Document 2

Briefing Paper to Health & Disability Review Transition Unit

Proof of Concept in Northland 26 January 2021

Introduction Northland DHB is seeking support from the Transition Unit to be considered a Proof of Conceptfor a number of system improvement initiatives. This paper sets out to describe the significant healthinequities and need that exists in Northland presenting a compelling case for system transformation. It also describes what we are currently doing, our vision for the future and a set of key recommendations totransform Tier 1 services in Northland, building on the recommendations within the Northern Region Primary and Community Care Deep Dive Report.

It is recommended that the Transition Unit: Receives this paper as a starting conversation, and Note that itdemonstrates Northland DHB’s readiness and willingness to prototype any system and/or servicedelivery changes in line with the recommendations of the Health & Disability System ReviewReport (the Review). Notes the considerable health challenges facing the Northlandpopulation, with significant inequities for and rurality as well as a significant burden of illhealth across the region. Notes the progress made in Northland over thepast five years towards community and -led models, locality networks, health and social carecoo dination and Tier 1 and 2 service integration. Endorses the need for additional investment and includes a Northland Budget bid for additional investment in the systemic issues ofprimary care funding. Endorses Northland DHB as a Proof of Concept and supports the proposed recommendations.

Advise any required next steps.

Why is this important tous?

Northland’s health and socialsector are aligned regarding the following goals:

We must bemore responsiveresponsive to wh nau and community needs, and ensure they are at the centre of developments and decision making. We must buildbetter relationships and partnerships, and jointly examine the status quo to identify issues and develop solutions. Wemust reach out across the wider social sector and develop initiatives that positively impact the social determinants of health outcomes and achieve Oranga. We must continue to support and grow our workforce and create an environment where health professionals n every tier, specialty, and provider are working together towards our common goal with responsive approaches that reflect our population.

We know through multiple sources of evidence that the current health system does not work for those most in need. Various outcome indicators show that die younger, live with more chronic conditions and are less able to access health care. Because of poverty and rurality, Northland are even more disadvantaged from a health outcome perspective. Our obligations to eliminating inequities mean we must do better and all new investment must demonstrate improved health outcomes for Maori.

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The Review is clear that major improvements in health outcomes will come from better primary and community services that are culturally safe and accessible for communities. This argument provides a compelling impetus for Northland to move sooner rather than later in transforming the way that primary and community services are commissioned, funded and reviewed. Northland DHB is committed to ensuring equity of access, experience and outcomes for those populations who need our support the most. This is particularly so for equity in Northland and to recognise their Tiriti status as . Our position on this matter aligns with our commitment to eliminate inequities and our overall approach to achieving optimal health and wellbeing for all Northlanders.

Northland DHB notes the need to refer to the four articles of Te Tiriti o Waitangi and acknowledgesthat they stand in contrast to the ‘principles of The ’. This is to further recognise that while not consulted about the principles, have always been clear it was the articles of Te Tiriti o Waitangi that were signed and agreed to.

Articles Health & Disability Sector Response

Stewardship

Tino Rangatiratanga Health development

Oritetanga Equity focus

Ritenga

Closely related to the articles of Te Tiriti are the cultural concepts and values that we, as a Crown agent of the NZ Government, acknowledge and take intoaccount:

Mana whakahaere: effective andappropriate stewardship or kaitiakitanga over the health and disability system, which goesbeyond themanagement of assets or resources : enablingthe right for to be self-determination), to exercise their authority over their lives, andto live on terms and according to philosophies, values, and practices, includingtikanga Mana tangata: achieving equity in health and disability outcomes for across the life course and contributing to wellness Mana enablingritenga customary rituals), which are framed by te ao (the world),enacted through tikanga philosophy and customary practices), and encapsulated within knowledge)

TheNorthern Region Context TheNorthern Region Primary and Community Care Deep Dive provides a compelling case for transfo ming Primary and Community services and Northland is uniquely placed to prototype this new systemwith the assistance of the Health and Disability System Review Transition team.

The key messages in the Regional Deep Dive include: Primary care plays a critical role in the overall health system o Health systems with a strong primary health care orientation have better population health outcomes, higher patient satisfaction, and lower aggregate costs o Most healthcare is provided in the community and primary health services facilitate appropriate access to wider primary and community services. o Primary and community service provision accounts for around 33 per cent of DHB spending, approximately $2 billion, although Northland’s per capita spend is significantly higher than its Auckland metro counterparts.

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New Zealand’s health system performs well for most people, but intractable health inequities persist. o It delivers similar health outcomes to people in comparable countries although there are areas such as health equity where it performs less well. o Most patients report a positive experience of primary care o We have made significant progress in a number of important areas such as childhood immunisations.

There are a number of systemic challenges including: o The current system is overly complicated and fragmented o There is a lack of leadership and lack of clarity in roles, responsibilities, and accountability across the system o as Te Tiriti partners have not been well served o The system needs to be driven by what consumers, and communitiesities want and need. o There needs to be a greater emphasis on promoting health and wellbeing

There are also 3 key problems that we face. Problem 1: Health status is variable and there are significantinequities for some population groups and geographic areas as well as a large burden of ill health across the Region. o There is a gap in life expectancy of 8.1 years for and 7.5 years for Pacific o People with disabilities have much lower satisfaction with health services, and people with intellectual disabilities and severe mental illness have markedly shorter life expectancy and higher rates of chronicconditions o There are 1,800 potentially amenable deaths eachyear in the Northern Region o Long term conditions, includingcardiovascular disease, cancers and mental illness, are the major cause of health loss and areresponsible for 88% of health loss in NZ o Tobacco, alcohol and unhealthy food are the major cause of preventable ill health and account for 32% of premature healthloss. Problem 2. Health services are notsufficiently centered around the patient and their and in certain areas the quality,safety and outcomes of care are not optimal. o One in five people inthe Region and 1 in 3 and Pacific are unable to access primary care services. o Patients and areinsufficiently involved in their care and decision making o There is variability in the quality and safety of primary and community care services o Service provision is fragmentedfragmented and complex and can be poorly coordinated particularly for patients withmore complex needs. Problem 3: Theneeds of a rapidly growing, ageing and changing population cannot be met in a clinicallyor financially sustainable way with our current capacity and models of care. o Significantincreases in capacity are required to meet future growth, for example, an extra 2 million GP consultations and 453 extra GPs would be required by 2038 if the current model of care remained the same o A third of GPs plan to retire in the next 5 years and approximately a third of practices have a GP vacancy and 70% have a nursing vacancy. o There are difficulties accessing and sharing information and there are multiple incompatible IT tools and applications o Change is difficult and slow - the environment is complex with a wide range of providers, governance structures, and business models and we have limited levers for change.

A large number of programmes and initiatives are underway in the Northern Region to address these challenges. o These programmes provide many of the solutions to the problems that we face but implementation is inconsistent and the size and scale of the initiatives and the pace of change is insufficient to address the problems that we face.

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There are also a number of programmes internationally that are promising. Ingredients for success include: o collaborative multidisciplinary teams where interventions are designed around a deep understanding of what local patients need; o patients are involved in their care and necessary decisions regarding treatment. o a high number of non-medical care givers such as health coaches. o An emphasis on the relationships between clinicians and staff o optimum use of technology for both patients and professionals – including better use of data for population health. o novel funding arrangements to make these new models possible

The way in which the health system across the region, and across the country hasworked together to respond to COVID19 has been impressive and illustrates some of the featuresneeded to achieve the transformation we all want.

The Northland Context Northland is the ideal region to consider prototyping a new system of care forTier 1 services. Northland has a perfect storm of demographic challenges. It has the fourth highest proportionof over 65s, the lowest economic performance, one of the most rural populations and thepoorest public infrastructure condition (roading, clean water, hospital facilities) Northland is home and Kaitiaki for Te Tiriti and has a high (37%) population. Northland has been the second fastest growing DHB over the last five years. Duringthe development of our Northland Health Strategy 20/40, patients, and communities statethat access to a GP is their biggest concern with the Northland Health system. Northland DHB is completing its Northland HealthStrategy 20/40 in March 2021. The strategy has involved wide engagement with patients, and stakeholders over the past 18 months. Northland is in a fortunate position in that the Review hasheavily informed the discussions and strategic direction of the Northland Health System. This providesNorthland with a significant opportunity to ensure that its new strategy is completely committed and aligned tothe future health system as envisaged in the Review. We are ready and able to commit our resourcesand investments into achieving the visions of the Review.

The extensive consultation process undertaken as part of the Northland Health Strategy development has delivered a draft framework ofcore principles principles, these are not dissimilar to the themes already discussed :

Within the rohe of kaitiaki o Te Tiriti o Waitangi, Te Tiriti is foundational to equity, wellbeing and health of allpeople in Te Tai Tokerau. Workcollectively and s strengthentrengthen alignment across agencies, local government and private enterprise to create real impact, transformational and generational change for communities and inTe Tai Tokerau. Improve accessibility of primary and community services by implementing a locality model. Co-designCo-design and co-decide with community and to design a system that meets their needs and aspirations. Strengthen and streamline health sector relationships, partnerships and pathways so that communication flows are improved and users regard it as one easy-to-navigate system. Shift health investment upstream, adopt more proactive approaches and focus on children to ‘get it right’ for the next generation. Use data and evidence to prioritise, monitor, and support informed, rational decisions about service design and investment. Grow a collaborative health workforce from within our rohe that reflects the population of Te Tai Tokerau. Kaitiakitanga of our to ensure environmental sustainability and thriving climate resilient communities

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Northland DHB has a history of investing in primary care services, providing innovative solutions and progressing integration. Northland’s health system is relatively self-contained, sharing only one geographical boundary with another DHB, and the distribution of urban and rural populations enables relatively natural localities to be identified. The interconnectedness and the limited number of providers, with a strong commitment to partnership that exists in Northland, allows us to position ourselves to adopt some of the identified solutions that result from the Tier 1 recommendations from the Review.

The timing of events in Northland enables us to implement and trial Review options before the Review is fully implemented. Strengthening commitments to Tai Tokerau and Health Providers thus farhave been only partially achieved. The Review provides opportunities to cement the work Northland hasalready undertaken by extending commissioned services that enable to have self-determined access to services within a connected Tier 1 mix.

Establishing Tier 1 networks will require a refreshed strategy for primary and communitycare. The Northland 2040 Strategy is committed to achieving equity for today’s new generation of by 2040, but it will need to be complemented with robust five year forward planning cycles, andannual delivery plans. As well as early adoption of recommendations described in the Review for Tier 1 - specifically ending funding primary care services via the PHO Services Agreement. Northland DHB would consolidate a number of functions within various DHB Directorates that have a responsibility for Tier 1 services.

Health Tai Tokerau has strong foundational relationships with Iwi and providers andhas anIwi Governance structure, Te Kahu o Taonui.Northland DHB is a member of Hauora – Northern Iwi-DHBDHB Partnership Board. This partnership is fundamental and enables us to fulfil our Aritcle 1 Te Tiriti obligations. Thepartnership is now firmly established with delegatedauthorities from Northland, Waitemata and AucklandDHBs for decision making. Northland DHB is committed to equity in the community, and is developing Ora and -led services to meet the many d fferent needs of each of our localities and communities.

One of Northland’s strengths is the large number of Providers who provide health and social services. Six of them also provide general practice services in addition to a wide range of Kaupapa services. Over the COVID-19 lockdown we saw how much can be achieved when they are well resourced, working in partnership with iwi and Northland DHB and other providers. They are our key providers in delivering on our commitment to achieve Equity of outcomes for whanau across Te Tai Tokerau.

Extensivec communityommunity feedback from a variety of recent sources continues to highlight how patients and expe ience poor service delivery due to the current complex and fragmented nature of the system. TheNorthland DHB Health Directorate, Te Poutokomanawa, has completed wide consultation and engagedwith providers and to inform a new approach to commissioning for outcomes utilising Ora frameworks.

A key aim is to enable patients and to experience care as one seamless process. The Review identifies that investing in tauranga M ways of working and embedding these into health services would provide additional options and choice for patients and their

The Review also identifies that improvements in i health outcomes will come from better primary and community services provided in ways that are more accessible, responsive and appropriate for communities. The Waitangi Tribunal Health Services and Outcomes Inquiry (WAI2575) also emphasises the necessity to start transformation sooner rather than later.

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A commissioned mix of services across localities will be required to meet health equity and as such co- design with communities and accountability frameworks to aspirations are crucial.

Primary Care

Northland DHB has a long-standing reputation for investing in innovative models of primary care and working closely with general practice and providers of community services such as Health providers and other NGOs.

Northland has a single PHO, which enables the DHB to work closely with primary care as an equalpartner in developing strong community based localities. Mahitahi Hauora has undertaken engagement with partnersin the planning of localities based upon priorities within the population demographic.

The aim of the localities is to have general practice, Health and other communityproviders working together on shared priorities, along with the community and they are serving. There are currently six geographic areas in Northland defined as localities:

The Review’s concept of Tier 1 with “services guaranteed for localities” provides an opportunity to further alignthe primary care localities with Northland DHB’s rural hospitals as a significant community and locality resourceresou to develop community determined Tier 1 provision that is accountable to and community aspirations. Alignment with the various iwi and hapu rohe on page 6 should also be considered. General practice in Northland remains under severe pressure. Northland’s challenging population demographics add complexity and time which significantly exacerbates the workforce issues felt by General Practice across . These issues impact recruitment and retention of staff at all levels of primary care staffing. This worsens clinician workloads, patient wait-times, and drives a vicious cycle of burnout and early retirement.

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GPNZ regularly promotes an ‘optimal’ workforce mix model for primary practice which is based on total enrolment across high needs and general practice patients. From the September 2020 enrolment figures for Mahitahi Hauora this formula shows the optimal number of full time equivalent GPs, Nurse Practitioners, and Registered nurses as 122, 53 and 92, respectively. Figures from Mahitahi show actual FTE for these categories currently are 110, 6 and 105, representing a GP FTE gap of 12, and 47 for Nurse Practitioners.

Earlier this year all but two practices in Northland had closed their books, with the number of practices with closed books continuing to fluctuate. For patients already enrolled in some practices there are significant delays in securing an appointment, reportedly up to three weeks in some cases. Many new families are unable to register with a general practice because of closed books, which further compounds equityissues. In rural areas it has long been difficult to recruit and retain GPs. However, in Northland,Whangarei has similar challenges which emphasises that the cause is more systemic in nature due to workload generated by the socio-economic features of Northland’s population.

Locums are used to fill gaps, they are expensive and lack the local knowledge and aspects ofcare continuity expected by patients and . The patient-doctor relationship is suffering, patientsmust retell their story, which diminishes trust, and causes late presentation of crucial patient conditions.Reduced capacity in primary care continues to place significant pressure on Emergency Departments.

Northland has been working closely with its GP partners, Health Providersand other stakeholders to develop short, medium and long-term workforce strategies to address these critical shortages. These include dedicated investment into new models of care, a wider workforce blend,GP pipeline initiatives, a health science academy, After hours support, GP recruitment bureau, Extending Regional Collaborative Community Care (shared community electronic health record) offering to General Practice and Maori Providers.

The Health and Disability Review notes that DHBs will beresponsible for ensuring access to Tier 1 services, including sourcing or developing new services toaddress any gaps, which could involve providing the service directly. The review also indicates a GP employment model should be considered in the review of Tier 1 services, with salaried arrangements tosupport services in high need and rural areas.

Rural Hospitals Northland DHB operates three rural hospitals:Kaitaia, Kawakawa (Bay of Islands), and Dargaville. We also fully fund an enhanced primary care with in-patientin-patient services model via Health Enterprises Trust. These rural hospital settings areideally placed to serve as hubs for the ongoing development of hub localities tailored to each community’s individual needs.

Dargaville: Dargaville Hospitalis co-locatedco-located with Te Ha Oranga and Dargaville Medical Centre within Dargaville township. Services nclude in-patient services, outreach and district nursing services, community allied health, palliative care,urgent care, drug and alcohol services, mental health services. The partnership with Te Ha Oranga provideslinks to Ora services such as social services and other services tailored to the needs of

Kawakawa: Bayof Isl Islandsands Hospital provides services across the mid-north servicing a diverse population catchment stretching from Hukerenui to Kaeo. After-hours services for the entire catchment are provided by GPs on a roster staffed by a consortium of nearly a dozen independent GP practices with DHB employed rural hosp tal specialists providing overnight urgent care. The DHB provides outreach services through visitingspecialists.

Kaita a: Kaitaia Hospital provides high quality hospital accommodation to people living in the far north. Services include theatre and surgical services provided by visiting specialists, mental health services and in- patient stays. Most General Practices serving the Kaitaia area are based on, or adjacent to the hospital campus.

Hokianga: Hokianga Health Enterprise Trust provides an enhanced primary care model for patients living within the area. NDHB contracts for full spectrum services, including maternity services, satellite primary care services and dedicated in patient acute services. The model of care is maintained and developed by the Trust to meet its patients’ needs. The population has high levels of socioeconomic deprivation with 75% identifying as Northland DHB has a longstanding relationship with the Trust and is supportive of its holistic primary care model which contains all the components of a fully developed locality.

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Health and Social Care Integration Northland DHB has made a significant investment in several health and social care projects over recent years with an overarching aim to integrate the care of patients and particularly those with chronic and complex care needs. This integration across primary, secondary and community based health care will continue to improve patient access, experience, and outcomes. These projects include:

Tahi and Advance Care Plans: Tahi is a shared care software tool used by health providers across Northland including: general practice; providers; community pharmacy; rest home facilities and many secondary care hospital services. Patient details can be accessed across nominated providers, with direct messaging available between all members of the care team(including patient and

Neighbourhood Healthcare Homes: The Healthcare Home (HCH) model of care is a centric approach which facilitates primary care to deliver a better and staffexperience, improved quality of care, and greater efficiency. The model seeks to improve accessto primary care services in order to reduce use of hospital services and encourage more efficientuse of practice staffing resource. 15 Northland practices are at varied stages of implementingthe NHH model, with a total enrolled population of more than 106,000.

Clinical Triage: A key component of NHH is Clinical Phone Triage,which enables patients that call for a same day appointment to have their concerns managedover the phone. Earlier practices to implement the NHH model of care have an average of 39.6% oftriaged calls resolved over the phone.

Patient Portal: Another key component is Patient Portals which allow patients to manage and own their medical information and communicate with their practice.

Calderdale Framework: The CalderdaleFramework provides a clear and systematic method of reviewing skill mix and roles within a service toensure quality and safety for patients. It is transferable to any health or social care setting and leadsto improved efficiency in utilisation of roles. Northland DHB has eight credentialed CalderdaleFramework Facilitators across Allied Health and Community Nursing services. A second cohort of 10 Facilitators are currently undertaking training.

Northland Community Hub: TheNorthland Community Hub is co-located NDHB community-based services for patients and with complex care needs. A dedicated, interdisciplinary team will provide triaging for co-located community services across Northland. Once operational in March 2021, the benefits for patients and will include: improved care planning and coordination; improved experience of care andreduced waiting times. In the future the Community Hub will facilitate opportunities for multidisciplinary team (MDT) care delivery using existing and developing MDT meetings.

Primary andsecondary care multidisciplinary team (MDT) Meetings: MDT meetings are run as in collaboration with general practice and providers, and are integrated in the Chronic Care and Child Health Locality Networks. Northland DHB intends to expand the scope and availability of these as part ofits short term GP workforce relief strategy. Te Tumu Waiora: A new model of primary mental health and addictions care and support which providesNorthlanders experiencing mental distress or addictions challenges with access to convenient, high quality, integrated and person-centred care and support. The model puts mental health and wellbeing at the heart of general practice with focused roles, Health Improvement Practitioners (HIP) and Health Coaches (HC), working as part of the general practice team. This model allows for a 'warm handover' which means that a GP or nurse in the general practice can offer someone who is experiencing mental distress or addiction issues the option of seeing the HIP in the same location quickly – often immediately.

The challenges in overall healthcare delivery in Northland are immense, but, to date, Northland DHB has not shied away from investment and promotion of innovative community health initiatives.

The increasing demand on our acute hospital service will continue to require significant upkeep investment, but the DHB recognises upstream investment does tame and, in some areas, reduce this critical hospital expenditure and more importantly keep patients out of hospital, and in their communities.

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Our Vision for the Future In order to address these challenges a fundamental transformation is required from the current provider and treatment focused approach to a and wellbeing focused regional system. This transformation is reflected in our vision which is for:

‘A centred health, disability, and social care system that enables equity and wellbeing for our population’.

Our aim is to enable to achieve Pae ora (healthy futures) which means living with goodhealth and wellbeing in an environment that supports good quality of life. There are 3 interconnectedelements that support Pae Ora: Mauri ora – healthy individuals; ora – healthy families; andWai ora – healthy environments. will be supported to stay as well and independent aspossible and to manage their own health and wellbeing in their own homes and in the community whereverpossible. Where care is needed we want this to be based on what matters to and provided in anaccessible, culturally safe, proactive and coordinated way.

Key features of this system for Primary and Community services include:

• A centred system that develops and delivers culturallysafe andand responsive services in localities based on what matters to and accountable tothe local community • A focus on closing the equity gap particularly for and Pacific populations. • Full implementation of the Te Tiriti O Waitangi and embedding rangatiratanga (authority, ownership, leadership) and mana motuhake (self-determination,autonomy). • An emphasis on getting it right for children andensuring that and Pacific children in particular achieve optimal outcomes • A wellbeing and population based approach thatemphasises equity, prevention and wellbeing provides proactive coordinated care • Integration and collaboration across the health andsocial care system with health and social care partners working together to address inequity and the determinants of health • Service redesign will enable more accessible, responsive and efficient services. • And multidisciplinary team based care, technology, new funding approaches and increased investment will support the delivery of modern, high performing, and sustainable services.

Vision for Primary and Community Care

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Transformation Approach Achieving this vision for the future will require a fundamental transformation in the way primary and community services are delivered. The diagram below summarises our approach to transforming primary and community services. The left side of the diagram summarises the key problems and challenges for that we are trying to address. The right side of the diagram sets out the 6 strategic focus areas and 5 system enablers that we will focus on to respond to these challenges.

Because of our strong relationships, collaboration and aligned vision, Northland has an opportunity to make rapid progress. Although ourunique challenges are outlined below, these also present opportunities for significant change and improvement. These opportunities,pportunities, inthe context of the wider change expected from The Review, emphasise why Northlandshould be considered for additional investment to help address the systemic issues in current Primary Care fundingand granted approval for a new contracting approach for primary care. TheReview noted addressing challenges requires a coordinated response across several dimensions, including thatthe health workforce is available and appropriately skilled to provide services in rural locations. Forsmall rural hospitals like those in Northland with locally based General Practices, managing increasing demand requires an integrated approach and strong collaboration between health care teams and hospital (Tier2) services in Whangarei. Tier 1 and 2 need to be well integrated. It enables the relationships and trust required to deliver on the priority of moving Tier 1 services currently provided in hospitals into communities. The system must reach out with the explicit aim of preventing illness and will not be sustainable unless the models of care and use of the workforce are changed. Northland DHB has considered how it can commission the differing needs of each of our communities through a hub and spoke locality model. Using a blend of innovative contracting, commissioning and procurement models, Northland DHB proposes to invest in integrated provider networks with shared accountability to population level outcomes. Governance for these outcomes will sit with Te Tiriti partners and provide accountability to the communities and localities in which the services are provided.

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Huge opportunities exist for Northlanders if we can realise the recommendations and aspirations of the Review. We are excited to see that our current -centred locality/community work, being developed by Northland DHB and Mahitahi Hauora, aligns with the Tier 1 vision of the review. The Northland health system has the structural and organisational elements already established to rapidly realise the establishment of tier one services across multiple localities that are accountable to and communities ’aspirations. Summary Recommendations Northland DHB is seeking support from the Transition Unit to be considered a Proof of Concept for a number of system improvement initiatives. In preparing this paper Northland DHB met with Mahitahi Hauora, Health Providers and general practice leads to establish a shared vision. Whilst there are somediffering perspectives on the required structure our relationships are strong and we have valuedthe diversity of thought. There is universal agreement on the required functions and the fundamental principlesin our new ‘health’ system. These are that our system is: Whanau and community led Based on the articles of Te Tiriti with special emphasis onPartnership, TinoRangatiratanga and Mana Motuhake, Equity and Matauranga Maori, Capable of restoring Health and wellbeing (Oranga inNorthland, eliminating inequities and ensuring Northland are healthier, wealthier andhappie happierr than the rest of NZ. To achieve this we need strong relationships and fundingagreements withother social sector agencies as well as our Iwi partners. We have a Social Wellbeinggovernance board of which Northland DHB is a very active member, but we also need an implementation arm for increasedinvestment. The concept of an indigenous health system was firstconsidered in 2016 with the guidance of Sir Mason Durie. Although there was some suspicion of DHBmotives, therethere was a high level of interest shown by iwi and Maori providers. We see the formation of the Oranga Maori Entity by Maori as an extension of some of this work as well as Wai 2575. We note that iwi areyet to beconsulted or involved. In addition, Northland DHB believes that our system mustmu bring all providers (community and hospital) together in an integrated manner that is not only structurally sound, but also enables clinical leadership and clinical integration, and supports thewellbeing of our workforce .

The followingrecommendations areindicative only and should the Transition Unit endorse these a detailed business case andprogramme plan would be developed including further consultation and change managementactivity.

1. Establish a Commissioning Partnership Model to improve Hauora in Northland Northland DHBagrees with the Review recommendations (alternate view) to prioritise Hauora and to establish a newcommissioning function through the Health Authority. Through Kotui Hauora, our NorthernIwi - DHB Partnership board we envisage a suitable local agency will be identified to lead the commissioningof all Hauora services.

Wesupport the proposal by Te Tai Tokerau Health Providers Alliance and the Ora Collective toestablish a local Oranga Entity who would have a direct funding relationship with the Health Authority and who would commission services as defined by the Authority as well as solely self-determining, commissioning and funding Health services. The Oranga Entity could also form the delivery arm for other social sector investment

As the Crown Agent we believe Northland DHB remains accountable to the Crown and our population, and funding for all other community services should continue to be funded through the DHB.

With the endorsement of the Transition Unit, Northland DHB will: Through Hauora, our Northern Iwi - DHB Partnership Board governance structure identify the delivery arm requirements Support the establishment of the proposed locally based Oranga Entity.

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Shift the commissioning and delivery of all Hauora services from Northland DHB to the new Oranga Entity. Strengthen the function and accountabilities of Hauora, the Northern Iwi Partnership Board, to oversee all regional Tier 1 functions.

2. Engage communities and ensure service planning is led with their needs and aspirations Northland DHB fully supports the Review recommendation to ensure what and how services are delivered are driven by the needs of whanau and communities. This position is also shared with that ofMahitahi Hauora and the Te Tai Tokerau Health Providers Alliance.

With the endorsement of the Transition Unit, Northland DHB will:

Support Mahitahi Hauora to accelerate the establishment of localities, with the formation oflocality governance boards who would oversee the planning and performance ofservices within that location. Establish a Tier 1 commissioning framework that includes an annualplanning process under the direction of Kotui Hauora and led by the needs and aspirations of It is envisaged that service commissioning and funding decisions would be jointlydetermined in partnership with Mahitahi Hauora and/or the new Oranga Entity asdetermined by the Iwi partnership governance.

3. Support Oranga Maori Entity through the SocialWellbeing Governance Group. Having helped found and Chair this group, Northland DHBhas strong relationships with other social sector agencies. providers through the Oranga Entity could be the delivery arm for many inter-sectoral initiatives that could address some of thesocial determinants of health.

4. Shift the commercial contracting relationship withGeneral Practice to Northland DHB directly Northland DHB agrees with the Reviewrecommendations thatDHBs should not be required to contract with PHOs for primary health care services. Northland DHB wisheswish to directly fund General Practices for their base capitation (i.e. first level services, VLCA andother current funding streams that flow direct to the practice).

In addition to the above funding, there is a sign ficant level of flexible Tier 1 service funding flowing under the current PHOSA agreement (e.g.Careplus, SIA, Health Promotion) and other local agreements that Northland DHB would contract MahitahiHauora to administer under a local service level agreement (SLA). Northland DHB proposes that fromom 1 July 2021 the national PHOSA agreement between Northland DHB and Mahitahi, is set aside – andin its place a local direct funding framework agreement is entered into with individual general practicesfor theabove direct funding.

This direct funding streamalong with co-payments and other practice revenue streams (e.g. ACC) would continue to fundthe base p actice operations. This framework, at a minimum, will be benchmarked against the nationalPHOSA funding levels with the ability for Northland DHB to augment the capitated funding with additionaltargeted capitation to further assist practices with demographic, geographic and health need challenges on an ongoing basis. Small step changes in this area can be accommodated within our existing funding trajectory however the systemic workforce issues within our non-DHB employed workforce will requiresignificant additional funding to address, particularly around employment salary parity.

The flexible funding above would be rolled into a SLA that funds specific general practice support functions, health initiatives, and other services in addition to the base first level access activities. The SLA would be developed with Northland general practices and Health Providers and be between Mahitahi Hauora (or indeed any Northland PHO) and Northland DHB and be very clear regarding mutual accountabilities.

This approach could be implemented relatively quickly but would require additional funding to enable a realistic strategy to fix tier 1 workforce issues and prototype new business models.

The change in contractual structure would ensure that general practice clinicians and staff feel directly connected to the health services within DHB hospital facilities, while also participating in the wider community and primary service planning through which Mahitahi would continue to play a key role.

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Northland DHB is asking the Transition Unit to endorse us to: Work with Mahitahi Hauora to transfer the capitation contract management function to Northland DHB effective 1 July 2021. On behalf of, and with general practice, develop an SLA with Mahitahi to clarify mutual expectations, outputs and outcomes Work with Mahitahi Hauora to continue to build relationships with and provide support togeneral practice through all their other programmes and other DHB contract/ Services to ImproveAccess (SIA) funding. Engage with the Mahitahi Hauora Board to consider any further services thatmay bemore appropriately delivered and/or managed through Northland DHB. Utilise the additional capitation funding requested below to work with the “willing” toimplement alternate business models such as DHB salaried general practice.

5. Improve access to services in communities Northland DHB agrees with the Review recommendation to improve theaccessibility and effectiveness of Tier 1 services through a networked approach. As mentioned earlier in thispaper Northland DHB is already well placed with the successful implementation of a number ofinitiatives that support primary secondary integration, health and social care coordination, shared careplanning, and clinicians working together in a Multi-Disciplinary Team (MDT) approach.

Endorsement from the Transition Unit would help accelerate andstreamline some of the following activities but Northland DHB and Mahitahi Hauora already agree that thefollowing are within our control and existing funding: We will use population information, data andevidence to support identification of and community needs aspirations within eachlocality, and to measure if needs are being met. Establish an integrated network of services within each locality ensuring access to “guaranteed services” as defined on page 104 withinthe Review. Northland’s four rural hospital settings are ideally placed to serve as hubs for ourkey rural localities. This model provides a Ora based approach, delivering seamlessaccess to all Tier 1 services in the same locality reflecting the communities’ aspirations and needs. Fund and Develop a Sustainable Primary Healthcare Multidisciplinary Team / Workforce o Establish a wider workforce blend in Tier 1 services providing additional funding to general practiceand Health Providers to implement alternate models and advanced practice rolesincluding Nurse Practitioners. Establish a new unit with the DHB Recruitment Directorate to provide direct support and administrationfor GP and Health Provider recruitment and workforce development. ExpandCommunit Community Based Attachment Placements / RMO Workforce Capacity Building to encourage greater numbers into General Practice Provide additional funding to support Whangarei After Hours service to expand access and to reduce onca lrequirements creating a more attractive offering to GP candidates. Expand the Healthcare Home model to more practices, with additional funding invested, and changes to models including greater focus on equity, proactive planned care and locality improvement initiatives. Scale up the recently piloted Primary / Secondary MDT case review initiative with increased funding to enable greater capacity for specialist and GPs to participate. Expand digital connectivity and use of telehealth models and patient portals Encourage and fund the expansion of clinical pharmacists working within and with general practice and other health providers for the benefit of patients. Strengthen and formalise the existing networked approach by our co-located services in Kaitaia and Dargaville Rural Hospitals Incentivise the implementation of Regional Collaborative Community Care (RCCC) Information System across all Tier 1 providers. Note: it is acknowledged that this will take a significant amount of time and additional funding to fully implement.

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Expand the promotion of health careers through the establishment of a Health Science Academy.

Relationships

Based on the above recommendations Northland DHB recommends the following structure and relationships.

OverallBe Benefitsnefits

1. Contracting directly with specific providers induces a closer primary/secondary collegial relationship be ween clinicians. 2 Genuine partnership with Iwi with joint commissioning decision making rather than DHB power and control. 3. Stronger Crown relationships and partnership. 4. Reduced barriers between organisations that have differing priorities. 5. Ring-fencing Tier 1 services reduces competition for finite resources being prioritised by traditionally provided DHB hospital level services 6. Planning and funding is driven by the communities needs with priority given to moving tier one services currently provided in the base hospital to the community. 7. The provision of a hub and spoke community model can share the workforce working at top of scope, with enhanced nursing and allied health roles supporting a specialist/generalist medical workforce.

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8. A Ora approach designed to meet the needs of a specific community. 9. Increasing system efficiencies and reducing overheads focused on commissioning services to meet agreed population outcomes. 10. Shared accountability between provider and funder to deliver value health care services. 11. Workforce equality and pay parity across the locality. 12. Opportunity to transform patient care pathways across transition points between Tier 1 and Tier 2 services to achieve equitable health care pathways across the whole system through reduced risk of falling between gaps in providers. 13. Investment into existing rural hospitals to provide enhanced access to diagnostics, treatmentand management of acute and chronic illnesses based on aspiration and healthcare need. 14. Reduced cost to in accessing of services. 15. DHB directly funding enhanced capitation (see below under “Costs”) allows integratedemployment models with rural hospitals and GPs, particularly for those with dual (Rural HospitalMedicine and GP) fellowships. Also allows introduction of DHB salaried practice proof ofconcepts in practices that desire this business model. 16. Reduces risk of hospital and community silos. Encourages vertical clinicalintegration and shifting hospital services into the community/ localities.

Issues / Risks 1. Appetite from individual organisations that perceive a reduced role within the system to agree to system overhaul may put up significant barriers and leadto disruption.

2. Short term disruption whilst internal changes are madeto enable the transformation to take place.

3. Changes to be made through consultationand repurposing of funding during transitional periods will need to be fully understood andmitigated.

4. Establishing the new models andprovision of hump funding may be required to safely transform the tier one landscape.

Costs Northland currently invests a significant level of operational funding into primary and community care services outside of thenational capitation model. These additional services are a necessary local augmentation to a baseprimary care funding model that is not well suited to a population with the geographic and demographicchallenges Northland faces.

In addition to the$55m funded under the national PHOSA arrangement, there is $13m of funding put towardsadditional primary care initiatives, including notable initiatives such as Healthcare Homes, and Acute Care DemandManagement. Northland DHBhave recently agreed to fund a further $5m investment in a suite of short and long-term workforceinvestments to support General Practice and Maori Providers. NorthlandDHB also funds $8m of specific Kaupapa Health Services, predominantly for Ora and primary care services in remote rural localities. When other Tier 1 services are taken into account, North and DHB fund over $30million services with Providers.

Allof this sits on top of our significant and growing expenditure in community pharmacy, residential care, home based support, and community mental health services. In total Northland spends over $1400 per capita on non-DHB Tier 1 services which is 30% greater than our Northern Region Metro DHB counterparts (Note: for further detail refer to the Northern Region Primary and Community Care Deep Dive Report, December 2020, which has also been submitted to the Transition Unit). More than $60m of annual funding goes towards Northland’s four rural hospitals (Kawakawa, Kaitaia, Dargaville and Rawene) who provide inpatient services and a considerable range of nursing, allied health and other services in the primary/secondary nexus. Although we have outlined further significant investments in workforce, and have also committed additional funding for providers, the reconfiguration of the general practice funding is not manageable within

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Northland DHB’s current expected funding trajectories because the items below will require additional funding via a Transition Team budget bid. We strongly recommended the following for consideration:

Pay Parity – Negotiations are ongoing at a national level around the differential between DHB and primary care / Health provider employment conditions. Implementing any change in this sphere at a local level without national consistency would not be sustainable. Revised Capitation Formula – This requires fundamental change. If DHBs are to offer or consider salaried models for some GPs in high need communities, the current inequities in funding must be addressed. The formula needs a significant weighting for need and complexity. Hence deprivation, and Pacifica and additional age bands (over 75, over 85 etc.) need to attractadditional funding. Copayments should be at the same low level across Northland, whether they aretargeted or universal. The additional funding needs to create a level playing field (parity) for allworkforces and be adequate to ensure that salaried GPs are not receiving more than those GPs thatwish to utilise capitation funding. Currently, nearly $70million is spent on general practiceservices, copayments, ACC and other revenue generate between $20-30m and thecost of fully funded general practice teams (see GPNZ model) would be approximately $120m. Hence, toenable this, it is likely to require between $20 and $30million of new funding.

With endorsement by the Transition Unit a detailed business case will beprepared to prototype this model which will require an additional 2021 budget bid.

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