked questions’ pamphlet for staff, patients/family/ whànau. Mahi Tahi – Better Together posters will be displayed on the ward also.

The commencement is scheduled for Monday 12 November 2018. The Nurse Project Lead will spend the week on Ward 26 to provide support for staff and patients/family/whànau; this also allows the project to gather experience based feedback and to implement rapid test cycles of change for improvement.

The project team have met with many key stakeholders over the past six months such as Infection Control, Spotless Services, and interviews with patient and families to ensure the success of this program.

13. RECOMMENDATION

It is recommended that the committee:

• endorse the progress made by Uru Arotau – Acute & Elective Specialist Services Cluster in 2018/19 • note the quality improvement programmes of work continue to be progressed, namely Takatū, Medimorph which includes Frailty and Transfer of Care • note the final phase of the Emergency Department renovations • note the Acute & Elective Specialist Services Cluster Business Improvement Programme.

Lyn Horgan Dr David Sapsford Operations Executive Clinical Executive Acute & Elective Specialist Services Acute & Elective Specialist Services

For:

Decision X Endorsement Noting

To Health & Disability Services Advisory Committee

Author Dr Marcel Westerlund, Clinical Executive Dr Vanessa Caldwell, Operations Executive

Endorsed by Kathryn Cook, Chief Executive Officer

Date 14 November 2018

Subject Uru Rauhī Mental Health & Addictions Cluster Report

RECOMMENDATION It is recommended that the committee: • endorse the progress made by Uru Rauhī, Mental Health & Addiction Services Cluster in 2018/19.

Strategic Alignment Uru Rauhī, Mental Health & Addition Services Cluster has aligned its key response actions with the NZ Health Strategy, and DHB’s strategic imperatives. This is to deliver an ambitious programme to design services that will deliver the right care in the right setting, and to develop new ways of delivering high quality care.

Glossary ACT Acute Care Team AH Allied Health AOD Alcohol & Other Drug ARC Aged Residential Care CAFS Child Adolescent and Family Service CMHT Community Mental Health Team CNS Clinical Nurse Specialist EH Elder Health EIS Early Intervention Service ELT Executive Leadership Team

COPY TO: Mental Health & Addition Services MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 87

HQSC Health Quality Safety Commission KPI Key Performance Indicator LMC Lead Maternity Carers MRFT Marama Real Time Feedback MDHB MidCentral District Health Board MH&A Mental Health and Addictions MHALG Mental Health and Addictions Leadership Group MHAS Mental Health & Addiction Service NASC Needs Assessment Service Coordination NESP New Entry to Specialist Practice NGO Non-Government Organisation OAMH Older Aged Mental Health OH Oranga Hinengaro OST Opioid Substitution Therapy PDRP Professional Development Recognition Portfolio RMO Resident Medical Officer RN Registered Nurse SAC Severity Assessment Code SMO Senior Medical Officer SPEC Safe Practice & Effective Communication SPHC Supporting Parents Healthy Children

UCOL Universal College of Learning

1. PURPOSE

The purpose of this report is to set out the Cluster’s performance against plans, budget and targets, and to advise any current and emerging matters.

2. SERVICE OVERVIEW

The Cluster is responsible for the planning, funding and provision of Mental Health & Addiction services across the region.

Services within the Cluster are structured into the following service groups:

• General adult mental health in community (moderate to severe and inclusive of management co-existing problems) • Primary Mental Health & Addictions • Mental Health Acute Inpatient services • Eating disorders • Maternal Mental Health • Community Rehabilitation • Child Adolescent and Family • Alcohol & other Drug Specialist Services (moderate to severe and inclusive of management co-existing problems) • Maori Mental Health • Older Adult Mental Health Services (Community and Inpatient) • 24 hour Mental Health Acute Care Team

Working towards an integrated health system, we are building stronger links with our key stakeholders including other DHB clusters and community providers. Over time, these links will be reflected within this report. Identified partners and stakeholders will include:

Key Partners Key Stakeholders • Central PHO • The Ministry of Social • MASH Trust Development • Dalcam Healthcare Group • Housing New Zealand • Rangitane Trust • The NZ Police • Ruakawa Trust • Community Corrections • Best Care Whakapai Hauora • Oranga Tamariki • The Youth One Stop Shop • Mana o Te Tangata Trust • Manawatu Supporting Families trust • The Salvation Army Bridge and Social detox programmes

3. CLUSTER’S AIM AND PRIORITIES

The Cluster’s aim is to ensure that all residents within MDHB will have access to high quality, compassionate and responsive mental health & addiction services.

Our aspirational goals and priorities include: • Early intervention (meeting needs early and preventing the escalation of mental problems) • Addressing the stigma and discrimination that surrounds mental health • Rapid and convenient access at all times (in all services and relevant settings) 89

• Equitable access for Maori, Pacific Island and other underrepresented groups • Fair access based on need • Recovery (service users moving through services, and being discharged where clinically appropriate) • Support to remain in own home and to live independently for as long as possible • The best possible outcomes for service users, their carers and families • The lowest possible number of complaints and untoward incidents • Excellent value for money • Using consumer and family/whanau feedback to make sustainable service improvements

Note: the Cluster’s Health & Service Plan is currently in development.

4. 2018/19 PLANNING INITIATIVES

In 2018/19, the Cluster will contribute to the delivery of the DHB’s Annual and Operational Business Plans. Key initiatives for the Cluster, grouped by MDHB’s Strategic priorities, are:

Initiative Rating & Trend MDHB Strategic Priority: Address the needs of targeted priority populations 1. Increase update of earlier assessment, treatment and support services available G  locally for people experiencing mental distress or illness 2. Support participation in the Government’s mental health inquiry G  MDHB Strategic Priority: Reduce health inequities 3. Improve the overall physical health of people with mental health and addiction G  conditions 4. Reduce Mental Health and Addictions health disparities for Māori G  MDHB Strategic Priority: Address our acute care demand 5. Improve the quality and safety of mental health services G  6. Improve transition of care arrangements for people who are discharged from G  specialist community mental health and addiction services

Rating & Trend Legend G On track, A Behind plan – R Behind plan – major D Not completed as progressing as remedial action risks and exception planned planned plan in place report required  Improved from last  Regressed from last  No change from last report report report

Commentary Support participation in the Government’s mental health inquiry - milestone completed. MHAS has supported Government’s National Mental Health and Addiction Inquiry. The inquiry officially closed on 8 August 2018. The Inquiry team has since sourced a one month extension (which was been agreed) to deliver their report to Government now by 30 November 2018.

5. KEY ACHIEVEMENTS IN THE MONTH

• The Perinatal Clinical Nurse Specialist (CNS) provided training for second year Otago midwifery students on Kapiti Coast in September 2018. Positive feedback was received from the students.

• The Tararua Community Mental Health Team’s relocation project to the Allardice Street premises is moving forward and on track for the end of November 2018. A joint blessing and opening of the new premises (with Rangitāne o Tamaki nui a Rua) will be held 3 December 2018.

• A Tele-health Hui at Palmerston North was held on 7th September, where ideas and the latest technology were presented. This looked at future use of video conferencing in Health.

• Early Intervention maintained responsiveness to home treatment in the context of patient crisis/distress. Closer partnership developed with Alcohol & Other Drug service. Early Psychosis liaison role piloted within Child Adolescent and Family Service (CAFS) context.

• Ward 21 has begun 3 month pilot of a dedicated role to oversee admissions and discharges to increase consistency of transitions of care.

• General Audits undertaken of Non-Government Organisations (NGOs) and work is underway to progress the corrective actions with each service provider.

• Planning commenced to increase the referral pathways for children with behavioural problems, and young people requiring earlier access to screening and treatment in primary care.

• Presentation of the NGO Collective Impact Framework (Appendix 1) to the Clinical Council and Consumer Council, was well received. This is a good representation of the high level of collaboration amongst our NGO partners

• Preparation has begun for the access of regional alcohol and drug services. These are services located in Christchurch and Auckland.

• Final response for MidCentral District Health Board (MDHB) contracts on Pay Equity has been sent to the Ministry of Health (MoH). This provides estimated pay equity funding for the eligible NGOs. Work is ongoing with the Ministry and dates have been scheduled for 2019.

• 0800 Phone line services project identified under-utilised free calling phone numbers across several mental health and addiction services. Work completed to review these and a plan to consolidate our 0800 phone access is underway.

• Funding proposals have been completed for increasing capacity across AOD regional residential services and child and youth mental health services.

• Needs Assessment Service Coordination (NASC) Mental Health has been reconfigured to sit with the SupportLinks team. Currently developing policy and access criteria with residential mental health NGOs.

• MDHB hosted the National Safe Practice and Effective Communication(SPEC) ‘train the trainer’ workshop for seven days between September and October 2018. Staff travelled from Auckland, Whanganui, MidCentral, Hawkes Bay, and Waikato DHB to complete this training. It is expected these staff will go back to their DHBs to implement the SPEC course with their colleagues.

• A presentation was made to the MHAS Grand Round and the Doctors meeting regarding a recent HDC case about Lithium Toxicity and Metabolic Monitoring. Plans are in place to ensure this is to be shared.

• Seven RNs have completed the Post Graduate Certificate in Nursing: Mental Health and Addiction and have also submitted their Professional Development Recognition Portfolios(PDRP) Competent level for assessment.

• Psychology Workforce Development Plan has been completed. This is currently being reviewed and progressed through the Operational Executive and Executive Director of Allied Health.

• Discussions regarding professional development training required for Allied Health (AH) and Nursing staff in MHAS has started with AH Advisor and Workforce Development role working collaboratively with the Nurse Director MHAS role

• Supporting Parents Healthy Children training delivered to nursing and allied health staff in July-September 2018 with very positive evaluations on the training provided by participants.

• Older Aged Mental Health Service (OAMH) Psychology proposal completed and is ready to be reviewed by MHAS leadership.

• Mana Akiaki (Life Keepers for Māori) suicide prevention training was provided in September 2018.

• Suicide Prevention Postvention Coordinator attended meeting in September 2018 to assist UCOL with their wellbeing service processes.

• The annual ‘coming together to remember those we have lost to suicide’ community gathering was held in October 2018.

• Minister of Parliament, Mr Iain Lees-Galloway attended the UNISON meeting (4 October 2018) to discuss nursing workforce implications within the community.

• Promotion of Mental Health Awareness Week (8-14 October 2018) included - all teams having available additional handout resources, advertising of NGO activities, daily wellbeing tips, and morning tea held on the ward

• Due to previous Marama Real Time Feedback (MRTF) data collected being low, MHAS has actively encouraged service users and whanau to provide feedback. This has seen the number of submissions increase. Further, key themes collected to date were presented to the Mental Health Addiction Leadership Group (MHALG) in September 2018 (Appendix 2).

6. AREAS OFF TRACK AND REMEDIAL PLANS

• Data collection issues are currently being experienced by Perinatal mental health for MoH non-financial reporting. Work is being undertaken to review and rectify these issues.

• We have contracted NZ Doctor to assist with targeted recruitment of SMO staff from overseas as these roles have been difficult to fill.

• Responsiveness to initial contacts has slipped from 1 day to 1 week. Plan in place to rectify this. Senior Medical Officer (SMO) absence for 4 weeks saw the requirement for day-to-day creative solutions.

• Referrals remain high for the Pahiatua Team, who have seen a large influx of crisis presentations within the past few months. The team based in Dannevirke is currently supporting staffing shortages due to leave, sickness and study leave to help cope with demand.

7. KEY ISSUES AND INITIATIVES IN COMING MONTHS

• In response to a request for training for front line workers on suicide prevention we are providing this for professionals working in the Ōtaki community on 11 December 2018. This is a prevention initiative under the MDHB Suicide Prevention Postvention Action Plan 2018-2019. In partnership with the Ōtaki medical centre, we are supporting a community MH101 workshop (Te Pou).

• The Government has agreed to a one month extension for delivery of the Mental Health Inquiry report (from 31 October to 30 November 2018). When the report is complete, this will be delivered to the Minister of Health. The Government will then decide what actions they will take on the report and its recommendations. The MCDHB Operations Executive sits on the MOH Sector Advisory Panel set up to support the implementation of these recommendations. This will also inform our cluster plan

• The National Adult Benchmarking Forum for the Mental Health and Addiction sector is to be held on 15 November 2018. Following this, Child and Youth Benchmarking Forum will follow on 6 December 2018. MHAS will be sending a team of participants to represent MDHB on both dates.

8. SCORECARD

While the Cluster develops a full continuum of care scorecard, in the interim, the following indicators (based on current KPI’s, and the DHB’s internal scorecard) are provided below. Additionally the MHAS Dashboard report is enclosed (appendix 1) to provide further commentary regarding significant variances and trends.

8.1 Patient Safety Indicators (as at 31 October 2018)

8.3 National MH&A Indicators (as at 31 October 2018)

9. FINANCIAL POSITION

9.1 MHAS financial summary for October 2018

9.2 Revenue for October 2018 on budget. 9.3 Total Personnel was $0.154m adverse to the budget. SMO medical costs were $0.030m favourable and locum costs $0.077m adverse covering four vacancies in Ward 21, CAFS and Star 1.

RMO medical costs were $0.026m adverse mainly in overtime callbacks, allowances and recruitment costs. Work is continuing on investigating the possibility of hiring an additional RMO and providing night shifts to replace the call back overtime system presently in place.

Nursing was $0.092m adverse with high demand in Ward 21 and Star 1. The Acute Care Team were also adverse with two additional staff employed as part of the MECA Hot Spot review, with attached MECA immediate funding relief to follow next month. Allied Health was $0.025m favourable due to challenges recruiting and was also adversely affected by the DHB accrual for the MECA back pay this month. Several vacancies have been successfully recruited to and other hard-to-fill vacancies are being reviewed for utilisation across the continuum of services.

Year-to-date net revenue was $0.385m favourable to budget. This is a result of the unbudgeted pay parity revenue provided for Health Care 95

Workers and is offset by adverse expenditure in Provider Payments. Net revenue is forecast to be $0.385m favourable to budget at year end.

9.4 Expenditure for October

Year-to-date total expenditure was $0.270m adverse to budget. This was due to high demand in the wards and challenges recruiting nursing personnel as well as locum expenditure covering SMO vacancies. Total expenditure is forecast to be $0.558m adverse to budget at year end. Work is currently underway to drive recruitment of medical and ward nursing personnel. Year-to-date Provider Payments was $0.450m adverse to budget offset by the additional revenue for pay parity and is forecast to be $0.450m adverse to budget at year end.

10. RECOMMENDATION

• It is recommended that the committee: endorse the progress made by Uru Rauhī, Mental Health & Addiction Services Cluster in 2018/19

Dr Vanessa Caldwell Dr Marcel Westerlund Operations Executive Clinical Executive

Appendices

1 – MHAS Integrated Performance Report 2 - NGO MH&A Collective Outcomes Framework 3 - Marama Realtime Feedback Presentation 4 - Profile on ACT

Appendix 1

MidCentral DHB Mental Health & Addiction Services

Integrated Performance Report

October 2018

1. Patient Experience

Comments: The number of complaints received has further increased. Of the 8 complaints raised, two complaints were raised by one service user. MCMHT received the highest number of complaints with 3. Between November 2017 and October 2018, of the total complaints raised within MHAS relate to MidCentral Community Mental Health Team. Year to date, the main theme continues to be ‘all aspects of clinical treatment’ followed by ‘attitude of staff’. 98

Comments MRTF is again continuing to increase since August 2018. Since implementation of MRTF, we have received feedback from 113 families and 272 service users. Themes include more readily available handout information, being part of the decision making process/felt listened to, staff attitude, need for more sensory tools, activities on ward for men and education workshops.

Positive feedback was received for Ward 21, CAFs and Oranga Hinengaro through compliments.

2. Community Services

2.1 Overall demographics at first contact/admission (Community) By sex By ethnicity

Not Stated Other Asian 275 Female European 354 Male Pacific Is. Maori 0 200 400 600

By age By region

Age 65+ Other DHB Tararua District Age 25-64 Kapiti Coast… Age 19-24 Horowhenua…

Age 0-18 Manawatu… Palmerston… 0 100 200 300 400 0 100 200 300

2.2 Overall demographics at discharge (Community) By sex By ethnicity

Not Stated Other 334 Female Asian European 369 Male Pacific Is. Maori

0 200 400 600

By age By region

Age 65+ Other DHB Tararua District Age 25-64 Kapiti Coast District Age 19-24 Horowhenua District Manawatu District Age 0-18 Palmerston North City 0 100 200 300 400 500 0 100 200 300 400

2.3 Acute Care Team – Crisis Response

Comments There was a reduction in demand against the average rate of 247 clients seen in crisis per month over the first 6 months of this calendar year. There was an increase in referrals on to Ward 21 with 36 clients, against an average of 27 referrals per month over the first 6 months of this calendar year.

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Comments For October, there were 37 police contacts with 22 seen within 3 hours and 15 seen outside of 3 hours. There was 1 error. We are waiting for contact from police to make arrangements for police officers to spend some shifts with ACT with the objective of building on relationships and increasing understanding of Mental Health and in particular use of Section 109.

2.4 Acute Care Team – Managed Referrals (Non-Urgent)

Comments The data for October shows 86 referrals. This reflects a relatively stable trend in rate of referrals.

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2.5 Older Adult Community

Comments Referral rate is up as is our discharge rate. Currently, there is only one Psychiatrist, as the other Psychiatrist has relocated to another service within mental health. Recruitment to this role is on-going.

2.6 Child, Adolescent and Family Service

Comments The team continues to work closely with service users who have high acuity and complex presentations. Currently there are vacancies within the team. We have just recruited 3 staff, 1 to Levin and a Psychologist and Co-existing disorder position to our Palmerston North team. We also have a NESP starting in February. This leaves 1 new Psychology vacancy and an eating disorders role that has been vacant for a year with no suitable applicants. We have had PR specialists review 102

our advertisement, have advertised across mediums and agencies and have had no response. We may also look to provide training to a new generalist recruit.

2.7 Perinatal Mental Health

Comments Admission to the service appears to be down in October from 15 to 5. This could possibly be due to a maternal MH clinician being on leave for most of October. The number of direct contacts for the month has increased by 1255 compared to previous month, which reflects the current complexity of presentations. Admissions are however down compared to previous months. At this stage, no single reason for decrease has been identified, this may just be an anomaly for the month. Team will however closely monitor admissions for both November and December. If trend continues, further investigation will be discussed with Clinical Manager in the first instance.

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2.8 Oranga Hinengaro

Comment Referrals continue to be at steady but low. Discharges continue to be reviewed and show an increase in this area. DNAs are lower this month compared to last month. Horowhenua will receive additional support in a 1fte to support the demographic within the Otaki/Levin area. Vacancies for Kaumatua, CAFs and Administrator role are yet to be filled.

2.9 Alcohol and Other Drugs Service

Comments There has been a slight increase in referrals in October. This month we received a larger than usual number of referrals from the Horowhenua area. Alcohol misuse remains a common reason for referral.

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2.10 Early Intervention Service

Comments Again another steady month with 4 referrals. Of note this month was the absence of lead SMO requiring creative solutions for providing SMO input into the assessments and caseload across the district. The lead SMO had planned leave for 4 weeks and has now returned. Cover, while arranged ahead of time, required to be re-distributed to meet urgent and critical service demand. Critical need for clients in the team was able to be accessed.

2.11 Manawatu Community Mental Health Team

Comments Referrals to the service have reduced from the previous two calendar months evidencing a small reduction in demand. The impact of this is negligible on caseloads given the turnover. The major referring source being Ward 21 in respect 105

of new clients to the service and Acute Care Team Urgent referrals. The Discharge rate whilst increased on last month again has had a negligible impact on the overall trend of high demand on clinical time due to the very complex caseloads.

Comments Referral trend is relatively constant. Whilst the figures are not high the dedicated team is small therefore any significant increase in referrals compared to discharges has a significant impact on workload. As can be seen, the discharge rate is significantly lower during October and this has resulted in high caseloads. As all discharges are the result of decisions made through the MDT process, the minimal Senior Medical staff availability because of annual leave has affected the ability of the Feilding Team to discharge.

2.12 Horowhenua Community Mental Health Team

106

Comments This month has been extremely busy for the team in general especially the duty team. We have had a high number of admissions to ward 21 over the month.

2.13 Tararua Community Mental Health Team

Comments Referrals down in October from September, discharges up. Crisis presentations were high in October, which were handled by the team who were working short staffed for the majority of the month.

Comments Increase in referrals this month from September, which has led to a busy month for this small team. Discharges remain steady.

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3. Inpatient Services

3.1 Psychiatric Intensive Care Unit (Ward 21)

Comments The demand on beds and the target of staying at 24 beds has been very challenging. The admission and discharge demand for inpatient beds is reflected in the utilization of high turnover. Ward 21 has been able to achieve almost daily patient discharging, however on the same day will receive an equal amount of new admissions.

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Comments Reflects the acuity of the clients and clinical decision making from the clinicians and endorsed by the medical teams on reviews.

3.2 Older Adult Mental Health Acute Inpatient

Comments There has been an increase in conduct and behaviour issues because of a patient admitted to STAR One unit area from a dementia care facility for displayed aggressive behaviours in the context of a known advanced dementia. The care facility was not able to cope.

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A ROADMAP FOR COLLECTIVE IMPACT

MENTAL HEALTH & ADDICTIONS NON-GOVERNMENT

ORGANISATION’s IN THE MIDCENTRAL DISTRICT

Collective Impact Framework 2018-2023 “How we make a difference”

April 2018

A 8 110

Table of Contents

He Mihi……………………………………………………………………………………………………………………………………………………………………….3 Acknowledgements...... 4 1. Section One ...... 5 1.1 An Agenda for the Future ...... 6 1.1.1 Focus on system redesign ...... 7 1.1.2 Improve workforce capability ...... 7 1.1.3 Address investment and sustainability issues ...... 7 1.1.4 Support service user self-determination ...... 7 1.1.5 Enhance community engagement ...... 8 1.1.6 Strengthen organisational infrastructure ...... 8 1.1.7 Use the evidence ...... 8 1.2 Overview- Community NGO Managed Mental Health & Addiction Services ...... 9 1.3 Key Strategic Documents ...... 10 1.3.1 On Track Co-Creating a Mental Health and Addiction System New Zealanders Want and Need ...... 10 1.3.2 MidCentral District Health Board Strategy ...... 11 2. Section Two ...... 12 2.1 Developing the Collective Outcomes Framework...... 12 2.2 Methodology...... 12 2.3 Using a Results Based Accountability tool approach to develop the measures ...... 13 3. Section Three ...... 14 3.1 NGO Collective Impact Framework...... 14 3.2 Utilising specific data to contribute to the Outcome Measures (Service and Client) ...... 15 3.3 Data Descriptors ...... 17 3.3.1 NGO Collective Impact Measures ...... 18 3.4 Data Collection Protocols for the Collecitve Impact Framework ...... 19 3.5 Assessing our Local Workforce ...... 19 3.6 Client/Tangata Whaiora Satisfaction survey ...... 20 4. Section Four ...... 21 4.1 Competency and Capability across the NGO Primary Mental Health and Addictions Sector ...... 21 5. Conclusion...... 22 Appendix 1: Client Satisfaction Survey of Mental Health & Addictions NGO Services Template ...... 23 Appendix 2: Workforce Profile Survey Template ...... 24 Appendix 3: Workforce Training Evaluation Template ...... 26 Appendix 4: NGO Workforce Development Training Calendar...... 27 Appendix 5: MidCentral District Health Board Strategy ...... 29 Appendix 6: Connected Workforce NGO Leadership Group ...... 30 References ...... 31

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He Mihi

E ngā pae maunga o Ruahine, o Tararua, e tu ake nei E ngā wai o Manawatu, o Ōroua, o Rangitikei e rarapa mai ana Karanga mai, karanga mai, karanga mai E ngā mana, e ngā karanga maha huri āwhiotia i ngā tōpito o te aotūroa nei tēnā koutou katoa Tena koutou i runga i ngā āhuatanga e uruhia mai nei i a tātou katoa, ahakoa ko wai, ahakoa nō hea Kei āku nui, kei aku rahi, e ngā iwi kainga, arā, Rangitāne o Manawatu, Ngāti Kauwhata, Rangitāne o Tamaki Nui a Rua me Ngāti Raukawa ki te tonga, karanga mai, karanga mai.

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Acknowledgements

The development of this Collective Impact Framework has been sponsored by MidCentral District Health Board and with a number of contributors particularly Authors Claudine Nepia-Tule, Rodger McLeod, Editors; Ian Ironside, Jo Smith (MidCentral DHB), Kylie Hoskin (Rangitāne Tamaki Nui A Rua Service), Graeme Munford (ACROSS Social Service), Megan Doran, Kate Matthews (MidCentral DHB), Administration support; Priya Anbalagan (Mana o te Tangata Trust) and Stacey Greaney (MASH Trust). The NGO Connected Workforce Leadership Group has provided oversight and contribution in the development of this Framework.

Glossary

MDHB - MidCentral District Health Board MH&A – Mental Health & Addictions NGO - Non-Government Organisation NZQA - New Zealand Qualifications Authority RBA - Results Based Accountability GP - General Practitioner

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1. Section One

Executive Summary

The rationale for developing a population outcomes-based approach is that people experience a different impact from complex problems that affect mental health, mental illness and addictions. For some the effect of these problems can lead to a cycle of socio-economic deprivation and poor mental health and addictions, which reaches across the life course and generations.

As a result, the unequal distribution of mental health and wellbeing outcomes can be used to identify disadvantaged or at-risk populations. Working towards shrewd outcomes encourages collaboration by organisations and services. This collaborative response is most effective when it is provided early in the life course and managed at the times of risk and need.

The Collective Impact Framework supports the Non-Government Organisations (NGO) sector (including Primary Mental Health Services) to cultivate a strong position as community based service providers and to initiate further population based indicators, which may be identified into the future as essential for the whole continuum of mental health and addictions - including secondary care.

The trust that has been developed across organisations as part of this process is important to acknowledge as the provision of data on a shared basis can be a challenge for most organisations.

The line of sight and how data contributes to support the collective impact framework of indicators is a clear direction of local and Ministry of Health strategic documents. The NGO sector in the MidCentral district has embraced this opportunity to develop an outcome focused framework for service providers and capture the outcomes of people who use mental health and addiction services in the district. This also supports a collective lens for NGO services moving forward.

Both the NGO leadership group and the District Health Board focus for mental health and addiction services in the community over the last five years, has been to oversee and implement the Let’s get real competencies and the NGO Primary Connected Workforce Work Plan (2012- 2017).

The Collective Impact framework has drawn on several key documents, including the MidCentral DHB NGO Results Based Accountability workshop discussion paper (April 2016), the MidCentral District Health Board Strategy and the On Track Co-Creating a Mental Health and Addiction System New Zealanders Want and Need (Te Pou, Platform Trust, 2016).

The leadership role involved will require service providers to act on reform and development. It will eventually require new partnerships with other sectors, in order to formalise systems and infrastructure across social and justice areas, with health.

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1.1 An Agenda for the Future

The Non-government Organisations Primary Connected Workforce Leadership Group (the Leadership group) is the peak body representing community based mental health and addictions’ services in the MidCentral district and has prepared this document to support the developmental work of the framework. The sector recognises the need for reform to meet changing community and government expectations and with the election of the new Government, there is a willingness to address community based innovation and designing of mental health and addictions sector and people whom access these services.

At the time of writing the Governments Mental Health and Addictions Inquiry 2018, adds urgency to the need for change and further service development, in which NGOs mental health and addiction service providers wish to take a lead role in defining the directions of a service development strategy that contributes to the MidCentral DHB vision ‘Quality Living, Healthy Lives, Well Communities’ and development towards an outcomes approach.

The Collective Impact framework aims to: . Provide a roadmap for the development of community based mental health and addiction services in MidCentral district over the next five years, towards services delivering positive population level outcomes of their clients and their whānau . Provide a resource for the Leadership group in their deliberations about required changes in their organisations to develop an outcome-based approach and data capture contributing to the framework . Influence the District Health Board and Governments’ policy and funding of services.

The Framework’s proposed outcome statement is ‘Contribute to all people thriving in their communities by reducing the impact of mental distress, mental illness and addictions’. Its goal statement expands on the shared purpose envisaging wide-ranging action that will contribute to people living well in their communities by reducing the impact of mental distress, mental illness and addiction problems.

The proposed outcome and goal statement means the MidCentral NGOs Collective Impact Framework has identified three main target populations: . Service users/ tangata whaiora . Family whānau and friends . Those at risk of becoming Service users/tangata whaiora.

The Collective Impact Framework covers seven Key Focus Areas over a range of health, social and economic problems that all impact upon mental health and wellbeing. These focus areas are: 1. Focus on system redesign 2. Improve workforce capability 3. Address investment and sustainability issues 4. Support service user self-determination 5. Enhance community engagement 6. Strengthen organisational infrastructure 7. Use the evidence.

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1.1.1 Focus on system redesign

A whole-of-system approach recognises that health and social systems are inextricably interrelated and that it is not possible to make a change in one part of the wider system without inevitably having an impact on another. Critical factors that support effective integration are more to do with how the vision is translated into practice rather than the model of integration that is selected. More cross-agency resources need to be focused on promoting wellbeing, identifying problems early and delivering an integrated service response, particularly for those at risk infants, children, adolescents and families who are experiencing harmful factors and outcomes (i.e. vulnerabilities).

1.1.2 Improve workforce capability

We need to amplify the core values and attitudes required to work in MH&A services, improve the cultural and linguistic competencies of the workforce, improve the capability of the workforce to deliver evidence-based programmes, provide easy access to appropriate levels of supervision for NGO staff, invest in NGO leadership at all levels and develop some succession planning, review the horizontal and vertical career paths of a number of related workforce programmes, to make it easier for people to enter the MH&A and continue to develop the peer support workforce.

1.1.3 Address investment and sustainability issues

While mental health and addiction NGO service providers are doing their best within limited resources and a largely inflexible system, the reality is that funding for NGOs has not kept pace with increases in the cost of living. This situation has been compounded year on year, resulting in a decrease in funding in real terms for many NGOs throughout the country (Platform Trust, 2015).

As the work of NGOs broadens and becomes more complex, concerns about the capacity, capability and sustainability of NGOs will become more of an issue for both funders and providers. These issues will need to be addressed in a systematic way in order for the sector to grow, evolve and move forward.

1.1.4 Support service user self-determination

The new approach to the delivery of services requires Mental Health and Addictions providers to adopt a recovery philosophy that is based on self-determination and the maintenance of wellbeing.

According to Ryan and Deci’s (2000) theory of self-determination, people have three core psychological needs – autonomy, competence and relatedness. They propose that people’s sense of wellbeing is dependent on those conditions that foster or thwart these three needs. To the extent that these needs are satisfied, people are more likely to feel good on a day-to-day basis, but to the extent that they are thwarted, people are more likely to experience ill-health.

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1.1.5 Enhance community engagement

Internationally there is a trend towards governments supporting local communities to develop bottom up solutions to apparently intractable economic and social problems. The trend has emerged in response to the growing amount of evidence that the application of prescribed top- down policies and initiatives is not working and, in some instances, has actually hindered progress. This trend represents a paradigm shift in thinking. With recent submissions to the Governments Mental Health Inquiry, there is plenty of opportunity moving forward.

1.1.6 Strengthen organisational infrastructure

The performance of the mental health and addictions NGO sector has increasingly come under the spotlight in the past decade. In the context of a financially restrictive environment and greater competition for resources, questions about the effectiveness and productivity of the social sector, including NGOs, are being raised by funders (New Zealand Productivity Commission, 2014). Central government and its funding agencies have expressed a view that New Zealand has too many small NGO providers and that too many frontline resources are being diverted towards supporting unsustainable operations. The popular solution to this problem has been for funders to encourage NGO providers to either share their administrative functions, or to merge services so that there are fewer, but larger and stronger organisations. In the absence of some credible evidence to help offset this view, it is very difficult for the NGO sector to argue that it is not the size of an organisation that matters, but its capability to deliver value to service users and to maximise its use of limited resources.

The New Zealand Treasury (2014) maintains that the specific elements that support ‘smart investment’ by funders are: clarity about the key outcomes; better use of data and cohort information to help target those people who most need services; clear institutional incentives; accountability to help drive performance and innovation; and organisational flexibility and evaluation loops with which to test, learn and adapt. Irrespective of whether or not these key elements are present in the current funding and contracting framework, NGO providers need to continue making progress on incorporating these elements into their own organisations, so that they are able to monitor both their organisational performance and the quality of the services that they are delivering to people - the development of this Collective Impact Framework is a concerted effort in this direction.

1.1.7 Use the evidence

There is now a great deal of research about the best evidence-based practices and programmes that Mental Health and Addictions services should be implementing, in order to achieve good outcomes for services users and their families/whānau. However, the most effective interventions will not produce positive outcomes if they are not implemented properly. The sector also needs to invest in on-going research and evaluation of new and emerging practices for particular sub- populations, in order to ensure there is a sound knowledge base that is supported by the appropriate level of training and supervision.

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1.2 Overview Community NGO Managed Mental Health & Addiction Services in MidCentral District

NGO (including primary mental health) services focus on people with varied levels of presentations from mild to complex mental health problems and addictions and those facing significant social and economic disadvantage. They provide support to people in managing their mental health and addiction problems and building their skills for life in the ways they choose.

It is part of the mental health and addictions service system, where there is the strongest evidence of commitment to a recovery approach and of the building of skills and systems that underpin effective practice.

Key achievements of NGO Mental Health & Addictions services include:

. A sustained focus on the needs, perspectives and interests of service users/tangata whaiora and whānau . Championing the introduction of recovery as a philosophy and framework for practice development and models that inform their practice . Investment in the development of consumer and peer focus engagement in services and basing their work on supporting clients . Developing innovative family, employment and other leading initiatives such as the Single Point of Entry for Offenders with Alcohol and Drug problems . Building capacity through the District Health Board to support people with very complex needs in the community and in so doing, supporting people to live outside clinical services . The development of unique services in collaboration with clinical mental health services for clients with highly complex needs . A workforce composition snapshot, which supported the workforce development approach across community based services from 2012-2017.

These achievements have:

. Enhanced the recovery and quality of life of service users/tangata whaiora and whānau . Reduced demand for clinical services . Demonstrated the capacity and potential of recovery orientated NGO services.

Currently 13 NGO (including primary health) Mental Health & Addiction organisations receive funding from the MidCentral District Health Board, for provision of services for people facing mild to complex mental health and addiction issues.

The organisations involved demonstrate a diversity of characteristics. These include:

. Organisations with a primary care focus . Kaupapa Māori and iwi Māori organisations . Organisations focused on youth . Organisations with broad health, employment, alternative education . Organisations with a primary mission to work with people needing residential care and support . Organisations focused on peer support and whānau/family advocacy and support.

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These organisations are governed by Boards of committed volunteers who make a vital contribution to the capability of their organisations and the work of the NGO sector.

MidCentral DHB has four relatively distinct elements of its mental health and addictions service system:

. A primary care-based service system provided by General Practitioners and allied health professionals working with more common mental health and addictions conditions . An acute and clinical services system that provides bed-based, community based and forensic services . A NGO service system providing psychosocial support, recovery services and other support services . A regional services system providing clinical consultation, liaison and bed-based services.

As the international evidence indicates, a combination of a strong primary care sector and a well- developed NGO sector is critical in improving outcomes for people and whānau and therefore increased system capability.

1.3 Key Strategic Documents

In 2012 three key national documents were released that set out the direction for the mental health and addiction sector over the next five to ten years: Blueprint II: How things need to be, along with its companion document Blueprint II: Making change happen and Rising to the Challenge The Mental Health and Addiction Service Development Plan 2012–2017 (Ministry of Health).

The overarching vision for Blueprint II is that ‘Mental health and wellbeing is everyone’s business, taking a broad view that considers the roles of not only health but also social services. It refers to district health board planners and funders as the ‘architects’ of the New Zealand system and as critical to making change happen as the sector is shaped by the types of services purchased and how these are purchased. Although the solutions for a paradigm shift and change also sit with whānau and the leaders and managers of services across the continuum of care. Rising to the Challenge the Mental Health and Addiction Service Development Plan 2012–2017, set the direction for delivering mental health and addiction services across the sector. It outlined key priority actions aimed at achieving further system-wide change to make service provision more consistent and to improve outcomes. The implementation of the Rising to the Challenge Plan was led by the Clinical Network Mental Health & Addictions, MidCentral DHB.

1.3.1 On Track Co-Creating a Mental Health and Addiction System New Zealanders Want and Need

The On Track document has been a very influential reference point for the NGOs, which has been used to fit the collective organisational needs of the NGO leadership group in conscripting the Collective Impact framework. On Track was designed by the National Workforce Centre Te Pou and Platform Trust and written from a true NGO perspective, with the principal aim of helping NGO service providers to make changes in their models of service delivery and serve as a road map for the NGOs as they work to achieve transformational goals.

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We are committed to meeting the objectives outlined in this framework of approach; to ensure the desired impact on service users and Mental Health and Addiction services is achieved. A focus on our current challenging areas – public perception, resourcing, developing services and client outcomes across the care continuum will remain a high priority this year.

1.3.2 MidCentral District Health Board Strategy

This outlines the high-level future direction for MidCentral District Health Board (MDHB). It lays out what is being aspired to achieve, including the culture, values and identifies four Strategic Imperatives.

The Strategy will guide the future work to make a positive contribution to the health outcomes of the population and to make the necessary changes to continuously improve the health system, as part of the wider health sector and social service network. The strategy (Appendix 5) is consistent with the goals of New Zealand Triple Aim, as well as the direction of the New Zealand Health Strategy.

MidCentral District Health Board’s vision is: Quality Living, Healthy Lives, Well Communities. This vision has been enhanced to include ‘well communities’, signaling a stronger focus on a more inclusive and integrated health system that includes the social sector partners; as well as people, their family, whānau and communities.

The District Health Board, have summarized the purpose as: ‘Better health outcomes, better health care for all’. In doing so, it acknowledges the key role in contributing to the best possible health and wellbeing for individuals, whānau and communities. The Collective Impact framework designed by the NGO sector, contributes to the District Health Boards vision and purpose.

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2. Section Two

2.1 Developing the Collective Outcomes Framework

In a recent report, the New Zealand Productivity Commission (2015), looked at how to make New Zealand’s government-funded social services more effective so that they improve people’s lives and raise social wellbeing. Its report highlights the importance of developing new approaches that better match services to those who need them and encourage service providers to innovate and continually improve their services.

This locally designed Collective Impact Framework (refer Table 1) addresses the issue by providing a structure that can be used to approach an outcomes focus for mental health and addictions service providers in a consistent and structured way. As NGOs in the MidCentral district have discussed, efficiency is outputs and what adds value is outcomes.

In April 2017, MDHB organised a planning day with the NGO leadership group and Shea Pita & Associates, to reflect on the previous four year work plan successfully completed by the group, identify gaps in service provision and co-design actions which could be taken to mitigate these gaps. This led to the development of an outcomes based approach as a collective of NGO service providers, attempting to improve the health of the population in the MidCentral district.

The planning workshop focused on common information and outcomes relevant to the Mental Health and Addictions sector and this was utilised to formulate a range of indicators and measures for the framework, which were then narrowed down to the vital few (refer Table 2).

2.2 Methodology

This Collective Impact framework was developed using the following methodology to design the indicators, areas of focus and key outcomes as a collective of NGOs. This has included:

. Literature review and analysis . Policy landscape; an assessment of the current policy landscape, in particular the refreshed Let’s get Real, On Track framework and consumer feedback tool Real Time Marama . Interviews with key stakeholders, service users/tangata whaiora, service providers . Educational workshops to understand the Results based Accountability framework . The framework was presented to the MDHB Consumer Council.

The Consumer Council provides independent strategic consumer perspective and commentary on all matters regarding implementation of MidCentral DHB’s Strategy and other related areas of work. The Council also provides advice and support to assist the DHB to achieve a person and whānau-centered model of care, where patients are partners in their own health care and consumer engagement and participation occurs throughout the district.

The Mental Health and Addiction NGOs have undertaken the challenge to develop not only a collaborative approach in working with one another for service improvements such as the indicators to collectively report on, but also position themselves as pioneers breaking new ground.

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This framework provides the first step in the provision of bringing together aggregated data from each NGO based on the initial three key areas of interest; referral demand, staff profile and service user satisfaction/recovery.

NGO providers have agreed to report to a common data set with agreed data descriptors, for which MDHB also supports and further work may be undertaken to mitigate any reporting burden.

The expectation has been made that NGO providers ensure there is awareness of the program of work to implement the Collective Impact Framework and the indicators are communicated to their Governance Boards.

2.3 Using a Results Based Accountability tool approach to develop the measures

Results Based Accountability (RBA) is a simple framework which communities and organisations can use to focus on results/outcomes to make a positive change for their communities and clients.

The RBA tool encourages a range of partners to share their ideas about what works to make their unique contributions towards the wellbeing of whānau and communities and helps keep the focus on who or what we are targeting and what we want to achieve and it insists on answering the question ‘how are our communities, whānau and clients better off?’ as a result of all our effort.

There are two types of accountability within the RBA Tool: . Population accountability and . Performance accountability.

Population Accountability No single organisation can possibly achieve a condition of wellbeing for a whole population on their own. It takes the unique contributions of a range of community partners who have a part to play in moving their community closer to achieving a result like ‘people thriving in a community’. This may include police, neighborhood support, schools, parents, extended whānau, churches and businesses.

Performance Accountability This type of accountability focuses on how an individual organisation or program performs.

Performance Accountability has three types of performance measures:

. How much did we do? (What was the quantity of the work done?) . How well did we do it? (What was the quality of the work done?) . Is anyone better off? (What was the impact of the work done/client results/outcomes?).

The NGO Leadership group utilised the tool as an approach in developing a shared purpose as a sector, the long-term goal and service delivery areas of focus, service measures and indicators.

There are three main components covered in the Collective Impact Framework that provide a demand profile and responsiveness. Within responsiveness we hope to identify how our workforce aligns with the needs of the community and how the working relationship and interventions provided, achieve outcomes that promote wellness and positive recovery.

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3. Section Three 3.1 NGO Collective Impact Framework Table 1

NGO Shared Purpose: What we want to achieve for people by our own efforts and by working with others

Long Term Goal: Contribute to all people thriving in their communities by reducing the impact of mental distress, mental illness and addictions

The Collective Impact Framework Seven Key Areas of Focus & On Track

Focus Support Improve Address Enhance Use on system self- Workforce investment and community the evidence Strengthen redesign determination capability sustainability engagement organisational issues infrastructure

NGO Results Based Accountability Outcomes

Building workforce Positive service user Improved wellbeing People are engaged capacity satisfaction awareness and in purposeful understanding for activities Improved health Person centred recovery service users literacy and Improved health Housing challenges literacy are addressed

Service Outcome Measures

Quantity (output) Quality (output/outcome) Quantity & Quality of Effect How Much How Well Better Off-ness for the client

# of people engaging in # of people achieving the goals they Do people tell us they are better programmes have set off? # of people referred to other # of people reporting improved How do people describe changes programmes and services wellbeing and independence in their wellbeing? # of people providing positive Can people say they have feedback about programmes and benefitted from NGO programmes services and services?

Client Outcome Measures

Quantity (output) Quality (output/outcome) Better Off (for the client)

*People/whānau have a positive *People/whānau use new skills *People/whānau have a better awareness of their needs relevant to their needs quality of life

Information will be collated by three Measures:

Workforce Client Satisfaction 14 Referral Demand Development

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3.2 Utilising specific data to contribute to the Outcome Measures (Service and Client)

How much is the ‘Quantity of Effort’. We considered Referral Volumes to be measured against both population demographics and deprivation demographics, providing us with an indication of the community need and demand patterns over time.

Referral volumes are an indicator of demand patterns and the responsiveness capability of the NGO sector. It is important moving forward to understand trend patterns of presentation across the NGO sector and any spikes in demand over time. Demand pressures allow us to look at what we do, how we do it and how to best maintain responsiveness to our communities.

How well is the ‘Quality of Effort’. The Workforce Profile provides a gauge of how our NGO workforce aligns with the referral demand patterns within our community.

The workforce profile matched against the client satisfaction survey across the services, assist to understand and appreciate client receptiveness and engagement or satisfaction with services and our clinicians, kaimahi, support workers.

The movement towards wellness and independence as a focused outcome is supported by a well- educated and prepared workforce that provides relevant needs-based interventions.

The Workforce profile survey is important to reflect on as a collective result, as it supports confidence and capabilities knowledge and workforce planning for the future. The age and ethnicity measures assist our equity lens that supports population demand and responsiveness patterns. The qualification profile allows knowledge and understanding for planning therapeutic intervention responsiveness as a sector (Appendix 2). 15

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Better Off-ness is the combination of ‘Quantity & Quality of Effect’. Service User satisfaction feedback was deemed critical to capture, assisting us to assess service user experience of our NGO mental health and addiction services in the district.

Client Service User satisfaction information is focused on the overall satisfaction and experience the person has had with accessing the mental health and addictions services and whether this engagement supported their wellbeing and independence.

As a sector, we want to understand how the population feels about access and intervention within the NGO services and whether it has made a self-determined difference in wellness and independence.

The question framework (Appendix 1) is based on the Marama Realtime Tool feedback questions and it does not capture readmissions to secondary services.

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3.3 Data Descriptors

The source of data is based on individual data collections obtained from both the collection protocols and data descriptors listed. Each NGO service provider is able to collect any relevant data; however, it is important that this aligns to the data descriptors below.

Data Descriptors Defined:

Results Based Accountability Measures Data Descriptors Components Quantity of Effort Referral Volumes The number of new referrals How Much opened to the service

Quality of Effort Family/Whānau Inclusion Use the ‘Client Satisfaction How Well Survey’ Question 4 “staff encourage my family/whānau to be involved”

Workforce Development Use the ‘Workforce Training Evaluation’. Each of the five questions will be tracked individually with an aggregated result added to the data table

Workforce Survey Use the ‘Workforce Profile Survey’ data. The demographics will be aggregated and a tracking of the eight levels of practice questions will be tabled individually with an aggregated score. The qualification NZQA level will be an aggregated number

Quantity & Quality of Effect Client Experience and Data will be collected using the Better Off-ness for the Client Satisfaction ‘Client Satisfaction Survey’ five questions (Questions 1, 2, 3, 5, Improvement in Client 6) will be reported and then Wellbeing and Independence aggregated for an overall result

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3.3.1 NGO Collective Impact Measures Table 2 NGOs Contributing to Healthy Futures (Goal) - all people thriving in their communities by reducing the impact of mental distress, mental illness and addictions Quality Living Kia Pai te noho, Healthy Lives Kia Ora te tangata, Well Communities Kia Ora te hapori Measures

Referral Demand (Access Measure)

Workforce Profile (Competency/Capability Measure- workforce reflecting the clients seen/referral type)

Client Satisfaction Survey (Satisfaction Measure)

There are multiple pathways and whole of system approaches to achieve population level outcomes Early life Adult life Older life Life course approach Prevention, Early identification and Self-management, Health information Continuum of health care intervention, Support and management, and

Rehabilitation, Palliative treatment Care Employment, Education Social determinants of Income and poverty Culture and ethnicity Housing, Social cohesion health and social support

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3.4 Data Collection Protocols for the Collective Impact Framework

The NGO Collective has agreed to collect and submit data based on the time agreements outlined below. The collective information is submitted by each individual NGO organisation based on the data descriptors and timeframes outlined below. The data is aggregated and housed by the NGO Project Coordinator and will be available as a collective NGO data set. This will demonstrate over time the difference made for the people we serve and the outcomes we strive towards as a collaborative sector.

Referral Demand data: Referral volumes are an indicator of demand patterns in the sector and the responsiveness capability of the NGO sector. This will be trended data and have two collection points annually: . 31 January: For the six-month period of 1 July – 31 December . 31 July: For the six-month period of 1 January – 30 June.

Client Feedback & Service Effectiveness data: This will be based on the client feedback survey questions and will be collected as an annual snapshot of each NGO and aggregated as a collective data set. This will be submitted by 31 January and 31 July, annually for the periods 1 July to 31 December and 1 January to 30 June.

Workforce Profile (Competency/Capability) data: This will be based on a workforce survey, as an annual snapshot of what our workforce skillset looks like at any given point in time. It will be based on a staff survey questions that includes New Zealand Qualification Accreditation qualification levels. This will be completed by each NGO between 1 January and 30 June annually and submitted for the aggregated data set by 31 July annually. A training evaluation measure has been developed alongside a brief five question evaluation form (Appendix 3), to be completed by those attending training workshops. The data from each workshop and aggregated data is then evaluated to assess the value of the training provided.

3.5 Assessing our Local Workforce

Workforce planning is the systematic identification, analysis and planning of future workforce needs based on population health needs and priorities. The workforce planning process for the Collective Impact data collation aims to assist in planning the service interventions needed in the future and identify workforce requirements across NGOs and primary mental health and addictions.

A Workforce survey (Appendix 2) has been produced to measure: . Age, ethnicity, gender - in line with current district or national percentages . Competencies - aligning with the Mental Health & Addictions Workforce Plan . Qualification level - aligning with qualification equivalencies for Pay Equity (Careerforce) and create a snapshot of qualification levels of the various workforce across NGOs.

The group took into consideration the need to use common language to ensure the Survey was easy to complete for all levels of the -workforce. Not only does the qualification equivalency score allow for an accurate measure of qualification level across the workforce, it also aligns with the Pay Equity proceedings being undertaken by the New Zealand government for levels one to four. 19

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3.6 Client/Tangata Whaiora Satisfaction survey

To evidence the work of the services of the NGO Leadership Group, a client satisfaction survey was developed (Appendix 1). This survey is to be used universally across member organisations, which are collected on a tablet from the client input, aggregated and then analysed annually.

The workforce is to encourage clients to complete the survey near the time of their discharge or at an appropriate time for the person, family/whānau being supported.

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4. Section Four

4.1 Competency and Capability across the NGO Primary Mental Health and Addictions Sector

Let’s get real describes the essential values, attitudes, knowledge and skills required to deliver effective services in partnership with people who experience mental health problems and addictions. The refreshed version in 2017 of the Let’s get real updates the 2008 framework and applies to everyone working with people who experience mental health problems and addiction wherever and whenever they are involved in or in contact with health services.

There is strong evidence that people who experience mental health problems and addiction have poorer health outcomes compared with the general population. Let’s get real framework provides shared values, attitudes and skills and is a tool to improve integration between mental health and addiction services and the broader sector.

The seven Real Skills provide a description of what people working in health do when working in partnership with people who experience mental health problems and addiction. Each skill is defined and has three levels of performance indicators: Essential, Enhanced and Leadership.

The Essential level applies to everyone working in health regardless of context or role. The Enhanced level applies to people working in mental health and addiction roles and others who want to further develop skills in working with people experiencing mental health problems and addiction. The Leadership level has an emphasis on skills to lead, guide, support and resource others in their work with people who experience mental health problems and addiction.

Let’s get real does not replace professional competency frameworks, but complements them by providing a shared language across roles, professions and health care contexts.

The seven Real Skills at a glance: 1. Working with people experiencing mental health problems and addiction 2. Working with Māori 3. Working with whānau 4. Working with communities 5. Challenging stigma and discrimination 6. Applying law, policy and standards 7. Maintaining professional and personal development.

A 12 month revolving training calendar has been developed by the NGO Leadership Group to provide training across three levels of the Let’s get real, Te Pou National Workforce Centre for Mental Health. These levels and competency components have been updated to the recently refreshed Let’s get real framework (2017) of Essential, Enhanced and Leadership (Appendix 4).

A high focus within the NGO Leadership Group has been the emphasis on organisations sharing their approach to workforce development within their teams and encouraging this approach as a collective of leaders and managers. An organisations learning culture has an impact on job satisfaction and the use of training and development in practice. Therefore, a learning organisation promotes learning amongst staff and it learns from that learning to achieve its goals, - this has been one of the key benefits of the collective Leadership Group.

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5. Conclusion

With the completion of the ninety-nine initiatives of the Ministry of Health’s Rising to the Challenge Service Development Plan for Mental Health and Addictions 2012-2017 by the MDHB Clinical Network Mental Health and Addictions and the NGO Primary Connected Workforce Action Plan (2013-2017) and the Primary Mental Health new service model of care Te Ara Rau, there is much cause for optimism. The platform needed to sustain change has been put in place and in several areas people who use mental health and addiction services, are beginning to feel the benefits of the new and expanded services on offer.

We must be mindful, that the implementation of the Collective Impact Framework is a long term programme and results will not be seen immediately in all areas. This first stage of the framework necessarily requires preparatory work to lay the foundations for transformation, including developing a plan that meets and assist provider implementation of the Framework for the benefit of our population. As drawn upon earlier, there is now a great deal of research about the best evidence-based practices and programmes that Mental Health and Addictions services should be implementing, in order to achieve good outcomes for services users and their families/whānau. However, the most effective interventions will not produce positive outcomes if they are not implemented properly. The sector also needs to invest in on-going research and evaluation of new and emerging practices for particular sub-populations, in order to ensure there is a sound knowledge base that is supported by the appropriate level of training and supervision.

Moreover, it is important to remember that even by 2020/2021 the Framework of capturing client outcomes will not fully bridge the gap that exists for people with poor mental health and wellbeing and further work will be needed beyond the traditional three year planning cycle to continue to expand transformation of mental health and addiction services and better meet the needs of the whole population.

Nonetheless, more people than ever before are talking about mental health and wellbeing and identifying it as a priority for the health and care system.

Across Aotearoa, mental health and addiction services are busier than ever, whether that be through improving the care of people in emergency departments, delivery of crisis care in the community, reducing the numbers of people detained in police custody or working with the voluntary sectors and other sectors to improve social housing access or employment services. Considerable thanks must go to the dedicated workforce who continues to deliver improvements in a tough climate.

There is clear momentum behind this programme and the challenge now is to maintain and build on this with other parts of the mental health and addictions continuum of care, to achieve next year and beyond.

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APPENDICES Appendix 1: Client Satisfaction Survey of Mental Health & Addictions NGO Services Template

1. I feel respected by staff

Strongly disagree Disagree Neutral Agree Strongly agree

2. Staff involve me in decision making

Strongly disagree Disagree Neutral Agree Strongly agree

3. I am supported by staff to become more independent

Strongly disagree Disagree Neutral Agree Strongly agree

4. Staff encourage my family/whānau to be involved

Strongly disagree Disagree Neutral Agree Strongly agree

5. My plan is regularly reviewed by staff

Strongly disagree Disagree Neutral Agree Strongly agree

6. I would recommend this service to others

Strongly disagree Disagree Neutral Agree Strongly agree

Note: Only five questions from the Client Satisfaction Survey will be collated to contribute to ‘How well’/Quality of Effort and ‘Better Off-ness’ Outcome Measure (refer to page 14).

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Appendix 2: Workforce Profile Survey Template (2 pages)

Practitioner/Kaimahi Name Job title Organisation Gender Ethnicity Rate yourself based on the NZ Qualifications Framework (Levels 1-7) and list your highest qualification Professional Body (or note Non-Applicable) Real Skills Competency Number of Essential Enhanced Leadership Domains Areas to Applies to everyone Applies to everyone working in mental Applies to everyone who is leading, guiding, meet in each working in health health & addiction roles and those wanting supporting, educating and resourcing the work Domain regardless of context, to develop skills to work effectively with of others in health. People in Leadership need to organisation, role or people. Staff are expected to progressively demonstrate the Essential and Leadership levels profession demonstrate both the Essential and of Real Skills Enhanced levels of seven Real Skills Circle the level that applies to you Challenging Stigma & 4 Essential Enhanced Leadership Comments Discrimination

Working with people 3 Essential Enhanced Leadership experiencing mental health problems and addiction Working with Māori 6 Essential Enhanced Leadership

Maintaining professional 5 Essential Enhanced Leadership and personal development Working with Whānau 4 Essential Enhanced Leadership

Working within Communities 3 Essential Enhanced Leadership

Applying law, policy and 3 Essential Enhanced Leadership standards

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Please list two practice models you use in your work with people

How often do you contribute ideas/innovation and support projects within your organisation?

Note: This information will be collated to contribute to ‘How well’/Quality of Effort Outcome Measure (refer to page 14).

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Appendix 3: Workforce Training Evaluation Template

Training/Workshop

Name

Job Title & Organisation

Gender

Ethnicity

1 Were your expectations met and well covered?

2 Were trainers/facilitators professional and/or inspiring?

3 Were your learning objectives achieved?

4 Will you share your learning outcomes in future?

5 Would you recommend others complete this training?

Note: This information will be collated to contribute to ‘How Well’/Quality of Effort Outcome Measure (refer to page 14).

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Appendix 4: NGO Workforce Development Training Calendar (reviewed annually)

LEVEL 1 ESSENTIAL

Depression/anxiety/suicide Rationale: Assist the workforce in contributing to suicide prevention, as well as understanding depression and anxiety and aligns to the MidCentral DHB Suicide Prevention/Postvention Action Plan

Alcohol and Other Drugs 101 Rationale: Provide accurate information about alcohol and other drug addictions; types of drugs that are abused; effects of drugs on the body; risk factors; useful screening tools

Trauma-informed care Rationale: Understanding the impact of trauma on behaviour; trauma identification and support

Stigma/discrimination in mental distress and recovery principles Rationale: Supporting behaviour and attitude change towards those in mental distress

Māori working with Māori Rationale: Cultural competence in working with Māori/whānau

Building Bi-cultural practice Rationale: Māori models of wellbeing; working in a culturally competent manner

Impacts in working with serious mental health conditions (focus on schizophrenia and bipolar disorder) Rationale: Build understanding of how serious MHA health conditions impact on a person socially and functionally and ways to work positively to improve the recovery pathway

Common medications used in mental health and addictions Rationale: Build understanding of medication as part of the intervention options and considerations for medications

Working with people in distress (de-escalation) Rationale: Build understanding of physical and psychological impacts of distress and how to work safely to support the person to gain control and autonomy; managing risk

Working with Youth 101 Rationale: Build knowledge on competencies when working with youth; ethics and boundaries

Working with whānau – Supporting Parents, Healthy Children Rationale: Whānau inclusive practice, aligns to Ministry of Health Guidelines

Suicide Prevention Rationale: to build staff confidence and to manage people with suicidal ideas and thoughts

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LEVEL 2 ENHANCED

Bi-cultural competence Rationale: Improving equity and equality practice and awareness Making it real – growing an outcome focus Rationale: Results based accountability, evaluation methodology in NGO Primary sector Motivational interviewing Rationale: Mobilising change and building capacity to support the recovery journey; crafting the next steps

Elderly and Mental Health Rationale: Working with age considerations and recovery

Co-existing conditions Rationale: Understanding how co-existing conditions inter-relate and impact on intervention planning; increased complexity

Domestic violence 101 Rationale: Dynamics of domestic violence; understanding and recognising the different forms of abuse; legislation and safety planning

Working with Pacifica Rationale: Cultural considerations when working with those who identify as Pacific Island

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual Rationale: Aligns to the Mid Central Health Suicide Prevention/Postvention Action Plan

LEVEL 3 LEADERSHIP

Transformational1 Leadership Rationale: Understanding transactional management and how leadership is transformational; building leadership collective impact

Shared learning workshops/presentations Rationale: Aimed at members of the NGO Primary Leadership group to utilise others’ skills and knowledge

Assorted leadership programmes – e.g. Brite spark Rationale: Adding to the leadership kete; building capability

Results Based Accountability framework Rationale: Strategic leadership and outcomes focus

Note: These training workshops contribute to enhancing skills and knowledge and implementing Real Skills Let’s get real, across the mental health and addictions workforce and non-mental health and addictions workforce.

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Appendix 5: MidCentral District Health Board Strategy

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Appendix 6: Connected Workforce NGO Leadership Group Members

ACROSS Social Services - Director, Graeme Munford Big Brothers Big Sisters - Manager, Julie Holden Best Care Whakapai Hauora - Team Leader, Donna Cummerfield Central PHO - Clinical Director Mental Health, Luke Rowe Dalcam HealthCare Limited - General Manager, Dean Chapman Mana o te Tangata Trust - Manager Leilani Maraku, Project Coordinator Priya Anbalagan MidCentral District Health Board - Portfolio Manager Mental Health and Addictions, Claudine Nepia-Tule MASH Trust - General Manager Sharon Saxton, Manager Rodger McLeod, Manager Community Services Christina Hemmingsen Rangitāne Tamaki Nui A Rua - General Manager, Kylie Hoskin, CEO Oriana Paewai Raukawa Whānau Ora - Manager, Liat Greenland Supporting Families in Mental Illness - Manager, Christine Zander-Campbell Whaioro Trust - General Manager, Kelly Bevan Youth One Stop Shop - Director, Trissel Eriksen

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References

MidCentral District Health Board. (2016). MidCentral District Health Board Strategy. Palmerston North: MidCentral District Health Board.

New Zealand Productivity Commission. (2014). More Effective Social Services: Issues paper. Wellington: New Zealand Treasury.

New Zealand Treasury. (2014). Holding on and letting go: Opportunities and challenges for New Zealand’s economic performance. Wellington: New Zealand Treasury.

Platform Trust & Te Pou o te Whakaaro Nui. (2015). On Track Knowing where we are going. Auckland: Te Pou o Te Whakaaro Nui.

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic Motivation, social development, and well-being. American Psychologist, 55, 68-78.

140 MDHB Mental Health & Addictions

September 2018 141 Waiting room seat prompts

142 How are we doing

By team

Ward 21

Tararua

Star 1

PNth

Horowhenua 22

Feilding

EIS

CAFs

AOD

ACT

0 102030405060708090100 Horowhenu ACT AOD CAFs EIS Feilding OH PNth Star 1 Tararua Ward 21 a 22 Series1 33 24 21 23 16 35 30 18 23 75 86 143 MDHB vs NZ scoring

4.5

4.4

4.3

4.2

4.1

4 Nat Ave 3.9 ave MDHB

3.8

3.7

3.6

3.5

3.4 sep oct nov dec Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 144 Question scores MDHB 145 Text editor comments - 181

20%

48 % Feedback

Negative comments

Thanks to staff 32 % 146 Themes

Areas of Improvement Improvement ideas • Reception information handouts • Can you offer more than a cuppa – medication tea and a bath when calling ACT • Include me in my plan Team A/H • Tips sheets dealing with • Invite whanau to meetings teenagers • Let me be part of the MDT • Listen to the family process • Psychologist Ward & Dannevirke • Sensory tools all reception areas • Petrol vouchers families visiting patients on the ward from out of • Activities for men on the ward Palmerston North • Fair distribution of KW time • Attitudes some staff • Involvement in my plan • Decisions made with out me • Education workshops to help with • Crisis respite locations daily living skills

147 What we have done

Information packs here today • MDT meeting notes to clients • Family / whąnau inclusion • Psychologist Star 1 proposal • Values & Attitudes workshop • Sensory tools Ward 21 & Star 1 • Education workshops • Community transition plans HQSC • Family inclusion KPI and file audit 148

Appendix 4 Uru Rauhī, Mental Health and Addiction Cluster

Spotlight on: Acute Care Team (ACT)

1. Service Description A mobile service that provides specialist assessment and treatment for people experiencing a psychiatric crisis/mental distress and addictions. Referrals are accepted by self-referral, family/whanau member, friend, GP, Police or community agencies. The service is made up of the following teams/functions:

(i) Crisis Response  24/7 first responder to all mental health crisis across the MidCentral Health district (Community teams manage their own clients during standard business hours).  Provide assessments for patients requiring crisis intervention, whether this is through the General Practice, Police, concerned family/friends, or self-presentation to ED or CMHTs.  Provide support to patients of both ACT and CMHT services who are assessed as requiring active contact as an outcome of enduring distress and risk.  The emphasis of Mental Health crisis intervention is to prioritise patient safety above all else.

(ii) Non-crisis Referrals  Triage of all non-crisis referrals into the Manawatū Adult Community Mental Health services.  Provide a pathway for access to specialist secondary services for referrals with complex presentations.  Recommend an alternative pathway in the occasion a referral does not meet criteria for acceptance.

(iii) Consult Liaison  Present activity has been to provide a first response to patients presenting to the Emergency Department during the hours of 3.30 pm - 8.30pm (Monday to Friday) from October.  First point of contact for general hospital teams who have patients with mental health problems under their care.  Provide support and back up for both ACT Crisis and Non-Crisis on occasion where the demand exceeds capacity of ACT to manage presenting demand. 149

2. Structure

3. Activity – ACT Crisis

No of Crisis referrals Patients seen in Crisis (already under MH Services) 350 350 300 300 250 250 200 200 150 150 100 100 50 50 0 0 Jul-18 Jan-18 Jun-18 Oct-18 Apr-18 Feb-18 Sep-18 Aug-18 Mar-18 43101 43132 43160 43191 43221 43252 43282 43313 43344 43374 May-18

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Patients seen in Crisis Transition from ACT to other MH Services

4. SWOT Analysis We have analysed our Strengths, Weaknesses, Opportunities and Threats and these are summarised in the table below. Strengths Weakness  Experienced team well supported by  From November 2018, ACT’s Mental Health leadership over the past dedicated psychiatrist has taken a year. position with another MHAS Team.  Gains from recruitment have This has resulted in the team supported the team to increase being served by a number of capacity to three staff for ACT Crisis different MHAS psychiatrists on a during both the day and evening day to day basis, with some shifts. locums allocated to the team for  From December 2018, ACT Crisis will periods of a week or more. We are be able to locate a clinician in optimistic that an applicant from Emergency Department four evenings the UK will join ACT at approx a week. March 2018  Consult Liaison Team from November 2018 will extend its capacity by an additional clinician. An outcome of this is to have a clinician in ED for four evenings a week.  Building of capacity for both ACT and Consult Liaison supports increased access and responsiveness to mental health patients presenting through Emergency Department after hours. Opportunities Threats  ACT to work closely with acute  That demand outstrips capacity. inpatient services and other key  ACT is an aging workforce. Whilst partners in the primary and NGO recruitment has been successful, 151

sectors, to develop alternatives to applicants to join the team has admission for some patients and largely been dominated by increased support at point of clinicians already working within discharge. MHAS.  Develop an alternative to the  Being unable to attract a dedicated Emergency Department as the place psychiatrist and ongoing pressure to which people in MH distress on other MHAS psychiatrists to present. cover.  Develop utilisation of technology to improve efficiency in clinical practice.  Continue to increase the MH presence in the Emergency Department by building capacity of the Consult Liaison team.  Develop relationships with police to improve joint responsiveness to patients brought to police attention.  Develop Consult Liaison services to support interface with primary providers  Increase medical capacity located on site after hours with ACT by reconfiguration of RMO roster

5. ACT initiatives previously reported against

Report Previously Reported Update on progress date 16-10-18  While recruitment is on-going to  Service has been sustained with replace the triage clinician for ACT patient’s continuing to be seen (non urgent) a CNS will work in appropriate time frames. closely with the ACT triage team  Recruitment to the vacant Non to ensure referrals are triaged and Urgent position has been seen within the appropriate successful with an RN joining timeframes. the team in early November.

 Video Conferencing - is this being  Video assessments have been utilised? completed with patients in Pahiatua, who required to be seen by ACT psychiatrist.

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24-7-18  ACT clinicians co-located within  This trial was successful and ED (afternoon shift). This initiative received positively by both ACT was trialled for a period of a week and ED. (ending 1 June 2018). Francis  In October 2018 a document Health and ED Leadership both was sent to NZNO, ACT , provided support for initiative. Consult Liaison and ED; proposing that a CL Clinician and an ACT clinician be located in ED each week day from 3.30 pm to 8.30 pm to support a more timely response being provided to MH patients

presenting to ED.

12-6-18  A one week trial of locating ACT  This trial was successful and clinicians within ED on the received positively by both ACT afternoon shift. This initiative is and ED. supported directly by Francis Health and ED Leadership. Trial began 28 May 2018.

 Two weekly meetings are held  Meetings continue to be held on between ACT and ED Operational a regular basis between CN ED Leadership. and CM of ACT

 ACT has introduced a shift  A shift Coordinator is allocated coordinator for out of hours who is to each out of hours shift. first point of contact for ED presentations outside standard working hours.

20-3-18  In 2017, a multi-agency response  Unfortunately the funding for initiative was proposed to be this initiative was put on hold established with Central Police when the Government changed District and St John’s ambulance. (2017 General Election). Since This is a national initiative, with to date, there has been no MidCentral being one of three further indication as to whether national pilot sites, which this proposal will proceed. proposed to create a combined Police, MHAS and St John’s response to 111 calls. Calls that are identified as requiring Mental Health input to be responded by a team comprising of a Police Officer, St Johns Responder and Mental Health Clinician. This initiative was proposed to be piloted in Horowhenua, but was changed to Palmerston North due to a higher demand for services out of hours.

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5-9-17  Operational plan - Further  The Consult Liaison Team implementing the acute care team aligned to ACT has been model of care of crisis care and providing a first response to referral management in patients presenting in ED Palmerston North by developing during standard offices hours consult and liaison capacity for Monday to Friday since early primary care referrers 2018, with CL capacity being increased and extended to being present in ED through to 8.30 as from late October for four weekday evenings a week.  ACT dedicated psychiatrist is regularly available to be contacted by GPs for several months with GPs making frequent contact. With the dedicated ACT psychiatrist

leaving ACT in early November,

this informal resource will not

be available until a permanent dedicated psychiatrist is recruited.

 It is important to note that the  The lag was occurring under actual number of referrals into CHIPs and not attended to due ACT- which are logged to the transition to Webpas at electronically has a data lag due December 2018. to administration workload. The The approach is currently Quality Team and the ACT staff reminding clinicians to enter all are working on an improvement in data for the month no later th data entry delays Referral Data for than by the 8 of the following month of July will reflect more month. The data then recorded accurately in the August Report. for the month remaining static meaning that there is no reconciliation of data not th entered by the 8 .

 ACT dedicated psychiatrist  ACT has had in place 1 FTE capacity has now increased from MOSS and 1 FTE Registrar 0.5 to 1.0 FTE in addition to a 1.0 since early 2018; with FTE registrar. This increase in additional input provided by resource is an investment in our the MHAS Clinical OE to ‘front door’ to the service and is support management of very improving relationships with complex cases. With the primary care through consult and current MOSS leaving in early liaison input to practices. November and the resignation of the OE effective from late December 2018, the service from early November 2018 is being maintained by the use of locums as available, and when not available by a roster of the 154

MHAS psychiatrists providing crisis cover on a day to day basis.

 Progress has been made with the potential appointment of a psychiatrist from the UK. This psychiatrist will not be available until sometime in Feb

/ March 2019.

 The 1.8fte administration  Allocated administration capacity continues to be stretched by the capacity continues to provide level of demand. an excellent service, but is continually challenged by the workload

 ACT continues to train DAOs as  Three further ACT clinicians have completed Duly Authorised Officer required in order that the training. requirements of the MH Act can be managed by having a DAO on every shift.

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For:

Decision Endorsement x Noting

To Health and Disability Advisory Committee

Author Stephanie Turner, General Manager, Māori

Endorsed by Kathryn Cook, Chief Executive

Date 15 November 2018

Subject Paiaka Whaiora – Hauora Māori Cluster Update

RECOMMENDATION It is recommended that the Committee:  note the Hauora Māori Cluster Update  note the plan and approach to the Hauora Māori Cluster establishment

Strategic Alignment This report is aligned to MidCentral DHB’s strategy and strategic imperatives, • achieve equity of outcomes across communities • partner with people and whanau to support health and wellbeing • achieve quality and excellence by design • connect and transform primary, community and specialist care.

Te Paiaka Whaiora (Hauora Māori Cluster) update is provided to HDAC members for information purposes. It outlines the development process to date, approach taken and agreed model at this point in time recognising Paiaka Whaiora is evolutionary and will continue to develop.

Glossary CAG Cluster Alliance Group CEO Chief Executive Officer DHB District Health Board HDAC Health & Disability Advisory Committee

Pae Ora COPY TO: MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8210 156

Hapū To be pregnant, Conceived in the womb ISM Integrated Service Model Kaiurungi Steerer, Coxswain, Controller, Pilot Kaupapa Level Surface, Platform, Floor, Stage, Layer, Subject, Purpose, Agenda, Theme NGO Non Government Organisation Paiaka Whaiora Root system of a tree, seeking wellbeing (name for Hauora Māori Cluster) WOSIDG Whanau Ora Strategic, Innovation & Development Group Whanau To Be Born, Give Birth, Family MWH Manawhenua Hauora (Iwi Partnership Board)

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1 PURPOSE

The purpose of this paper is to clarify the process used to establish Paiaka Whaiora and to clearly articulate the Cluster approach and any points of difference to that of other clusters.

2 BACKGROUND

The Integrated Service Model (ISM) vision is about improving the integration of services to better meet the needs of individuals and whanau journeying through the health system. This vision offers our organisation further opportunity to achieve equity of outcomes for Māori across our district.

Implicit is the notion that every Cluster has purposeful focus, actions and measures to achieve equity within our district. This requires measures that are both quantitative and qualitative which have a focus on equity of access, equity of experience, and equity of health outcomes. It is clearly a responsibility and accountability line that sits with every Cluster.

The role of the Paiaka Whaiora-Hauora Māori Cluster is to ensure we have an integrated approach to the provision of Kaupapa Māori services across the district. Kaupapa Services are viewed as distinct from other general health services in that they are specialist Māori health services; developed, delivered and governed by Māori. These services are currently contracted by the DHB to deliver specific Māori worldview service provision. The services can cover the lifespan and extend across multiple health conditions. Services may also include prevention, promotion and wellbeing initiatives. A standard Kaupapa Māori provider can for example, have multiple contracts across the health care continuum, from the care of hapu (pregnant) mothers and the delivery of antenatal programmes, through to Tamariki Ora (Wellchild), Disability Support, Long Term Conditions Nursing, Aukati – Stop Smoking Support, Alcohol & Drug Services, Suicide Prevention, Screening Services, Cancer Care Coordination, Whanau Ora Services, Social Support Programmes, Kaumatua Day Activity Programmes and General Practice provision.

There are currently a number of Kaupapa Māori providers the DHB contracts with across the MidCentral District. There are also Kaupapa – Māori worldview developed and delivered services that sit within NGOs who deliver wide-ranging general services to the public.

Paiaka Whaiora will provide coordination and oversight of all Kaupapa provision across the district and facilitate support within each cluster to discuss, design, advance and further invest in Kaupapa Māori provision across and within all Clusters as deemed appropriate in partnership with Cluster leads and teams.

The Paiaka Whaiora Cluster offers us further opportunity to better understand and distribute the Kaupapa provision across the district and to proactively partner with Clusters to enable quality Kaupapa provision within their Clusters. This is not about new investment, it is about understanding the current provision, knowing what’s working and what isn’t, knowing where the current gaps are, and further exploring Kaupapa investment opportunities.

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What has been highlighted in the Health Treaty Enquiry Wai 2575 is that as Crown led health organisations that procure and commission services, we have significantly underinvested in Kaupapa Māori service provision throughout the country.

3 MANAWHENUA HAUORA –ROLE IN HAUOA MĀORI CLUSTER DEVELOPMENT

The ISM approach has been discussed with Manawhenua Hauora at every part of the development. In 2017, MDHB Chief Executive Officer (CEO) supported Manawhenua Hauora to consider and develop a unique response to the Integrated Services Model. This was an important step in recognising the maturity of the Iwi/DHB Treaty partnership. It is also consistent with the new Government’s health priorities to address health inequities for our Māori communities. Consequently Manawhenua Hauora held a number of workshops which have formed the basis and rationale for the development of Paiaka Whaiora.

Workshops were held with iwi representatives from Rangitāne o Manawatu me Tamaki Nui a Rua, Ngāti Kahungunu ki Tamaki Nui a Rua, Ngāti Raukawa ki te Tonga, Ngāti Kauwhata and Muaupoko Tribal Authorities as well as iwi and Māori providers: Whakapai Hauora, Te Kete Hauora, Te Wakahuia, He Puna Hauora, Te Tihi o Ruahine Whānau Ora Alliance, Raukawa Whānau Ora Services and the Pae Ora - Māori Health Directorate.

The workshops enabled this group to come up with a set of recommendations regarding the establishment of a Paiaka Whaiora Cluster; purpose, role, function, interface with other clusters, working relationship with/to Pae Ora Māori Directorate, establishment of a Hauora Māori Cluster Alliance Group (CAG) and the required resourcing.

Manawhenua Hauora were cognisant of the financial constraints and pressures currently facing the organisation. They discussed and developed a paper with a set of clear recommendations that were considered within the current fiscal context. This first set of recommendations they considered to be the bare essentials for resourcing Paiaka Whaiora.

Manawhenua Hauora expressed their recognition of the investment in Pae Ora – Māori Health Directorate from 2015 and articulated that they had seen the significant impact and increased focus on advancing Māori health through systems, strategy, quality, delivery and practice since establishment.

Manawhenua Hauora reiterated that the development of the ISM within the DHB provided another practical opportunity to further advance Māori health gain and consequently identified a set of priorities and recommendations to further progress Paiaka Whaiora – The Hauora Māori Cluster.

The Paiaka Whaiora Cluster paper has been discussed and considered by the MDHB CEO, the Integrated Services Model Transition Group and the Executive Leadership Team. All have endorsed the approach.

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4 HAUORA MĀORI CLUSTER – THE PAIAKA WHAIORA DEVELOPMENT APPROACH

An overview of the Paiaka Whaiora Cluster structure role and functions are articulated below. The priorities are taken from the MWH paper and summarised for HDAC’s perusal.

5 OVERVIEW OF PAIAKA WHAIORA PRIORITIES/RECOMMENDATIONS

5.1 Priority 1 – Organisational Commitment

Priority one identified the need for the organisation to:

• Commit and invest in the Paiaka Whaiora establishment • Develop the stewardship of all current Kaupapa Māori provision within the district • Support the transparency and alignment of the current Kaupapa provision across the district • Partner with all other Clusters to discuss and consider best quality approach of Kaupapa provision • Consider the current Kaupapa service opportunities or gaps in provision across the district • Provide oversight in the commissioning/contracting of Kaupapa service provision both with the Kaupapa Māori providers and with each Cluster who provide general health services (community to specialist services) within the district • Explore opportunities to build or integrate Kaupapa Māori provision into/or as a component of general (mainstream) services.

5.2 Priority 2 - Support & Alignment

Priority 2 identified the need for the organisation to:

• Align current Kaupapa Māori and Māori Provider contracts under the oversight of Paiaka Whaiora • Consolidate the Māori Health investment and support a more integrated approach across the district • Recognise the holistic whole of life span Kaupapa Māori provision currently being provided via these Māori provider contracts • Maintain the Kaupapa provision and progress conversations across and with other Clusters to increase understanding of current provision • Develop a Kaupapa Māori Commissioning Framework to enable a partnering approach with all other Clusters.

5.3 Priority 3 – Cluster Alliance Approach

Priority 3 identified the need for the organisation to:

• Establish the Paiaka Whaiora Kaiurungi-Māori Cluster Alliance Group (CAG) • Develop the Paiaka Whaiora Kaiurungi (CAG) to bring together Kaupapa Māori expertise, knowledge of local whanau Māori needs and an understanding of the current Kaupapa provision across the district 160

• Ensure the Paiaka Whaiora Kaiurungi (CAG) effectively consider, advocate and guide Kaupapa provision using a partnership approach with the Clusters • Establish membership from well-established Iwi and Māori providers experienced in service delivery that is high functioning in the areas of health, social services and Whānau Ora • Ensure the participation on the other CAGs to occur via the Paiaka Whaiora Kaiurungi • Develop the terms of reference for the Paiaka Whaiora Kaiurungi (CAG) using the recommendations made by Manawhenua Hauora which consist oif the following:

 Paiaka Whaiora Kaiurungi will include representation from Iwi/Māori providers throughout the district to ensure an inclusive approach  The Alliance is about providing Hauora Māori strategic overview from the perspective of whānau and Iwi across the rohe (district)  Existing collaborative groups such as the Whanau Ora Strategic, Innovation & Development Group (WOSIDG) will form a key part in advising and informing through the CAG.

5.4 Priority 4 - Confirm and Socialise

Priority 4 identified the need for the organisation to:

• Confirm the Paiaka Whaiora - Hauora Māori structure • Ensure all decision makers understand and have endorsed the establishment • Begin socialisation of Paiaka Whaiora within the organisation as a key component of the ISM implementation.

6 OVERVIEW OF ROLES AND FUNCTIONS

To provide an overview of the Paiaka Whaiora – Hauora Māori Cluster roles and functions we firstly need to articulate the role and functions that the Pae Ora Māori Directorate currently has within the organisation to clarify the points of difference.

6.1 Pae Ora Māori Directorate Roles & Functions

The role and functions of the Pae Ora Maori Directorate are articulated below.

• Works as an Enabler within the DHB • Has a stewardship role within the organisation partnering with others to ensure Treaty principles are implemented within all of our systems, strategies, planning, policies, commissioning and contracting, quality initiatives, health practice delivery, and monitoring frameworks • Partners with all Clusters to facilitate meaningful equity focused actions and measures that consider the equity issues and points of difference for communities and localities within the district • Provides guidance and facilitation across Cluster service planning and review approaches to ensure an equity lens and Māori worldview lens is applied within all General Health Service Provision and within each Cluster • Advances the DHB’s Equity Trilogy approach ensuring the development and use of an Equity toolkit in the planning, development, commissioning and 161

monitoring of services district wide to address the inequities and increase better health outcomes for all • Leads and partners across workforce development initiatives and across all aspects of our Organisational Development Plan to ensure our entire workforce is competent in working with Māori, that we are growing and retaining Māori staff numbers, that we have an excellent education approach that builds Māori responsiveness and cultural confidence of staff & that performance planning & review reflects Treaty principles

6.2 Paiaka Whaiora–Hauora Māori Cluster Roles and Functions

The roles and functions of Paiaka Whaiora – The Hauora Māori Cluster are articulated below. Paiaka Whaiora will:

• oversee all current Kaupapa provision across the district • Bring transparency and increase the integration approach across Kaupapa provision • Work with the current Kaupapa Māori providers district wide to ensure current Māori Provider Kaupapa provision is understood by each Cluster and integrated not siloed from (General) mainstream services and considered as part of the suite of specialised services we provide • Engage with Clusters to ensure Kaupapa Māori Provider Services are understood as specifically Māori worldview centric in all aspects. This includes governance, service provision and service delivery • Recognise the special nature of Kaupapa Maori providers as using Māori cultural norms and systems in service development and delivery • Increase the knowledge of Kaupapa provision across the ISM • Work with Clusters to discuss further opportunities to consider and develop specialist Kaupapa Māori service provision as part of their suite of integrated general (mainstream) services community to specialist services • Ensure an integrated and transparent approach to Kaupapa provision across the district • Support Kaupapa provision to be better understood, further enabled and integrated where appropriate within Clusters.

7 NEXT STEPS

The overarching goal of Pae Ora together with Paiaka Whaiora is to ensure that all of our services are working well with whānau Māori. This includes all general health services from community through to specialist services and all Kaupapa services that cover the lifespan and complexity of conditions from prevention through to health service delivery.

Under the priorities articulated to advance Paiaka Whaiora (the Hauora Māori Cluster) the recommendation from Manawhenua Hauora is that Pae Ora plays a key role in providing a Korowai (cloak of support) for the Paiaka Whaiora development, consequently a steering group inclusive of the CEO, GM Māori, the GM Quality & Innovation, and GM Planning Strategy & Performance has been established to draft the structural elements of the roles and reporting lines for the Paiaka Whaiora Cluster. This steering process will ensure drafts are considered by the DHB’s Treaty Partner Manawhenua Hauora. Following this, the Paiaka Whaiora structure, roles 162

and functions will be shared with other key stakeholders, finalised and a report provided to Manawhenua Hauora and the Board in February 2019.

The steering group is cognisant that the Paiaka Whaiora leadership functions can potentially be fashioned in ways that may not necessarily conform to that of other Clusters. There is recognition of Maori worldview leadership ideologies that need to be central to informing the Paiaka Whaiora leadership structure. The intention of the steering group is to ensure we configure a leadership structure that maintains the integrity of both Pae Ora enabler functions and Paiaka Whaiora cluster functions and that the structure ensures a robust interface with all other Cluster leaders.

Paiaka Whaiora is another mechanism for driving Māori health improvement and developing service delivery solutions that use Māori worldview systems, concepts and approaches. This is a core component for driving further improvement in equity of access, equity of service experience and equity of outcomes for Māori.

8 SUMMARY

This paper is provided to HDAC as an overview of the thinking and development process to date regarding Paiaka Whaiora - The Hauora Māori Cluster.

It is provided for information purposes and offers an opportunity for HDAC members to discuss and seek clarity on any of the following:

• Hauora Māori Cluster development process • Hauora Māori role and functions • Hauora Māori CAG – role and functions • Pae Ora role and functions in relation to the Hauora Māori Cluster.

9 RECOMMENDATIONS

That the Committee:

• note the Hauora Māori Cluster Update • note the plan and approach to the Hauora Māori Cluster establishment.

Stephanie Turner General Manager Māori Health 163

For:

Decision Endorsement X Noting

To Health and Disability Advisory Committee

Authors Vivienne Ayres Manager, DHB Planning and Accountability

Endorsed by Craig Johnston General Manager, Strategy Planning and Performance

Date 15 November 2018

Subject 2018/19 Regional Services Plan Implementation Update

RECOMMENDATION It is recommended that: • The Committee note the update on progress with the 2018/19 Regional Service Plan

Strategic Alignment The attached paper is aligned to implementation of the DHB’s Strategy, with a focus on providing information to support improving the health and wellbeing of our communities, better health outcomes and health care for all through reducing inequities.

Glossary COOs Chief Operating Officers DHB(s) District Health Boards GMs General Managers MoH Ministry of Health RSP Regional Services Plan TAS Central Regions Technical Advisory Services Limited

COPY TO: Strategy, Planning and Performance MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8928 Fax +64 (6) 355 0616 164

1. PURPOSE

This report provides an update on progress with the 2018/19 Regional Services Plan. It is for the Committee’s consideration. No decision is required.

2. BACKGROUND

The 2018/19 Regional Services Plan (RSP) advances Central Region’s three strategic objectives: i. digitally enabled health system ii. clinically and financially sustainable health system iii. enabled and capable workforce

The Plan is based on four strategic priority areas, and a continuation of regional programmes to be progressed. The priority areas are the: • Regional Cancer Strategy • Regional Cardiac Strategy • Regional Mental Health and Addictions Strategy • Regional Care Arrangements

The regional programmes, some of which are national planning priorities, include: • Radiology • Electives • Healthy Ageing • Hepatitis C • Major Trauma • Stroke

These are all underpinned by a key focus area of equitable access and outcomes.

The key regional enablers continue to feature – workforce, technology and digital services, health quality and safety, clinical leadership and pathways.

The DHB’s contribution and linkages to the RSP programmes of work are outlined in the DHB’s Annual Plan. As part of the DHB Non Financial Monitoring Framework, a quarterly report of progress on delivering the national priorities outlined in the RSP is required to be submitted to the MoH. The quarterly reports are prepared by TAS on behalf of the six DHBs. The MoH provides feedback and an assessment of progress against the planned actions and regional performance results.

A copy of the full quarterly reports is made available to Board members on the Governance sharednet site when they become available.

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3. UPDATE

The final draft of the 2018/19 RSP was submitted to the MoH on 1 November. As is the case for DHBs’ Annual Plans, feedback following the Ministry’s final review and recommendations to the Minister for approval is awaited. There is no confirmed date of when this might be expected.

Nonetheless, implementation of the planned actions for each of the regional programmes expected for the first quarter of 2018/19 is underway.

Most of the eleven programmes reported are progressing well as at the end of quarter one. The self-assessment of current status identified three programmes as “partially achieved” in that there were some indicators/deliverables/milestones not tracking to plan at the end of quarter one, but there was an adequate resolution plan is in place. These areas are summarised below.

Major Trauma: Workforce development is required to support the national and regional major trauma programme. Allocation of resources for the regional programme is required to develop quality initiatives, enable audit processes and reporting to achieve the national KPIs.

Mental Health and Addictions: Some actions have not started or are not being substantively progressed, due to RSP development process not being finalised at submission of the report. Most actions have begun investigative or explorative action. Additional actions included in response to the Ministry of Health feedback on initial draft RSP have been included.

Stroke Services: The Central Region Stroke Network is progressing its work programme. A regional clot retrieval service will be piloted from 23 October to test pathways and protocols with full implementation expected in early 2019. The region has had some challenges meeting national targets, in particular relating to on time access for inpatient and community rehabilitation. Late data submissions from one DHB influenced lower regional results reported this quarter for the acute stroke service target.

The remaining programmes were all noted as being on track

It should be noted that the regional COOs / GMs have asked TAS to prepare a half year report on the RSP for DHBs to submit to their Board’s December meeting.

4. RECOMMENDATION

It is recommended:

• That the Committee note the update on progress with the 2018/19 Regional Service Plan

Vivienne Ayres Manager, DHB Planning and Accountability

166

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Authors Vivienne Ayres Manager, DHB Planning and Accountability Dr Janine Stevens Public Health Physician and Māori Health Practice Leader, Pae Ora Directorate

Endorsed by Craig Johnston General Manager, Strategy Planning and Performance

Date 14 November 2018

Subject Population and Health Profile Update, with an Equity Lens

RECOMMENDATION It is recommended that: • The Committee note the 2018 profile of the population and health status for the district • endorse the findings being used in future planning

COPY TO: Strategy, Planning and Performance MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8928 Fax +64 (6) 355 0616 167

Glossary ASH Ambulatory sensitive hospitalisations CHF Congestive heart failure COPD Chronic obstructive pulmonary disease CPHO Central Primary Health Organisation CVD Cardiovascular disease CVRA Cardiovascular risk assessment DHB District Health Board ED Emergency Department GPT(s) General Practice Team(s) LMC(s) Lead Maternity Carer(s) NZ New Zealand PHO Primary Health Organisation Stats NZ Statistics New Zealand TLA(s) Territorial Local Authority(ies) WCTO Well Child Tamariki Ora

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1. PURPOSE

This report provides an update on the population demographics and health profile of MidCentral’s district. It is an annual report and a key input to strategic and service planning. The Committee is invited to discuss and provide feedback on this summary report.

2. BACKGROUND

Each year MidCentral DHB publishes an update on demographic, health status and equity status trends. This information is a key input to service planning, and is extensively used across the organisation.

In past years, the annual “health needs assessment” has been a weighty technical document comprising demographic trends with morbidity and mortality data. This year a different approach has been taken in an attempt to respond to our changing environment. In particular, the new approach is in response to the needs of the new service clusters, the emphasis on localities as the basis for service planning, and the continued emphasis on addressing equity.

The attached report provides a summary of the 2018 update to the statistics for the usually resident population for the four Territorial Local Authorities (TLAs) and Otaki ward within MidCentral’s district, as produced by Statistics New Zealand. The 2018 update to the population estimates is still based on the 2013 Census, using medium projections for fertility, mortality and migration. The subnational population datasets do not yet include ethnicity data.

The 2018 Census data is not expected until later in 2019. Stats NZ is in the process of establishing an independent review of the 2018 Census; full terms of reference are currently being developed with the State Services Commission before consultation with critical stakeholders. It has also convened an external data quality panel to provide independent advice to the Government Statistician about whether the methodologies used to produce information from the 2018 Census are based on sound research and a strong evidence base, among other aspects of the 2018 Census that impact data quality.

3. SUMMARY

The population estimates for the four TLAs and Otaki Ward show an increase in the size of each population ranging from 0.3 percent in the Tararua district to 1.9 percent in the Manawatu compared to the previous year. The estimates show an increase of 2,700 people for the usually resident population of MidCentral’s district – a total of 179,300 people as at 30 June 2018.

For the first time the report includes a summary of information on economic and social trends. This information has been gleaned from each of the local and district Council websites and gives some context to the changes in population demographics. In particular, Peter Crawford from Palmerston North City Council has provided a wealth of useful information.

The demographic and economic data together provides a strong locality perspective to the report.

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A life stages approach to population health is taken which attempts to draw the links between the population demographics by using a selection of indicators across the lifespan that highlight some key areas showing differences in equity of health outcomes and/or equity of access.

When combined with the district’s population demographic profile, trends in mortality and morbidity data, and with some selected health markers or outcome measures, some insights into an array of equity issues can be posited for further investigation. The selected indicators in this report highlight some areas as a start point.

In turn, this information forms a positional basis from which each service Cluster could further explore for their target population group, identify additional information requirements and data to inform complementary, or new, measures and outcomes for their population group(s). It should also help by posing suggested opportunities for improvement and consideration of service changes that could contribute to improving the health and wellbeing of our population.

4. RECOMMENDATION

It is recommended that:

• The Committee note the 2018 profile of the population and health status for the district • endorse the findings being used in future planning

Vivienne Ayres Manager, DHB Planning and Accountability 170

MidCentral district - Demographic profile update

Statistics New Zealand supplies the Ministry of Health with population projections for District Health Boards (DHBs) each year, based on certain assumptions and are used to inform population based funding, policy development and planning. For the 2018/19 year MidCentral DHB has an estimated population of 178,820 people across the four Territorial Local Authorities and the Otaki ward of the Kapiti Coast district (Population projections, Census 2013 base 2017 Update).

Statistics New Zealand has released data for its annual update of the usually resident population estimates as at 30 June 2018 and medium projections for fertility, mortality and migration. The update uses the Census 2013 as the base year for these projections (Census 2018 data is not due to be released until later in 2019).

The following tables provide an overview of the November 2018 update of population estimates1. The 2018 update does not yet include subnational populations by ethnicity groups; the 2017 update is inlcuded for reference.

Territorial Local Authority Net migration Natural increase Horowhenua 1.9% 0.2% Manawatu 1.7% 0.3% Palmerston North City 0.9% 0.6% Tararua 0.2% 0.5% Table 1: Estimated resident population projections - assumptions (Statistics New Zealand Usually Resident Population Estimates, November 2018 Update, Census 2013 base)

Territorial Local Authority / Ward – Population estimates (2018) Age Palmerston Group Horowhenua Manawatu Tararua Otaki North City (Years) Number Percent Number Percent Number Percent Number Percent Number Percent 0 – 14 17,000 19.2 6,100 18.5 6,400 20.8 3,900 21.8 1,650 18.6 15 – 39 34,100 38.4 8,000 24.2 8,700 28.2 4,650 26.0 1,950 21.9 40 – 64 24,900 28.1 10,600 32.1 10,200 33.1 6,000 33.5 2,990 33.6 65+ 12,600 14.2 8,300 25.2 5,600 18.2 3,350 18.7 2,300 25.9 Total * 88,700 33,000 30,800 17,900 8,890

Median age 33.6 47.2 41.0 42.1 48.1 Table 2: Subnational population estimates by TA, Ward and Age Group (Statistics New Zealand Usually Resident Population Estimates, November 2018 Update Census 2013 base)

*Note: Due to rounding, individual figures may not always sum to the stated total(s).

1 The estimated resident population is based on the 2013 census usually resident population count, updated for residents missed or counted more than once by the census (net census undercount); residents temporarily overseas on census night; and births, deaths, and net migration between census night and the date of the estimate. Page | 1

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Estimated resident population (2018) – Change by TLA Territorial Local Population change, Aurthority / Ward At 30 At 30 At 30 Average annual year ended 30 June Area June June June change 2013-17 2018 2013 2017 2018 Number Percent Number Percent Palmerston North City 83,500 87,300 88,700 1,000 1.1 1,400 1.6 Horowhenua 31,200 32,500 33,000 300 1.1 500 1.7 Manawatu 28,500 30,300 30,800 400 1.5 600 1.9 Tararua 17,450 17,850 17,900 100 0.6 50 0.3 Otaki 8,370 8,760 8,890 100 1.1 130 1.5 Table 3: Subnational population estimates by TA, Ward (Statistics New Zealand, November 2018 Update Census 2013 base).

The November 2018 update by Statistics New Zealand shows an estimated population of 179,300 people across MidCentral DHB’s district as at 30 June 2018. Data by ethnicity is not yet available in the 2018 update. The ethnicity profile for the DHB shown below is from the 2017 update.

Estimated resident population (Population projections, 2017) Ethnicity - MidCentral District Health Board - 2013/14 2015/16 2017/18 2018/19 2019/20 2020/21 2021/22 Other 121,780 122,110 122,980 122,720 122,210 121,640 121,040 Māori 32,420 33,840 35,320 36,090 36,830 37,610 38,330 Asian 10,670 12,120 13,770 14,510 15,120 15,700 16,150 Pacific 4,760 5,020 5,330 5,500 5,630 5,760 5,900 Total 169,630 173,030 177,400 178,820 179,790 180,710 181,420 Table 4: Population estimates by ethnicity (Statistics New Zealand Usually Resident Population, 2017 Update Census 2013 base). Financial years use 31 December Projections produced by Statistics NZ for the first time in 2015.

Some insights about our population demographics and economic trends

Palmerston North • Solid population growth for Palmerston North is expected in the next 30 years. It is expected to average 1.0 percent per year over the next 30 years. This is an increase on growth in the past 20 years which averaged 0.6 percent per year. This expected increase is due to sustained increases in international migration to New Zealand • Refugee resettlement has become an increasing contributor to population growth, rising from 60 people a year in the mid-2000s to 170 people (equating to around 45 households) in the year to June 2018 • Households are expected to get smaller as the population ages. In the Sense Partners projections for Palmerston North, the population is expected to age and a consequence of this is that there will be proportionately fewer households with children in them. The fastest growing households are expected to be couple households and people living alone • Applicants for social housing in Palmerston North have increased significantly since 2014

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• There is a shift of beneficiaries into Palmerston North from the outer areas as rental prices have increased in Tararua and Horowhenua and there are rentals available in Palmerston North since tertiary student numbers have dropped • The number of tertiary students studying in Palmerston North has dropped over the last six years. There were 8,614 equivalent full time students on 31 March 2012 (7,029 domestic and 1,585 international) across the four main tertiary institutions. In 2018 there were 6,797 students (5,493 were domestic students) • Thirteen percent of residents in Palmerston North were registered with the Ministry of Social Development in October 2017 as superannuitants2– slightly lower than all New Zealand (14.4%). However, the number of recipients in the city is growing at a faster rate (6.7%) than the national average (3.3%) • Residential care is a significant sector for employment in Palmerston North, with 1,450 people employed in the sector in February 2017 – an increase of 46 percent between 2000 and 2017, compared with an increase of 25 percent in total employment in the city. This sector is expected to continue to experience growth in employment due to the projected strong growth in the population aged 65 years and older

Horowhenua • Over the past three years, 336 international migrants moved to the Horowhenua district • Levin is being proposed as one of six new refugee settlement areas. A decision about the new areas is due this month although decisions on likely numbers and exact timing of the first settlement in districts have not yet been made • The average house value for the year exceeded $300,000 for the first time, causing housing affordability to deteriorate to levels last observed at the peak 2006/07 housing boom. These dynamics tend to negatively impact levels of home ownership over time. House price inflation continues to influence rental costs; supply for rentals was not meeting demand. New residential consent numbers grew by 9.8 percent over the year to June 2018 (246 new homes) • Almost 25 percent (24.6%) of Horowhenua residents were registered with the Ministry of Social Development in October 2017 as superannuitants – considerably higher than all New Zealand (14.4%). The growth rate per annum is much lower than in Palmerston North – 2.8 percent over this last year (3.3% nationally). • The unemployment rate rose to eight percent compared to 6.7 percent a year earlier. This may be due to a higher number of unemployed young people as opposed to fewer jobs being offered • Beneficiary numbers continued on a downward trend, with overall beneficiary recipients decreasing by 3.8 percent. However, Horowhenua has had a 35 percent increase over the last four years in the number of people on sickness benefits for psychological or psychiatric reasons

Tararua • The Tararua district experienced a permanent and long-term net migration gain of 3 persons in the year to June 2018. This compares with a gain of 76 a year ago, and a ten year average of 19 (loss)

2 Not all people aged 65 years and over are eligible to receive New Zealand Superannuation

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• Tararua district’s economic growth fell back to 2.7 percent in the June 2018 year, the same as the national average growth rate and below the Manawatu-Wanganui regional growth rate of 3.6 percent • The proportion of the workforce that was not in employment edged to an average of 4.7 percent (4.3% in 2017), similar to the New Zealand rate (4.5%). The proportion of young people aged 15 – 24 years not employed or engaged in education or training was slightly less than previous year at 17.2 percent (17.7% in 2016) but considerably higher than the New Zealand rate (12.1%) • Working age Jobseeker Support recipients in the year to June 2018 decreased by 2.8 percent compared with the previous year. An average of 614 people were receiving a Jobseeker Support benefit in the 12 months ended June 2018. This compares with an average of 612 since 2010 • On an annual basis the number of residential building consents in the Tararua district increased by 11 percent compared with the same 12-month period a year ago. The number of consents in New Zealand increased by 7.9 percent over the same period • There was a 5.1 percent (n.170) increase over the year in the number of residents registered in the Tararua district as superannuitants at the end of September 2018 (3,482 total). This is considerably higher than the increase for all New Zealand (3.3%), but not as high as the Horowhenua district (6.7%)

Manawatu • Manawatu experienced a permanent and long-term net migration gain of 747 persons in the year to June 2018. This compares with a gain of 797 a year ago, and a ten year average of 328 (gain) • The average annual unemployment rate in Manawatu was 4.2 percent in June 2018, lower than the average in New Zealand (4.5%) • Jobseeker numbers to the year ended June 2018 declined by 6.5 percent. Compared with June 2017, the number of youth receiving the jobseeker benefit declined by 32 • Strong growth in property values continue. Average house prices for the district increased by 9.7 percent to $338,538 to year ending June 2018. Growth outperformed relative to New Zealand, where house prices increased by 6.4 percent. The average weekly rent for houses in the Manawatu district increased 8.2 percent in the year to August 2018 to $291 per week • The number of consents for new dwellings in the district flattened in the year to June 2018. Specifically, 161 consents for new dwellings were issued over the timeframe versus 163 consents for the previous year • The number of superannuitants registered with the Ministry of Social Development and living in the Manawatu district fell by 1.3 percent over the year ending September 2018 (n. 5,370 total) – the only TLA in MidCentral’s district to have shown a decrease

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MidCentral district - Mortality and morbidity profile

5 year Life Expectancy at Birth – MidCentral DHB population period ending 30 Total Māori Pacific Asian Other June Male Female Male Female Male Female Male Female Male Female 2018 79.4 82.8 74.1 78.1 76.0 80.2 85.9 88.3 75.0 78.5 2023 80.5 83.8 75.7 79.5 77.3 81.5 86.6 89.0 76.1 79.6 2028 81.6 84.8 77.3 81.0 78.8 82.8 87.4 89.8 77.2 80.6 2033 82.6 85.8 78.9 82.4 80.2 84.0 88.1 90.5 78.4 81.6 2038 83.6 86.6 80.3 83.8 81.5 85.1 88.7 91.1 79.4 82.5 Table 5: Statistics New Zealand, DHB Population Projection Assumptions, Census 2013 (2017 Update)

There were 1,384 deaths registered (all- New Zealand and MidCentral DHB All Cause Mortality by Ethnicity, Yearly Age Adjusted Rates per 100,000 causes) across MidCentral’s population in Population. 2007 - 2015 800 2015 – an increase of 154 deaths 700 compared to 2007 (but 74 fewer than in 600 500 2014). From an age-adjusted perspective 400 300 (compensating for differences in 200 100 population age balance) the general 0 health status of MidCentral DHB’s 2007 2008 2009 2010 2011 2012 2013 2014 2015 population, as for New Zealand, has been MidCentral Maori MidCentral Asian MidCentral Other improving over the years, as shown by an NZ Maori NZ Asian NZ Other overall decrease in age-adjusted mortality rates. MidCentral’s age-adjusted all-cause mortality rate suggests a slightly worse health status than New Zealand’s health status. This may be expected because MidCentral’s population has higher proportions of higher needs groups (Māori, socio-economically disadvantaged people, and older people) than New Zealand overall. The factors that influence all-cause mortality are much wider than health treatment service performance. They include for example: lifestyle changes (healthier eating, greater physical activity), living conditions, economic conditions (unemployment, income, housing, food and other living costs) and better preventive care. Non age-adjusted rates indicate increasing levels of illness and increasing need for health services. MidCentral’s crude mortality rates rise across time, implying greater numbers of people who are seriously ill. This is because of the ageing population structure – older people are at higher risk of serious illness than younger people. It is therefore expected that there will be increasing demand for health services in the future and the type of services required will be those associated with ageing: chronic diseases and their complications, and disability. The term amenable mortality refers to potentially preventable deaths that might have been prevented if health services had been delivered more effectively or if patients had accessed services earlier. Amenable mortality analysis shows the same patterns and inequities that exist for all-cause mortality.

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The amenable mortality rate for the MidCentral’s population tended to be higher than for the New Zealand population overall. In 2015, MidCentral Non Māori and Non Pacific rate was 90.0 per 100,000 population compared to 74.7 for all New Zealand. The rate for Māori however was much higher at 181.5 per 100,000 population – slightly lower than for all New Zealand (188.8 per 100,000 population). Coronary disease was the predominant cause of premature death followed by, chronic obstructive pulmonary disease, female breast cancer, cerebrovascular disease and suicide. MidCentral Māori, and the populations of Horowhenua and Tararua have statistically significant higher amenable mortality rates compared to New Zealand total population. The key conditions that contribute most to health loss are much the same as those for premature deaths: cancer, cardiovascular and cerebrovascular disease, musculoskeletal conditions, mental illness, respiratory conditions and diabetes.

So what does this tell us?

Key findings from the 2018 update to the 2017 analysis of the health status of our population and the equity snapshot undertaken by the District Health Board (DHB) clearly shows that (in summary) • The people experiencing inequity in our district are: o Māori o Pacific people o People experiencing socio-economic disadvantage o Horowhenua residents (as they have high proportions of the above people among their residents) • The reports also show that: o Māori are least advantaged in the MidCentral district with respect to both socioeconomic opportunities for good health as well as mortality outcomes o Notable disadvantage may be emerging for Tararua residents o Health inequities in our community are driven by significant financial and material deprivation • The health status of our population has been gradually improving over time (as it has been for New Zealand overall). This is indicated by reducing age-adjusted mortality rates. The main conditions causing mortality were: o Circulatory diseases o Cancers o Respiratory diseases o Injuries and accidents These conditions are the same for the population overall and for disadvantaged populations. Therefore, these are the conditions which should be focused on to improve the health of the greatest numbers of people in those populations.

While disease patterns are important, the importance of socio-economic and cultural factors to health status should not be underestimated in terms of seeking to improve health outcomes. The following graphic highlights this.

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Source: “Breaking the dependency cycle: Tackling health inequalities of vulnerable families” by the Deloitte Centre for Health Solutions

This emphasises the importance of socio-economic factors to health outcomes (responsible for about 50 percent of health outcomes), especially compared to health care, which is responsible for about only 25 percent of health outcomes. This does not mean that the health system cannot do anything about it. We still have to take responsibility for the things we can influence and take a stronger role in advocating for changes outside of the health sector to improve health and wellbeing in an equitable way.

These present both opportunities and challenges as our population continues to grow, age and diversify. It reinforces the need to be future-focused and collaborative across the health and social system, other government agencies as well as capitalise on the complex network of organisations, people, whānau and our communities to address these determinants of health.

Additionally, the engagement processes that we undertook during the 2017/18 year as part of our locality planning for the Horowhenua, Ōtaki, Tararua and Manawatu districts identified four key themes that were important to our communities: • Access to primary care: easy and timely access to my healthcare practice, build and maintain a trusted relationship with my healthcare practice, and reduce the barriers of time, distance and transport on access • Improved easy access to Mental Health and Addiction support in our community: easy and timely access to Mental Health services locally, reduce the presence and impact of drugs, and increase early intervention and prevention • Valuing the power of communication: increase the awareness of how to get to the right help at the right time, people have a positive experience of healthcare from a joined-up system, and people feel well informed and can better manage their health and wellbeing • Encourage, support and maintain the health and wellbeing of our community: improved management of long term conditions, encourage and support healthy eating, physical activity and spiritual health, provide children with the best possible start, and have healthy and safe environments.

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The following section highlights some potential areas for improving equity of access and equity of health outcomes for our population. It includes selected indicators only and does not provide a complete or all-encompassing view of all of the things that can be done to improve equity.

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Health profile by population life course group, with an equity lens - Selected Indicators (Equity of access and equity of health outcomes – MidCentral DHB Māori and non Māori populations)

Pregnancy – A healthy start to life

Registration with a LMC in first trimester of pregnancy - Why is this important? MidCentral DHB and New Zealand Maori and Non Maori. Access to effective maternity care from early in pregnancy 2010 - 2016 90% can improve maternal and fetal health. Early identification 85% 80% of women with at risk pregnancies, may require more 75% 70% support and wrap around packages for ante natal care 65% 60% 55% What does this tell us? 50% 45% The proportion of pregnant women registering with a Lead 40% 35% Maternity Carer (LMC) in the first trimester of pregnancy 30% 25% has been steadily increasing in the MidCentral district and 20% nationally between 2010 and 2016. However there is a 2010 2011 2012 2013 2014 2015 2016 significant inequity between Māori and non-Māori women MidCentral DHB - Maori New Zealand - Maori with the proportion of Māori women registering with an MidCentral DHB Non Maori New Zealand Non Maori LMC early being about 25 percent lower than for non- Data source: Ministry of Health: New Zealand Maternity Clinical Māori women. The proportion of women in the MidCentral Indicators 2016 – Trends. December 2017. district who register with an LMC early in pregnancy is slightly higher than the NZ average for Māori and non- Māori women. What is the opportunity for improvement? Reinvigorating and consistent messaging using a range of forums to increase early registration and support ongoing engagement with an LMC throughout pregancy, labour and birth is necessary to improve access to maternity care for Māori women and whānau in particular.

Percent of pregnant women seen by Lead Maternity Carers who Why is this important? identified as smokers - MidCentral DHB of domicile Maori and Maternal smoking during pregnancy is associated with a non Maori ethnicities. 2014/15 - 2017/18 range of adverse maternal, fetal and infant health 50.0% 45.0% outcomes such as sudden unexpected death in infancy, low 40.0% birth weight babies, premature births and increased 35.0% likelihood of intervention during labour and birth.. 30.0% 25.0% What does this tell us? 20.0% Maternal smoking rates for pregnant women in the 15.0% 10.0% MidCentral district appeared to be declining between 5.0% 2014/15 and 2016/17 but this apparent trend was not 0.0% maintained in 2017/18. A significant inequity exists 2014/15 2015/16 2016/17 2017/18 between Māori and non-Māori pregnant women with Maori Other Total respect to smoking status. Māori women are almost three

Data source: Ministry of Health: Midwifery and Maternity times as likely as non-Māori women to be identified as Providers Organisation (MMPO) database. Quarterly reporting- smokers during pregnancy. What is the opportunity for improvement? Strengthen the collective efforts across a range of clinical and non-clinical networks with targeting support for Māori women to quit smoking during pregnancy and beyond to smoke free homes for newborns. Lifestyle change approaches with whānau (including alcohol and drug use, nutrition and physical activity) have considerable potential to improve the health of mothers and babies.

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Percentage of babies (live births) born under 37 weeks Why is this important? gestation (pre-term babies) - MidCentral DHB and New Babies born before 37 weeks gestation are more likely to Zealand Maori and Non Maori. 2010 - 2016 11% experience adverse health outcomes in the neonatal period 10% than babies born at full-term. 9% 8% 7% What does this tell us? 6% 5% The percentage of babies born before 37 weeks gestation is 4% similar for Māori and non-Māori. The data indicates that 3% 2% rates have increased slightly between 2010 and 2016 in 1% MidCentral’s district, however more data is needed to 0% 2010 2011 2012 2013 2014 2015 2016 determine whether this is a true increasing trend, and to MidCentral Maori New Zealand Maori understand the multiple factors that may contribute to MidCentral DHB Non Maori New Zealand Non Maori preterm babies.

Data source: Ministry of Health: New Zealand Maternity Clinical What is the opportunity for improvement? Indicators 2016 – Trends. December 2017. Supporting early engagement with LMCs and access to regular antenatal care with links to GPTs, will enable earlier presentation for labour and birth and access to interventions such as corticosteroids and transfers to tertiary units if required. Strengthening effective and timely maternity care is important to support healthy pregnancies and minimise adverse outomes for mothers and babies. MidCentral DHB expects to participate in a review of Neonatal services in New Zealand that has been commissioned by the Ministry of Health with support from DHB Chief Executives with the New Zealand Newborn Clinical Network taking the lead. Exclusively or fully breast feeding babies at six weeks Why is this important? LMC discharge and at three months - MidCentral Exclusive breast feeding (including expressed breast milk) DHB, Maori and Non Maori up to the age of six months helps to promote the healthy 75.0% 70.0% development, security and safety of babies and protect 65.0% them against infections and allergies. 60.0% 55.0% 50.0% What does this tell us? 45.0% 40.0% The proportion of babies who are exclusively or fully 35.0% 30.0% breastfed is lower for Māori than for non-Māori. The 25.0% difference exists at both 6 weeks and three months post- 20.0% Maori Non Maori Maori Non Maori natally, however it is more marked at three months with exclusive or fully breast feeding rates dropping dramtaically At 6 weeks At 3 months between these milestone dates for both population groups Mar-15 Sep-15 Mar-16 Sep-16 Mar-17 Sep-17 Mar-18 – more so for Māori mama and pēpi. The data suggests an Data source: Ministry of Health: Well Child Tamariki Ora Quality increase in breastfeeding at 3 months for non-Māori babies Indicators Reports, March 2015 – March 2018 between 2015 and 2018, but this is less apparent for Māori babies. What is the opportunity for improvement? Implementing actions arising from the cross-sector, district wide Breast feeding strategy currently under development will improve access by connecting and streamlining support for mothers to breast feed. Increased breast feeding support specifically targeted and tailored for Māori women is necessary to reduce inequities. Ensuring that this support encourages and enables sustainable breast feeding for Māori women and babies is key to maintaining increased breast feeding to three months post-partum and beyond

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Early years and childhood – Safe and ready to learn

Percentage of eligible eight month old Why is this important? 100% infants who have had their first course 99% A high rate of immunisation coverage leads directly to 98% immunisations on time reduced mortality and morbidity from vaccine-preventable 97% 96% disease. The National Immunisation Schedule provides a 95% 94% series of free vaccinations timed for different life stages. 93% Immunising on time provides the best protection; missing 92% 91% or delaying a vaccination can put a family’s health at risk. 90% 89% The first course immunisation events are at six weeks, 88% three months and five months. 87% 86% 85% What does this tell us? 2013/14 2014/15 2015/16 2016/17 2017/18 Our data shows a declining rate of eight month old infants Māori Non Māori being fully immunised on time. The gap in coverage rates Total Target between Māori and non Māori infants has widened over

Data source: Ministry of Health: National Immunisation Register, the last two years. This places Māori children and whānau 12 month periods from 2013/14 to 2017/18 at increased risk of infection and the potential complications of vaccine-preventable diseases, including avoidable hospitalisations, morbidity, and preventable deaths, as compared to non-Māori children. What is the opportunity for improvement? Around 70 Māori infants and their whānau in MidCentral’s district over a year could achieve a reduced risk of infection from vaccine-preventable diseases if they were adequately supported through relevant and appropriate health services to access timely immunisation. A cohesive, well informed collective approach by whānau, hapu and Iwi, together with Lead Maternity Carers, Well Child / Tamariki Ora providers, General Practice Teams and Iwi/Māori providers working with the Newborn enrolment and Immunisation teams and Outreach service has the potential to increase immunisation coverage. Implementing culturally relevant use of reminders and recalls, follow up, workforce training, myth-busting campaigns and informed consent process are likely to contribute to a reduction in missed, delayed or declined opportunities for on time immunisations. Non standardised ASH rate per 100,000 population: Why is this important? MidCentral DHB of Domicile, 0 - 4 years of age 8000 Early detection and intervention in primary health care 7750 7500 settings can reduce morbidity and potentially reduce acute 7250 7000 hospitalisations. Ambulatory sensitive hospitalisations 6750 6500 (ASH) account for around 30 percent of all acute medical 6250 6000 and surgical discharges in a year. A whole of system 5750 5500 measure – determining the reasons for high or low 5250 admission rates is complex, but they can serve as a proxy 5000 4750 marker for primary care access and quality. 4500 4250 4000 What does this tell us? Mar-14 Mar-15 Mar-16 Mar-17 Mar-18 Our data shows relatively low ASH rates compared to the 12 months to all New Zealand rates for this age group. However, the ASH MidCentral Non Maori MidCentral Maori rates for Māori children over the last two years have been MidCentral Total National Total higher, and, have not reduced to the same extent as they Data source: Ministry of Health: SI1 report (data to 2018Mar) have for non Māori children. Persistent, contributing (wiesnz14) v1.04 conditions to ASH events and rates for Māori children are dental caries, upper respiratory infection, asthma, pneumonia and cellulitis (skin infections/inflammation).

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What is the opportunity for improvement? Targeting higher risk children and whānau through intersectoral and culturally specific programmes promoting good oral health, potential for fluoridation, access to healthier food options, insulated houses, safe hygiene practices, supporting earlier access to primary and community based health care practitioners. Improving access to primary care for Māori children and whānau is an important priority to address ASH inequities.

Percentage of five year old children examined Why is this important? each year who are caries free Prevention of dental caries in childhood reduces morbidity 80% from dental conditions throughout the lifespan. Poor oral 70% hygience, dental caries with decayed or missing teeth can 60% contribute to lower self esteem and social isolation, 50% 40% recurrent infection and compromised health. 30% 20% What does this tell us? 10% Five year old Māori children are more likely to have dental 0% caries than non-Māori children. The data shows a 2011 2012 2013 2014 2015 2016 2017 persistent gap between Māori and non-Māori rates that Māori Non Māori Total has not decreased the over the time period. There is some correlation between water fluoridation status, higher levels Data source: MidCentral DHB Child and Adolescent Oral Health of deprivation and poor oral health. (The apparent Service, April 2018 improvement in 2017 reflects data integrity issues rather than a real increase in caries free children). What is the opportunity for improvement? Targeted approaches to prevent dental caries and improve access to timely, effective dental care for Māori children are essential to address inequities, reduce preventable hospital admissions for extractions, and improve dental health outcomes in the MidCentral district Percentage of children seen for their Before School Why is this important? (Health) Check who were identified as obese. June 2016 - May 2018 Obesity is an important contributor to morbidity from a 14% 13% variety of health conditions. Achieving and maintaining a 12% 11% healthy body weight is important for health and wellbeing 10% throughout the lifespan. 9% 8% 7% What does this tell us? 6% 5% Over the last two years local data suggests that the 4% 3% difference between the percentage of Māori and non- 2% 1% Māori children identified as obese at the Before School 0% (Health) Check has reduced. However, proportionately Jun16-Nov16 Dec16-May17 Jun17-Nov17 Dec17-May18 more of the Māori childen seen at their health check have a Maori Non Maori Total higher body mass index than their non-Māori counterparts. * Classification of obese is a Body Mass Index greater than 98th What is the opportunity for improvement? percentile Continuing to promote healthy nutrition and physical Data source: Ministry of Health Before School Check Programme activity for children (including school settings) and – Raising Healthy Kids Health Target quarterly reporting to June 2018. increasing culturally relevant opportunities for a stronger multi-pronged approach are important to reduce the burden of obesity across our communities.

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Why is this important? Equitable access to timely, effective primary care is central to a relevant and effective health care system, with a focus on health and wellbeing for all. Early detection of health issues in childhood with effective primary care and timely interventions when required contributes to a reduction in morbidity and hospitalisations. What does this tell us? For those children enrolled with Central PHO, consultation rates with a General Practice Team (GPT) are slightly less for Māori than for non-Māori children aged under 13 years. Consultations with GPTs for children up to five years of age Data source: Central PHO Quarterly Reports – First Level Service are more likely than for those aged 6 – 12 years, which is Utilisation – Capitated Consultations per month to June 2018. consistent with the immunisation schedule. There have been marginal increases each year in the rates for under 5 year olds since 2015 – supported by the coordinated programme that facilitates enrolment of newborn babies with a GP and well child providers. What is the opportunity for improvement? Investigate whether access to primary health care is an issue for primary school aged children; there may be an opportunity to work more closely with schools to deliver broader health programmes for earlier detection and early intervention or referral.

Adolescence and young adulthood – Healthy, safe and supported Percent of projected MidCentral DHB population aged Why is this important? 15 - 24 years enrolled with a Primary Health Young people are generally not in the habit of seeking the 81.0% Organisation. October 2018 80.0% services or advice of a registered health practitioner when 79.0% 78.0% unwell, tending more to the advice of friends and whānau 77.0% 76.0% to cope with their illness. Enrolment with a PHO enables 75.0% relatively easier access to a health practitioner, and can 74.0% 73.0% include cheaper doctors’ visits and reduced costs of 72.0% 71.0% prescription medicines. 70.0% 69.0% What does this tell us? 68.0% 67.0% Just over three quarters of MidCentral’s estimated 66.0% 65.0% population aged 15 – 24 years are enrolled with a Primary Maori Non Maori Total Health Organisation. However, enrolment by Māori Percent enrolled with any PHO Percent enrolled with CPHO adolescents and young adults is considerably lower than

Data source: Ministry of Health Primary Health Care Access – non-Māori in ths age group. Of those who are enrolled, Demographics. October 2018 most are registered with Central PHO. What is the opportunity for improvement? Promoting the benefits of PHO enrolment and reducing barriers to accessing primary care services, with the provision of youth-appropriate services relevant to the young person’s cultural and social context may increase the likelihood of detecting illness, preventing disease and promoting sustainable health and wellbeing over the longer term.

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Top six diagnostic categories of publicly funded hospital discharges Why is this important? per 1,000 MidCentral DHB Maori and Non Maori population Hospitalisation rates are a useful indicator of morbidity in aged 15 - 24 years. 2013/14 - 2015/16 70 our communities. Identifying the most common reasons Pregnancy & childbirth 60 for hospitalisations by young people assists with targeting

50 Injury, poisoning age appropriate programmes to support health and wellbeing and minimise the potential for ongoing 40 Symptoms & signs not morbidity. 30 elsewhere classified Digestive system 20 What does this tell us? Of the top six diagnostic categories for hospital discharges 10 Respiratory system across this age group, the data shows higher hospitalisation

Crude rate per per 1,000 rate Crude population 0 2013/14 2014/15 2015/16 2013/14 2014/15 2015/16 Mental & behavioural rates by young Māori people following pregnancy and disorders Māori Non Māori childbirth, injury or poisonings, and, mental and behavioural disorders than non-Māori. There was an Data source: Ministry of Health, National Minimum Dataset – Publicly Funded Hospital Discharges series. Published July 2016, increase in discharge rates over the 2015/16 year for injury October 2017 and October 2018 or poisonings and mental and behavioural disorders for both groups, but more notably by young Māori people. What is the opportunity for improvement? A focus on better connecting health and social services with young Māori people and their whānau may contribute to a reversal in the increasing number of young Māori people being admitted to hospital for mental health related issues.

Actual intentional self harm hospitalisation rate per Why is this important? 10,000 population aged 10 - 24 years - MidCentral Suicide features as one of the top ten causes of amenable DHB and New Zealand Maori and Total mortality in MidCentral’s district. Injuries and poisonings 60 are common methods for suicide. Injuries and poisonings 50 are the most common methods for intentional self-harm 40 resulting in an hospitalisation. Intentional self-harm 30 hospitalisations may be a precursor for suicide, and/or 20 indicate significant mental distress being experienced by Rate per 10,000 10 the young person, with or without psychopathy. 0 What does this tell us? MidCentral MidCentral National National Maori Non Maori Maori Non Māori Intentional self-harm hospitalisations in MidCentral’s Year to Jun 2016 Year to Jun 2017 Year to Jun 2018 district are somewhat higher when compared to New Zealand’s Māori and non-Māori populations. Data source: Ministry of Health – Youth Self Harm Hospitalisation Hospitalisation rates for young Māori people have been Rates – Report for DHB of Domicile, June 2018 steadily increasing, with a notable increase in the 2017/18 year, while rates for non-Māori appear to be decreasing in MidCentral’s district. Most of the intentional self-harm hospitalisations occur in the 15-19 year old age group. What is the opportunity for improvement? Identifying individual, whānau and community stressors, risk factors and unmet health need assist with supporting the young person to successfully transition to adulthood. As a system-wide measure, removing barriers to accessing age-appropriate health and social services together with earlier interventions supporting younger populations may potentially be effective strategies for improving the health and wellbeing of young people, avoiding negative outcomes and smoothing their transition to adulthood.

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Adulthood – Connected and managing their health Why is this important? Prevention and early detection are key to achieving better cancer health outcomes. Effective population screening programmes are important to reduce morbidity and mortality from cervical and breast cancer for women in the MidCentral district. What does this tell us? Our data shows us that not all groups of eligible women in our district have equitable access to screening. This is a significant contributor to inequitable outcomes for breast and cervical cancer across our communities. What is the opportunity for improvement? Our data also demonstrates that implementation of targeted programmes to increase participation in screening for priority population groups can address inequity. A targeted programme was initiated in cervical screening in early 2018 and is showing promising results for Māori women. Targeted programmes which show success in addressing inequities for priority population groups must be applied across screening programmes.

Data source: Ministry of Health National Screening Unit – Cervical Screening and Breast Screening Coverage Reports from June 2015 to June 2018. Why is this important? Cardiovascular disease is the most common cause of death in our population. Prevention, early detection and timely intervention are key to achieving better cardiovascular health outcomes. Regular cardiovascular risk assessment (CVRA) offers an opportunity to identify and manage cardiovascular risk factors early to reduce morbidity and mortality from cardiovascular conditions. What does this tell us? Not only has the proportion of the total enrolled eligible population who have had an assessment for cardiovascular risk in the past five years reduced markedly over the last

Data source: Central PHO Quarterly Reports – Cardiovascular Risk two years, but also the persistent gap between Māori and Assessments Pacific people and Other ethnicities is evident. Of note, the drop for Māori between 2016/17 and 2017/18, whilst present, has been less pronounced. This was largely as a result of a focus on increasing CVD risk assessments for younger Māori men over this year. What is the opportunity for improvement? There remains a significant disparity between Māori, Pacific and non-Māori non-Pacific access to primary care services and risk assessments making an equity focus for assessment coverage and risk management imperative. Targeted approaches to increase CVRA are essential to reduce inequities in cardiovascular health outcomes. This specific focus must be part of a broader, sustainable population approach to increase the percentage of eligible people having regular and timely CVRAs completed. Page | 15

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Proportion of CPHO enrolled population aged 15 - 74 years Why is this important? with diabetes who have an HbA1c of equal to or less than Diabetes is a disease that can be life-threatening and can 64mmol/mol (good glycaemic control) lead to other health conditions, serious complications and 80% 2014/15 - 2017/18 70% death, if not kept under control. Good control of blood 60% sugar levels in people with diabetes (as evidenced by 50% HbA1c levels of less than or equal to 64mmol/mol) results 40% in fewer short and long-term complications of this 30% 20% important cause of morbidity and mortality. 10% What does this tell us? 0% 2014/15 2015/16 2016/17 2017/18 Of the enrolled population who have a diagnosis of diabetes, the proportion of Māori who have good Māori Non Māori Total Data source: Central PHO Quarterly Reports – Diabetes, for 12 glycaemic control is consistently lower than the enrolled month periods from July 2014 to June 2018 non-Māori population. That is, proportionately more Māori have higher average blood glucose levels than non- Māori and this inequity has persisted for the last three years. What is the opportunity for improvement? Addressing the inequity in glycaemic control between Māori and non-Māori with diabetes will have a direct impact on the inequity in diabetes-related health outcomes between Māori and non-Māori in the MidCentral district.

Ambulatory sensitive hospital rate per 100,000 Maori and non Why is this important? Maori population groups aged 45 - 64 years for certain Hospitalisations resulting from ambulatory sensitive cardiovascular and respiratory diseases, stroke and diabetes. conditions are potentially avoidable through early 2015 - 2018 4200 detection and intervention in primary health care settings, 4000 3800 individuals adopting healthier lifestyles and better 3600 3400 managing their health conditions to avoid ongoing 3200 3000 morbidity and premature death. 2800 2600 2400 What does this tell us? 2200 2000 The data shows an obvious difference between 1800 1600 MidCentral’s Māori and non-Māori populations being

RAte per population 100,000 per RAte 1400 1200 hospitalised for ambulatory sensitive conditions in the mid- March 2015 March 2016 March 2017 March 2018 adult years. This difference has persisted over the years. The most common conditions for which Māori were Māori Non Māori Total admitted to hospital were angina and chest pain, Data source: Ministry of Health: SI1 report (data to 2018Mar) congestive heart failure, pneumonia, chronic obstructive (wiesnz14) v1.04 pulmonary disease and cellulitis, followed by diabetes. What is the opportunity for improvement? Increasing enrolment of Māori in a PHO, reducing barriers to accessing primary health care, enabling earlier detection of illness, promoting health literacy earlier amd adopting whānau based approaches to improving health and social wellbeing may contribute to reducing morbidity and premature death in our Māori population.

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Proportion of MidCentral Maori and non Maori population, Why is this important? aged 20 - 64 years accessing Mental Health and Addiction The prevalence of mental distress and illness has wide- Services, 2014 - 2018 ranging impacts on the health and wellbeing of our 9.0% communities, the burden for individuals and their family or 8.0% whānau as well as the costs to the wider health and social 7.0% 6.0% service system. Access to primary and secondary level 5.0% mental health and addiction services remains critical to the 4.0% 3.0% health and wellbeing of our communities. 2.0% 1.0% What does this tell us? 0.0% The data shows that as a proportion of the population, March 2014 March 2015 March 2016 March 2017 March 2018 more adult Māori are being seen by Mental Health and Maori Other Total Addiction services than non-Māori. This has been consistent over the years. This dispropotionate Data source: Ministry of Health - Programme for the Integration representation in utilisation of these services highlights a of Mental Health Data (PRIMHD), PP6 Clients Seen Reports, 12 significant equity issue in MidCentral (and New Zealand). month periods from April 2013 to March 2018 This may also indicate that Māori whānau are less likely to access these services in their younger years, delaying the potential to intervene earlier to minimise the impact of mental distress and illness in adulthood. What is the opportunity for improvement? Further investigating the data behind these higher rates for Māori, together with reviewing referral pathways, approaches to at risk behaviours and addictions at an earlier stage, as well as the service models relevant to whānau, may present opportunities to better understand the (mental) health of whānau, to reshape the service models and access to health and social services that could positively influence a reduction in these rates for Māori in our community.

Older People – Functioning well and independently

Percentage of estimated MidCentral DHB and New Why is this important? Zealand Maori and Non Maori population aged 65 Influenza is an important cause of potentially preventable years and over who have completed their annual morbidity and mortality. Annual immunisation reduces the influenza immunisation, 2017 and 2018 risk of infection with influenza and is fully funded for all National Non Maori people aged 65 years and over.

MidCentral Non Maori What does this tell us? Vaccination among people aged 65 years and over in the National Maori MidCentral district is similar to natioanl rates. A lower MidCentral DHB Maori proportion of MidCentral Māori received the annual influenza vaccination in 2017 and 2018 as compared to 0% 20% 40% 60% 80% MidCentral non-Māori. 2017 2018 What is the opportunity for improvement? Data source: Ministry of Health – NIR STD Influenza Coverage by A culturally relevant, age-appropriate, collective approach age band and by DHB, 2017 and 2018 to increasing uptake of influenza vaccination for people aged 65 years and over is required to reduce the morbidity and mortality from influenza in this population. A specific focus on approaches to increase uptake for Māori is essential to address the inequities and reduce the risk of influenza and its complications for older Māori in our communities.

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Average consultation rate by registered patients with General Why is this important? Practice Teams per month by Maori and Non Maori aged 65+ Equitable access to timely, effective primary care is central years, each quarter from October 2015 to September 2018 to a relevant and effective health care system, with a focus 0.84 0.82 on health and wellbeing. Effective primary care and timely 0.80 0.78 interventions when required contributes to a reduction in 0.76 0.74 morbidity, hospitalisations and mortality. 0.72 0.70 0.68 What does this tell us? 0.66 Rate per registered patient registered per Rate The average primary care consultation rate for people aged 65 years and over differs between Māori and non-Māori in the MidCentral district. Māori have a lower average Maori Non Maori consultation rate than non-Māori, and coupled with our Central PHO Quarterly Reports – First Level Service Utilisation – knowledge about higher mortality rates and increased Capitated Consultations per month to September 2018 prevalence of long term conditions for Māori, this suggests that this access inequity may have important implications for health outcomes. What is the opportunity for improvement? Reducing access barriers to primary care for Māori aged 65 years and over has the potential to improve health outcomes for older Māori and reduce inequities.

Percent of projected MidCentral DHB Māori and non Māori Why is this important? population who have attended the Emergency Department at least Attendance rates to the Emergency Department are an once in the year. 2013/14 - 2017/18 indicator of either serious illness requiring hospital-led 45% 40% assessment and intervention, or they may indicate less 35% than optimal access to primary care (which may be due to a 30% variety of reasons). 25% 20% What does this tell us? 15% These graphs compare the percentage of our Māori and 10% 5% non-Māori populations over the age of 65 years who 0% attended ED at least once in the year. For people aged 65- 65-74yrs 75-84yrs 85+yrs 65-74yrs 75-84yrs 85+yrs 74 years and 75-84 years, a similar proportion of our Māori Non Māori Maori and non-Māori populations attended ED at least once per year. However, for people aged 85 years and over, a much 2013/14 2014/15 2015/16 2016/17 2017/18 greater percentage of the non-Māori population attended ED at least when compared to the Māori population. This pattern was evident across the five year time period. This suggests that older Māori aged 85 years and older are not accessing ED to the same extent as non-Māori in this age group. However, it does not tell us why this might be the case. What is the opportunity for improvement? The evidence of a difference between Māori and non- Māori for this indicator represents an opportunity for improving our understanding of the drivers and potential implications of this pattern of utilisation. Increased knowledge, in turn, may support the development of interventions to facilitate appropriate and equitable access to primary care and the ED for our older Māori population.

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Percent of total admissions to PNH by MidCentral residents for Why is this important? specified conditions by people aged 65 years and older who Hospital admissions for chronic obstructive pulmonary identified as Maori. 2013/14 - 2017/18 disease (COPD), diabetes, congestive heart failure (CHF), 2017/18 stroke and acute respiratory conditions all have an element of “preventability” or are potentially amenable to timely 2016/17 and effective primary health care. These conditions at this age group can lead to increased severity of illness, co- 2015/16 morbidities, frailty and disability with increased burden on the individual, whānau and health system. 2014/15 What does this tell us? Of these five conditions, COPD and diabetes feature as the 2013/14 predominant conditions for which older Māori people were admitted to hospital, accounting for around 13 percent of 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% the total admissions each year for these two conditions by COPD Diabetes Acute Respiratory CHF Stroke this age group. Admissions by Māori for CHF account for around 10 percent of the total admissions for CHF – more so in the 65-74 age group – earlier than non-Māori. What is the opportunity for improvement? Preventing the development and progression of these conditions earlier in the lifespan will lead to reduced (or at least delayed) admissions for these conditions later in life. Supporting healthy lifestyles and behaviours, improving access to primary care, facilitating early detection, treatment and self-management are all important to delay the onset or reduce the prevalence or severity of these conditions in Māori over the age of 65 years.

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For:

Decision X Endorsement Noting

To Health and Disability Services Advisory Committee

Author Angela Rainham, Project Manager, Strategy, Planning & Performance

Endorsed by Craig Johnston, General Manager, Strategy, Planning & Performance

Date 7 November 2018

Subject Palmerston North Health and Wellbeing Plan Presentation

RECOMMENDATION It is recommended:

• that the committee endorse the approach that is being taken for the Palmerston North Health and Wellbeing Plan.

Strategic Alignment This report is aligned to achievement of the DHB’s strategy and four imperatives.

Glossary HDAC – Health and Disability Services Advisory Committee TLA – Territorial Local Authority PNCC – Palmerston North City Council

COPY TO: Strategy, Planning & Performance MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8928 Fax +64 (6) 355 8926 190

1. PURPOSE

This report is for the Committee’s information and a presentation will be provided on 27 November 2018.

The purpose of this presentation is to provide HDAC members with:

• a summary of the process undertaken to develop the Palmerston North Health and Wellbeing Plan. • an overview of key learnings about the population and their health and wellbeing priorities.

Endorsement from HDAC is being sought for the approach being taken to the format of the plan.

2. BACKGROUND

Health and Wellbeing Plans are being produced for five different localities (TLA areas) across the MidCentral district and will be unique to meeting each area’s identified priority needs. The Plans aim to make a positive contribution to the health outcomes of the area and will be used to make changes necessary to continuously improve our health system, as part of the wider heath sector and social services network. The Plans place residents and their families/whānau at the centre of planning decisions and design to best meet the needs of the community.

Plans for Tararua, Manawatū, Ōtaki and Horowhenua have been completed and presented back to their communities. A copy of these plans can be found at www.midcentraldhb.govt.nz/engage

3. PLAN DEVELOPMENT FOR PALMERSTON NORTH CITY

The Palmerston North locality planning process has been undertaken in the last six months and has included:

• extensive community engagement involving more than 1300 residents. • working with PNCC to gather population health intelligence. • a Local Advisory Group (with members from across the community) providing advice – particularly in regards to the best ways to engage with the community.

3.1 Current Project Phase

The project team is working with Cluster Executives, the Public Health Service Health Promotion team and other agencies to establish action points that can be included in the plan.

Formating and content of the draft plan is being finalised for consideration by the Board at its December meeting.

Attached to this paper is a copy of the population information for Palmerston North (Appendix 1) and the presentation slides (Appendix 2) for HDAC’s information.

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4. RECOMMENDATION

It is recommended:

• that the committee endorse the approach that is being taken for the Palmerston North Health and Wellbeing Plan.

Angela Rainham Project Manager

192 PALMERSTON NORTH POPULATION SNAPSHOT

Palmerston North population estimate as at 30 June 2017: 87,300

14% were 65 years and over. This is compared to 15.1% nationally, 38.5% were 15-39 years. This is compared to 34.1% nationally. 19.2% were 0-14 33.6 years. This is compared to 19.5% nationally. MEDIAN The median age is 33.6 years, compared to AGE a national median age of 37.0 years

of people in Palmerston North live in areas designated as being among the most deprived in New Zealand in 2013 (Deciles 9 and 10). 56% lived in decile 6 – 10 areas 18% compared to 49% nationally. Higher levels of deprivation are associated with higher mortality rates and higher rates of many diseases, as well as social problems such as crime, family violence, disengagement from education and risk-taking behaviours

In the 2013 Census: 33.8% of families with dependent children in Palmerston North were single-parent families. 45.7% of single parent families had a total annual family income of less than $30,000.

Sources: Palmerston North City Council 193 By 2038 Statistics NZ predict that:

There will be a 83% increase in The proportion of residents identifying residents aged 65 years and over. as Māori is expected to increase to (9000 more residents aged 65+ than there were in 2013) 24.2% (from 17.1% in 2013).

These trends are important because Māori and older people are known to have poorer health status than other New Zealanders.

• The proportion of residents identifying as Pacific is expected to increase to 7.8% (from 4.6% in 2013). • The proportion of residents identifying as Asian is expected to increase to 17.5% (from 10.2% in 2013).

Housing(if the projections are accurate)

Home ownership rates in Palmerston North are below the 62.4% national average (2013 census). 62.4% of households own their own their own dwelling in Palmerston North compared to 64.8% nationally. own home

The estimated mean weekly rent for the year to March 2018 was $299 in Palmerston North compared to $244 for the MidCentral District and Whanganui Regions and $398 for New Zealand. $299 Education

The increase in all Maori school leavers with 61-72% NCEA Level 2 or above from 2009 - 2017

The increase in all school leavers with 70-82.1% NCEA Level 2 or above from 2009 - 2017 Income

In 2013, 53.9% of people aged 15 years and over had an annual personal income of $30,000 or less 194

Populations more likely to have higher health needs

The mapPopulations below highlights more areas likely of toPalmerston have higher North health with high needs deprivation ratings, above average proportions of people aged over 65, and above average percentages of Maori and/or Pasifika residents. These statisticsThe map below are important highlights abecausereas of Palmerston these population North with groups high deprivation are more likelyratings to, above have averagepoorer health proportions of people aged over 65, and above average percentages of Maori and/or Pasifika residents. status than other New Zealanders. These statistics are important because these population groups are more likely to have poorer health In the 2013status Censusthan other Palmerston New Zealanders. North was split into 27 areas: • FiveIn areas the 2013 were Census considered Palmerston among North the was most split deprived into 27 areas in New: Zealand (deciles 9 and 10). These are highlighted orange below. A further 13 areas were rated deciles 5 to 8. • Five areas were considered among the most deprived in New Zealand (deciles 9 and 10). These • 15.1 percent of New Zealand were age 65+. Six areas of Palmerston North had higher than the are highlighted orange below. A further 13 areas were rated deciles 5 to 8. national average proportion of the community aged 65+ (highlighted green below). • 15.1 percent of New Zealand were age 65+. Six areas of Palmerston North had higher than the • 17.5 percentnational of the average New Zealand proportion population of the community identified aged as Maori.65+ (highlighted Eight areas green of below)Palmerston. North had higher •than 17.5 the percent national of theaverage New Zealand proportion population of Maori identified (highlighted as Maori red. Eight below). areas of Palmerston • 7.4 percentNorth of the had population higher than in the New national Zealand average identified proportion as Pasifika. of Maori Four (highlighted areas in red Palmerston below). North higher •than 7.4 the percent national of the average population proportion in New Zealand of Pasifika iden tifiedpeople as (highlightedPasifika. Four areasblue below).in Palmerston North higher than the national average proportion of Pasifika people (highlighted blue below).

Milson Decile 6 Roslyn Terrace End 17.5% aged 65+ Decile 9 Decile 6 Takaro 16.7% Maori 13.3% aged 65+ 15.2% aged 65+ Cloverlea Decile 8 3.6% Pasifika 22.1% Maori 14.4% Maori Decile 7 12.6% aged 65+ 7.0% Pasifika 4.2% Pasifika 13.9% aged 65+ 20.9% Maori 21.9% Maori 5.1% Pasifika 4.3% Pasifika Papaioea Highbury Decile 8 Decile 10 17.2% aged 65+ 14.3% aged 65+ 12.9% Maori 36.4% Maori 2.7% Pasifika 12.7% Pasifika

PN Central Decile 9 Westbrook 10.1% aged 65+ Decile 9 16.1% Maori 18.4% aged 65+ 4.0% Pasifika 24.1% Maori 8.5% Pasifika

Hokowhitu Lagoon Longburn Decile 3 Decile 6 18.3% aged 65+ 6.5% aged 65+ 5.4% Maori 18.8% Maori 1.9% Pasifika 8.2% Pasifika

Awapuni North Linton Military Camp Decile 9 Decile 5 13.9% aged 65+ 1.1% aged 65+ Awapuni South 22.4% Maori 47.3% Maori Decile 3 7.8% Pasifika 11.0% Pasifika 16.1% aged 65+ 12.2% Maori 3.0% Pasifika 195

Palmerston North - a young city Palmerston North – a young city

In 2013, 20.4 percent of New Zealanders were aged 0 – 14. 12 of the 27 census areas in Palmerston North had higherIn 2013, than 20.4 the percent national of average New Zealanders number ofwere children aged 0aged – 14. 0 12– 14. of the 27 census areas in Palmerston North had higher than the national average number of children aged 0 – 14.

Roslyn Kelvin Grove 21.6% aged 0 - 14 26.9% aged 0 - 14

Cloverlea Ashhurst 22.0% aged 0 - 14 24.7% aged 0 - 14

Highbury 26% aged 0 - 14

Terrace End 20.9% aged 0 - 14 Longburn 24.5% aged 0 - 14

Takaro 20.7% aged 0 - 14

Turitea 23.3% aged 0-14

Awapuni South Awapuni North Linton Military Camp 20.8% aged 0-14 23.2% aged 0 - 14 24.5% aged 0 - 14

Future ethnic makeup of our children: By 2038 it is predicted that, 41 percent of 0 – 14 year olds in the city will identify as Maori and 17 Future ethnic makeup of our children: percent with a Pasifika ethnicity. 18 percent will identify as Asian and 70 percent European1. By 2038 it is predicted that, 41 percent of 0 – 14 year olds in the city will identify as Maori and 17 percent with a

Pasifika ethnicity. 18 percent will identify as Asian and 70 percent European.1 Other significant population groups: Other significant• Refugees population - Palmerston groups: North is a refugee resettlement area. Currently approximately 170 • Refugees -former Palmerston refugees North are is a arrivingrefugee resettlementin the city each area. year. Currently This equates approximately to approximately 170 former refugees 45 households. are arriving in theThese city refugees each year. come This equates from many to approximately different countries 45 households. and cultural These backgrounds refugees come and from have many often different countriesexperienced and culturaltraumatic backgrounds pasts. and have often experienced traumatic pasts. • Defence• ForceDefence – There Force are approximately– There are approximately 2,600 defence 2,600force personnel defence forcebased personn at Lintonel Army based Camp at Linton and 830 Army at Ohakea AirforceCamp and Base 830 (and at thisOhakea number Airforce is set toBase increase). (and this Many number of these is personnelset to increase). and their Many families of these live in the Palmerston North City boundaries. personnel and their families live in the Palmerston North City boundaries. • Students• - StudentsPalmerston - Palmerston North is home North to four is hometertiary to institutions four tertiary (Massey institutions University, (Massey Universal University, College ofUniversal Learning, Institute of the Pacific United and Te Wānanga o Aotearoa). Early in 2018 there were approximately College of Learning, Institute of the Pacific United and Te Wānanga o Aotearoa). Early in 2018 8,900 students studying at these institutions. there were approximately 8,900 students studying at these institutions.

1 Note the number of ethnicities adds to more than 100 percent, reflecting that many people identify with more than one ethnicity. 1 Note the number of ethnicities adds to more than 100 percent, reflecting that many people identify with more than one ethnicity. 11/7/2018 196

Palmerston North Locality Planning

Population Health Intelligence • Population groups likely to have higher health needs are spread throughout the city

• Palmerston North is a young city

• There are some unique population groups in comparison to the rest of our district: • Refugees • Defence Force • Students

1 11/7/2018 197

Community Engagement This included:

- completed by 529 residents and 14 service providers

- with service providers - with community groups - at community events - attended by 843 people

Community Engagement - Strengths What works well to keep people and their families/ whānau healthy and well in Palmerston North? • Strong communities and community groups • Free GPs for U13 and Dental for U18 • Community Organisations, services and support groups • Recreation areas and facilities • Health Services – hospital in city, hospice • Community Gardens and Community events • Family friendly and easy to travel around

2 11/7/2018 198

Community Engagement - Challenges What are the main challenges affecting the health and wellbeing of people and whānau in Palmerston North? 1. Access to GPs – wait times 10. Drugs and alcohol/addictions 2. Cost of doctors and dentists 11. Communication barriers 3. Lack of transport 12. Family Violence 4. Hospital waiting lists 13. Lack of parenting skills 5. Mental Health 14. Overburdened service providers 6. Housing 15. Inequity in education and employment opportunities 7. Healthy food vs Junk food 16. Isolation – older people and refugees 8. Lack of knowledge of support available 9. Poverty/unaffordable living costs

Community Priorities

Easy access to Healthcare when people need it.

Improved Mental Health and Addiction support for communities within Palmerston North.

A city that has quality communications and connections between health services, people, whānau and communities.

A city where people and whānau feel safe and are supported to make healthy choices and stay well.

A city where residents have a good quality of life and everybody has the opportunity to achieve equitable health and wellbeing outcomes.

3 11/7/2018 199

Focus Areas

Access to Mental Health Better Building Wider Healthcare and Addiction Communication Healthy Determinants and Connections Whānau and of Health and Communities Wellbeing General Practice People being able Providing people Local Initiatives that Advocacy around Teams to get help when focused services help people and wider determinants they need it . whānau to make of health for those good lifestyle most in need choices Hospital and Reducing the Improve awareness of Supporting our Increasing specialist care impact of drugs services and support young people to education and and alcohol available make good lifestyle employment addictions choices opportunities for young people

Targeting Enhancing youth Health working Supporting quality Improving communities likely resilience. together as one team. living for targeted infrastructure to to have higher Supporting All sectors involved in populationgroups – support quality health needs and families/whānau. wellbeing working disabled, refugees, living children together Pasifika, Maori

What is different?

- Extra population information - Including a “Youth Voice” page - Focus areas targeting youth

4 200

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Author Steve Carey, Portfolio Manager – Clinical Services

Endorsed by Craig Johnston, General Manager – Strategy, Planning and Performance.

Date 20 November 2018

Subject Development of a Strategy for Pharmacy in MidCentral and a Moratorium on Community Pharmacy Contracts

RECOMMENDATION It is recommended that the Committee: • note that as of the 1st of October 2018, all 32 MidCentral Community Pharmacies have signed the new national Integrated Community Pharmacy Services Agreement. • note that the DHB is drafting a Strategy for Pharmacy in MidCentral for pharmacy services and that once the draft strategy is formalised, an engagement phase with wider stakeholders and the community will proceed. • note that the DHBs have received legal advice that neither the Commerce Act 1986 nor administrative law prevents a DHB from adopting a policy under which the DHB chooses which licensed pharmacies receive a contract or chooses the types of pharmacy services covered by an individual contract. • endorse for the Board’s consideration a proposal to impose a moratorium on issuing new contracts for community pharmacy providers from the 18th of December 2018, until the adoption of a policy on contracting pharmacy services within MidCentral in 2019.

COPY TO: Strategy, Planning & Performance MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8928 Fax +64 (6) 355 8926 201

Strategic Alignment The Pharmacy in MidCentral Strategy is closely aligned to the key strategic priorities and enablers in the MidCentral DHBs Strategy. The themes are consistent with our desire to invest in services that support Quality Living, Healthy Lives and Well Communities. There is a strong equity focus in the ‘Pharmacy in MidCentral Strategy’, ensuring that we maximise our investment in areas that will improve equity of health outcomes for our priority populations, including those with financial barriers and those with complex health and social needs.

Glossary CPHO – Central Primary Health Organisation GP – General Practitioners HVDHB - Hutt Valley District Health Board ICPSA – Integrated Community Pharmacy Services Agreement MDHB - MidCentral District Health Board NGO – Non Governmental Organisation OECD – Organisation for Economic Co-operation and Development 202

1. PURPOSE

The purpose of this paper is to advise the Committee of the drafting of the ‘Pharmacy in MidCentral Strategy’ before wider engagement and to seek Committee endorsement to place a moratorium on new pharmacy contracts until a new contracting policy is approved.

Subsequently, the Strategy once finalised, will return to the Committee for review and endorsement.

2. SUMMARY

As of 1 October 2018, all community pharmacies within MidCentral have signed the new Integrated Community Pharmacy Services Agreement (ICPSA). ICPSA is a departure from the old CPSA 2012 agreement that largely focussed on the supply of pharmaceuticals. The new contract places more emphasis on clinical services and enables local DHBs to purchase locally focused and targeted services. For MDHB, this gives us an opportunity to configure and shape our pharmacy services to ensure greater emphasis on targeting inequities and lead to better health outcomes for our community.

Although there will be limited funding flexibility initially, there will be some funding for new services in 2018/2019. The use of that funding needs to be guided by local DHB strategies to ensure we are addressing the pharmacist service priorities. As a result, MDHB is developing a Pharmacy in MidCentral Strategy to guide the commissioning of services. In order to ensure that quality providers deliver the services, we are developing a regionally consistent Quality Contracting Framework. This will enable MDHB to carefully manage the distribution of pharmacist services across MidCentral.

3. BACKGROUND

3.1 Why do we need a Pharmacy in MidCentral Strategy?

The DHB currently spends $63million on pharmacy services annually (2017/2018). Much of this expenditure is ‘Fee for Service’, is not well targeted, and does not recognise the various needs of some of our priority populations. The majority of these services are nationally mandated through the ICPSA, such as the filling of prescriptions and hospital administration of medications.

Our community pharmacist services are presently provided through a network of 32 community pharmacies in MidCentral employing 86 full time and/or part time registered pharmacists.

We know that timely access and adherence to medicines is part of good health outcomes. We also know that clinical advice for prescribers is critical in maximising impacts of medicines. Pharmacists and GPs traditionally worked in silos, and were not integrated in a way where the clinical skills of the pharmacist were maximised to improve medicines management. Through the implementation of the Pharmacy in MidCentral hospital to community care continuum (figure 1), we have further imbedded Clinical Pharmacy in the hospital and the primary care sectors through targeted initiatives. The community pharmacists will be involved in the future

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through undertaking Medicine Utilisation Reviews to ensure patient medicine concordance.

Figure 1: Hospital to Community Care Continuum

3.2 Government Priorities

The Pharmacy in MidCentral Strategy supports the government priorities of equity, supporting those with complex long-term conditions including mental health clients, integrating pharmacist services with primary care, as well as improved DHB performance. The government has developed a Pharmacy Action Plan in 2017, and one of the key requirements of that Plan was for DHBs to advance improved medicines management in the community.

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3.3 What are the priorities of the Strategy?

The strategy is being developed to enable MidCentral DHB to implement national and local priorities for Pharmacy Services. The strategy draws from:

• the first MidCentral DHB Pharmacy Forum • Quality Living, Healthy Lives and Well Communities – MidCentral DHB Strategy • Central Primary Health Organisation Strategic Plan 2016-2019 • the New Zealand Health Strategy • Pharmacy Action Plan 2016 – 2020 • Implementing Medicines New Zealand 2015 to 2020 • Integrated Pharmacist Services in the Community – Evolving consumer focused pharmacist services.

Unlocking the potential amongst the pharmacist workforce to contribute to the challenges that the health sector faces lies largely in: • embracing technologies • utilising top of scope skills to release them from the medication supply process.

The success of the strategy relies on integrating pharmacists into the wider care teams, including from hospital to community pharmacies, primary care, DHBs, community health, mental health, NGOs and aged residential care providers. It will also require shifting some of the pharmacist resource towards our priority populations, where our pharmacists can make the most difference.

The draft strategy develops the ‘WHY’ of Pharmacy in MidCentral, and it is important to ensure that we follow the objectives of: • encouraging our Pharmacist community (Hospital, Central PHO (CPHO) and Community Pharmacy) to be actively involved in the development of pharmaceutical services within MidCentral; • placing the patient at the centre of the design and development of services; • targeting and addressing inequities within MidCentral • ensuring that the development of future services align to our ‘WHY’ • enabling workforce development decisions to be made to align to our ‘WHY’ – through ensuring that those coming into MidCentral support our vision and values • informing investment decisions and providing focus for future planning.

Using the guiding principles, the first MidCentral DHB Pharmacy Forum held on 17 July 2018, saw more than 65 Pharmacists, Pharmacist Interns, Pharmacy Technicians, Pharmacy Technician trainees, Pharmacy Assistants, Pae Ora and sector leadership meet to discuss and develop the ‘WHY’ of Pharmacy in MidCentral. Over 90 pieces of feedback were collected following the forum and three important themes were identified as the ‘WHY’ of Pharmacy in MidCentral: • Everything we do is for the benefit of our people in MidCentral. • The services we provide are to address inequities to ensure our people achieve better health outcomes. • We maintain best practice in everything we do .

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From these themes, three guiding principles have been identified – our ‘WHY’. • People Centric • Better Health Outcomes • Best Practice

The future direction of Pharmacy in MidCentral has been produced into an infographic format (figure 2). Our path has been laid through the MidCentral DHB and CPHO strategies which enable us to focus on our future vision of – People Centric, Best Practice, Better Health Outcomes. Through this, we are paving our way towards being ‘Committed to delivering better health outcomes to the people of MidCentral through best practice’.

Figure 2: Pharmacy in MidCentral Infographic

3.4 Progress to Date

• A Pharmacy Services overview underway to help identify what and where our services are being provided in the district • The first Pharmacy forum was held on 17 July 2018 • The draft of the first stage of the strategy has been completed and endorsed by the Pharmacy in MidCentral Programme Board.

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3.4.1 Next Steps – finalisation of the Strategy

• The final stages of the strategy will be developed in the second Pharmacy forum where the next five to ten years of Pharmacy Services is the focus. The compiled strategy document will come back to the Committee for endorsement. • Subject to Committee endorsement, we will then go out to the wider sector and consumers for engagement. Once finalised, this will go before the Board.

3.5 A Policy for issuing pharmacist service contracts

One aspect relating to the services overview and draft strategy requires immediate action. We seek the Committee’s endorsement to develop a policy for entering into ICPSA contracts and impose an immediate moratorium on new contracts while we develop that policy. Currently, pharmacies that wish to establish themselves are not refused this request, allowing the market to determine the distribution of services rather than the needs of the community.

The OECD standards of 1 pharmacy per 5,000 population illustrate MidCentral is over represented with community pharmacies in Palmerston North and have the recommended number for Foxton, Levin, Pahiatua and Feilding. There is an under- representation of community pharmacies in Dannevirke and marginal representation in Otaki (figure 3).

Figure 3: Ward Locations and estimated timeframes for a new pharmacy based on population increase Pharmacy Location Population Number of Population Estimated timeframes till Ratio Pharmacies change new pharmacy (years) (current) 2016/2017 Otaki 8,620 1 - Marginal Levin 5,459 5 400 12 Foxton 5,205 1 200 24 Palmerston North 4,365 20 1,000 17 – Over-serviced currently Feilding 5,256 3 400 10 Woodville 1,401 Depot 50 72 Pahiatua 5,436 1 100 46 Dannevirke 11,013 1 150 Under Serviced

We would like to better manage where new pharmacist services are located, and ensure the type of provider will demonstrate a collaborative partnership with primary care, and is able to provide a range of quality services to our priority populations. To better manage the distribution of pharmacist services, and ensure the market is configured to best address our vision for quality pharmacist services.

As a result, we seek the moratorium for new contracts in Palmerston North, Foxton, Levin, Pahiatua and Feilding. This will not apply to a new contract for Otaki and Dannevirke and will not apply to the purchasing of existing pharmacies or amalgamations. It is not being sought to reduce the number of pharmacies within MidCentral.

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3.5.1 Other DHBs have similar concerns

Several DHBs share concerns that the greatest impact of additional pharmacies is to compromise the quality of the services able to be provided to consumers.

Since a number of DHBs have concerns about entry to the market and the effect on service quality and efficiency, DHB representatives intend to work together to develop a quality contracting policy. A regionally consistent quality framework to the contracting for pharmacy services will ensure that providers are committed to aligning to our strategy and focus on quality and addressing inequities. To date, Hutt Valley DHB (HVDHB) have implemented a moratorium, with other DHBs likely to impose similar moratoriums to help develop the quality framework to contracting.

3.5.2 Legal Advice confirms restrictions on contracts is permissible

Following the concern of several DHBs, legal advice was sought as to whether there were any barriers to DHBs establishing policies to limit the issuing of new contracts. The legal advice was provided in July and confirms that “Neither the Commerce Act 1986 nor administrative law prevent a DHB from: • adopting a policy under which the DHB chooses which licenced pharmacies receive a contract • making a decision to reduce the number of pharmacies with which it contracts • choosing the types of pharmacy services covered by an individual contract, or refusing to enter into a contract because a pharmacy is unwilling or unable to provide the types of pharmacy services that the DHB requires.

The legal advice also addressed questions of the steps for DHBs to take when establishing a policy to guide decisions on pharmacy contracts. It confirmed DHBs may impose a moratorium while developing a new quality contracting policy. That will avoid further start-ups and a possible rush to set up new pharmacies before a policy takes effect.

3.5.3 Next steps – Implementing a Moratorium and developing of a quality framework for contracting.

Should the Committee endorse the recommendation to implement a moratorium on new community pharmacy contracts (subject to exceptions as outlined previously), it will be presented to the Board for approval. It is recommended that the moratorium is in place from the 18th of December 2018 (the day after the Board meeting). DHB representatives will contact the Ministry of Health to advise of the decision, as it may result in some public comment. MidCentral will continue to work with other DHBs on developing a framework for quality contracting and then bring this to the Committee and Board for approval.

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4. RECOMMENDATION

It is recommended that the Committee:

• note that as of the 1st of October 2018, all 32 MidCentral Community Pharmacies have signed the new national Integrated Community Pharmacy Services Agreement. • note that the DHB is drafting a Strategy for Pharmacy in MidCentral for pharmacy services and that once the draft strategy is formalised, an engagement phase with wider stakeholders and the community will proceed. • note that the DHBs have received legal advice that neither the Commerce Act 1986 nor administrative law prevents a DHB from adopting a policy under which the DHB chooses which licensed pharmacies receive a contract or chooses the types of pharmacy services covered by an individual contract. • endorse for the Board’s consideration a proposal to impose a moratorium on issuing new contracts for community pharmacy providers from the 18th of December 2018, until the adoption of a policy on contracting pharmacy services within MidCentral in 2019.

Steve Carey Portfolio Manager, Clinical Services 209

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Author Barbara Ruby Acting Manager Quality Improvement and Assurance

Endorsed by Judith Catherwood General Manager, Quality and Innovation

Date 5 November 2018

Subject Clinical Governance and Quality Improvement Report

RECOMMENDATION It is recommended that: • the content of the clinical governance and quality improvement report be noted • the Quality Agenda - Clinical Governance Framework be endorsed • progress in delivering improvements in Clinical Governance and Quality Improvement be endorsed.

Strategic Alignment This Clinical Governance and Quality Improvement report is aligned to the MDHB Strategy and the strategic imperative Achieve Quality and Excellence by Design.

COPY TO: Quality and Innovation MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8030

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Glossary

ACC Accident Compensation Corporation BAU Business as usual CL Control line CPHO Central Primary Health Organisation EWS Early Warning Score ELT Executive Leadership Team HDAC Health and Disability Advisory Committee HQSC Health Quality and Safety Commission LCL Lower Control Line MAPU Medical Assessment and Planning Unit MDHB MidCentral District Health Board PI Pressure Injury PICC Peripherally Inserted Central Catheter QSM Quality and Safety Marker RN Registered Nurse SAC Severity Assessment Code UCL Upper Control Line VTE Venous thromboembolism

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1. PURPOSE

This report is for the Health and Disability Advisory Committee (HDAC) information and discussion. It provides information about aspects of clinical governance system and performance across the MidCentral District Health Board. It also provides an update on annual plan and operational plan initiatives within the Quality and Innovation Enabler Team.

The HDAC is asked to endorse the final version of “The Quality Agenda – Clinical Governance Framework” and implementation plan.

The report format and content will be developed further as “The Quality Agenda - Clinical Governance Framework” is implemented, and as the safety and quality dashboard and analytical function is further developed.

2. SERVICE OVERVIEW

The Quality and Innovation Team encompasses a number of support services that work across the organisation, enabling and supporting our staff, patients and family/whānau. These are the Quality Improvement and Assurance Team, Consumer Relations, Spiritual Care Liaison, Travel and Welfare, the Enterprise Programme Management Office, Improving Value Programme and the Clinical Library. In addition, the General Manager, Quality and Innovation leads the implementation of the Integrated Service Model across the MidCentral District.

3. UPDATES

3.1 The Quality Agenda - Clinical Governance Framework

The revision of the MidCentral District Clinical Governance Framework has been a major piece of work over the course of 2018. A draft document was developed to support engagement with a large number of system stakeholders. This included Consumer and Clinical Council, CPHO Clinical Board, MidCentral Clinical Board, professional groups and committees, ELT and other key bodies. A workshop has also been held with the MidCentral DHB Committee members. The final document is now ready for HDAC endorsement and is included in Appendix 1. An implementation plan has also been developed and is attached in Appendix 2.

The key features of the revised framework is to strengthen our clinical governance culture though the development of a team shared governance system. The fundamental premise behind this is to ensure front line staff engagement in the quality assurance and improvement efforts and in supported shared decision making to support safer and higher quality services. In addition, the revised framework will support a whole of system approach, consistent with the new Cluster arrangement. In keeping with the HQSC recent publications and dashboard, the Institute of Medicines, six dimensions of quality will form the backbone of our refreshed framework. The involvement of consumers in all aspects of safety, quality and clinical governance will be further enhanced and a new safety and quality dashboard will be developed and shaped by the Clusters who will determine their measures and indicators aligned to the MidCentral DHB strategy and outcomes framework.

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This report will include many aspects of this approach and Committee members will see this evolve of the course of the next financial year and beyond.

3.2 Operational Plan

Rating & Trend Legend

On Track, Behind plan – Behind plan – Not progressing as remedial action major risks and completed G A R D planned plan in place exception report as planned required

Improved from Regressed from No change from    last report last report last report

Rating Initiative and Commentary Trend Refresh and embed • A Clinical Governance Workshop was held Clinical Governance on 14 February 2018 for the Executive framework across Leadership Team and Senior Leadership organisation G  Team. This was facilitated by HQSC. • The refreshed framework is now ready for endorsement and implementation has begun.

Consumer Engagement • A draft consumer engagement framework Framework has been facilitated by Lee Welch, Quality and Clinical Risk Coordinator. • A  Work continues with the Consumer Council and Pae Ora to finalise the framework which we anticipate to be completed in November 2018.

Implement real time • The current quarterly inpatient survey feedback system with has been extended to fortnightly to consumers, and provide increase our consumer feedback direct feedback to staff response. resulting from consumer • Consumer feedback reports are in feedback development which will be provided to Clusters, Committee and Board, Consumer Council and Clinical Council etc. • A week long campaign, ‘Update Your G  Details’ has been completed primarily to increase the number of email addresses recorded to enable greater feedback response. The secondary aim, was to update all of the details for consumers, this included an update on consumer’s GP. • Updated documentation and forms have been completed to support collection of these details. 213

• Once the above actions achieve a satisfactory level of email contact details, a phased approach will be taken to increase consumer feedback in outpatients and other areas.

Continue current work • Achieving target or above in the majority on improvement of Quality and Safety Markers. projects to achieve and • Preliminary work on the future Safe Use sustain programme of Opioids Quality and Safety Marker is targets of the Health progressing well. Quality and Safety • Preliminary work on the Pressure Injuries Commission’s quality Quality and Safety Marker is progressing markers well. • Hand hygiene is an area where improvement is required and MidCentral G  DHB is not meeting the target. We will have an increase in focus as part of the implementation of the ‘Bare Below the Elbows’ policy. • Hand Hygiene will also be the focus of the National Patient Safety Week, 4- 10 November 2018. This year, we will be looking at how we engage with our consumers and identify strategies to empower them to ask staff to clean their hands in front of them.

Support staff to • Training has been delivered to our participate in the ACP trainers. A plan to use their skills across train the trainers our workforce is in development. programme and G  communications skills training delivered by HQSC Implement the • Specific detailed reporting is in place on a Integrated Service 90 day cycle via the Board. Model and Cluster establishment to G  support the delivery of integrated service

model Create a support system • The Enterprise Programme Management and navigation tool that Office is being established. This will supports staff to be support coordinated programme and creative and innovative project management and provide a in their work places, central point of contact for quality that supports new ways improvement and innovation ideas. G  of working and a • An approach to build capacity and decision making system capability in the Quality Improvement that supports local and Assurance team has been finalised. improvements This will create capacity to mainstream continuous quality improvement into all parts of our business. 214

• The current contracted Innovation programme is under review so as to enable mainstreaming the approach.

Oversee delivery of the • Improving Value Programme is reported savings initiatives and separately via HDAC. The next report is the Improving Value due in February 2019. Programmes of Programme to realise G  work are progressing. Financial savings planned budget and will be reported to FRAC and the Board business process throughout the year. efficiencies

3.3 Quality Improvement Updates

The Quality Improvement and Assurance team are starting to work more closely with Clusters. The business partnering approach is still in development and the table below indicates the current support being offered while we transition towards a more robust business partnering model.

The table outlines Quality Improvement Initiatives, by cluster or enabler, which the Quality Improvement and Assurance team are supporting but is not a full list of all initiatives being delivered by Clusters.

Rating & Trend Legend

On Track, Behind plan – Behind plan – Not progressing as remedial action major risks and completed G A R D planned plan in place exception report as planned required Improved from Regressed from No change from    last report last report last report

Uru Arotau - Acute and Elective Specialist Services

Rating Improvement Location and Due Commentary Initiative Trend Nurse-Led PICC Transitory June 2018 • A service being Insertion Service Care Unit delivered within one session A  each week • Training of RN staff in progress MEDIMORPH MAPU March 2019 • Embedding • MAPU Model of Care Medical March 2019 G  • Scoping and • Inpatient wards, inpatient testing of ideas acute flow wards

• Older people Medical June 2019 • Scoping and Inpatient with frailty testing of ideas wards

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ED – Tākatu Emergency August • Ongoing testing, Department G  2019 with some tasks becoming BAU Missing person All inpatient September • Testing has process – Inpatient wards excl. 2018 been wards excl. MH Mental Health completed, now embedding with G  wards and loading on Controlled Documents site Management of the All inpatient TBC • Developing acute aggressive wards excl. • Will be merged patient Mental Health into the overarching work on G  ‘Violence Prevention’ being led by People and Culture Renal service pre- Renal Service June 2019 • Embedding dialysis and HHD G  Transferring to patients BAU Safe Use of Opioids September • Embedding Ward 24 2018 opioid induced G  constipation and widening scope

Uru Whakamauora - Healthy Ageing and Rehabilitation

Improvement Location Status Due Commentary Initiative Older people with *Across April 2019 • Business case Frailty – Acute medical developed and Frailty Unit model inpatient G  presented to (OPAAL) wards and ELT STAR 2 Patient diaries STAR 2 December • Testing 2018 complete, developing BAU process and G  education for staff and patients/family/ whānau STAR 4 Spirituality STAR 4 August • Complete. Project 2018 Working group G  now formulating final report including 216

outcomes and recommendatio ns and scoping next steps

Uru Matai Matengau - Cancer Screening, Treatment and Support

Improvement Location Status Due Commentary Initiative Treatment Radiation November • Testing new Pathway for Oncology 2018 improvement Health Issues G  activity Arising from Radiation-therapy

VTE Reduction Clinical No end date • Scoping and Haematology G  testing new direction for *Hospital wide VTE reduction National Bowel Radiation July 2019 • Detailed Screening Oncology planning Programme G  continues to *Hospital wide Project take place

Hospital Clinical Ongoing • Data Transfusion Haematology evaluation identified a *Hospital wide gap requiring a G  system change. This is being progressed by the group Supportive Care Radiation Dec 2018 • Analysing Information Oncology G  different Application platforms

Uru Pa-Harakeke - Women and Children’s Health

Improvement Location Status Due Commentary Initiative Improving the Gynaecology September • Completed and Experience for and Ward 27 2018 embedding into Women BAU and nd Experiencing 2 evaluation with Trimester Fetal women Loss G  experiencing 2nd trimester fetal loss • Results: New Resource Book, new procedure 217

with enhanced communication tree, consistent ward and room, new patient information booklet and external e- learning module ‘Communicating and Interacting with Bereaved Parents, Families and Whānau Following Baby Loss: For Health and Caring Professionals’ completed • Monitor women’s experience as BAU

Professional LeadsLeads

Improvement Location Status Due Commentary Initiative Falls Nursing Ongoing • Continuous  G cycles of improvement Pressure Injuries Nursing Ongoing • Greater awareness of measurement G  data for improvement • Continuous cycles of improvement Deteriorating Adult Inpatient July 2021 • Progressing patient wards very well • Currently scoping the G  HQSC Korero Mai programme as part of work plan

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3.4 Clinical Audit

Clinical Audits are undertaken by services across MDHB on a regular basis. Clinical audit is strongly encouraged and included in our refreshed framework as an expectation of all services. Audits aim to document current practice, monitor practice to standards or policy and understand any reasons relating to variation. Audits are a core basic element of any quality improvement plan. Staff are encouraged to complete an audit proposal form electronically or in paper form to ensure an accurate log of all clinical audit activity and to support sharing of outcomes.

The table below outlines the number of clinical audit activities that have been recorded electronically in the RiskMan Quality Module. These audits represent activity over the period 1 January 2017 to 31 August 2018. The audits were completed by the Audit Lead in the relevant cluster, or the Clinical Audit Facilitator within the Quality Improvement and Assurance team.

The Clinical Audit Facilitator works closely in partnership with the MDHB Research Support Officer. Both positions work together to support clinical audit activity and reporting across Clusters and service areas.

Cluster Number of Clinical Audits in Quality Module

Uru Arotau - Acute and Elective Services 28

Uru Matai Matengau - Cancer Screening, Treatment 9 and Support

Uru Whakamauora - Healthy Ageing and 1 Rehabilitation

Uru Rauhi - Mental Health and Addictions 2

Uru Kiriora - Primary Public and Community Health 2

Uru Pa-Harakeke – Healthy Women, Children and 2 Youth

As the business partnership develops between the Quality and Innovation Team and the Clusters, and in keeping with the refreshed clinical governance framework, we anticipate developing audit programmes with all Clusters.

3.5 Quality and Safety Markers

The quality and safety markers reported below are national measures for all DHBs to ensure that we are taking steps to reduce actual and potential harm to our patients. Most of these measures are process orientated and reflect practice that will ensure a reduction in harm.

MidCentral DHB has historically achieved the majority of these markers. There was a small decline in our markers in safer surgery but these are not significant. There is specific work being led on improving hand hygiene performance and ongoing improvement initiatives in place.

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Marker Definition NZ Jul – Oct – Jan – Apr – On Goal Sep Dec Mar Jul Target 2017 2017 2018 2018 Preventing Patient Falls Percentage of patients aged 75 and 90% 95% No 98% 99%  over (Maori and Pacific Islanders 55 data and over) that are given a falls risk assessment Preventing Patient Falls Percentage of patients assessed as 95% 100% No 100% 100%  being at risk have had an data individualized care plan which addresses their falls risk Safe surgery: Percentage of audits where all components of the checklist were reviewed. • Sign in 100% 93% 94% 100% 94% X • Time out 95% 95% 100% 93% • Sign out 100% 98% 100% 95%

Safe surgery: Percentage of audits with engagement scores of 5 or higher (on a scale of 1- 7) • Sign in 95% 98% 98% 98% 94% X • Time out 96% 100% 100% 100% • Sign out 90% 92% 96% 93% Reducing Surgical Site Infections: Right antibiotics in the right dose – 2 100% 98% 100% 100% 96%  grams or more cefazolin given Reducing Surgical Site Infections: Antibiotic given (0-60 minutes before 95% 97% 98% 99% 97%  “knife to skin”) Patient deterioration Percentage of eligible wards using the 100% 100% 100%  New Zealand early warning score Improving Hand Hygiene: Percentage of opportunities for hand 80% 79% N/A* 75% 79% X hygiene for health professionals. Note: *Hand hygiene is audited three times a year, not each quarter. Unable to provide data due to the introduction new patient information system Patient deterioration was reported for the first time from 31 March 2018.  On target X Not on target

3.6 Consumer Experience

Our team believe Consumer Experience is much more than managing complaints, in accordance with the Health and Disability Commission Act i.e. “facilitate the fair, simple, speedy and efficient resolution of complaints”.

We want to ensure that we understand from our consumers, family/whānau, what matters to them and how we can identify opportunities for continuous improvement. We also want to share the compliments that we received, to share with our staff what we are doing well and how their experience with their care was received.

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There are multiple ways that our consumers can let us know how we are doing, e.g.: via an email, the phone, or the website or even in person. We also seek feedback from consumers as part of the national patient experience survey.

All of this information helps us, as an organisation, to ensure that we continue to do what has made a difference to our patients, family/whānau and to identify where we can work collectively to make improvements.

The consumer experience services are working to make enhancements to how we view, manage and respond to feedback, no matter how we receive it.

3.6.1 Feedback – Complaints

Figure 1: Total Number of Complaints September 17 – September 18

Total Number of Complaints Sept 17 - Sept 18 70 UCL 66.3 60 50 41.2 CL 40 Average 30 Number 20 LCL 16.2 10 0

During the period September 2017 to September 2018, we received a total of 536 complaints, on average this is 41 per month. The above chart demonstrates normal variation to the number of complaints we receive each month for the last 13 months.

Figure 2: Complaints by Issue Category

140 Complaints by Issue Category September 17 - September 18 120 100 80 60 Number 40 20 0

(NB. ‘Other’ category includes: facilities, equipment, referral declined, waiting time, confidentiality.)

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Overwhelmingly, the highest area where we can make improvements to our patients, family/whānau, is around our communication with them. This is closely followed by the second largest being around aspects of care. As our data system develops we will review these areas in more detail by Cluster to enable learning to take place.

The team will also be developing “Open Book” approaches to learning from feedback, which will review themes from our feedback system and share this widely with all our staff and with consumers.

3.6.2 Feedback – Queries

The definition of a query is any expression of concern by a patient/consumer/ consumers or their family/whānau/support person regarding any aspect of the service offered or provided by MDHB where an immediate response and resolution, and acknowledgement if appropriate is able to be gained.

Customer Relations may assist a consumer to reach an agreeable resolution to feedback concerns where an immediate resolution is desired by the consumer. Actions will be copied to the Service involved for their information including steps taken and noting an agreeable resolution. These can then be used for service improvement.

Figure 3: Total Number of Queries September 2017 – September 2018

Total Number of Queries Sept 17 - Sept 18 65 UCL 59.4 55 36.1 45 Average CL 35

Number 25 15 LCL 12.8 5 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

During the period September 2017 to September 2018, we received a total of 469 queries, on average this is 36 per month. The above chart demonstrates normal variation to the number of queries we received each month for the last 13 months.

3.6.3 Rating of Feedback

From 1 July 2018, all feedback including complaints and queries are assigned a rating of either minor, moderate or major.

Rating Descriptor Minor Resolution is straightforward consisting of an explanation, clarification of policy or procedure, investigation or an 222

apology/phone call/response letter to the consumer/family/whānau Moderate Resolution requires investigation, meetings with consumer, family/whānau and other providers, some corrective actions. Major Resolution requires extensive investigation, meetings with consumers/family/whānau and other providers, extensive corrective actions or reporting of event to regulatory body or authority.

This forms part of the enhancements to feedback reporting that will assist in the management of feedback. Appendix 1 outlines additional feedback reporting for clusters.

Figure 4: Complaint and Query Rating 1 July 2017 – 30 September 2018

Rating Number Minor 172 Moderate 31 Major 20

Further work will be progressed in our data reporting, on the number of complaints requiring an extension beyond the 15 working day standard of response and the number of HDC complaints by cluster. Trend reporting will be planned once analytical capacity is enhanced in 2019.

3.6.4 Feedback – Compliments

We are fortunate that many patients or their family/whānau take the time to tell us how we have provided them with a positive experience.

Figure 5: Total Number of Compliments September 2017 – September 2018

Total Number of Compliments Sept 17 - Sept 18 80 UCL 71.5 70 60 46.9 50 CL Average 40

Number 30 LCL 22.3 20 10 0 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

In the period September 2017 to September 2018, we received a total of 610 compliments. The average number of compliments received per month was 47. The above chart demonstrates normal variation to the number of compliments we received each month for the last 13 months.

Please refer to Appendix 3 for Cluster Reporting. 223

Figure 6: Compliments by Issue Category Compliments by Issue Category Sept 17 - Sept 18 300 250 200 150 100 Number 50 0

During the period September 2017 to September 2018, 610 patients wrote to us to show appreciation, and how grateful they were for the care that the provided for them.

3.6.5 National Patient Experience Survey

A national Inpatient Experience Survey is conducted by all DHBs every quarter. This survey is sent to a random selection of patients discharged over each quarter. All those with an email address are selected first, by an external provider, and then the remainder chosen randomly to make up 400, which in the minimum number required for this survey. This is currently for adult inpatients only aged 15 years and over and excludes Mental Health and Addictions.

The Quality and Innovation Team have commenced improvement work to ensure we make the most of the valuable information that our patients inform us about their experience of care, to celebrate what we are doing well and to also identify where we can make meaningful improvements for our patients.

There are several dimensions to this improvement work from developing more visual and user friendly reports for the organisation and clusters, to increasing the frequency that we seek feedback from consumers on their experience. An example of a more visual and user-friendly report can be viewed in Appendix 4. In order to reduce the burden from increased frequency of seeking patient feedback, related to a manual mail out of surveys, a small working group has been set up to increase the number of email addresses collected so we can utilise a less resource intensive process. As part of this working group, revisions to our privacy statements and general admissions sheets has been undertaken to inform our patients why we are collecting email addresses and what they can be used for. The campaign ‘Update Your Details’ ran for the week 15 October 2018. The resources will be used on an ongoing basis, including an electronic form on the MDHB internet site for the community to use to update their details. Please refer to Appendix 5 for campaign branding information.

For the latest results, the MDHB response rate was 40 percent. MDHB has consistently had a higher response rate than the national average. 224

Figure 7: Response Rate

A summary of the four dimensions are summarised below. The results in all four dimensions are slightly higher than the previous quarter and all are within normal variation parameters.

Figure 8: Score out of 10

3.7 Incident Reporting

All incidents are assessed against the Severity Assessment Code (SAC) rating. SAC ratings range from one to four, with one being the most serious. All events coded SAC 1 and 2, have a detailed review or investigation and report. Each will have detailed time lined action plan when recommendations are made as a result of any review or investigation. SAC 3 and 4 rated incidents are assessed to identify future potential risk and trends.

Please refer to Appendix 3 for Cluster Reporting. 225

Figure 9: Total Number of Incidents September 2017 – September 2018

Total Number of Incidents Sept 17 - Sept 18

600 UCL 548.7 411.7 500 Average CL 400

300 LCL 274.7

Number 200

100

Figure 10: The graphic below demonstrates the top 5 incident categories from September 2017 to September 2018

Top 5 Incident Categories Sept 17 - Sept 18 1400 1233 1200 1036 1000

800 668 643 Number 561 600

400

200

0 Conduct/Behaviour Clinical Medication Patient Fall Skin Integrity Management

Conduct/Behaviour/Abuse An incident that involves any of the following: intimidation, intent to harm, threatening behaviour, sexually aggressive or inappropriate behaviour or rape.

Incidents of violence are always of concern and are mostly experienced in the Mental Health and Addictions Service and Older Adult Mental Health. These incidents reflect the patient group who have serious mental illness. Admission to a mental health inpatient setting is often necessitated by significant clinical risk, which can include behaviours that pose a risk to others.

There has been a rise in recent months in the number of these incidents reported. This coincided with a specific patient admission. The number of incidents has now dropped to normal reporting levels. We will continue to monitor these incidents and take action to minimise these wherever feasible. The development of an occupational violence prevention strategy is being led by the General Manager, People and Culture. 226

Figure 11: Total Number of Conduct/Behaviour Incidents September 2017 – September 2018

Total Number of Conduct/Behaviour Incidents Sept 17 - Sept 18

160 UCL 149.2 140 120 94.8 100 CL Average 80

Number 60 40 LCL 40.5 20 0 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

Medication These incidents are defined as incidents involving medicines and IV fluids, in particular, errors associated with the selection of the patient, route, amount, dose, timing or prescription.

All medication incidents are forwarded to the Chief Pharmacist, who reviews these, in addition to the local service review being completed. The Chief Pharmacist reports any concerns to the professional leads and/or Medicines Advice and Policy Committee (MAPC), to ensure that improvement initiatives are identified and implemented. Work has commenced to improve medication incident reporting, with a focus on high risk incidents or medications, and mitigation plans, and will reported more fully in our next report.

Figure 12: Total Number of Medication Related Incidents September 2017 – September 2018

Total Number of Medication Related Incidents Sept 17 - Sept 18

90 UCL 83.7 80 70 51.4 60 Average 50 CL 40

Number 30 20 LCL 19.0 10 0 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

Patient Falls Any slip, trip or fall that may or may not cause injury, which happens to any patient or visitor while on MCH property or in the course of MCH business.

227

Figure 13: Total Number of Patient Falls September 2017 – September 2018

Total Number of Patient Falls Sept 17 - Sept 18 100 UCL 90.2 80

60 CL 49.5

Number 40

20 LCL 8.7 0 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

Skin Integrity Skin Integrity incidents are defined as “incidents involving pressure ulcers and wounds such as skin tears, blisters, bruises, burns, cellulitis, haematomas, rashes and other wounds”.

Figure 14: Total Number of Skin Integrity September 2017 – September 2018

Total Number of Skin Integrity Incidents Sept 17 - Sept 18 80 70 UCL 67.5 60 43.2 50 Average CL 40

Number 30 20 LCL 18.8 10 0 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

The Pressure Injury and Nutrition Action Group are continuing to work across the district to improve prevention and management of pressure injuries and to meet the requirements of the new QSM reported in the operational plan table above. So far in 2018/19 there have been two, SAC2 rated, pressure injuries reported. Following review of one of these events reported, the SAC rating was downgraded as more accurate information was available during the review on the stage of the pressure injury.

A number of initiatives are underway to further reduce the incidence of pressure injuries. A new assessment tool and mattress ordering process has been introduced across all adult inpatient wards to ensure individualised strategies are in place for all at risk patients. This is being audited intensively using the iAuditor tool with quality improvement in the local area the goal. This will provide data for our quality and safety measures and will be reported to the HQSC. Additionally, a 228

project funded by ACC has commenced with recruitment completed. Outcomes of the project will include: • Focused education across the district and agreed standards of care • Development of a district wide pressure injury database • Development of mechanisms to share information and improve collaboration and continuity of care • Establishment of a process to ensure equipment is provided in a timely way and tracked • Implementation of a people first approach to have greater engagement and information for the public to improve knowledge and capability to prevent the occurrence of PI • The project will include a co design approach to incorporate the consumer voice and stories. A dashboard is in place to enable the district wide pressure injury and malnutrition council to review to a detailed level all pressure injuries, ensure that all are staged and reported correctly and continuous improvement in processes and outcomes for patients is achieved.

Clinical Management Clinical Management incidents are defined as incidents which involve poor or inappropriate delay in provision of treatment or reduced staffing levels.

Figure 15: Total Number of Clinical Management September 2018 – September 2018

Total Number of Clinical Management Incidents Sept 17 - Sept 18

140 UCL 129.3 120 79.7 100 Average

80 CL

60 Number

40 LCL 30.0 20

0 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

3.8 Potential or Actual Serious Adverse Events

A serious adverse event is one that causes or has potential to result in a lasting disability or death of a patient, and is not related to the natural course of the patient’s illness or underlying health condition.

We want to ensure that we do not cause harm in any way. Unfortunately, events do occur and our aim is to learn and improve what we do as a result.

For the period 1 July 2017 – 31 October 2018, 18 potential or actual serious adverse events were reported by MDHB.

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These are related to the following:

MDHB (excluding Mental Health & Addiction Service)

Type Number Clinical process 11 (assessment, diagnosis, treatment and general care) Pressure Injuries (>stage 3) 2* Consumer/patient falls 4 Medication management 1

* One of these related to a pressure injury and the review has been completed and SAC rating subsequently downgraded.

Always Report and Review (including near misses)

Type Number Clinical Process 1

These numbers exclude serious adverse events in the Mental Health and Addiction Service which are reported separately.

There have been six potential SAC1 or SAC 2 events reported within the Mental Health and Addictions Service.

Mental Health and Addiction Service

Type Number Behaviour (e.g. intended self-harm, aggression, assault, 6 dangerous behaviour, suspected suicide)

In line with guidance from the National Policy, from the Health Quality and Safety Commission, we are aiming for all reviews to be completed within 70 working days with an agreed full action plan. Analysis of the average time taken, in working days, for the SAEs in 2017/2018 has been completed. On average, we achieve complete our reviews in 69.6 days. There is variation in completion time but these are minimised. Action plans are monitored and steps taken to ensure that these are evaluated to ensure that services are learning from serious adverse events and the required actions have been applied into practice.

As part of our commitment for consumer engagement, the Serious Adverse Events Governance Group is seeking an experienced consumer representative to be part of its standing membership.

4. RECOMMENDATION It is recommended that: • the content of the clinical governance and quality improvement report be noted • The Quality Agenda - Clinical Governance Framework be endorsed • progress in delivering improvements in Clinical Governance and Quality Improvement be endorsed.

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Barbara Ruby Acting Manager Quality Improvement and Assurance

Appendices:

Appendix 1 – The Quality Agenda 2018 Appendix 2 – Implementation Plan Appendix 3 – Cluster Reporting Appendix 4 – Example Inpatient Survey Report Appendix 5 – Update Your Details Poster

Appendix 1 - Quality Agenda 2018 231 TheQuality

AgendaShared Clinical Governance is Everyone’s Business 232

Ko Te Horo ki runga Ko Rangiwāhia ki raro Ko Ōahanga me Mātaikona Introduction ki te Tai tamawahine and Ko Tāwhirihoe ki te Tai Tamatāne Ko Ruahine ko Tararua ngā Tuahiwi Torino ana ngā Waiora huhua ki Hinemoana ki background Tangaroa Ko te rohe whānui tēnei o Te Pae Hauora o Ruahine o He kupu whakataki me te whakamārama Tararua

We all live in the MidCentral district. Our family and friends live here too. It’s our community. We want nothing but Te Horo to the South the best health care, and the best health and wellbeing for everyone. This includes our local population and the Rangiwāhia to the North people who require our support from other districts and neighbouring health boards. We recognise that as a system From Ōahanga to we have much to be proud of, but also that we often fall short of being the best we can be. There are instances Mātaikona to the East where it is hard to evaluate the quality of care and times when we don’t yet know what the best care looks like. We Tāwhirihoe to the West are committed to treaty partnership and will reflect this. There are also certain segments of the population who are Ruahine and Tararua are not receiving acceptable levels of support. A well embedded, all-inclusive and transparent shared quality agenda the summits (clinical governance) which is supported by all our staff, is a critical factor for us to achieve our vision of The many tributaries flow from the peaks to the Ocean This is the beautiful region of MidCentral DHB

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WE ARE ABOUT INDIVIDUALLY AND TOGETHER Better health outcomes, better health care for all WE WILL Ko tā mātou mahi Achieve quality and excellence by design Connect and transform primary, He whakapai ake i te hauora hei oranga mō te katoa community and specialist care Partner with people and whānau to support health and wellbeing WE WILL BE Achieve equity of outcomes across communities He mahi takitahi hei toa takitini Compassionate Respectful Kia kounga, kia hiranga te hoahoa Courageous Accountable Kia mahi tahi me te tangata, me te whānau hei tautoko i te hauora me te oranga Ka pēnei mātou Kia tūhono e pai ake ai te atawhai tuatahi, While all four Ka whai aroha Ka whai ngākau te atawhai hapori, te atawhai ngaio strategic Ka mātātoa Ka noho haepapa Kia tōkeke ngā hua mō ngā hapori katoa imperatives are relevant to the shared quality agenda, this WE WILL ACHIEVE THIS SUCCESS THROUGH OUR quality agenda is central to People Partners Information Stewardship Innovation achieving quality Ka eke angitu mātou mā of excellence by Ō mātou iwi Ō mātou hoa mahi Te whakamōhio Te tiaki Te auaha design.

To enable implementation of our quality agenda and improve system-wide engagement in clinical governance, we need to apply our four values: • Be compassionate – Ka whai aroha: By engaging and listening to our consumers, family/whānau; by promoting and delivering holistic person-centred care; by developing a culture of continuous improvement and learning. • Be respectful – Ka whai ngākau: Through encouraging diversity and inclusivity in decision-making. • Be courageous – Ka mātātoa: By challenging inequity in care or outcomes; by being open to new ways of working; by having and supporting an enquiring mind. • Be accountable – Ka noho haepapa: By delivering on the principles of the Treaty of Waitangi; being open to challenges and receiving feedback.

3 234

A whānau-centred approach to care involving several services culture was welcomed by a ahurea mum with a newborn baby and her whānau. quality kounga district rohe We want journey haerenga community hapori to achieve support tautoko Kia eke āngitū mātou service model A culture of quality that is embedded across our district and is evidenced at all points in the tauira mahi health care journey of our consumers, families and the communities we serve. To support the achievement of this strong quality culture we are transitioning to an integrated service decisions model across our district. An integrated service model is a health care approach that gives ngā whakatau consumers and whānau the experience of integrated care with the best possible outcomes. At the heart of the integrated service model is the development of seven clusters, supported sustainable by a number of enabler groups. The cluster arrangement is a structure that will enable us to tauwhiro organise our services to deliver an integrated health model and better outcomes for all. integrated Ultimately we will improve the consumer/whānau/family experience, reduce harm, improve tūhononga health inequities and improve the health of our community. We will measure our progress and success by identifying and reporting a suite of measures at district, organisation, staff cluster, service, team or community level. We will develop plans for improvement and be kai mahi accountable at all levels for sharing, improving and innovating our approach. voice reo 4 235 Whakamāramatanga Clinical Governance – Haumanu Whakahaere. What Is It – He aha tēnei mea? “put simply, clinical governance is a collaborative venture between clinicians, managers Definitions and consumers that aims to create a culture where quality and safety is everybody’s primary goal” (Flynn et al 2015). A clinical governance system encompasses all of the components of quality described below into a systems approach to ensure that we are always doing the best we can do with consumers, family/whānau and community. Clinical governance provides the framework that enables us to connect these components. Consumers and family/whānau will be engaged in all components through our plans in the consumer engagement framework.

Quality Quality Improvement Quality Assurance Quality Control the degree to which health services for individuals and a systematic approach using specific a process of verifying if a service a process by which quality is gauged and populations increase the likelihood of desired health techniques to improve quality. meets the required specification monitored in a service. It involves measuring, outcomes and are consistent with current professional This is the method by which we and customer expectations. reporting, and resolving problems in the process knowledge. It has six dimensions: safe, effective, undertake improvement initiatives. Primary goal is tracking and against the standard we expect, examples include equitable, timely, efficient and consumer-centred. The well-known process of Plan, resolving deficiencies in the service incident management, serious adverse event Quality encompasses the six dimensions of Do, Study, Act, is commonly used to prevent quality problems arising management and complaint management, and quality that will strengthen and sustain ongoing across our health care system. and is about putting in place a is about detecting quality problems. improvement in a systematised way. A high quality There are a wide range of other plan to prevent quality problems. Quality control is a process whereby services health system, service or team/ward, will be quality improvement tools, which Examples of quality assurance in look at individual stages of a process to achieving improvement in all six areas. It is important we use and will be implementing our healthcare system include determine if agreed standards have been met. to enable quality improvement across all six areas, in supporting the framework to be certification audits, service led For example when a complaint was made so to enable the best value consumer experience used in all settings. or external audits, credentialing by a family about inadequate processes for and health outcomes from our resources. Addressing processes, or external reviews. prevention of deep venous thromboembolism a single domain in isolation would create a lack of the process was reviewed against the agreed balance in the quality agenda for our health system. standard and a number of changes were made.

Kounga Te kounga whakapai ake Te kounga whakaū Te kounga whaimana

For the Integrated Service Model to work and to support a whole-of-system approach to enable the clusters, clinical governance, structures and systems will need to embrace all who care for our people in our district. If you care for our population, no matter your employer, your contribution to the Quality Agenda is vital.

5 236 the domains of quality E ono ngā mātāpono kounga matua

Domain Consumer Meaning Provider Meaning System Meaning

I will not be harmed by the The care my consumer receives Our safety system is robust and will Safe health system. does not cause my consumer to be identify if things are going wrong. harmed. It looks after our people (our Haumaru population and our staff).

I receive the right treatment for The care I provide is based on best Our quality culture supports quality Effective my condition, and it contributes evidence and produces the desired improvement, innovation and Whaihua to improving my health. outcome. research.

My goals and preferences drive Decisions about my consumers care We have an organised consumer Consumer- my care plan. My family and I reflect the goals and preferences of voice across our district that ensures centred are treated with respect and the consumer and his or her family we partner with people and whānau Arotahi dignity. I am centre of all my or caregivers. to support health and well being. 6 care decisions. Nothing about ki te kiritaki me without me.

The care I receive from all I deliver care to my consumer’s The integrated service model Efficient practitioners is well co- using available human, physical and ensures cluster and system wide coordinated and efforts are not financial resources efficiently, with ordination. Resources are deployed to Māia duplicated. no waste to the system. ensure best value for our community.

I know how long I have to wait My consumer can receive care within Our integrated system will ensure Timely to see my health care team for an appropriate and acceptable time people receive health care in a timely tests or treatments I need and after the need is identified. way. Wā tōtika why. I am confident this wait time is safe and appropriate. Feedback from cancer patients has resulted in No matter who I am or where Every individual has access to the We have strong and enduring health a special menu being I live, I can access services that services they need regardless of his equity leadership across the district developed for cancer Equitable benefit me. My care services are or her location, age, gender or socio- at all levels. patients with symptoms planned to ensure equitable economic status. The treatment I impacting on their Kia tōkeke ai outcomes, not equitable care. provide aims to ensure equity of appetite and wellbeing. outcome so may be different to suit the specific needs of the person.

6 237 Principles to support a culture of quality Ngā mātāpono matua kia pai ake he ahurea ā-kounga

A culture of quality can only happen when we stay true to the following:

Ā taumata pūnaha hauora At system level

Ma te arotau ka whakapai ake ā-kounga It is focused on improving quality

Our proposed framework for a high quality health-care system is about more than improving discrete services or outcomes. In order to have a system- wide impact, efforts to improve quality must have a broad focus, across the full range of quality dimensions and work across sectors to reflect the consumer journey and encompass Māori worldview approaches and solutions.

Me tūhono te hauora me te atawhai, kaua te hauora te tino aronga It is about health and wellbeing, not just health care

Too often our focus is on taking care of people after they become ill or crisis management. A health care system focused on quality must be concerned with preventing illness – through health promotion and illness prevention – just as much as with treating illness. It must acknowledge the importance of the many factors that shape an individual’s health. Encompassing and recognising Whānau Ora as part of the health system will enhance this focus.

Kia whiwhi te katoa It is accessible to everyone

Currently, our focus is on improving care for consumers accessing the system. Meeting the health needs of those who cannot easily access the health care system can often be neglected. If we are to commit to continuous quality improvement, we must provide access for all regardless of how far consumers live from where the services are provided, what language they speak, their health status, their cultural preferences or other sociodemographic factors. Programs and initiatives must take into account issues of equity, address them where possible, and avoid contributing to barriers to access for marginalised populations. 7 238

Kia whaihua ai e te Kiritaki It is responsive to the needs of the consumer

As we build a culture of quality, we need to co-design our health care system in partnership with consumers and families. Consumers and providers alike feel the effects of the disjointed nature of the health system. Recognition of the Treaty partnership means the integration ofMaori values, concepts and practice models. Communication between hospitals and primary care, for instance, continues to be a challenge, true system integration is our goal. As our clusters mature, our system will facilitate consumer and provider roles so we will achieve common goals.

Ka whakatutuki i te paerewa i waenga i ngā kaupapa matua e whakataetae ana It achieves a balance among competing priorities

Strategies for improving our health care system must consider safety and effectiveness, accessibility, and consumer experience while also maximising efficiency and equity. Although these priorities may appear to be in competition, it is not always the case. There are many examples in our health system that demonstrate how delivering higher quality care can actually contribute to more efficient operations or more equitable outcomes. Improvement efforts need not neglect one dimension at the expense of those that are harder to change or take longer to show improvement.

Hei aha pea te whakamahi I tētahi pūtea hou It may not depend on the infusion of new funding

With little new money invested, a re-allocation of existing resources is called for. Scarce financial and human resources need to be directed to the areas of greatest impact on consumer outcomes according to the best evidence. Reducing medical errors, strengthening supports for health promotion, prevention, and screening, and improving care coordination are just some of the investments that can lead to better consumer experiences and health outcomes and bigger system savings. Applying Maori values and an equity of health care outcomes lens is essential to ensuring best use of resources. Our focus needs to shift to creating improved value; this is the best possible outcome for our population from the resources we can access.

Kia waihangatia he punaha hou It requires fundamental change

Recognition that our current health care system delivers care of high quality to some and not to others leads to our need to adapt the quality of our health system to meet the needs of those it is currently failing. Fundamental change is required to advance the quality of health service provision across the district. This change will only occur if all partners are familiar with the quality agenda and are committed to it across all settings. We recognise that when quality has been made the main focus, significant improvement in the consumer experience, outcomes and sustainability can occur.

8 239 Kia Kotahi Ra Te taumata aropū At cluster level

Consumers Data and Understanding Improving Demand, Enthusing, Involving Leadership An open Identification Multidisciplinary and their measurement the process to reliabilty capacity involving consumers/ that culture of trust, and control working that carers/ for identify and of and flow and family/ motivates openness, of risks to focuses on the family/ improvement explain the processes and their engaging whānau/ staff respect and achieve interdependence whānau are are vital problem and and relationship all staff carers and towards caring where effective, between our primary elements of why it exists systems to to each community ownership achievements efficient individuals and focus any attempt mitigate other is when of common are recognised, and positive groups delivering to improve against clearly designing goals and errors openly outcomes services quality and waste, and understood improvements drives disclosed and assess impact reduce and measuring sustainable learning is error and results change supported harm

Te taumata Tīma At team level

Focus on Support Avoid Focus on system Led by clinicians, Multidisciplinary Data to inform Evidence-based An enabling and involve integrated care duplication and and structure for in services to approach is improvement practice is leadership consumer and by working promote shared improvement support shared adopted is routinely enabled supports team whānau toward joined-up learning (not individual learning provided level continuous care around our performance) improvement consumers

9 240 Shared governance at He rau ringa I oti ai team level

The shared quality agenda needs to be understood and integral to practice across all health service settings. Achieving quality and excellence will be dependent on the people working within the clusters across multiple settings, with various and diverse teams. A shared quality agenda will lead to collective ownership and shared decision making at all levels. From the point of care, the Quality Agenda will be built into service delivery and will be led by the Clinical Executive and supported and monitored in each cluster. The Clinical Board and Board ensure support and enabling leadership to support us in meeting our Quality Agenda goals and measures. Formal and informal multidisciplinary activities that contribute to the cluster achieving their goals and to the success of the system level measures and goals will be required. A forum will provide a defined place to be represented and to engage and participate at many levels on quality matters such as morbidity and mortality reviews, incident reviews and learning, consumer feedback, safety issues, cultural confidence in practice and a team approach to identifying and driving quality improvement initiatives. It will also be important that teams have a shared philosophy that embodies their approach to quality and consumer safety such as “Tirohia – See it, Kōrerotia – Say it, Whakatikaina – Fix it, Tohaina – Share it.” Simply put this means identifying a safety or improvement issue, reporting it, addressing it at unit, ward or team level, and importantly sharing your learning with others. Ensuring Māori health concepts such as Whare Tapa Wha (the four sided house) are considered and utilised to support a culture of safety is an essential part of the Quality Agenda. Whare Tapa Wha clearly articulates the importance of balance within health care provision. People are more than their physical, consideration of their spiritual, whānau, and emotional needs is essential to quality of care.

a truly multidisciplinary approach we share challenges and celebrate succeses improved staff morale we share in decision making everybody has a say i have a voice in my workplace

10 241 He rau ringa I oti ai – Ma te katoa te mahi atawhai Shared Clinical Governance – is Everyone’s Business at Every Point of Care

What is it? • A model for empowering staff • A model for engaging with all disciplines – consumers, family/whānau, and all providers – to support the care and wellbeing of our community whether in hospital or at home. • ‘True’ shared governance is when our staff, our consumers and our system partners are empowered to make decisions on the quality of care. • All teams/units/services in our district need to embrace a shared governance model.

What can it do? Young people aged 12 to 24 said that it • Create a place for team decisions to be made about care, plans, processes or day to day improvements, by those was too hard to find delivering that patient care – the team at point of care information about health • Empower staff in shared decision making, continuous improvement and accountability services. They lead the • Foster leadership at the point of care development of an app • Promote teamwork with fair and transparent decision making at all services/units/wards or providers. to meet their needs.

Across the 24/ 7 district Nursing Service frontline Central PHO promotes the environment for In the ED we have restarted our critical District clinicians provide the clinical situation of each Primary excellence in service delivery and improved clinical incident meetings, and we have opened them client via workload pre- scheduling to inform the outcomes across the PHO network of providers Hospital up to house officers, paramedics, nurses Nursing workload allocation for upcoming shifts. The day Care through developing and facilitating processes and those inpatient specialties involved in coordinator assesses the predicted workload and tools required to enable health care teams to each case. We have also reset the tone of and capacity continuously across the district and continuously monitor and improve the quality of the meetings and now look at each case supports the flexing and allocation of available staff. their care provided. An example of this is the co- from a quality assessment and improvement Staff within teams are encouraged to flex workloads design of contributory measures for the Ministry perspective. We are concerned with not only within, including utilisation of General Practice of Health System Level Measures Framework and cognitive biases at the individual level but Team partners. The DNS is currently piloting a the sharing of non-anonymised data across the also with larger systemic dysfunction that variance response management (VRM) tool to alert provider network. This has encouraged practices may have lead to a less than ideal outcome. the wider organisation to capacity issues as they who are “doing well” to share their approach with We think that looking at difficult cases arise and are working on linking this to the hospital practices who are not “doing so well”. General regardless of outcome is incredibly valuable, operations centre. Nurses are continuously engaged Practice teams’ knowledge has increased of looking closely at what the team did well in in quality improvement in the service with a focus on system measures like ED presentation and ASH managing a challenging case will go a long workload, safety and wellbeing of staff and patients. through this shared governance approach. way to building reliability and resilience.

11 242 Tō mātou rau ringa kounga rārangi take Our Shared Quality Agenda

A shared quality agenda supports the system to work together for higher quality healthcare and improved system level outcomes. He Korowai Oranga – The National Māori Health Strategy 2014 provides three clear quality concepts to set priorities, goals, tactics and measures using a Māori worldview. The concepts are simple, they include three elements:

Mauri Ora Whānau Ora Wai Ora Healthy Individuals Healthy Families Healthy Environments The concept of mauriora captures the The concept of whānau ora is about The concept of Wai Ora encapsulates the importance of the importance of the individual. It sets supporting families to achieve their environments in which we live and that have a significant direction for the health system to ensure maximum health and wellbeing. Each impact on the health and wellbeing of individuals, whānau and that Māori as consumers of health whānau is different and has a unique communities. Wai Ora literally refers to water, both as a resource services, have pathways to care that meet set of aspirations. To achieve whānau and an essential part of the environment that provides sustenance their immediate needs as well as their ora the health system will work in a way for life. Achieving Wai Ora will mean that the environment in future needs across all stages of life. that acknowledges these aspirations. which Māori and all New Zealanders live work and play is safe. The health system can make a significant It pertains to our health and wellbeing environments, it also contribution to helping whānau achieve reminds us that addressing the determinants of health, is essential their aspirations particularly those related to improving outcomes for Maori, this is something we can effect, to their health and wellbeing. have impact on and change as a health system.

Our framework supports all providers to have shared goals. These are in the form of national health targets, system level measures, cluster improvement goals and measures and team level indicators of quality and safety. All contribute to New Zealanders living well, staying well and getting well. 12 243 Measuring effectiveness He inenga tōtika o te haumanu whakahaere of clinical governance

can’t manage or improve what we can’t measure E kore mātou e whakahaere ana me te whakapai ake te mea tē taea te inehia Measurement is used to focus improvement efforts and to track long term progress in improving the quality of care and improving the health of our population. A WE continuous quality improvement process has at its centre a step to ensure measurement is undertaken on a regular basis. Improvement methodologies including Plan Do Study Act (PDSA) explicitly refers to measuring in the reference to study, simply put if we don’t measure we don’t know where we started, what our goal is or how we are progressing. The framework supports measurement at all levels. This will include areas we must measure, system level measures, cluster goals and measures, and team or provider measures. We will measure both process and outcome metrics.

receives the information Mā wai te pārongo e pānuitia The high level system wide measures will form a core part of reporting for all, including the seven clusters. Each cluster will then identify subsets of measures relevant WHO to their unique client group, service delivery and setting. will I find the information Ko hea te pārongo ka taea We will develop online dashboards to support all teams, clusters and system level measures to be reported, analysed and support continuous improvement. WHERE These will be designed with consumers and clinicians and be relevant to the team, service or cluster. will identify opportunity for improvement Ma wai e whai wāhi ana he ara kia whakapai ake All of us, at every level and in any role, have a part to play in critically evaluating information, seeking or providing supporting evidence and individually or collectively WHO identifying opportunities for improving the quality of care. The pathway for this is through your team, ward, unit, service and/or cluster and/or your professional council. This will lead to shared decision making at all levels, collective ownership of issues and achievements and will enable continuous quality improvement by those providing and supporting the delivery of care.

13 244

Individual Team Ward, Site Service, IFHC CPHO, Locality Board Dashboard Tararua, Horowhenua, Otaki, Manawatu, Palmerston North

MidCentral DHB and all partners recognise the importance of data to inform operational delivery, quality and safety, quality improvement, performance, future planning and evaluation of our service. We are committed to development of a dashboard of indicators which supports all our staff and our partners to use data effectively and efficiently. We recognise this is an area of development for MidCentral district and all our partners. Cluster leaders, managers and clinical staff have indicated how critical this is to the successful implementation of the quality agenda and any clinical governance system. To support improvement in this area, we will work with clusters and consumers to identify measures and indicators that matter to them, to support their priorities aligned to this framework, as well as ensuring the data we need for continuous operational and performance measurement are available in a format that supports our teams to deliver high quality care. Over time as our analytics and information systems develop, we expect to be able to review and respond to information at many levels, supporting quality monitoring and assurance work with individual patients, within teams or professions, in a ward or health team location, and at aggregate level in our integrated family health centres, at locality level, cluster level or at district or Board level. Being able to slice and report outcomes, process improvement measures, consumer experience feedback and system performance measures etc and enable access and ownership of this data is critical to the culture of improvement we are seeking to support. We also will enable teams to drill down, as it is vital we support our people and our consumers to engage in driving the quality of their own health care experience or care, and in quality assurance or improvement activity.

Health Targets System Level Measures Quality & Safety System Markers Shorter Stays in Emergency Departments Amenable mortality Falls prevention Improved access to elective surgery Smokefree households Surgical safety checklists Faster cancer treatment Ambulatory sensitive hospitalisations Surgical site infection rates Increased immunisation Youth appropriate services Hand hygiene rates Better help for smokers to quit Acute hospital bed days Deteriorating patient measurement Raising healthy kids Patient experience Safe use of opiods More heart and diabetes checks Pressure injury rates and prevention

14 245 The quality network explained Te kōtuitui kounga whakamārama

Clinical Boards – Ngā poari haumanu

These are the peak body responsible for leading clinical governance in each provider. How clinical boards and sovereign body boards will connect and support our health system will be further considered, as our cluster structure evolves.

Professional Councils – Ngā kaunihera ngaio

There are currently four professional councils representing nursing and midwifery, allied health, medical and clerical groups in MidCentral DHB. Their membership and scope will be developed to govern, lead and support their professional group across the system. Their work programme will be based on a subset of indicators relevant to their professional group.

Consumer Council – Ngā kaunihera Kiritaki

The Consumer Council provides independent strategic consumer perspective and commentary on all matters regarding implementation of our strategy and will ensure that consumers are engaged with all areas of the system, at all levels and in all activities. They also provide advice and support to help us achieve a person and whānau-centred partnership and model of care, where patients are partners in their own health care and consumer engagement and participation occurs throughout the district. The Council is representative of our diverse and widespread community.

Clinical Council – Kaunihera haumanu

The Clinical Council provides independent strategic clinical perspective and commentary on all matters regarding implementation of our strategy across the health and wellbeing system. The Council provides input on planning priorities, clinical leadership, systems, quality and on factors influencing both the health and wellbeing of the people of our district and the local health sector.

15 246

Expert Clinical Groups – Ngā rōpū ngaio

These groups each represent a specialised function who govern, lead and drive active improvement across their specialist function. They are representative of experts in that particular field and those who intersect at critical points of this function. For example the Medicines Advice and Policy Committee includes a midwife, given they have a role in prescribing and administering medicines. These groups, where relevant, be reviewed to enable them to support the clusters as they support their work across the system.

Enabler – Ngā uru whakamana

An enabler is a service that supports or enables clusters to succeed. Enablers will develop their business partnership to support a culture of quality and safety in all clusters services.

Cluster Clinical Governance Group – Uru haumanu whakahaere

The cluster arrangement is a structure that will enable us to organise our services to deliver an integrated health model. There are seven service clusters, including Haoura Maori that are the vehicle by which our integrated service model is delivered. Each cluster will have its own Quality and Clinical Governance Group (QCGG). This group will be led by the Clinical Executive and will be representative of professional groups, providers and services that make up the cluster from across the health care system, and it will include consumers. The QCGG will have a work programme that reflects a whole of system approach and will also develop subsets of measures that are relevant to the cluster and component parts. The work programme will address all aspects of clinical governance as relevant to the cluster priorities and population health needs.

Team/Service Shared Governance Group – He rōpū rau ringa whakahaere

Each cluster will have a variety of shared service governance groups (SSGG) depending on the diversity and configuration of services across a cluster.

16 247

Our framework Tā mātou mahere ā-mahi All clusters will support the Quality Agenda. They will act on, promote, celebrate, lead and learn from use of the framework. Ka eke angitū mātou mā – We will ensure:

An engaged workforce via applying shared governance Safe Effective Consumer-centred Efficient Timely Equitable models Haumaru Hāngai tonu Arotahi ki te kiritaki Māia Wā tōtika Kia tōkeke ai

Measure what Unwarranted Audit is Waste is identified Access to care matters including variation is measured embedded and Learning from feedback and eliminated where is measured and clinical and patient and a focus of Integration; via learning shared possible proactively managed development of reported outcomes improvement efforts wraparound models of Incidents are Focus improvement Outcomes are care and alliancing reviewed an Building models based on Duplication of efforts No harm is caused due efforts on areas measured using an approaches trends observed partnership is avoided to delays in care requiring attention equity lens and acted on

Waiting lists are actively Learnings from Multidisciplinary Hauora Maori All efforts are focused reviewed and risks to adverse events teams engage in Engage consumers in all Cluster activities are Engaged active on valuing consumers’ outcomes are identified, are applied morbidity and levels of governance applied to achieve consumers; via applying time and escalated as rigorously mortality reviews improvement our engagement appropriate framework Credentialing Variation is Measurement will at all levels Value in how we Waiting times are a progressively measured and Practice supports consider quality of deploy healthcare feature of continuous improves service reduced where person-centred goals life and other holistic resources is prioritised improvement activity delivery appropriate metrics

Resources are Clinical risks Contemporary models Health literacy is directed towards are reported, Benchmarking is of care and new ways supported and enabled for escalated and supported of working are openly agreed quality consumers in all activities improvement actively managed encouraged/supported activity Research is Patient reported outcome encouraged and measurement will become enabled routine practice 17 248 Achieve Kia kounga kia hiranga te hoahoa quality & excellence by design

What difference will it make and what does this mean for me?

ACROSS OU NAU R CO OVIDERS OF CA HĀ MM PR RE A W U F & CR D NI F O N TY TA SS A S O LY I play my part in improving safety U I R M I had a positive experience of care A I use resources effectively, with no waste H F E , A E I feel well informed I strive for excellence in the care I provide L L T H P

My views are respected & O I participate in ongoing professional development

P I know how long I will have to wait I have time to focus on quality and excellence E

L L

I can access services that benefit I am encouraged and supported to be innovative B

me and my whānau I am open to change and willing to be challenged N G

I feel safe when receiving health care S My ideas are listened to and valued Y

E The care I provide is person-centred M

18 249

Commit to embracing the six dimensions of quality into all decision making Have credible, capable and Enable the engaged continuous leadership pursuit of Whānau Ora excellence in care Healthy Families delivery

Promote quality through everything that Develop we do Our and support a capable, accessible commitment and empowered from “Point of work force Wai Ora Healthy Environments Care to Board” Support active We will... and engaged consumers Recognise and reward quality

Ensure what Mauri Ora is important is Create measured not just supportive Healthy Individuals what is easy to clinical governance measure structures that enable a whole of system view

MidCentral District Health Board would like to acknowledge the work of Health Quality Ontario, Canada. This has helped to shape this document. 19 19/11/2018 250

Te Wao Nui a Tāne A system that is connected & supportive

20 251

Appendix 2 - Implementation Plan

Plan Owner: Judith Catherwood Approved by: Kathryn Cook Date: November 2018

The Quality Agenda – Clinical Governance Framework is a central support to our Clusters, our entire health and wellbeing workforce, consumers and communities. The implementation plan will progress in phases over the course of 2018/19 and across the next two years. The phases will address development of the quality agenda within the MidCentral DHB and with all partner providers and agencies.

Rating & Trend Legend

On Track, Behind plan – Behind plan – Not completed progressing as remedial action major risks and as planned G A R D planned plan in place exception report required

Improved from Regressed from No change from    last report last report last report

Actions Person Due Status Comments Responsible Approve, launch and publish Judith Nov Plan post HDAC Catherwood 2018 endorsement Identify implementation lead Judith Nov Confirmed Catherwood 2018 Develop communication plan and core messages Jonathon Dec Plan post HDAC Howe 2018 endorsement Building Quality and Safety Capability Sourced from “NHS Building Capacity and Capability for Improvement” 2017 and “From Knowledge to Action; A framework for building quality and safety capability in the New Zealand Health System” HQSC 2016.

252

Actions Person Due Status Comments Responsible Develop a partnership and plan with HQSC and/or other Judith Feb Ongoing DHBs/agencies to plan and roll out the programme for capability Catherwood 2019 building Enable and promote access to Improving Together e-Learning Barb Ruby Feb Modules (HQSC) for all staff. 2019 Develop a staged education programme suitable to meet the Judith March Education knowledge to action requirements of all including front line staff, Catherwood 2019 programme will clinical and operational leaders, executive, service improvement be scoped and co- leads. There will be an annual workshop for Committee/Board designed with members. Clusters and Level 1 quality improvement education programme, identifying Enablers improvement, identifying problems, change ideas, testing and measuring change (All front line staff) Level 2 programme of quality improvement education, measurement and using data and leading teams in QI. (Clinical and operational leaders) Level 3 programme suitable for executive or senior leadership on improvement methodology, understanding variation, coaching teams, sponsoring or leading improvement, and implementation and supporting spread. (Executive level including cluster and service improvement leaders) Support and enable MidCentral DHB staff in engaging in national Judith Ongoing Will be further and local quality assurance and support training and initiatives Catherwood progressed Develop toolkit for use by all staff/teams/services/clusters Barb Ruby March To be progressed and Quality 2019 after HDAC Team endorsement Building a Culture of Quality Assurance and Improvement Develop quality assurance and improvement team resources and Judith April Commenced role capability to support delivery of framework Catherwood 2019 review to meet future requirements 253

Actions Person Due Status Comments Responsible Implement the shared governance model in all professions and Celina Eves, April Nursing have support implementation in all teams Gabrielle 2019 commenced work Scott, Ken as the early Clark adopter Develop the audit and research support systems to support Kelly Butler June To be progressed teams/clusters and Nicola 2019 Buckland Complete RFP for electronic clinical audit tool to support our Grieg Russell March Steering Group Clusters 2019 being established Implement speaking up for safety and promoting professional Gabrielle April Already in accountability programme Scott and 2019 progress Keyur Anjaria Develop a reward and recognition programme and awards system Judith March To be progressed to support the Quality Agenda Catherwood 2019 during 2019 and Keyur Anjaria Implement an end to end consumer experience plan including Judith June Work has already revised whole of system customer feedback system Catherwood 2019 begun as reported to Committee Develop clinical risk management process: development, reporting Judith April Cluster and Catherwood 2019 oversight and Darren reporting will be Horsley progressed Clinical Governance Structure Review and make recommendations for improvement in clinical Judith Feb To be progressed governance structures, meeting approach, membership and Catherwood 2018 reporting to Clinical Board Review and make recommendations to support effective clinical Judith Dec This work has governance structure within clusters including ensuring appropriate Catherwood 2018 already linkages with other contracted providers commenced to 254

Actions Person Due Status Comments Responsible support Cluster governance Develop reporting to HDAC from across the clinical governance Judith March Analytics capacity system to ensure a whole of system approach is taken and Catherwood 2019 commences in considered at Committee January which will support this activity Ensure effective relationship and reporting process is in place with Judith Ongoing Ongoing outside agencies e.g. HQSC, HDC etc. Catherwood Establish professional councils and shared governance Celina Eves, June Nursing have approach/structures/leadership and work programme Ken Clark 2019 commenced a and review, others to Gabrielle follow Scott Transition to the new structures and evaluate Judith Dec Catherwood 2019 Clinical Governance and Improvement Measures - Dashboard Development Develop data analytics capacity to support quality and improvement Darryl Purdy Jan Analytics capacity measures and indicators i.e. principle data analyst 2019 to commence in January 2018 Develop and agree core indicators and measures for reporting at Judith March Extension of HDAC Catherwood 2018 existing measures will progress Develop and agree core indicators and measures at organisational Judith Feb As above level for Clinical Board Catherwood 2018 Work with Clusters to develop appropriate measures and indicators Judith March As above Catherwood 2019 Develop and agree measures and indicators for Professional Celina Eves, June As above Councils Gabrielle 2019 Scott, Ken Clark 255

Actions Person Due Status Comments Responsible Develop dashboard presentation, functionality and usability for Darryl Purdy August New platform in teams, Clusters etc. 2019 development Support education and workforce development necessary to support Principal March dashboard use Data Analyst 2018 onward s Consumer and Community Engagement Complete and implement the consumer engagement framework Lee Welch Dec In progress 2018 Implement relationship based practice educational programme in Lee Welch June In progress partnership with Central Region 2018 Increase use of patient reporting outcome/evaluation measures in Principal Ongoing practice and in clinical governance reporting Data Analyst Engage consumers and communities in all aspects of work via Judith Dec In progress locality forums, Cluster Alliance Groups, Consumer Council and Catherwood 2018 other relevant governance or engagement meetings Evaluation and Review Determine baseline measures to support future evaluation Judith Dec Catherwood 2018 Regularly review the implementation programme through a treaty Stephanie Ongoing Commenced and partnership e.g. equity requirements, bi-cultural perspective Turner ongoing Evaluation of implementation of The Quality Agenda - clinical Judith Dec governance framework progress Catherwood 2019 Re-audit: Internal Audit of Clinical Governance system Internal July Audit 2020

256

Appendix 3 – Cluster Reporting

Uru Arotau - Acute and Elective Services

Figure 16: Figure 17:

Incidents - Acute & Elective Compliments - Acute & Elective Sept 17 to Sept 18 Sept 17 - Sept 18 250 UCL 229.8 50 200 40 UCL 40.7 CL 150 166.4 30 Average CL 25.2 100 LCL 20 Number 103.0 LCL 9.7 Number 10 50 0 0

Jul-18 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Aug-18 Nov-17 Mar-18 May-18

Figure 18: Figure 19:

Complaints - Acute & Elective Queries - Acute & Elective Sept 17 - Sept 18 Sept 17 - Sept 18 50 40 UCL 36.8 UCL 42.0 35 40 30 19.7 25.8 25 Average 30 CL 20 CL Average 15

20 Number Number 10 10 LCL 9.6 5 LCL 2.6 0 0

Jul-18 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Aug-18 Nov-17 Mar-18 May-18

Figure 20: Number of Complaints Closed (by rating) and Average days to resolve

Complaint Rating Month Number Average Days Rating tbc August 2 12 Minor July 17 13 August 18 14 September 6 9 Moderate July 4 31 August 2 16 September 4 13 Major July 2 20 August 1 7 September 1 18 Total: 57 Average: 14

257

Uru Matai Matengau - Cancer Screening, Treatment and Support

Figure 21: Number of Incidents Figure 22:

Incidents - Cancer, Screening & Treatment Compliments - Cancer, Screening & Treatment Sept 17 - Sept 18 Sept 17 - Sept 18 35 UCL 32.8 14 UCL 13.3 30 12 25 21.5 CL 10 20 Average 8 15 6 5.1 Number CL LCL 10.2 Number 10 4 Average 5 2 0 0

Figure 23: Number of Complaints Figure 24:

Complaints - Cancer, Screening & Treatment Queries - Cancer, Screening & Treatment Sept 17 - Sept 18 Sept 17 - Sept 18

5 6 5 UCL 4.9 4 UCL 3.9 4 3 3 1.2 2 2 Average 1.0 Number CL Number CL 1 1 Average 0 0

Figure 25: Number of Complaints Closed (by rating) and Average days to resolve

Complaint Month Number Average Rating Days Minor July 2 4 Moderate August 1 31 Total 3 Average 13

258

Uru Whakamauora - Healthy Ageing and Rehabilitation

Figure 26: Figure 27:

Incidents - Health Ageing & Rehab Compliments - Healthy Ageing & Rehab Sept 17 - Sept 18 Sept 17 - Sept 18

60 UCL 56.7 6 UCL 5.6 50 40.9 5 CL Average 40 4 2.5 30 LCL 25.2 3 CL Average 20 Number

Number 2 10 1 0 0

Figure 28: Figure 29:

Complaints - Healthy Ageing & Rehab Queries - Healthy Ageing & Rehab

Sept 17 - Sept 18 Sept 17 - Sept 18

5 6 UCL 4.4 UCL 5.3 4 5 4 3 3 2 1.3

Number 1.3 2 Average

Number CL Average CL 1 1

0 0

Figure 30: Number of Complaints Closed (by rating) and Average days to resolve

Complaint Rating Month Number Average Days Minor August 3 10 September 2 15 Moderate July 1 45 September 1 16 Total 7 Average 17

259

Uru Rauhi - Mental Health and Addictions

Figure 31: Figure 32:

Incidents - Mental Health & Addictions Compliments - MH&AS Sept 17 - Sept 18 Sept 17 - Sept 18

250 14 UCL 11.9 200 UCL 202.9 12 10 126.2 4.6 150 8 CL Avera… Average

Number 100 6

Number CL 4 50 LCL 49.5 2 0 0

Jul-18 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Aug-18 Nov-17 Mar-18 May-18

Figure 33: Figure 34:

Queries - MH&AS Complaints - MH&AS Sep 17 - Sept 18 Sept 17 - Sept 18

14 12 UCL 10.2 12 UCL 11.6 10 10 6.1 8 8 Average 6 4.7 6 CL CL

Number Number 4 Average 4 2 2 LCL 0.5 0 0

Jul-18 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Aug-18 Nov-17 Mar-18 May-18

Figure 35: Number of Complaints Closed (by rating) and Average days to resolve

Complaint Month Number Average Days Rating Minor July 2 16 August 5 17 September 5 13 Moderate August 1 43 Total 13 Average 17

260

Uru Kiriora - Primary Public and Community Health

Figure 36: Figure 37:

Incidents - PPC Compliments - PPC Sept 17 - Sept 18 Sept 17 - Sept 18 60 12 50 UCL 48.2 10 UCL 9.7

40 8

30 6 CL 23.8 Number 20 4 2.6 Average Number CL 10 2 Average 0 0

Figure 38: Figure 39:

Compliments - PPC Queries - PPC

Sept 17 - Sept 18 Sept 17 - Sept 18

4 UCL 3.7 3 UCL 2.5 3 2 2 0.6 Number Number 1 1 CL Average CL 0.8 0 0

Jul-18 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Aug-18 Nov-17 Mar-18 May-18

Figure 40: Number of Complaints Closed (by rating) and Average days to resolve

Complaint Month Number Average Rating Days Minor September 1 8 Moderate August 1 14 Major August 1 19 Total 3 Average 14

261

Uru Pa-Harakeke – Healthy Women, Children and Youth

Figure 41: Figure 42:

Incidents - Healthy Women, Child & Youth Compliments - Healthy Women, Children & Sept 17 - Sept 18 Youth 45 Sept 17 - Sept 18 40 UCL 38.4 10 35 UCL 8.6 30 8 25 3.8 20 CL 19.5 6 Average

Number 15 Average 4 CL Number 10 2 5 LCL 0.7 0 0

Figure 43: Figure 44:

Complaints - Healthy Women, Children & Youth Queries - Healthy Women, Children & Youth

Sept 17 - Sept 18 Sept 17 - Sept 18

8 UCL 7.3 6 5 UCL 4.9 6 2.5 4 3 Average 4 2.8 CL CL 2 Number Average 2 Number 1

0 LCL 0.0 0

Jul-18 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Aug-18 Nov-17 Mar-18 May-18

Figure 45: Number of Complaints Closed (by rating) and Average days to resolve

Complaint Rating Month Number Average Days Minor July 3 24 August 1 15 September 2 26 Moderate August 1 33 Total 7 Average 25

262

Appendix 4 – Example Inpatient Survey Report

263

264

265

266

267

Appendix 5 – Update Your Details Poster

268

For:

Decision X Endorsement X Noting

To Health and Disability Advisory Committee

Author Dr Bart Baker, Clinical Lead, Choosing Wisely John Manderson, Programme Manager, Quality and Innovation

Endorsed by Judith Catherwood, General Manager, Quality and Innovation

Date 19 November 2018

Subject Choosing Wisely Progress Report

RECOMMENDATION It is recommended that: • the content of the report be noted • the progress with Choosing Wisely in MidCentral district be endorsed.

Strategic Alignment This report supports the DHB’s strategy and specifically our strategic imperative of achieving quality and excellence by design through the key enablers of “Stewardship and Innovation”. The Plan supports the DHB to enable change in our models of care, systems and processes. This will ensure the delivery of best value, through best use of our resources to meet our population’s healthcare needs and wellbeing.

Glossary

CPHO Central Primary Health Organisation DHB District Health Board ELT Executive Leadership Team EPMO Enterprise Programme Management Office GP General Practitioner HDAC Health and Disability Advisory Committee MDHB MidCentral District Health Board

COPY TO: Quality and Innovation MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8030 269

1. PURPOSE

The purpose of this paper is to provide information to the Health and Disability Advisory Committee (HDAC) on the progress with Choosing Wisely.

2. SUMMARY

2.1 Background

Choosing Wisely is a global initiative aiming to support a culture where patients and health professionals have well-informed conversations around their treatment options, leading to better decisions and outcomes.

In 2016 the Council of Medical Colleges surveyed New Zealand doctors regarding their attitudes towards unnecessary care. Of those who completed the survey;

• 49.7 percent of doctors expressed that unnecessary care “was either a ‘serious’ or ‘very serious’ issue in their current area of practice.” • 61.6 percent felt this was a problem for the health sector in general1.

MidCentral DHB and the Central PHO have joined together to endorse, promote and actively participate in everyday improvements using the founding principles of Choosing Wisely.

2.2 Principles and official four questions

Choosing Wisely New Zealand is built on five founding principles:

• Health Professional-led • Patient-centred • Evidence-based • Transparent • Multi-professional.

These principles underpin the official four questions, which consumers/patients with their whānau are encouraged to ask their health professional at any stage of their health journey:

• Do I really need this test, treatment or procedure? • What are the risks? • Are there simpler, safer options? • What happens if I don’t do anything?

To support the questions, official guidance materials are also provided for consumers/patients and their whānau in making decisions with their health professional. This includes preparing for your appointment, during and following up after.

The official materials are a key part of the workplan as preliminary socialisation suggests they do not resonate well so localisation might be required to make them more effective.

1 https://choosingwisely.org.nz/wp-content/uploads/2018/04/Implementing-Choose-Wisely-29.08.2017.pdf 270

2.3 Governance

A system wide governance group is in place with representatives from primary, community and secondary health services including consumer and equity champions:

Executive Sponsor: Dr Ken Clark Clinical Lead: Dr Bart Baker Consumer Lead: Stephan Paewai

Members:

Lorraine Welman, Chief Pharmacist, MDHB Dr Bruce van den Heever, Pathologist, MedLab Central Deborah Davies, Operations Executive, Primary, Community and Public Health, MDHB Nicola Russell, Practice Development Manager, Central PHO Judy Leader, Nurse Practitioner, MDHB Dr Paul Cooper, General Practitioner (GP) Dr Scott Wilson, Registrar, MDHB Dr David Prisk, ED Consultant, MDHB Roxanne Waru, Whānau Ora Project Manager, Te Tihi Robyn Smart, Practice Development Programme Lead, Central PHO

Support Lead: John Manderson

The Steering Group participates in a national Community of Practice forum facilitated by the central Choosing Wisely office. This regular conference call is an opportunity for health professionals to discuss and share their efforts and challenges they face. This information is feedback to the steering group and clinical leads to determine if something is the discussion and outcomes are relevant for local implementation.

2.4 Objectives and Outcome

The objectives for this work are:

• Short-term: A system wide steering group endorsing, promoting and actively participating in improvements using the principles of Choosing Wisely. • Long-term: Choosing Wisely principles are part of everyday improvement efforts.

The outcome of achieving these objectives:

Through knowledge and understanding with their health professionals, patients and whānau will have greater confidence in the health and well-being decisions they make together.

2.5 Workplan

The workplan for 2018/19 has two related but distinct components:

• Reviewing in partnership formally approved recommendations and participating in the national community of practice 271

• Endorsement, promotion and participation of local improvement efforts.

Progress to date:

• Clinical Practice Recommendations: 154 official clinical practice recommendations have been released by Choosing Wisely New Zealand so far. To date the outcome from the review by MDHB clinical leads indicates we are already practising these or the service/intervention is not provided here. An additional 34 new recommendations totalling the 154 was released in August 2018. These new recommendations are currently under review. All recommendations will be regularly communicated and discussed with services and opportunities to apply recommendations continuously reviewed • Endorse and support projects: Three improvement projects have been identified by the Steering group as examples of applying the choosing wisely principles. The steering group provides official endorsement alongside support to either develop and/or promote their efforts. This includes the Acute Oncology project and the Labour and Birth (Caesarean) project. A Peri-operative project which is being developed currently • Governance support to projects: Steering Group members continue to provide support to the Hospital to Community Clinical Pharmacy pilot which started in May 2018 • New initiative - Laboratory: A previous working group has been re-established to use the choosing wisely clinical practice recommendations to review laboratory testing and utilisation across the system • New initiative – official choosing wisely materials: In partnership with Te Tihi, a piece of work has started to socialise the four questions and guidance materials with our community to firstly understand their effectiveness and then localise as required. The goal is to ensure our consumers/patients can use them with confidence during their health journey. This will inform any projects in the New Year.

For further detail, please refer to appendix 1 of this report.

2.6 Reflecting on the last year

In summary:

• Choosing Wisely needs to be more aligned with our organisational wide improvements efforts to increase both opportunities and visibility • Based on discussions with our clinical leads to date, the clinical practice recommendations are practised or the service/intervention is not provided locally. Both new and existing recommendations will be continuously reviewed. This includes ensuring a greater emphasis on working with the Central PHO in the new year to ensure our primary care providers are part of the process. • In discussions with health professionals and health providers, there are clear benefits in providing consumers/patients and their whānau more targeted and relevant information/guidance to improve both their experience and outcomes.

3. RECOMMENDATION It is recommended that: • the content of the report be noted 272

• the progress with Choosing Wisely in MidCentral district be endorsed.

John Manderson Dr Bart Baker Programme Manager, Business Improvement Clinical Lead Quality and Innovation Choosing wisely

Attachment:

Appendix 1 - Progress against the workplan

273

Appendix 1: Progress against the workplan

Type Measure Metric Performance Commentary Note (last 12 months) Initiative Official # of 120/154 reviewed Timeline to review the new Of the 120 recommendations recommendations 34 recommendations released recommendations reviewed by reviewed against 02/09/2018 is by 13/12/2018 reviewed, they are Specialty Leads total either practiced or the recommendations The recommendations have service/intervention is Target is based on issued been discussed with clinical not provided locally recommendations leads and will be continuously released during year shared to pick up any model of care changes and staffing. Although no specific improvement projects have adventured, change in practice can result from socialising the information

Initiative Improvement # of 3/6 currently The Acute Oncology project, The steering group projects/activities projects/activities achieved Caesareans project and the continues to support identified for supported under Perioperative project have generation of new endorsement, the Choosing been identified ideas promotion and Wisely banner participation support through socialisation

This is also part of sharing opportunities and approaches through the national forums

Target is six projects/activities per year

274

Type Measure Metric Performance Commentary Note (last 12 months) Initiative Promoting the four Consumer survey Complete The survey initiative was In the new year, questions and feedback on engagement/survey launched in September 2018 projects will be guidance materials: materials 28/02/2019 developed based on results from this work Note: Further information in the presentation

Project/Activity Laboratory testing 1 test campaign First test campaign The laboratory project was and utilisation per quarter by March 2019 launched in November 2018 against official Utilisation metrics clinical practice will be monitored recommendations when tests are identified to gauge success against baseline and target

Project/Activity Hospital to # of MTAs Q1 2018/19 The pilot started in May 2008 Community performed 57 new referrals and is set for two years with Pharmacist # of bed days 37 medical reviews a budget set aside to measures saved 36 patient complete an evaluation of its # of Medical education sessions efficacy. avoidance events 22 MTAs activity related performance metrics 43 bed days saved 16 major to Actuals will moderate harm determine baseline events prevented for targets to be set in year 2 of pilot

275

For:

Decision Endorsement X Noting

To Health and Disability Advisory Committee

Author Jo Smith, Senior Portfolio Manager, Health of Older People, Strategy, Planning & Performance

Endorsed by Craig Johnston, General Manager, Strategy, Planning & Performance

Date 9 November 2018

Subject Transport Services Return from Wellington

RECOMMENDATION It is recommended that the Committee: • note the commentary around transport services • note the activity currently underway to improve information and services

Strategic Alignment Improving service access and support is aligned to the DHB’s Strategy, in particular to the four strategic imperatives that underpin our focus for MidCentral District Health Board with an overarching focus on quality.

Glossary PNH – Palmerston North Hospital CCM – Coronary Care TLA – Territorial Land Authority NTA – National Travel Assistance

COPY TO: Strategy, Planning & Performance MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 276

1. PURPOSE

This paper is in response to a concern raised by a member of the public at the May Board meeting in Levin. The key concern was with cost and knowledge of transport options for patients returning from Wellington Hospital. No decision is required.

2. BACKGROUND

People are often transported to Wellington hospital for tertiary services. Return transport requires the client to organise their best options that suit their own circumstance.

The issue raised involved a transfer from Palmerston North Hospital to Wellington for elective services. Through our research the scale of concern appears small. We included discussions with consumers within GreyPower Levin, ward staff and particularly the Welfare Officer role held in the Welfare and Travel Office at MidCentral DHB. The local Health Committee in Levin was canvassed on their views on transport issues and they were not aware of any examples where an older person had a problem with return transport.

Notwithstanding that there were few instances to case review, the notion of suitable information regarding transport options and cost is real. There is continued advocacy for improved public transport up and down the trunk line in general. The issue of public transport comes up in each area within Locality Planning as are conversations with Local Authorities who are involved in similar discussions.

3. TRANSPORT DATA, OPTIONS AND SUPPORT

3.1 Data on transfers to Wellington

The graph below illustrates the over 65 age group by Ward and key transfers. It does not take into account those having elective services and being admitted to Wellington Hospital without first passing through PNH.

A total of 165 transfers occurred over an eleven month period. Two key areas for transfer were from the coronary care unit and Ward 28. 277

age

Count of nhi

18 16 dischargeward 14 CCM 12 CDU 10 EDM 8 ICM 6 W23 4 W24 2 W25 0 W26 W27

dischargedate

3.2 Transport

Transport to and from health services are largely the responsibility of the patient. The types of options available include personal transport, (family or friends), public transport (buses, train) or shuttle services. For out of district services, many people utilise personal transport as the first option.

Public transport arrangements out of Wellington include a range of private and public options from trains, buses, taxis, Driving Miss Daisy franchise, friends, neighbours and some shuttle services. The Wellington district has various shuttle services available to service their own population.

Shuttle availability tends to be a localised service to the person’s place of domicile and often by TLA area. For example, Horowhenua has a well embedded scheduled service to Palmerston North. Feilding, Tararua and Foxton operate similarly.

For shuttle services their scheduled route is for local community members. Levin residents use the Levin shuttle which runs at four visits per day to PNH and back to Levin with scheduled stops in between for Horowhenua residents on the agreed route.

For residents living in Foxton Beach, the Community Centre runs a shuttle service for people who need medical appointments and other non-health related matters. Within the Otaki area, St John has a shuttle service based around volunteer support.

Coordinating the scheduled shuttle services across the various TLA areas has potential if well-coordinated for ad hoc requests. Several shuttles are able to do this for their own local community if they are contacted in advance. However, general coordination of the various shuttles themselves across the district would require a different focus. An initial query from local services to travel out of district is that this is not able to be achieved without disrupting existing scheduled runs. 278

Adhoc requests would require coordination from DHB services on day of discharge. This aspect is often an unknown until the actual date of discharge. One patient reported being given a brief period of time to organise transport as “his bed was needed”. His family member had been on ‘standby’ to travel to a Wellington hospital to pick him up on a Friday which was later moved to be “the Monday or Tuesday”. On the Monday he was told with very little notice that he would be discharged. Arranging his family to travel at short notice was difficult for him.

Though in this instance he had a family member, the issue of optimising discharge for out of domicile patients who have no family would require respective social work departments to coordinate requests.

3.3 The National Travel Assistance (NTA) Policy

The NTA scheme is in place to provide some financial assistance to people for whom the cost of travel is a barrier to accessing treatment. It does not cover the total cost in all instances. DHBs are responsible for funding the NTA for their population. The policy is currently under review; it’s a comprehensive document to navigate, and covers a range of information across eligibility and claiming. In general terms, the transport is funded if people meet eligibility criteria within the policy (i.e. distance and frequency).

Information about the NTA for patients is generally shared via ward social workers and the DHB travel coordinator. For payment claiming, Sector Operations is the point of contact as the payment arm of DHBs. The NTA policy appears to be well known by some people and not others. Advice is given verbally and information is not always well understood.

3.4 Support and information for the inpatient

The general principle in the hospital is that patients are seen by a social worker if transport is likely to be an issue. The Ward Social worker visits with the patient or their family and advises them about the National Travel Assistance policy (NTA) and information on the various options. We know this to be a critical time for patients to ‘take in’ information as they are often acutely unwell. It isn’t clear to patients that their discharge from Wellington is straight to home, not back to PNH, it’s this latter point that creates some confusion.

In all instances social workers are the first port of call for ward staff concerned that discharging patients may experience transport issues. One example occurred recently of a Levin resident discharged out of PNH after 5pm in the evening. We reassured the Levin Health Committee that the DHB does have a policy guideline to support older people after the last shuttle has gone for the day. Similarly across DHBs, Wellington Hospital has social workers connected to the wards who support patients discharging requirements. The availability of information, resources for clinical teams and services could be used at both Palmerston North and Wellington Hospitals.

4 NEXT STEPS

• Develop a pamphlet of information for inpatients on the respective wards transporting to Wellington (this is currently underway) • Website guidance on information and transport– suggest a list of various shuttle arrangements in each district 279

• Discussions with advocacy groups - preparation for transport for acute events in the same way recommendations are made for disaster preparedness – “what’s your plan?” • The work programme for this is currently within the HAR Cluster and will emerge over the coming months.

5. RECOMMENDATION

It is recommended that the Committee: • note the commentary around transport services • note the activity currently underway to improve information and services

Jo Smith Senior Portfolio Manager Health of Older People & Palliative Care

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For:

Decision Endorsement X Noting

To Health and Disability Advisory Committee

Author Craig Johnston, General Manager, Strategy, Planning & Performance

Endorsed by Kathryn Cook, Chief Executive

Date 7 November 2018

Subject Air Ambulance Helicopter Service Arrangements

RECOMMENDATION It is recommended that the Committee: • note this update on changes occurring to Air Ambulance Helicopter Services

Strategic Alignment This report relates to a priority programme of work undertaken by the Ministry of Health, but has a strong link to the MidCentral Strategy, particularly the Strategic Imperative for Quality and Excellence by Design.

Glossary ACC – Accident Compensation Corporation CAARL – Central Air Ambulance Rescue Ltd DHB – District Health Board DHBs – District Health Boards EHRT – Eastland Helicopter Rescue Trust HBRHT – Hawkes Bay Rescue Helicopter Trust IHT – Inter Hospital Transfer LFT – Life Flight Trust NASO – National Ambulance Sector Office PSRT – Philips Search and Rescue Trust TRHT – Taranaki Rescue Helicopter Trust SAR – Search and Rescue

COPY TO: Strategy, Planning & Performance MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440

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1. PURPOSE

This report provides an update on the national Air Ambulance procurement exercise that has recently been undertaken. It is in response to a request from the November Board meeting. No decision is required.

2. SUMMARY

The National Ambulance Service Office, a division of the Ministry of Health, has led a major procurement process for Air Ambulance Helicopter Services. ACC and DHBs have been involved in the process. The procurement programme is in response to a development strategy for Air Ambulance Services aimed at addressing a range of issues with the existing service.

The result of the procurement process has been new contracts with three organisations covering the Northern, Central and South Island zones. The Central zone provider is newly created from the amalgamation of the existing contracted trust-based providers. Within the Central zone there will be nine helicopters running from eight bases, including Palmerston North.

For MidCentral, the new arrangement does not in any way reduce service availability. In fact, it is likely to improve it through better coordination and workload management across the Central zone and nationally. We should also see improvements in equipment, clinical staffing and aviation safety standards as the service progresses.

Pricing for the new arrangement has only recently been released, but it will likely come at additional cost to some DHBs. The bulk of the expenditure on Air Ambulance Helicopter services is covered by the Ministry of Health, but DHBs pay for Inter Hospital Transfers. In future, DHBs are obliged to work through the National Ambulance Service Office at the contracted regional prices. These are sustainable prices for a superior service, but they are generally higher than what some DHBs have been paying. We are in the process of analysing the financial impact for MidCentral. This will be updated in a future report.

3. BACKGROUND

3.1 Emergency Air Ambulance Services

Emergency Air Ambulance Services operate 24 hours a day, seven days a week and are part of the first line in the continuum of health care. They respond to medical emergencies and accidents, treat patients at the scene and, if necessary, transport them to hospital. A range of aircraft is used including helicopters (rotary) and aeroplanes (fixed wing). Emergency Air Ambulance Services have two main roles:

• Primary retrieval for emergency accident or medical-related missions for eligible people • Inter-hospital Transfer (IHT) missions within 24 hours for accident-related or three hours for medical-related missions.

They also provide: • Search and rescue (SAR) missions funded by SAR Coordinating Authorities which are Police and the New Zealand Rescue Coordination Centre • Inter-hospital transfer missions funded by District Health Boards 282

• Fire service missions funded by the New Zealand Fire Service • Commercial services, eg, television crews, tourists.

These other services are funded through separate arrangements with other agencies and not included in the current discussion.

Nationally, demand for air ambulance services has been rising and is expected to continue to rise in the future. The country has been served by a network of small to medium size operators supported by a raft of purchasing and contracting arrangements.

The air ambulance helicopter fleet has an average age of 29 years. There are increasing aviation and clinical compliance requirements and many of the helicopters currently in use for medical emergencies are smaller, single engine helicopters which do not allow full access to the patient for treatment. Also, these single-engine helicopters do not meet Civil Aviation Rules, which limits flying over urban areas (eg, flying into hospital helipads). Over time these will need to be replaced with more modern double-engine helicopters.

The National Ambulance Sector Office (NASO), the district health boards (DHBs) and the air ambulance sector recognised that the existing operating model is not sustainable. Accordingly, the Ministry of Health, the Accident Compensation Corporation and DHBs, through NASO, have developed a 10 year modernisation programme for the country’s air ambulance services (see Appendix 1).

The intent is to build a national integrated network that covers all of New Zealand, is well linked with other emergency services, is available around the clock, is safer and is more appropriately clinically resourced. This will contribute to improved patient outcomes.

The first stage has been a procurement exercise for Air Ambulance Helicopter Services. The new service will cover accidents and incidents that require an air ambulance helicopter due to the need for medical support.

Procurement Round One was published as a Request for Proposal on GETS on 26 March and closed on Monday 7 May 2018. The aim was to:

• improve patient outcomes • meet all safety requirements (removing single-engine helicopters from the service, increase clinical crew, and ensure appropriate fatigue management processes are in place for aviation crew that meet Civil Aviation Rules) • gather information to support the completion of a comprehensive design of the future service and inform the second procurement process • consolidate regions from the current 12 to three, aligned to the district health board regional structure • provide greater value for money by improving the efficiency of the service through better use of clinical and aviation resources.

Procurement Round Two will require further Cabinet approval before it can commence. It will be a five year contract plus five year extension – 2021/22– 2031/32. A key objective of the second procurement will be to actively manage the swap out of ageing air ambulance helicopters to a higher and specified standard. The objectives of the first stage were as follows:

283

• establish sufficient capacity for pre hospital and inter hospital national demand • move from single engine to twin engine helicopters to meet CAA safety requirements • implement higher crewing levels to meet CAA fatigue management guidelines and higher standard in clinical crewing • phase in of SPIFR (single pilot instrument flight rules) navigation technology • improve data collection and establish key performance indicators • establish independent service clinical governance • implement a sustainable funding model for providers nationally

4. OUTCOMES OF ROUND ONE PROCUREMENT

The Round one procurement process has successfully resulted in the selection of three regional providers. This involves the following changes:

• Moved from ten local providers to three regional providers o Northern (Northland, Waitemata, Auckland and Counties Manukau) o Central (Waikato, Bay of Plenty, Lakes, Tairawhiti, Taranaki, Whanganui, Hawke’s Bay, MidCentral, Wairarapa, Capital & Coast, Hutt Valley) o Southern (Nelson Marlborough, West Coast, Canterbury, South Canterbury, Southern) • Five fully crewed (pilots, flight crew and paramedics) bases with 24/7 coverage • Single call access to regional assets, fall back access via national coordination and tasking service (Air Desk) • All single engine assets phased out by end of 2019 • NASO will continue to work with DHBs to assess if and how Inter Hospital Transfer calls will transition to the national coordination and tasking service

284

12+

24/7

24/7 12+

12+ 12+ 12+

12+ 12+

24/7 12+

12+

24/7

12+ 12+ 24/7 Daytime Staffed, on call at night

Staffed round the clock 24/7

The new arrangements came into effect on 1 November for the Central and Southern regions. There is an ongoing work programme to ensure successful implementation. This includes particularly:

• Strengthening clinical governance, with workshops planned for later in November. • Finance and reporting, with a workshop held in early November to design financial and reporting operation systems to support the invoicing process.

5. ADVANTAGES OF THE NEW ARRANGEMENTS

The new arrangements will result in improved coordination and tasking and improved information on the impact of the service on our community.

285

Appendix 2 contains a slide from the National Ambulance Service Office summarising before and after perspectives.

6. NEW ARRANGEMENTS FOR THE CENTRAL ZONE

The Ministry of Health has provided the following statement about the new arrangements for the Central zone.

Five existing air ambulance helicopter trusts in the North Island have formed a joint venture to provide services in the Central region. The new provider, which will be known as Central Air Ambulance Rescue Limited (CAARL), has entered into an agreement with the National Ambulance Sector Office (NASO) and will begin operating in the region from 1 November.

The Central region covers the North Island from Wellington up to the Waikato, including the East Cape, Bay of Plenty, Hawke’s Bay, Taranaki, Manawatu and Wairarapa. The contract will cover pre-hospital retrieval and inter-hospital helicopter transfers for medical and injury services across the Central region. All bases will continue to service local search and rescue needs.

The five trusts are the Eastland Helicopter Rescue Trust (EHRT), Hawke’s Bay Rescue Helicopter Trust (HBRHT), Philips Search & Rescue Trust (PSRT), Taranaki Rescue Helicopter Trust (TRHT) and the Life Flight Trust (LFT). The trusts will work together to modernise operations, increase efficiencies and continue to improve patient outcomes. They have a long history of working with their communities and this new arrangement will enable them to build on their existing strengths and relationships.

CAARL will provide air ambulance helicopter services from bases in Hamilton, Wellington, New Plymouth, Hastings, Taupo, Gisborne, Tauranga and Palmerston North. The Rotorua region will be well-covered by the bases in Taupo, Tauranga and Hamilton, with the response times to incidents estimated to be the same or faster than under the current model. 286

The trusts will phase in additional twin-engine helicopters over the next 12 months. This will give clinical staff more room to provide comprehensive care on board, ensuring patients needing urgent clinical attention can get that care while being transported to the most appropriate hospital for their needs

7. IMPACT OF SUSTAINABLE FUNDING

The Business Case cost model behind the new service contracts was built on open book financial reviews of three providers and independent analysis completed by Deloitte directly with providers and using overseas comparators.

The anticipated Business Case cost, once fundraising is applied, was $60.8m, year one actual projected to be $57.8m. The 2016 estimated DHB cost was $6.9m (volume and price increases have occurred between 2016 and 2018, current actual DHB cost is unknown). The Business Case projected DHB cost $13.7m, year one actual projected to be $12.6m.

The full hourly rates received (fixed and variable) are comparable across providers.

Specific confidential pricing information has only recently been received and we are now in the process of calculating the cost implications for MidCentral DHB. It is highly likely there will be additional cost to MidCentral DHB.

8. RECOMMENDATION

It is recommended that the Committee:

• note this update on changes occurring to Air Ambulance Helicopter Services

Craig Johnston General Manager, Strategy, Planning and Performance

287

APPENDIX 1: TEN YEAR FORWARD PLAN

288

APPENDIX 2: WHAT WILL BE DIFFERENT IN THE FUTURE

Current service to New service

Airframe Seven single engine helicopters, 13 twin 19 Twin engine helicopters, engine helicopters, 69% of capacity utilised, 8 80% of capacity utilised back up helicopters Clinical governance Outsourced to St John Provider develops own Clinical Governance capability which interacts with national clinical and operational governance frameworks.

Activation time (clinical Some full time crew, pre hospital mostly Five bases full time dedicated crew 24/7 crew) crewed on a best endeavours basis across 17 Eight bases dedicated crew daytime Two bases crew on call bases * On average 4 night missions are flown in NZ per day, five locations will have 24/7 clinical crew coverage

Clinical crewing Best endeavours from road ambulance service Five bases full time dedicated crew 24/7 Eight bases dedicated crew daytime Two bases crew on call

KPIs Activation times • Clinical crew requirements • Activation times • Aircraft availability • Clinical crew capability • Clinical standards • Reporting Model Helicopter operator Aeromedical provider

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APPENDIX 3. KEY PERFORMANCE INDICATORS FOR PROVIDERS

Ref # Name Description Targets Category Measurement Period of Calculation Data Source of Responsibility Calculation Measurement KPI001 Clinical Crew This KPI aims to ensure At least 25% of all services Service Provider, with Monthly, Number of pre-hospital National requirements for that Clinical Crew performed by the Delivery selected audit by quarterly missions Tasking and pre-hospital Air requirements are provider with two clinical crew NASO and annually crewed with 2 Clinical Crew Coordination Ambulance missions introduced at, or above the level of ICP/ reporting against (one being ICP) / total Centre TracPlus progressively as set out Paramedic KPI target number of pre- hospitals Reporting and in the Agreement missions X 100% ePRF System

KPI002 Activation time This KPI aims to ensure (i) Day Time Response: Service Provider, with Monthly, Total number of prehospital National (Pre-hospital) that the Activation time 90% of the Delivery selected audit by quarterly missions Activated within the Tasking and for pre-hospital Activation time for all Day Time NASO and annually targeted times / total Coordination missions is within missions (08:00 to 18:00 Hours) reporting against number of pre-hospital Centre CAD agreed range for both within the median time of 10 KPI target missions assigned x 100% System Day Time and Night minutes. Time Missions. (ii) Night Time Response: 90% of the Activation time for all Night Time missions (18:00 to 08:00 Hours) within the median time of 20 minutes. KPI003 Activation time This KPI aims to ensure 90% of time the Activation time Service Provider, with Monthly, Total number of IHT missions National (urgent IHT) that the Activation time for urgent Delivery selected audit by quarterly and meet the Activation time Tasking and for IHT missions is IHTs meet the target time set NASO annually target Coordination within agreed range. out below: reporting against / the total number of IHT Centre CAD (i) Urgent IHT (60 minutes KPI target missions assigned x 100% System and to pick-up on hospital TracPlus heliport) (ii) Urgent IHT (120 minutes from picking up clinical team to destination hospital) 290

KPI005 Aircraft availability This KPI aims to ensure 95% of the time Aircraft is Service Provider, with Monthly, Number of Aircraft National that the aircraft is dispatched from the nearest Delivery selected audit by quarterly dispatched Tasking and dispatched from the base. NASO and annually from the nearest base / total Coordination nearest base most of reporting against number of Aircraft Centre CAD the time. KPI target dispatched x 100% System and TracPlus KPI006 Pre-hospital This KPI requirement At least 50% of clinical resource Clinical Provider, with Monthly, Number of Clinical Crew at National Clinical Crew relates specifically to must be at the selected audit by quarterly ICP Tasking and capability ICP Clinical Crew level of ICP NASO and annually hours rostered / Total Coordination Members. reporting against number of Clinical Crew Centre TracPlus KPI target hours rostered Reporting and ePRF System KPI007 Clinical standards This KPI ensures the 95% of audited cases meet Clinical Provider, with Quarterly Number of cases meet National clinical standards are clinical selected audit by clinical Tasking and met. standards. NASO standards / total number of Coordination case audited Centre ePRF System

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For:

Decision X Endorsement Noting

To Health & Disability Advisory Committee

Author Judith Catherwood, General Manager, Quality & Innovation

Endorsed by Chief Executive

Date 15 November 2018

Subject Committee’s Work Programme, 2018/19

RECOMMENDATION It is recommended that the Committee: • endorse the progress being made in the delivery of the 2018/19 work programme.

Strategic Alignment This report is aligned to the DHB’s Strategy and key enabler, “Stewardship”. It discusses an aspect of effective governance.

Glossary HDAC – Health & Disability Advisory Committee MDHB – MidCentral

COPY TO: Quality & Innovation MidCentral DHB Heretaunga Street PO Box 2056 Palmerston North 4440 Phone +64 (6) 350 8030 292

1. PURPOSE

This report sets out the Health & Disability Advisory Committee’s 2018/19 work programme and advises any areas where reporting is not occurring in line with the programme.

The report is for HDAC’s consideration and no decision is required.

2. BACKGROUND

The annual reporting framework for the Board and its Committees is in place for the 2018/19 year. The purpose of the framework is to ensure the Board and its committees will receive appropriate information at the right time to enable members to carry out their duties.

From the framework, the Committee’s work programme has been developed and this is attached. It sets outs all reports scheduled for submission to HDAC during 2018/19. The purpose of each report is detailed, together with the date it is to be provided. The Committee is advised of progress against this work programme, including any variations, each time it meets.

A separate schedule of “matters arising” from HDAC’s meetings is maintained and this is included as a separate agenda item.

3. 2018/19 WORK PROGRAMME

The Board, on the recommendation of the Enable New Zealand Governance Group, has determined that the Governance Group will be disbanded. Enable New Zealand will now report to the Health & Disability Advisory Committee on a six-weekly basis in line with the cluster reports. The work programme has been amended to reflect this. Reporting will commence in February 2019.

Reporting against the work programme is generally on track. A review of the Smoke-Free Policy is underway and a report will be submitted to the Committee’s next meeting.

Three presentations will be provided to the Committee on 27th November. These are:

• Primary, Public & Community Health Cluster • Health & Wellbeing Plan for Palmerston North • Choosing Wisely

293

4. RECOMMENDATION

It is recommended that the Committee:

• endorse the progress being made in the delivery of the 2018/19 work programme.

Judith Catherwood General Manager, Quality & Innovation 294

Health & Disability Advisory Committee | 2018/19 Work Programme Report Fqncy Jul Sep Oct Nov Feb Mar May Jun Jul Resp Strategy/Planning Health Needs Assessment & Equity Snapshot Annual X GMSPP & • to consider the health needs assessment of the district and sub-region GMP&P Ka Ao Ka Awatea – Maori Health Strategic Framework Triennial GMM&P • on a three-yearly basis, review/refresh the strategy to ensure it remains relevant and reflects Oct 20 the DHB’s Strategy Disability Strategy One-off X GMENZ • to determine a disability strategy and roadmap for the district, and thereafter how it has been (Aug 19) Update EDAH advanced, changes, and priorities/investments for the future (3-5 years). then triennial Public Health Unit Annual Plan Annual X GMSPP • to determine the annual plan Locality Plan – Palmerston North One-off X X OEPPC • to determine a locality plan for Palmerston North GMSPP Locality Plans – Update Annual X GMSPP • to determine how the locality plans have been advanced, what’s changed & priority initiatives/investments for the future (3-5 years), and to receive community feedback Cluster Health & Service Plans – draft One-off X OEs & CEs • to determine each cluster’s planned outcomes, priorities & targets for the next three years, and the roadmap for achieving these, including required investment & resources Cluster Health & Service Plans - final One-off X OEs & CEs • as above Quality Improvement Clinical governance & quality improvement framework – progress & trends Qtrly X X X X GMQ&I & • to monitor the quality and safety of health care services in the district, including trends, Prof Leads performance against dashboard and markers, and confirm the adequacy of the programme planned or established to advance or address issues • professional governance (as from March 19) Business improvement Qtrly X X X X GMQ&I • to monitor the effectiveness of the programme, including outcomes being sought in regards quality, safety & patient experience, and progress being made toward these Quality account Annual X GMQ&I • to determine the Quality Account for the financial year Research Annual X CMO • to receive details of research activity underway within MidCentral DHB Performance Cluster Reports 6-wkly X X X X X X X X X OE & CEs • to monitor each Cluster’s performance, including the implementation of their Health & Service Plans, including progress against key targets, initiatives and outcomes. Annual MHA CSTS PPCH AESS EHR W&C • to monitor current and emerging matters, including quality & safety, opportunities and presen- challenges, and the adequacy of any mitigations tation ENZ Reports 6-wkly X X X X X • to monitor operational performance, including the implementation of the annual plan, Annual X including progress against key targets, initiatives and outcomes. Presttn

Health & Disability Services Advisory Committee | 2018/19 Work Programme | Page 4 295

Health & Disability Advisory Committee | 2018/19 Work Programme Report Fqncy Jul Sep Oct Nov Feb Mar May Jun Jul Resp

• to monitor current and emerging matters, including quality & safety, opportunities and challenges, and the adequacy of any mitigations 2018/19 Regional Service plan (implementation) Qtrly X X X X GMSPP • to monitor the implementation of the Plan and achievement of stated outcomes. (NB: detailed report to be provided from Governance SharedNet site.) Equity Ka Ao Ka Awatea – Maori Health Strategic Framework Annual X GMM&P • to monitor progress being made in achieving the Framework, including the appropriateness of initiatives and investment planned/established. Equity Targets – Progress 6-mthly X X GMM&P • to monitor progress being made in achieving the national Maori health targets, including the appropriateness of initiatives planned/established Disability Disability Strategy Annual X GMENZ • to monitor progress in implementing the Disability Strategy, including opportunities and EDAH challenges, and confirming the priorities and initiatives/investment for years ahead Understanding the DHB’s responsibilities re Disability Support Services One-off X GMENZ • a briefing paper to inform on the role & responsibilities of DHBs in respect of funding, planning EDAH & providing disability support services, particularly those for people under 65 years of age • to explain and describe the new prototype for DSS established for the MidCentral DHB region as a result of the national DSS transformation programme Integration & Partnership Presentations GMF&CS & • to hear from key organisations and agencies face-to-face • Central PHO Annual X OE PPCH CEO CPHO • Health Quality & Safety Commission Annual X GMQ&I • PHARMAC– TBC Annual GMSPP Governance Policies Triennial • to determine governance and significant quality & improvement policies • Serious & Sentinel Event Reporting Policy Dec 19 GMQ&I • Smokefree – Auahi Kore Policy Nov 18 X GMQ&I OEPPCH • Intimate Partner Violence Policy Feb 21 GMQ&I • Child-Young Person Abuse and/or Neglect “child in need” Policy Feb 21 GMQ&I

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Key: AESS Acute & Elective Specialist Services EDAH Executive Director, Allied Health GMQ&I General Manager, Quality & Innovation CE Clinical Executive EHR Elder Health & Rehabilitation GMSPP General Manager, Strategy, Planning & Performance CEO Chief Executive Officer GMENZ General Manager, Enable New Zealand MHA Mental Health & Addictions CMO Chief Medical Officer GMF&CS General Manager, Finance & Corporate Services OE Operations Executive CPHO Central Primary Health Organisation GMM&P General Manager, Maori & Pacific PPCH Primary Public & Community Health CSTS Cancer Screening, Treatment & Support GMP&C General Manager, People & Culture W&CS Women and Children’s Health

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