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Foreword

Mahitahi Hauora is a ground-breaking collaborative endeavour led by Te Tai Tokerau and Manaia Health Primary Health Organisations with support from the Northland District Health Board, Māori led health providers, general practice, and Northland Iwi Leaders. These key parties have a bold vision for the well-being of the people of Te Taitokerau and this vision is given form through the establishment of Mahi Tahi Hauora.

The purpose of Mahitahi Hauora is to support a primary healthcare system that sustains equitable, self-determined wellbeing, and ensures every person has an opportunity to live a long healthy life. This is currently not happening for parts of our community, particularly for Maori, so to realise our vision Mahi Tahi Hauora commits to Te Tiriti o Waitangi and has entrenched it in our constitution, policies, plans and practices.

Moreover, Mahi Tahi Hauora aspires to bring the best thinking, people and methods to bare on our purpose and we will demonstrate a clear commitment to tāngata (people), whānau (family) and Iwi Whānui (community) centered design, planning and delivery in our strategies and delivery.

Given our deeper understanding about the determinants of health within the Northland context we will take a broader and more joined-up approach with other sectors and agencies so that we can leverage opportunities or learn from other initiatives that are improving the health and well-being of Northlanders.

It is an exciting time for Northland. We have had unprecedented economic growth, population growth and employment growth. Mahi Tahi Hauora is our opportunity to work-as-one to support our region and communities to continue to build our resilience and prosperity through making strides in the health and well-being of our population.

Nga manaakitanga,

Eru Lyndon Chairman Mahitahi Hauora

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Contents

Foreword............................................................................................................................................... 2

Executive Summary..........................................................................................................................4-7

Introduction.......................................................................................................................................... 8

Section One:- Why do we need a transformational change in the way health and

social care systems operate within Northland ....................................................................10

- An outline of the future demand pressures associated with a rapidlygrowing and ageing population ..............................................................................................11

- 2013 Census Report Compared to 2006 ........................................................................12-13

- Key Points from 2011/2014 Pooled New Zealand HealthSurvey Data for Northland .................................................................................................14-15

- An overview of the gap that exists in both the Northlandpopulation and more specifically Māori ................................................................................16

- Life Expectancy ............................................................................................................................18

- Amenable Mortality due to Circulatory Diseases ................................................................19

- Determinants of Health .............................................................................................................20

- Lifestyle Factors with an Equity Lens......................................................................................21

- Socioeconomic Factors that Impact on Self-determined Wellbeing ..............................22

- Ambulatory Sensitive (avoidable) Hospital Admissions ..................................................... 24

- An outline of the challenges in closing the gap ...................................................................25

- Ultimate goals of better value, better outcomesand closure of the equity gap ..................................................................................................26

- Sustainable Workforce .........................................................................................................28-30

- An overview of the policy and strategic agenda nationally,regionally and locally ...........................................................................................................31-40

- Northland DHB ............................................................................................................................41

- Mahitahi Hauora ....................................................................................................................48-56

- Benefits of the Proposal ............................................................................................................57

Section Two:- Your Feedback ..........................................................................................................................58

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Executive Summary

Mahitahi Hauora Vision “A 2026 Northland healthcare system that sustains

equitable self-determined wellbeing.”We all know a vision without an action plan to achieve it remains simply a dream. We know that in health we work in an environment like the ocean that is constantly changing. If we are to achieve the strategic vision, of Mahitahi Hauora, we will need to chart a course with a clear and well-defined plan that can deal with the uncertainty, complexity, and ambiguity and challenges that exist in the present and future environments.

In charting this course towards 2026, we will need to ensure we apply the three P’s of partnership, protection, and participation in all parts of the planning and delivery process as follows:

Partnership requires Māori to be involved in all levels of the health sector including decision making, planning and development of healthcare services, to ensure equity of outcomes and power sharing in priority setting. The challenge in realising the vision is so significant that we can’t achieve it as a Mahitahi Hauora working alone. We need to grow collaborative leadership, connection and effective partnership with communities, hapu and Iwi and other social and healthcare providers. We need transparency, about what is working and what is not, and we need to commit to working towards common goals and ideally with a shared outcomes framework.

Protection means actively using and protecting Māori knowledge, interests and values. Identity, language and culture are important expressions of what it means to be Māori and we need to build on the richness that this brings. This includes valuing, validating and protecting local knowledge or mātauranga, normalising Te Reo, learning and applying tikanga in all we do. It also includes ensuring we understand and apply a Māori perspective in the planning we do.

Participation is about positive Māori involvement through positive working relationships and ensuring the aspirations and priorities of Māori individuals, whānau and communities are reflected in our priorities. Strong partnership leads to greater participation. This means we need to shift the focus for the design and delivery of health and social services to the people who use them.

“The challenge to realise the transformational vision has been accepted.”

Many of us have been working to improve health outcomes for New Zealanders and we have seen significant health and life expectancy gains for all populations for which we can be proud. However persistent equity gaps remain in health access, quality of services, and health outcomes. Māori and those from lower socioeconomic groups are still the most disadvantaged.

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The Ministry of Health has asked DHB’s to take a bold approach to addressing health inequities in order to deliver tangible transformations to health system design and delivery over a three to five year horizon.

It was recognised by Northland DHB, PHOs, and the leadership of Te Kahu o Taonui that in order to deliver an ambitious transformation agenda within the time frame provided there needs to be transformation of the way primary and community services are provided.

This transformation is needed to accelerate the speed and scale of transformation, to close the equity gap, and to meet the demographic pressures associated with both a growing population and a growing older population. For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect Māori. We will need to accelerate the learning process across the region by building on existing knowledge, experience and research of what works and applying it, and continuing to learn and scale faster.

As you are aware, Northland is very different to the rest of the country being largely rural, with a significant proportion Māori and a large proportion amongst the lowest socioeconomic levels in NZ. If we are to improve outcomes for individuals, whānau, communities, hapu, Iwi and populations, so that each is able to be healthier and more able to live independent and full lives we need to tailor our transformation agenda to the Northland context.

The Role of Mahitahi HauoraThe representative Mahitahi Hauora Board have indicated they want to establish a long term sustainable transformation plan of the health system that includes integration and preventing poor health and reducing health inequalities. This plan will not only improve lives for each member of our community it will also reduce demand on health and social services. The key goals of the Mahitahi Hauora transformation agenda are described below:

1. People living in Te Tai Tokerau using health and social services will experience outcomes that are positive including right place, right time, and right way by engaging them in their care and growing their respect and dignity.

We will do this by providing an outcome focused, person and whānau centred care delivery system in or close to where people live. Our focus is on growing individual, whānau, community, hapu and Iwi engagement in the design and delivery of services so that we can develop systems of care to achieve the best outcomes for them rather than designing systems and processes around organisational silos;

2. Individuals, whānau, communities, hapu and Iwi and populations will achieve equitable self-determined wellbeing.

We will do this by combining the collective efforts of all partners within the community, region and nation to work collectively to address the determinants of health and wellbeing and associated inequalities. We will bring a wider population health lens, that focuses on preventing poor health, reducing inequalities, and mobilising the capabilities of every individual to maximise their own ability to live well, get well, stay well and die well. This focus will help reduce the overall need for care and support, from existing services and make the health system more sustainable.

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3. We will provide a place based focus to address the determinants of health and wellbeing

Given the challenges of rurality, geography, and population differences place or locality based solutions will need to be tailored to the local context with the relevant partners at the table such as employment, education, housing, health and social services.

4. We will grow a shared agenda and focus from relevant leaders from separate organisations and structures to make it their number one priority to work together to drive a transformation agenda that will improve health and wellbeing of the population served.

To achieve this transformation agenda we will need to grow a collaborative culture with a shared commitment to combining the resources of people’s time, energy, expertise and focus to achieve transformation at scale and pace. We will also need strong support from leaders across the sector to agree and work towards a shared outcome framework. We need to grow a focus on placing first the whole team before the home team which makes system wide priorities the predominant shared focus of their organisation. The shared premise is that if we work together we can achieve better outcomes and a more effective use of resources.

5. Our front line care providers will be empowered to use their knowledge, experience and expertise to develop a seamless care delivery system that makes it easy for care providers to do the right thing and to address the broader determinants of health and wellbeing.

Care teams in localities will work together in collaboration and partnership to address what matters to individuals and whānau and to achieve healthier communities and improved long term outcomes. They will be encouraged to see the problem, own the problem and solve the problem and share the learning with support from an experienced transformation team.

“In summary we will need to develop an integrated delivery model between health and social service providers, to deliver

care that is evidence based, person centred, and able to address the wider determinants of health and wellbeing.”

Success in achieving the vision of Mahitahi Hauora ultimately will depend on the level of ambition and determination from key providers such as yourselves, your innovative ideas and your ability to implement them through an effective transformation process. While exemplars may exist of where this is working well, we need wider spread of best practice, to ensure transformation is embedded in the broader health care system so that every day, every person, whānau, community, hapu or Iwi are able to achieve health and well-being (see Transformation Approach section).

We will also need to understand and address the barriers to care and associated health and wellbeing that are unique to each community (see questions in section).

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It is important that you carefully consider and understand the information contained in this document and supporting material as it explains the transformation agenda.

At this time we know where we want to go based on the direction of the Boards and key leaders described above. We do not however have a predetermined plan how to get there apart from the key building blocks. This paper asks you to contribute your thoughts and ideas to developing this plan.

Once we have received your input and advice we will provide you with an overview of a more detailed and definitive plan. At this time we will be able to outline in more detail how the plan we are proposing may affect you, your current role, your team and relationship with your employer going forward.

The information provided in this paper reflects a broad overview of the current thinking in New Zealand (NZ) by way of background. If you wish to focus only on the role of Mahitahi Hauora and related challenges it is trying to address go to page 38.

We want to hear from you about all aspects of the proposal. We will keep an open mind and consider all your feedback before a decision is made about the final structure.

Transformation is never easy, and we know many of you have been through previous changes in recent years.

Our environment has been changing for the better, and as such we need to adapt to those changes to ensure our healthcare services are meeting the needs of our patients’, whānau, hapu and Iwi and the population as a whole both now and into the future.

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Introduction

The purpose of this document is:

A. To describe the reasons why the health and social care systems need to transform the way they operate within Northland. The rationale for the transformation agenda includes:

1. An outline of the future demand pressures associated with a rapidly growing and ageing population

2. An overview of the equity gap that exists in both the Northland population and more specifically Māori in achieving health and wellbeing for individuals (Tangata), families (whānau) and communities (Hapori) hapu and Iwi

3. An outline of the challenges those working in the health system in Northland face in improving health outcomes and closing the equity gap

4. An overview of the policy and strategic agenda nationally, regionally and locally to significantly transform the way we deliver health services to close the equity gap and fulfil our Te Tiriti o Waitangi commitment to improve Māori health outcomes

5. An overview of why both Northland DHB and the Boards of Manaia Health and Te Tai Tokerau PHOs’ believe we need to develop an ambitious new transformation agenda building on the excellent work from each PHO

6. An outline of why this ambitious transformation agenda needs to be led through a new Primary Healthcare Entity (PHE) Mahitahi Hauora, in partnership with other providers in the health and social care systems

7. An overview of what success for Mahitahi Hauora will look like as defined by both the Manaia Health and Te Tai Tokerau PHO Boards and the Board of Te Kaupapa Mahitahi Hauora – Papa O Te Raki Trust.

“Together, we envision a 2026 Northland healthcare system that sustains equitable, self-determined well-being for the

people of Northland.”

B. To seek input from the respective PHO team members and leaders on how the challenges can be met and the vision realised.

I recognise that many of you would prefer that this paper provided a definitive overview of the following:

1. The planned transformations to the role and function for each of you, and to outline the future role and function of the PHOs and the Mahitahi Hauora.

2. To describe the future model of care and care delivery system.

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This is your opportunity to contribute your thoughts and ideas on how we can ensure the change agenda for the Mahitahi Hauora is successful. We acknowledge that some of you may have only recently become aware of the establishment of the Mahitahi Hauora as the single entity that the DHB will work with from 1 July 2019.

This paper therefore is structured to provide you with the opportunity to describe how the future should or could look by asking each of you to provide feedback on:

1. Your thoughts and ideas as to how we can ensure we can be successful in the change programme

2. What approaches you believe have been, or are effective, that we can learn from, and

3. How you individually and within your team would like to contribute to making the Vision a reality for all who live in Northland.

The questions posed are on the website where you can find this document and provide your feedback. We will collate the feedback and provide an aggregate summary of your thoughts and suggestions as well as a list of all those who provided feedback. It is important to differentiate between consultation and consensus. This is a consultation process in which we seek your input into how the future can be shaped.

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Section One: Why do we need a transformational change in the way health and social care systems operate within Northland ? ‘Te Whakaritenga – The Aspiration’The new Primary Healthcare Entity (PHE - Collaboration Kaupapa) ‘Te Kaupapa Mahitahi Hauora-Papa o te Raki’ (known as Mahitahi Hauora) is a ground breaking collaborative endeavour led by Te Tai Tokerau and Manaia Health Primary Health Organisations with support from the Northland District Health Board (Northland DHB), Māori led health providers, general practice, and Northland Iwi Leaders, represented by Te Kahu o Taonui.

We aspire to contribute to ensuring that the vibrant, diverse and dynamic communities living in the Te Tai Tokerau district can live well, get well and stay well.

Together, we envision a 2026 Northland healthcare system that sustains equitable, self-determined well-being for the people of Northland.

We value:

• Self-determined wellness• Equity• Transparency• Collaborative and empowering leadership.

The purpose of Mahitahi Hauora is to support a primary healthcare system in the community that sustains equitable, self-determined wellbeing, and ensures every person in the community has a fair opportunity to live a long healthy life.

In achieving this purpose Mahitahi Hauora will demonstrate commitment to Te Tiriti o Waitangi and its principles, namely: Partnership, Participation and Protection.

For clarity, this means that we will pro-actively involve Māori, as individuals and through their representative whānau, hapū and iwi institutions, in the design, delivery and decision making of services that impact them (including mainstream services that they are likely to use).

Mahitahi Hauora will demonstrate commitment to tāngata (people), whānau (family) and Iwi Whānau (community) centered design, planning and delivery in its strategies and its delivery.

The role of the Mahitahi Hauora will include:

• a single primary care entity to address governance issues • allocating resources to priorities that whānau, communities and providers identify via

locality driven planning • streamlined primary healthcare planning processes• patient and whānau needs and aspirations at the centre• single primary health outcomes framework, and• single point of contracting.

We will build on the many innovations and learnings generated from across the Northland health system both within and outside health. We will sharpen our focus on ensuring we deliver excellent system-wide services to every patient, every time, and grow the range and scope of community-based services so that our communities can access healthcare services much closer to home.

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1. An outline of the future demand pressures associated with a rapidly growing and ageing population.

Northland Population Changes and Challenges 2016/17In 2018/19 it was confirmed that Northland now has the fastest growing population in NZ and the third highest growth in people over 65 years. It has the highest proportion of Māori in the country and a large proportion of the population living in rural areas (43 percent) and in the most deprived parts of New Zealand (37 percent).

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2013 Census Report Compared with 20060-15 years: population has fallen in absolute numbers: 32,478 in 2013 (5.8 percent

decline or 0.8 percent per annum); proportion of the total population 21.6 percent compared with 23.4 percent in 2006).46.3 percent of the total <15 year population identify as Māori.

20-<65years: population classified as the “working age” group has seen a small absolute decline (-0.1 percent), Māori numbers have increased slightly (0.9 percent per annum), offset by non-Māori losses.

30-50 years: population has fallen by more than 5600 people in Northland (14 percent decline) due to significant employment (job) losses in Northland (see below, and the population pyramid graphs).

> 50 years: population growth has occurred in each 5-year age band. Largest percentage increase is for Māori over 80 years of age (10.35 percent per annum). Non-Māori population growth is highest in the 65-80 year and >80year age groups (>4 percent per annum).

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The most recent population data obtained from PHO enrolment shows 47 percent of the population are over 45 and 37 percent of households in Northland consist of a couple over 50 with no children. Northland has the third highest proportion of households with this family type, just behind Nelson and West Coast.

“This means we have an older population potentially without the immediate support of other family members.”

1996

2017

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Key Points From 2011/2014 Pooled New Zealand Health Survey Data For Northland: The current health status is described in the tables below comparing reported health for > 15 years

2011-14 New Zealand Health Survey: Results for adults aged 15 years and overResults for all District Health Boards (DHBs)Region:

Type:

Sex:

Age group:

Table: Result by indicator, and comparison with NZ rate

Northland DHB New Zealand

Excellent, very good or good self-rated health 87.9 90.7 0.03 ↓Current smoking 29.1 19.0 0.00 ↑Daily smoking 26.4 16.9 0.00 ↑Ex-smoker 23.3 22.3 0.33

Hazardous drinking 20.7 17.4 0.04 ↑Meets vegetable intake guidelines 71.0 64.6 0.01 ↑Meets fruit intake guidelines 57.7 56.6 0.61

Physically active 48.3 53.1 0.08

Obesity 33.3 28.7 0.01 ↑Overweight but not obese 35.8 33.7 0.24

High blood pressure (medicated) 12.6 11.6 0.34

High cholesterol (medicated) 7.3 8.0 0.32

Ischaemic heart disease (diagnosed) 4.3 3.5 0.04 ↑Stroke (diagnosed) 1.7 1.3 0.17

Diabetes (diagnosed) 5.3 4.4 0.18

Asthma (medicated) 12.0 11.1 0.36

Arthritis (diagnosed) 12.3 11.6 0.37

Osteoarthritis (diagnosed) 7.3 6.7 0.40

Chronic pain 17.1 15.6 0.16

Mood or anxiety disorder (diagnosed) 20.1 16.6 0.02 ↑Psychological distress 7.8 5.8 0.13

Visited a GP 79.1 76.4 0.19

Visited practice nurse 34.0 27.9 0.00 ↑Visited after-hours medical centre 11.0 12.5 0.17

Unmet need for primary health care 29.3 28.1 0.50

Unable to get appointment at usual medical centre within 24 hours 19.7 16.1 0.01 ↑Unmet need for GP due to cost 13.8 15.3 0.18

Unmet need for GP due to lack of transport 5.2 3.5 0.07

Unmet need for after-hours due to cost 5.6 7.4 0.07

Unmet need for after-hours due to lack of transport 2.1 1.5 0.30

Unfilled prescription due to cost 10.4 6.8 0.02 ↑Definitely had confidence and trust in GP 81.0 80.1 0.77

Visited a dental health care worker (dentate only) 43.0 48.0 0.02 ↓Had one or more teeth removed 8.9 6.9 0.12

Usually only visits dental health care worker for dental problems or never visits (dentate only) 64.0 54.7 0.00 ↑

Notes #N/A = not available. Yellow p-values show statistically significant differences between the DHB rate and the NZ rate (p<0.05).

Sources: 2011/12, 2012/13 and 2013/14 New Zealand Health Survey↑ ↓ DHB has a higher (↑) or lower (↓) prevalence than the NZ rate (Statistically significant)

Indicator for adults aged 15 years and over

Comparing DHB and national resultsAge-standardised prevalence

(%), 2011-14Test of significance

(of difference between DHB and NZ rate) (p-

value; yellow = significant difference)

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The current health status is described in the tables below comparing reported health for children <15 years

2011-2014 New Zealand Health Survey: Results for ChildrenResults for all indicators for a selected DHBRegion:

Sex:

Table: Result by indicator, and comparison with NZ rate

Northland DHB

New Zealand

Excellent, very good or good parent-rated health (0–14 years) 97.8 98.2 0.56

Given solids before 4 months (4 months-4 years) 13.5 9.4 0.25

Ate fast food 3+ times in past week (2-14 years) 4.0 6.2 0.05 ↓

Had fizzy drink 3+ times in past week (2-14 years) 16.6 18.5 0.31

Breakfast at home every day in past week (2-14 years) 85.6 86.7 0.56

Meets age-specific vegetable intake guidelines (2-14 years) 56.3 56.7 0.88

Meets fruit intake guidelines (2+ servings per day) (2-14 years) 77.9 72.5 0.07

Usually watched two or more hours of television each day (2-14 years) 54.8 51.6 0.17

Obesity (2-14 years) 12.2 10.4 0.38

Overweight but not obese (2-14 years) 26.6 21.6 0.01 ↑

Asthma medicated (2-14 years) 19.3 14.6 0.01 ↑

Diagnosed diabetes (0-14 years) 0.2 0.3 0.95

Diagnosed emotional or behavioural problems (2-14 years) 4.4 3.9 0.78

Diagnosed Autism Spectrum Disorder (including Aspergers Syndrome) (2-14 years) 1.6 1.7 0.94

Visited a GP in last 12 months (0-14 years) 75.7 74.5 0.62

Visited a practice nurse (without seeing a GP at the same visit) in last 12 months (0-14 years) 25.6 24.8 0.74

Visited an after-hours medical centre in last 12 months (0-14 years) 21.0 21.3 0.89

Unmet need for primary health care (0-14 years) 23.9 20.7 0.27

Unable to get appointment at usual medical centre within 24 hours (0–14 years) 18.1 13.8 0.13

Unmet need for GP services due to cost (0–14 years) 5.4 5.5 0.95

Unmet need for GP services due to lack of transport (0–14 years) 4.5 2.9 0.16

Unmet need for after-hours services due to cost (0–14 years) 4.2 4.2 0.95

Unmet need for after-hours services due to lack of transport (0-14 years) 2.6 1.2 0.13

Unmet need for GP services due to lack of child care (0-14 years) 3.6 2.4 0.35

Unfilled prescription due to cost (0-14 years) 7.3 5.1 0.13

Definitely had confidence and trust in GP (0-14 years) 75.6 80.1 0.71

Visited a dental health care worker (1-14 years) 77.2 81.2 0.08

Had one or more teeth removed (1-14 years) 6.4 3.9 0.02 ↑

Sources: 2011/12, 2012/13 and 2013/14 New Zealand Health Surveys↑ ↓ DHB has a higher (↑) or lower (↓) prevalence than the NZ rate (Statistically significant)

Unadjusted Comparing DHB and national results

Indicator for children

Notes: na = not available. Yellow p-values show statistically significant differences between the DHB rate and the NZ rate (p<0.05).

Test of significance

(p-value)

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2. An overview of the gap that exists in both the Northland population and more specifically Māori in achieving health and wellbeing for individuals (Tangata), families (Whānau) and communities (Hapori).

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing both the social determinants to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, as well as improving access to healthcare.

Social determinants of health, including social and physical environments, and factors such as income, education, social cohesion, and neighbourhood quality, explain most of the inequities in population health outcomes in both Aotearoa/NZ, with healthcare estimated to account for approximately 10-20 percent of the variation (see diagram below).

The emerging awareness of the relationship between place and health has reignited interest in leveraging community improvements for health equity and to identify where to intervene to address social processes that affect health.

There are predictable geographic patterns caused by a combination of biology, psychology and social processes in communities that lead to these health inequalities. This is why the strategy of Mahitahi Hauora is to bring a focus around communities through the locality transformation program. Research in NZ has shown that ethnic density is protective of health and results in reduced exposure to racial discrimination of Māori. However this effect is impacted by the detrimental effect of area deprivation, signalling that the benefits of ethnic density must be interpreted within the current socio-political context.

It is important therefore that in impacting on health outcomes we measure health equity at a local level as well as at a DHB level and that the measures include:

• an indicator of health or modifiable determinants of health, such as healthcare, living conditions or the policies that shape them

• an indicator of social position, a way of categorising people into different groups• a method of comparing the health, or health determinant indicators across the different

social strata.

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“Significant Disparities in Health Outcomes still exist in Northland.”

Disparities in health outcomes by race and ethnicity and by income status have been persistent and are difficult to reduce.

Health status is variable and there are significant inequities for Māori and non- Māori and non-Pacific.

• Average life expectancy for Northland is 79.9 with an 8.7 life expectancy gap between Māori and non-Māori and non-Pacific

• Northland deprivation levels are 37 percent overall and 46 percent among children• Geographic challenges exist in Northland with 43 percent of the population living in rural

areas spread over large distances• There is a significant burden of preventable ill health and as a result the amenable mortality

rates for Northland Māori are 2.5x higher compared to non-Māori• The cardiovascular, cancer, and infant mortality rates are some of the highest in the

country• Suicide rates are very high and almost double the rates of the rest of the Northern region• Determinants of health such as smoking rates and obesity levels amongst adults and

children are very high when compared with the rest of the country. • Barriers to care exist with 1 in 5 people with unmet needs for primary care due to cost,

transport, or ability to get an appointment (27 percent Northland DHB).

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Life Expectancy for Male Māori/Non-Māori at Birth

Key observations: Male Māori life expectancy in Northland remains about 10 years less than non-Māori Male Māori life expectancy in Northland is about 2.7 years less than NZ Māori

Life Expectancy for Female Māori/Non-Māori at Birth

Key Observations Female Māori life expectancy in Northland remains about 8.6 years less than non-Māori Female Māori life expectancy in Northland is about 1.2 years less than NZ Māori

Amenable Mortality 2015 (see below)

• The amenable mortality rate for NZ Māori was 2.4 times higher than the non-Māori ratein 2012

• The amenable mortality rate for Northland Māori has improved however in 2015 it wasover 2.5 times that of non-Māori

N.B: Amenable mortality is defined as premature deaths (deaths under age 75) that couldpotentially be avoided, given effective and timely healthcare.

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Amenable Mortality due to Circulatory Diseases.

Life expectancy gains can be made with investments in health. A major area of improved life expectancy has been through the dramatic reduction in Coronary Heart Disease (CHD) and stroke mortality (up to 70 percent since 1980). Over 90 percent of the gains are attributed to health sector treatments and primary and secondary prevention interventions such as smoking, CVD risk assessment and management, acute MI and stroke management and PCI and angioplasty. As shown below in the Northern Region ANZACSQI quarterly report for the quarter ended 31 December 2018. Northland has room for improvement in increasing the number of patients identified as at risk for Cardiovascular disease risk who are on either dual therapy or triple therapy.

The major cause of death in Northland includes cancer and circulatory diseases.

Māori in Northland Non-Māori in NorthlandCancer CirculatoryCirculatory CancerRespiratory RespiratoryExternal Causes External CausesEndocrine and Metabolic Nervous System

The greatest cause of cancer related deaths over the last five years was lung, breast, and bowel.

Māori in Northland(Number of deaths over five years)

Non-Māori in Northland (Number of deaths over five years)

1. Lung (100) 1. Lung (84)2. Breast (32) 2. Prostate (21)3. Pancreas (16) 3. Liver (17)4. Stomach (13) 4. Stomach (15)5. Ovary (11) 5. Colon (14) & Pancreas (14)

Cancer survival rates are trending down due to reductions in smoking and increased screening and improvements in treatment.

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Determinants of HealthThe 2017 New Zealand Burden of Disease study has estimated that being overweight is the leading risk factor to health accounting for 8.9 percent of disability adjusted life years loss from all causes in 2017, followed by unhealthy diet and tobacco use.

What has driven life expectancy gains in recent decades? A cross-country analysis of OECD member states As shown below in a comparison of 35 OECD countries over 10 years, there are many factors that contribute to health status, including determinants of health that go beyond the health system. The table shows that on average, a 10 percent increase in health spending per capita is associated with a gain of 3.5 months of life expectancy. The same rate of improvement in healthier lifestyles (10 percent) is associated with a gain of 2.6 months of life expectancy. Wider social determinants are also important: a 10 percent increase in income per capita is associated with a gain of 2.2 months of life expectancy, and a 10 percent increase in primary education coverage with 3.2 months. For income, minimum absolute levels are particularly critical to protecting people’s health.

The main policy implication emerging from this analysis is the significant opportunities for health improvement from coordinated action across ministries responsible for education, the environment, income and social protection, alongside health ministries. This includes inter-sectoral action to address health-related behaviours. Collaboration with the private sector will also be important, especially with employers in relation to working conditions.

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Lifestyle Factors with an Equity Lens – DHBs Health Survey Results 2011-14 Current status > 15 years

• Highest rates of healthy eating in the North Island meeting fruit and vegetable intake guidelines

• Highest rates of physical activity in the Northern region and increasing • Highest rates for >15 smokers in NZ at 25percent with Māori almost double non-Māori • Fifth highest levels of obesity in NZ and increasing; higher for Māori.

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Socioeconomic Factors that Impact on Self-determined Wellbeing

Education: There is a higher proportion of Māori who leave school with no qualification at 38.9 percent vs non-Māori. As shown in the graph below income impacts education outcomes.

Income: 70 precent of Māori earn less than $30k/year

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Housing• 22.4 percent of Māori in the lowest income quintile in Northland are living in crowded

households• 6.1 percent of New Zealand Europeans in Northland live in the lowest quintile.

Nutrition• 28.1 percent of Māori under 15 consume 3 or more sugary drinks a week• 20.7 percent of the general Northland population under 15 consume 3 or more sugary

drinks a week• 11.3 percent of Māori children under 15 consumed fast food takeaways 3 or more times

a week• 8.5 percent of the general population in Northland consumed fast food takeaways 3 or

more times a week.

Lack of Income Impacts on Access to Healthcare Services• Diagnosed rates for diabetes, asthma, and congestive heart failure is high• Highest rates of prescribed blood pressure medication and second highest in the country

for cholesterol medication• High proportion have accessed their GP or practice nurse.

Visiting the GP:

• 15.9 percent of Māori in Northland have not seen a GP due to cost in the last year as compared to 21.6 percent of Māori in New Zealand

• 9.0 percent of Māori in Northland did not visit their GP due to transport in the last year

• Patients find it hard to get an appointment at usual medical centre within 24 hours for Māori 0-14 yrs was 29 percent vs non- Māori of 18 percent

• Gaining access to a GP out of hours is a problem.Prescriptions:

• > 15 years unfilled prescriptions due to cost is very high which makes it the fourth highest in the country in terms of cost being a barrier to access

• < 15yrs unfilled prescriptions due to cost for Māori was 10% vs 3.5% for non-Māori.Dental Care:

• > 15 yrs fifth lowest number of people over 15 accessing dental care• <15 yrs accessing dental care Māori vs non-Māori was 10 percent lower (73 percent

vs 83 percent )• > 15 yrs fourth highest number who have had one or more teeth removed.

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Ambulatory Sensitive (avoidable) Hospital Admissions (ASH) RatesIf patients can not access primary care they attend the emergency department (ED) and hospital for conditions that could have been managed in primary care. They often present with an advanced stage of their disease progression with worse outcomes. This is measured by ASH rates. As shown below ASH rates for Māori are much higher than for non-Māori and for decile 5 than for decile 1 with associated costs of the ED attendance and acute bed days.

Accessing Healthcare Services (ASH rates)

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3. An outline of the challenges those working in the health system face in closing the gap in health outcomes

What are some of the barriers to achieving the goals of health & wellbeing for individuals (Tangata), our families and loved ones (Whānau) and our communities (Hapori), including hapu and Iwi?

1. Parallel funding streams through a combination of national, regional and local contracts to a multitude of providers without joint planning makes it hard to realise the synergies described above (see fig 1 below).

Sector Services: payment agent for DHBs

PHO capitation funding

Pay for performance

Pay for performance

Additional funding

includingafter-hours

Baseline funding(population-based

funding formula)

Additional appropriations

PHO capitation funding

Additional sources of Government funding

General medical services

Flexible fundingpool

Additional funding with national service specifications, including after-hours:• general $9m• rural after-hours $5m• rural sustainability $2m• rural transition $0.4m

• Discretionary localcontracting

• PHO Agreement‘Part J’ (local variation)

National pharmacy services agreement

National PHO

agreement or alliance agreement

Crown Funding Agreement (or CMS1)

CMS1

Local

National services contracts

Section 88 Notices3

‘Back-to-back’ agreements

Primary Health Care Services Funding and Contracting

Community pharmaceuticals

(subsidised medicines)

• NGOs and other health providers (eg dental)

• 280 Maori health providers• 33 Pacific health providers• 51 Urgent care clinics

National Services:• Telehealth $22.6m• Plunketline $3.9m• Family Planning $19.7m • WellChild $65.3m• Emergency ambulance $110.1m• Screening (breast, cervical,

bowel, antenatal and newborn) $129.1m

Maternity services $161.4m

Pharmacies

1,0 39General Practices

20District Health Boards

Inter-districtflows

SCDHB PCS2

Sect

or S

ervic

es

$512.3m

$450m

$954m

$6.9m + $13.7m

‘clawbacks’

$907m

$744.7m

$23.7m2

1

3

Primary Care Team, Service Commissioning, Ministry of Health August 2018

includingafter-hoursproviders

Ministry of Health

Other service fees

Immunisationfee

$36.2m 31Primary HealthOrganisations

including Health Allianc-

es

(approx)

Primarymentalhealth

Primarymental health

Management Servicesorganisation

1,108

$587.4m

Funding flows

Contract type

$m – funding per annum for 2018/19

1 Contract Management System (Sector Services)2 South Canterbury District Health Board – Primary and Community Services3 Advice notices issued under Section 88 of the NZPHD Act 2000

Figure 1: Primary care funding flows and related contracts

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2. The determinants of health and wellbeing that need to be addressed are wider than simply the quality of health services provided (see figure 2 below). We need to find effective ways to address social needs in their own communities. This in many ways reflects the broader focus brought by whānau ora in identifying and addressing broader needs across a range of social and health as described above.

To realise the ultimate goals of better value, better outcomes and closure of the equity gap we need to make it easy for our people and their whānau to connect with their own and the wider community resources.

“Mā te taiao kia whakapakari tōu oranga Let nature in, strengthen your wellbeing.”

Figure 2

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System level measures include a comparison of acute bed days with the premise that improved primary and community care will result in reduced secondary hospital demand. As shown in figure 3 below, these factors also turn potentially manageable health issues into high cost care and worse outcomes for the patient, whānau and the provider.

Counties Manukau District Health Board (Counties) estimated that just 2.5 percent of their 500k population accounts for 30 percent of the total cost of care (30 percent inpatient beds, 20 percent outpatients see below). Counties managed 24260 patients with one or more chronic diseases in the 12 months to December 2016. Counties managed 24260 patients with one or more chronic diseases in the 12 months to December 2016.

Northland currently has 6000 patients who are being managed by the wider health team through shared care planning.

Figure 3

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3. Sustainable Workforce

From international evidence, we know that primary care is associated with better health, a more equitable distribution of health in populations, and lower health costs.

As shown below Spain is now ranking number one in the world in 2019 according to the Healthy Nation index ranking. The index grades nations based on variables including life expectancy while imposing penalties on risks such as tobacco use and obesity. It also takes into consideration environmental factors including access to clean water and sanitation.

4. An overview of the policy and strategic agenda nationally, regionally and locallyto significantly change the way we deliver health services to close the equity gapand fulfil Te Tiriti o Waitangi obligations

What makes Spain the healthiest country? According to the report Spain’s top ranking is attributable to their Mediterranean diet and their access to excellent primary care.

“Primary care is essentially provided by public providers, specialized family doctors and staff nurses, who provide preventive services to children, women and elderly patients, and acute and chronic care. Primary care doctors are the first contact point for the system and they are the gatekeepers of the system. Public expenditure on primary care (including pharmaceutical expenditure), however, has decreased, from 38 percent in 2002 to 31 percent in 2014, while public expenditure on secondary care has increased from 53.3 percent in 2002 to 62.4 percent in 2015.”

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Greater complexity is observed in the regional “agencies” that provide health services, where the two main actors are the Primary Health Care and the Specialized Care divisions. Both are implemented across the territory by way of an administrative distribution of the population in the, so-called, health care areas. Interestingly, within a health care area, the population is allocated around primary care centres (PCCs), in the primary care areas. The primary care areas are perfectly nested into the hospital care areas, facilitating continuity across care levels by design.

European Observatory on Health Systems and Policies 2018 review of Spain.

“It is essential therefore that we grow and sustain the primary care workforce.”

GPs numbers have gone up however ratios of GPs per 100k people is quite variable from 56 GPs per 100k to 78 GP per 100k. 70 percent are young and female.

What we know is:

• Primary health care accounts for around 5 percent of Vote Health ($920m in 2017/18)• Funding to support access to first-contact primary health care services as a proportion

of DHB and total funding has fallen between 2008/09 and 2015/16• As a result at the general practice level, the proportion of revenue from patient co-

payments and capitation funding can vary considerably, but because capitation funding rates ‘have not increased in line with inflation’ ‘the proportion of general practice funded by Government is decreasing and the proportion funded by patients via co-payments is increasing’. The result has been that incentives over the years have continued to prioritise the volume of primary care over new models of care

• Adult fees in very-low-cost-access (VLCA) practices declined by 20 percent in real terms between 2008 and 2016, while in non-VLCA practices fees rose by between 20-25 percent over the same period, with fees rising most for most adults of prime working age (25-64) in non-VLCA practices (HSRC analyses)

• Around half of GP respondents in the latest RNZCGP survey were over the age of 52 and just over half were female. A third intended to retire within the next five years (almost double the figure in the same survey in 2014), and 50 percent within the next 10 years. Almost a quarter reported feeling burnt out

• The total number of GP visits increased by nearly 12 percent between 2008 and 2016, from 11.8m to around 13.2m – with the largest increases among those aged 5-14 years and 65+

• The total number of practice nurse visits rose by nearly 132 percent over the same period, from around 1.4m in 2008 to around 3.3m in 2016. Over the same period, the estimated resident population grew by 10.2 percent

• Nearly 30 percent of New Zealand adults reported having experienced one or more types of unmet need for primary care in the last round of the New Zealand Health Survey (2016/17) – this was higher for Māori and Pacific peoples and those living in the most deprived neighbourhoods, and among some age groups

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• Results from the pilot of the patient experience survey highlight both positive experiencesof care and some issues in terms of continuity and coordination, and communicationaround medications, with some groups routinely reporting less positive experiences (forexample, those with a mental health diagnosis)

• New funding was provided in the Budget 2018 to increase the number of New Zealanderseligible for a Community Services Card, and to introduce VLCA levels of funding in generalpractices for all those holding such a card.

Addressing the Workforce Challenge

In Northland, rurality adds a further challenge to workforce growth and retention. There is a whole range of factors that make it hard to attract and retain clinical staff and more particularly medical staff to the region. These include lack of support, difficulties getting locum cover for professional development and holidays, fewer opportunities for partners and children and limited access to professional development. We need to see a number of partners (DHBs, Iwi, Educators, clinicians, local Govt working together). Funding mix needs to change so more GP training places go to rural trainees.

There are differences in the incentives for small businesses and large corporately led and owned practice models. The disadvantage is that the innovative ideas most likely to be mainstreamed are likely to be those that are based on a medical practice model of primary care as opposed to a community health approach based on strong public health nursing which are a key option for improving access to care in rural communities. More investment in rural primary health care nurses and midwives and in running rural inter-professional education programmes.

‘We have also seen slow growth in our Māori Workforce.’ Documents such as Thriving as Māori 2030 which states health services need to triple the Māori workforce to reflect the communities we serve. Yet the initiatives have had limited impact to grow the Māori proportion of the nursing workforce and the numbers have been static since the 1990s.

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Reason for ChangeTHE WHY:

“The most important single change in the Health system would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. To realise this improvement journey the best changes are

synergistic; with each a piece of the greater whole all working together to provide integrated, patient-centred care.”

Don Berwick (Institute for Healthcare Improvement)As Berwick describes we need to have a view of, and ambition to improve, the patient journey throughout the whole system. It is important to know and understand what each piece or part of the health system is planning to prioritise so that we can realise the synergies between them for the benefit of each individual, their whānau, and their communities, and for hapu and Iwi.

Below are described the various pieces: plans and priorities at a national, regional, and within Te Tai Tokerau. As you review each of you will note how well aligned the strategies are with the ambitions and goals of Mahitahi Hauora and with our Te Tiriti o Waitangi commitments.

A. Health and Disability System Review

The Minister of Health, Dr David Clark in 2018 established a Committee led by Heather Simpson to review the New Zealand Health and Disability Sector. The goal of the review is to identify changes that could improve the performance, structure, and fairness of the sector. The overall purpose of the review is to provide recommendations to the Government for an equitable, sustainable public health service that delivers the healthcare that New Zealanders expect and deserve. In particular, the review is examining the impact of demographic and inflationary pressures on the health service and the resources required, as a result of those pressures, to deliver services into the future. The Review will provide an interim report by the end of July 2019 and a final report by 31 January 2020

Background

The New Zealand health and disability system has many strengths, particularly in the areas of acute illness and injury, and is generally well regarded, both domestically and by international comparisons. Overall, New Zealanders are living longer and healthier lives and as per the Health statistics report shown below, those over 15 in 2015 perceived their health to be the best out of all OECD countries compared.

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However, mortality from cancer, ischaemic heart disease, suicide, and for infants is higher than the OECD average. It is also clear that our health services are not serving all people equitably. In reviewing the Health and Disability Sector there is opportunity to improve overall outcomes and address the pervasive inequities that exist across our health system. More must be done to improve equity of access to services, and health outcomes across the population.

The system is under increasing pressure with an ageing population and an increasing prevalence of chronic disease (e.g. cardiovascular disease, diabetes) and cancer which is consistent with international trends for developed nations (see below).

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This is leading to increased demand for health services. Addressing these trends and ensuring the ongoing sustainability of the health system requires a greater focus towards primary and community-based care (Tier 1 services), while also maintaining our world-class tertiary care services. Given the rapid pace of technological change in the health sector, there are also many exciting and potentially transformative opportunities to prevent, rather than wait to cure, illness in the future.

But for now, we are seeing demand, and resources directed to secondary services grow faster than primary services. Current incentives within the health system are causing many people, particularly those on low incomes, to wait until they are sick, instead of accessing the care they need to stay well. The rapidly changing global, societal and technological context within which New Zealand’s health and disability system operates makes a review timely.

Scope of review

The Government’s starting position is that the guiding principle for the New Zealand health system – namely, a public health service that delivers good health outcomes for all New Zealanders – is sound. The Public Health System in the review has been defined as the science and art of preventing disease, prolonging life and promoting health through organised efforts and informed choices of society organisations public private and communities and Iwi, individuals.

We need the review to be very explicit and provide evidence around where the system is not achieving this core goal. This includes meeting with a diverse range of New Zealanders, identifying who is missing out, why and how we need to improve the health system.

The review would culminate in a report to Government, including recommendations, on:

• How the health system can improve accessibility and outcomes for all populations • Whether the health system promotes the right balance between availability of services,

(particularly tertiary services) population density and proximity • Whether the current system is well-placed to deal with environmental challenges such

as climate change, antibiotic resistance and technological advances • Whether there are changes that can be made to the health system that would make it

fairer, more equitable and effective • How the technological and global healthcare context is evolving, what opportunities and

risks this rapidly-evolving context presents, and whether there are changes that would support the health system to adapt effectively given the rapid changes underway.

The Government has also completed an Inquiry into Mental Health and Addictions. The Waitangi Tribunal also has the WAI 2575 Health Services and Outcomes Kaupapa Inquiry underway. The Government expects that the review would give due regard to the outcome and information generated through these inquiries and reviews when they become available.

B. National context: Director General comments in response to 2017 Health and Independence report.1

It is a priority for the Ministry of Health to improve equitable health outcomes for all New Zealanders, particularly those that the system does not serve so well at present. Equally important is ensuring the way services are designed and delivered work for the people using them. That is why the Ministry is increasingly seeking to better understand people’s needs by working collaboratively with communities.1, Ministry of Health. 2018. Health and Independence Report 2017: The Director-General of Health’s Annual Report on the State of Public Health. Wellington: Ministry of Health

The full report is available at https://www.health.govt.nz/publication/health-and-independence-report-2017

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Looking ahead, our growing, ageing and increasingly diverse population, coupled with the increasing prevalence of long-term conditions and disability, means the current approach to healthcare will be hard to sustain. There is a need for a shift in approach, with a greater focus on prevention and wellness, if we are to meet the challenges ahead.

We need to embrace new opportunities to secure health improvements for individuals, whānau, the community and our health system. We need to do this together, in partnership with district health boards, primary care providers, Iwi providers, community organisations, social sector agencies, whānau and individuals. This shift includes optimising the skills of the workforce and harnessing new technologies to enable more person-centred care to be delivered in the community, close to where people live, work and learn.

Primary healthcare, which is at the centre of our health system, has a vital role to play in this reoriented system by promoting good health, addressing health concerns early and supporting people living in the community with long-term conditions. Timely access to primary healthcare services is important for reducing health inequities, preventing the development of health conditions, avoiding hospitalisations and ensuring the system as whole works for optimal health and wellbeing.

A primary focus of the health system is to improve overall population health. In this focus is recognition that health is a holistic concept covering a number of domains. Health and wellbeing are also strongly linked to whānau, culture, social connectedness, beliefs and spirituality; concepts that are woven into the fabric of New Zealand society and that have particular prominence in Māori and Pacific models of health and wellbeing.

C. Regional context: Northern Region Ten Year Strategic and Long-Term InvestmentPlan (NRLTIP).2

The four DHBs of the Northern region have collectively agreed a ten-year strategic and Long-Term Investment Plan (LTIP) to use health dollars available to secure the best health gain for the people living in the Northern region. The following summarises the key challenges and opportunities that face the region in the next two decades. It also identifies the potential responses to these challenges that are relevant for the Northland region and the Board of Mahitahi Hauora.

Key Challenges Facing the Northern RegionSubstantial population growth and demographic shifts will occur over the next two decades (57 percent of NZs population growth with additional people (562k using medium and 781k using high growth projections) living in Northland and Auckland and a rapidly growing over 65+ population).

• We need to align our efforts on how we invest to improve health outcomes• Health equity is an important priority for the LTIP to address the gap that remains in life

expectancy and health outcomes attributable to ethnicity and deprivation particularly forMāori and Pacific

• The plan commits to working more seamlessly across DHB boundaries, to integratingand sharing resources, assets and services and to making healthcare more patient andwhānau centric and to ensure every dollar spent optimises health gain for all.

2, The full report is available on the Northern Regional Alliance website at www.nra.health.nz/our-services/regional-planning-and-service-delivery

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NRLTIP Goals over the next 20 years are to:i. Improve health equityii. Increase prevention and early intervention workiii. Provide a more patient and whānau centric approach to servicesiv. Fix and address hospital future capacity.

The NRLTIP identifies three investment priorities to improve health outcomes:i. Accelerating model of care changes in the Region will improve health outcomes, reduce

inequities and mitigate demand for healthcare services for our whole population

ii. Future proofing capacity to meet future demand will require us to expand our current facilities as well as build at least one new acute site

iii. Fixing, remediating and redesigning our current facilities are necessary to ensure they are fit for their future purpose in our regional healthcare system.

Actions to address the problems are outlined below:

Problem Statement One:Health status is variable and there are significant inequities for some population groups and geographic areas as well as a large burden of ill health across the Region

Optimising health outcomes and the quality of care in our Region will mean addressing these inequities to ensure everyone has equitable access to care and equitable health outcomes, regardless of background or where they live in the Region. Figure 3 below shows the most impactful and well evidenced interventions which fall into the areas of patient activation, proactive care and networked models. We need to develop a model of care that evolves towards a proactive, networked model that helps people to activate patients and whānau to become engaged in their healthcare.

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Action Plan: Develop the new model of care containing the following key building blocks including:i. Patient activation (Individual and whānau level)

Empower our patients and whānau with the knowledge, skills and confidence to manage their own health and healthcare. Supporting vulnerable people and communities and empowering them to drive their own health outcomes will help reduce inequities in a health system which has historically underserved these populations.

ii. Patient activation (community and population level)

A focus on population health interventions, particularly those which address known modifiable risk factors, including smoking, obesity and hazardous use of alcohol, which have a disproportionate impact on the health of Māori and Pacific populations. By co-designing our population health interventions with those groups most affected we will be able to ensure that our solutions are culturally responsive and delivered in a way that meets the needs and expectations of our patients.

iii. Proactive care

There needs to be a shift to proactive care, supported by extensive use of digital technology including predictive analytics. This would help us understand the needs of our vulnerable populations and, by working with them, develop evidence-based interventions to help them before they develop illness or require acute care. This will require us to understand both the physical and mental health of our population to predict when they may face health challenges, and to intervene early.

iv. Networked models: Increase communication, collaboration and coordination across the health system

We need to work with intersectoral partners to address social determinants of health, both at the level of whānau/families (e.g. social work and whānau ora service referrals; addressing unconscious bias in service provision), and at the system level (e.g. influencing social and economic policies).

N O R T H E R N R E G I O N L O N G T E R M I N V E S T M E N T P L A N – 2 0 1 8

Future Opportunities: Model of Care Changes

The NRLTIP identifies interventions which have the greatest impact on Hospital use. Key interventions where evidence demonstrates change has been effective at keeping people healthier, and reducing their need for hospital services.

Figure 4

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Problem Statement TwoHealth services are not sufficiently centred around the patient and their whānau, and in certain areas the quality, safety and outcomes of care are not optimal

Historically, structural challenges have presented obstacles to how DHBs provide care for their patients and also to the integration of service delivery across care settings. Our DHB boundaries create artificial barriers which lead to inefficiencies as services and funding mechanisms are duplicated across the Region. Despite funding primary and community care, our DHBs have only achieved limited integration with community services to create a single health system. This can impede the patient journey through the healthcare system.

Action Plan: Strengthen the design and delivery of care around the patient their whānau and what matters to them including:i. Co-design services with those groups most affected to ensure changes in care

provision meet their unique health and cultural needs.

The Nuffield Trust evidence stated that where interventions are co-designed with the population of interest there is generally increased ‘reach’ and acceptability of the intervention and therefore likelihood of success.

ii. Increase communication, collaboration and coordination across the health system.

We need to ensure all players within our healthcare system connect with each other, working across boundaries and borders to deliver optimal outcomes that patients want, and working to improve access, equity and outcomes of healthcare.

iii. Standardise care pathways to reduce the variability of care.

There is evidence internationally, that outcomes are improved where standards are set for the full pathway of services and where providers are supported to meet these standards.

iv. Develop an integrated care system that focuses on proactively preventing and managing the impact of long term conditions.

Nuffield Evidence of What Works: How well embedded are these areas in Northland?While Mahitahi’s vision and aspiration is new, the goal of delivering healthcare closer to people’s homes is not. The National Health Service (NHS) have defined an ambitious goal to deliver the vision set out in a plan called the Five Year Forward View.

The plan draws on research and evidence of what is working to ensure the healthcare system is sustainable in the face of rising demand workforce pressures, and financial constraints. With the rise of frail older people with multiple chronic conditions it is logical that we grow the support and delivery of care closer to home if we want to deliver the ‘triple aim’ of improving population health and the quality of care for patients, while reducing costs. The challenge however is that while progress is a result of change, not all change results in progress.

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The goal therefore is to review the evidence of what has been shown to be effective and to ask whether it can be applied in Northland. This evidence is summarised in the Nuffield Research report March 2017,’Shifting the balance of care Great expectations’ as shown below.

Evidence has also shown improving access to General Practice and supporting ongoing continuity of care improves outcomes and benefits the wider health service. Patients who are vulnerable with complex needs particularly benefit from a known and trusted health professional to coordinate care on their behalf. High trust patient clinician relationships support shared decision making and improve adherence to treatment and improve patient satisfaction. Relational continuity is seen as a core element of and effective professional role.

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Problem Statement ThreeThe needs of a rapidly growing, ageing and changing population cannot be met in a clinically or financially sustainable way with our current capacity and models of care

Our current hospital facilities are already at capacity. This issue will be compounded as our population grows and ages and as the demographic mix continues to evolve. Assuming current levels of activity and our existing rate of change, the Region will require significant investment to develop the necessary additional capacity to meet the expected population growth over the next 20 years.

It is projected that by 2036/37 using current demand growth there will need to be 2,055 beds in the region which is an increase of 1900 additional beds. If we accelerate the model of care changes, described above we can expect to reduce demand on hospital beds to around 1600 additional beds. An even more dramatic model of care change programme would reduce the number of beds required to 1200 as patients have improved health and / or are supported outside of hospital settings.

Action Plan to ensure we realise the best outcome for resources available the evidence suggests we need to:i. Balance care across all settings by investing in: cost-effective public health

interventions; primary and community based services; different types of hospital based services; and increased productivity across the whole system.

Hospitals will continue to play a crucial role in the delivery of highly specialised and urgent care, however, we can increase the range of services provided outside of our acute hospitals to mitigate the demand placed on acute facilities. This will help us to improve how we manage: long term chronic conditions and people who are frail, improve equity of access across the Region, and enhance the patient experience.

ii. Increase our investment in intermediate care settings particularly for our older patients for whom an extended hospital stay can do as much harm as good.

To successfully increase community care and reduce length of stay, we need to provide options for enhanced care in a community setting that includes access to specialised health expertise. Supporting community and home-based care requires us to equip our health practitioners with the skills and technology they need to be mobile and connected with specialist expertise when that’s necessary.

iii. Extend service delivery across all settings, locations and times which will allow us to maximise outcomes, access to care and make better use of expensive clinical equipment.

iv. Invest in digital technologies that offer significant opportunities to improve the quality and efficiency of all health services.

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Electronic health records, data sharing, telehealth and improved data collection all offer us the chance to enhance the patient experience, support population health improvement efforts and proactive intervention while simultaneously improving efficiency and productivity of all services.

v. Develop a more agile and flexible workforce, with the capability and diversityto deliver on our population health strategy; to help it meet the demands formore integrated healthcare, prevention, self-care and to deliver care closer to thepatient’s home.

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Northland DHBNorthland DHB supports the Northern Region’s vision for a future model of care which is delivered through a collaborative, patient-centred web of primary, community, Iwi and hospital-based healthcare settings depicted in figure 5 below.

Northland DHB’s policy is not to “apply resources equally to Māori and non-Māori” but to invest more in services that will improve equity.

To achieve this, the new model of care will need to include:

1. Adoption of a new model of care where all service providers, DHB owned or otherwise, are ‘nodes’ within a more integrated regional health system.

2. Increased collaboration and coordination between all nodes of the health delivery system such as patient self-care, primary, community and Iwi care, private and NGO services and DHB hospital, public health and community services. Increasing collaboration with other care providers, will improve the overall health of our population, increase access to care and reduce inequities.

3. A reduction in the boundaries between care settings, with the focus on providing care in the most appropriate setting.

4. Identification of what services should be centralised and what services can be localised to improve quality, safety and outcomes of care.

5. The delivery mechanisms being sensitive to the requirements of our populations and their expressed local needs.

N O R T H E R N R E G I O N L O N G T E R M I N V E S T M E N T P L A N – 2 0 1 8

Future Opportunities: Our Vision

We will deliver care through an integrated, collaborative, patient centred web of primary, community and hospital based healthcare settings. • In the future we will adopt a new model of care

where all service providers, DHB owned or otherwise, are ‘nodes’ within a more integrated Regional health system.

• These nodes include all components of the health delivery system such as patient self-care, primary and community care, private and NGO services and DHB hospital, public health and community services.

Elective surgery focus

Major Hospital Local Hospitals

Enablers of the model of care e.g. IT, w orkforce, pathways / transfer rules

Key:

Path

way

s /

Tran

sfer

rule

s

Self-care

Community

Aged care

Social Services

Primary Care

PopulationHealth

Patient &Whānau

Figure 5 “An integrated, collaborative, and patient-centred primary and community care system”

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As shown on previous page over time, the current rigid boundaries between primary, community and secondary care will become increasingly blurred. A more integrated model of care will be supported by agreed pathways and protocols, shared electronic records and telemedicine links. The expertise of the hospital consultant will transcend geography. The job of the “hospital” consultant may change to one that involves more time spent in community settings. They will increasingly consult patients and support other healthcare professionals remotely, reserving face to face consultations for those that most need them and situations where physical examination remains essential to problem solving.

Proactive not reactiveOne of the biggest changes in the management of patients will be a shift from a reactive to proactive model of care, supported by extensive use digital technology including predictive analytics. Vital sign monitoring in the community and in the hospital will enable rapid intervention and help prevent disease exacerbations and complications. Resource management tools will deploy staff and other resources as efficiently as possible.

Research, innovation and improvement capability Sophisticated use of data and informatics will also give health and social care systems enhanced research, innovation and improvement capabilities. We need to grow capability where healthcare providers can monitor their performance and outcomes, and continual learn and work to improve these outcomes.

Northland DHB in collaboration with Te Kahu O Taonui/Northland Iwi Chairs Forum iwi leadership, PHO Boards, Māori health providers and NGOs, have developed locally driven strategies to improve the primary and community health care systems in the Northland region to ensure we realise the best outcomes for the resources available. This includes:

1. Investment into evidenced based models of care

2. Support for the establishment of Mahitahi Hauora to strengthen primary and community service delivery and improve outcomes.

1. Investment into Evidenced Based Models of Care The stakeholders have invested in multiple streams of work supported by evidence to transformation the curve of inequity across Northland. Examples of some of these complementary range of projects running across the Northland DHB and the PHOs demonstrate the desire to invest in primary care and communities include:

• Neighbourhood Healthcare Homes• Calderdale Framework• Health and Social Care Coordination• Nursing Model of Care• Kia Ora Vision• Consultation hui with Māori communities• Primary Options Acute Demand Management Service.

43

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The building blocks to improve patient outcomes and deliver care closer to home as shown below.

44

Neighbourhood Healthcare HomesThe Neighbourhood Healthcare Homes programme aims to re-organise systems in primary care to respond to the challenges described facing primary health care and the wider health system.

Neighbourhood Healthcare Homes is a team-based health care delivery model, led by primary care clinicians, that provides comprehensive and continuous health and social care with the goal of supporting individuals to obtain maximised, equitable health outcomes.

To achieve the goals of the programme, with its high quality operating and sustainable model, general practices need to address the following three key areas:

• integration with community• internal general practice transformation, and• primary and secondary integration.

It is envisioned that a key component of the model is that localities will help inform decision making on local service provision. These localities will also form the ‘Neighbourhoods’ for Neighbourhood Healthcare Homes and multidisciplinary teams will work within these localities and networks of general practices, Māori and other NGO providers.

Further information about the transformation process and the components of care is available on a dedicated Neighbourhood Healthcare Homes page on Northland DHBs community website. Results from Neighbourhood Healthcare Homes http://community.northlanddhb.org.nz/NHH/

Currently there are two piloted expansions of Neighbourhood Healthcare Homes which includes interventions targeting people with mild to moderate mental health needs. Here funding is used to support development of enhanced integrated practice teams in practices as well as for the expansion of Awhi Ora Supporting Wellbeing (Awhi Ora). Enhanced practice teams have seen the introduction of two new roles: a Health Improvement Practitioner (HIP; based on the behavioural health consultant model in the United States) and a Health Coach.

The goals of Awhi Ora are as follows:

• reach the missing middle through engaging people with a range of mental health needs who would otherwise have fallen through the cracks, as they were unlikely to engage with traditional psychological support services or meet the criteria for specialist support

• provide immediate/rapid access to a range of person-centred support options. People are seen the same day at the practice or within a week through Awhi Ora

• facilitate equity of access for Māori, and youth, particularly through location at high-needs or youth-focused practices

• provide a brief preventative response that recognises and responds to broader determinants of ill health, including social and economic needs.

This programme sets out to address what matters to the patient’s essential needs that include the broader determinants of wellbeing such as housing, money, employment. Immediate or fast access to services and supports.

45

Benefits for people providing services and supports reduce the burden on general practice teams. The service gives general practice confidence to have the conversation about mental health because issues identified are able to be addressed through access to community support.

“Practice and system outcomes. Better use of psychological support services.”

It also ensures there is a framework and training programme to support Allied Health and Practice assistant roles.

Calderdale FrameworkThis project seeks to improve both the capacity and capability of Northland DHB allied health and district nursing services, through application of the Calderdale Framework. This framework provides a structure for health professionals to work at the top of their clinical scope, freeing time for more face-to-face patient care delivery by exploring opportunities for clinical task delegation or skills sharing.

Finally, we are also in the early stages of investigating the development of a Northland Community Hub, to assist in streamlining referrals and triaging for Northland DHB community allied health and nursing services. The aim of this work is to address issues of triage duplication and wasted clinician time spent in the triage administration.

Health and Social Care Co-ordination ModelThe Health and Social Care Co-ordination model has been developed from background work and consultation involving a range of health and social care services, including Māori health providers, DHB community services, allied health services and district nursing services, general practices and consumers. It is these building blocks that enable Mahitahi Hauora to set a solid foundation on progressing to a new operating model – putting whānau in the driving seat to hold our system to account.

1. Innovation Support (formerly The Northland Initiative)Primary and secondary clinicians collaborate to address demand/capacity issues. The goal is to develop care pathways to improve consistent care delivery based on evidence and what matters to patients and whānau.

• The Primary Option Acute Demand Management Service (enhanced primary options) • Provides funding for managing patients with complex needs in community closer to home

rather than hospital.

2. Mahitahi Hauora Boards of both Manaia Health and Te Tai Tokerau PHOs’ with the support of the DHB are aligned with National, regional and DHB thinking in recognising that we need to develop an ambitious new transformation agenda if we are to improve health outcomes, improve access, quality and experience of care. It is believed by the respective Boards that Mahitahi Hauora is best placed to support our enhanced primary care model and to more effectively meet the current and future needs of our population.

46

The redesign proposed by Mahitahi Hauora is enabling something to be done that has not been done anywhere else in NZ, and the model being developed is completely consistent with the terms of reference and goals of the current Health and Disability System Review.

Mahitahi Hauora will work to deliver new models of care that break out of the artificial boundaries between hospitals and primary care, between health and social care, between generalists and specialists to deliver care that is coordinated around what people need and want. We will use data and improvement science to support and evaluate our improvement journey.

The key features of the future model of primary and community care services as defined by the Mahitahi Board will include:

• Working collaboratively with health and social care partners as part of a joined-up approach• Service redesign will be patient and whānau centric about what matters to them which

will include ensuring services are more accessible and responsive• Patients will be supported by a multidisciplinary care team coordinated by general practice

and with much greater nursing and allied health input and a broader role for navigators,and care coordination

• Providers will provide support for self-care, prevention, planned proactive care, timelyurgent care and more intensive support for those who need it most

• Technology will enable better connectivity and support more coordinated and integratedcare.

• There will be clear accountability for the quality of care at individual provider level supportedby robust data, measurement, quality improvement capacity and capability and alignedfinancial arrangement.

Our focus will be to develop a whānau centered design approach that recognises and nurtures whānau capability and resilience while using their consumer views to shape and develop our services so that they can become more effective. The strength-based approach empowers whānau to develop their own appropriate responses to their needs and aspirations.

Whānau OraWe recognise this is only one part of the primary care sector, with innovation also happening with Whānau Ora. In many ways what is being described is already in place in many parts of Northland as a result of the Whānau Ora Taskforce which established a policy framework for ‘a new method of government interaction with Māori service providers to meet the social service needs of whānau’.

After a period of consultation, the Taskforce published its final report in 2010. Later that year, 25 provider collectives (bringing together 158 providers across New Zealand) were announced to develop and deliver Whānau Ora services across the country with support from Te Puni Kōkiri, the Ministry of Social Development and Ministry of Health.

From 2014, implementation moved to three non-government Commissioning Agencies so that ‘funding decisions are made closer to communities’ and to allow ‘for flexible and innovative approaches to meet the needs and aspirations of whānau’. Many of these services are already in place.

The creation of Māori Primary health Organisations and Iwi providers reflects a coming together of organisations with a strong history of community and iwi engagement and the offering of services including access to general practitioners.

47

The challenge remains with smaller providers as while they have a long history of applying a community approach to overcoming health inequalities and tailoring the services they deliver to the specific barriers faced by their enrolled populations. It is challenging to develop a broader collaborative approach between medical services (delivered through general practices), and social and cultural support (often mandated by iwi, hapu or marae communities).

Funding formulas which failed to cover the costs associated with high needs populations, agreeing performance measures that reflected the reality of caring for those with chronic conditions, and maintaining a stable clinical workforce, were all signalled out as key issues.

It is envisioned that Mahitahi as one primary Health Entity for Northland will provide the scale and capability to grow this broader model for collaboration between iwi, hapu and marae communities.

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Mahitahi Hauora Te Kahu o Taonui and the Northland District Health Board Partnership Group act as a high-level forum to inform complementary efforts within and across regional health portfolios and within and amongst iwi. The Mahitahi Board will ensure the purpose, vision, strategy, priorities and values are delivered defined as follows:

Nga Wawata - Purpose: Mahitahi Hauora has one purpose to promote the health and wellbeing of the Northland population served.

Rapua Ka Kitea - Vision: By 2026 we have in place a primary healthcare system that sustains equitable, self-determined wellbeing.

Tohenga Rautaki - Strategic Goal: Equitable health spend driven through localities by whānau need and aspiration leading to a healthier community and improved long term outcomes (Locality Based Whānau Driven Services).

Nga Waariu - Values: Self determined wellness, Equity, Transparency, Collaborative and Empowering leadership.

Strategic priorities of Mahitahi Hauora as supported by the two PHOs, Northland DHB services and Te Kahu o Taonui are as follows:

1. Mama Kōhungahunga Tamariki Ora: All children well and ready to start school.

2. Self-determined Wellness: 90 percent of patients understand their wellness needs and can access services to meet these needs.

3. Resource Growth: Collective alignment of services between secondary to primary healthcare and communities. Funding and resourcing is in place as needed to achieve equitable self-determined wellness.

4. Sustainable: Vibrant health and social service workforce (90 percent satisfied in their work.

Responsibilities of Mahitahi Hauora include:i. developing a strategy that ensures the success and sustainability of better health

outcomes

ii. building iwi and Crown collaboration in the development of policies, practices, systems and investment approaches that contribute to the effective achievement of agreed outcomes

iii. informing government agencies and iwi of investment priorities in a manner that enables coherent, coordinated and responsible Whānau Ora investment outcomes; and sharing information on complementary initiatives and approaches across and amongst iwi and the Crown, with respective agencies and the broader public sector.

49

Whānau Centric Design

“The best way to predict the future is to design it around what matters to individuals (Tangata), families (Whānau) and

communities (Hapori), hapu and Iwi and the wider population.”The Mahitahi Hauora Board and Programme Steering Group comprising Northland DHB, PHOs, Māori health providers and Te Kahu o Taonui (Te Tai Tokerau Iwi Leaders Forum) are working through an establishment plan. The initial focus is on the design of the whānau / community-led planning model and the establishment of the new intermediary, localities and district support offices (see system planning and design thinking below). The establishment plan will be implemented by June 2019. This is being led by a project team with membership from each PHO.

As shown in figure 6, Mahitahi Hauora role will focus on addressing ‘what matters to individuals and whānau.’ We will also work to improve the design and coordination of care so that every patient has the best experience and outcomes.

We will work with patients and whānau to address these identified needs in conjunction with formal and informal health and social care providers that work in the communities to create a health system that will transform the way we deliver health and social care delivery in Northland.

Throughout this work we will maintain our commitment to Tiriti o Waitangi and to improving Māori health outcomes. We will gauge our effectiveness in large part by how well we close the equity gap.

We will use the Northern region prioritisation framework to determine our investment priorities which includes a weighting of initiatives that close the equity gap.

Data driven outcomes: We will learn from the individual and whānau to benefit the population. We will also with localities grow a Community Hub model, in which community health workers perform a structured assessment of clients’ health and social service needs and use standardized “pathways” to link beneficiaries to community resources and track outcomes.

These projects have generated valuable insights regarding addressing the social determinants of health, including the importance of establishing cross-sector partnerships, building data systems that bridge health and community services, and developing a workforce to deliver interventions to vulnerable populations. This requires an integrated technology platform and redesign solution as described by the Northern Region ISSP described below.

Figure 6

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Information Systems Strategic Plan

The Transformation Approach of Mahitahi Hauora To achieve this end goal will be difficult. We will need to be both smart and healthy in our approach. Smart in that we have the right ideas and approach and healthy in that we work collaboratively together through a systems approach using design thinking.

A systems approach, considers problems and potential solutions through the wider lens of the entire system. A change in one part of the system can have dramatic effects on other parts of the system, for better or for worse. This is why it is important to look at each component of the system and how one organisation, profession or team interacts with other parts of the system so an intervention in one part of the system does not negatively affect other parts. If we align planning, focus and effort within the system to achieve common goals and continue to improve the system through working collaboratively, I know from experience, we can achieve them.

Design thinking is a specific and careful process for identifying the problems within a system and for developing potential solutions. It is based on the simple yet revolutionary idea that the people who face the problems every day are most likely the ones who hold the keys to the solutions. We need to grow support for those within the system both consumers and providers to see, own and solve the problems. We need to help by using a robust improvement process to identify the root causes of problems, and teasing out dynamics that could be shifted, behaviours that can be avoided or minimised, and test and implement carefully to identify the potential for and avoid unintended consequences of any changes made.

Once this has been done we can use the planning principles to design a new model of care that includes three aspects: desirability, feasibility, and viability.

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The goal of desirability is to fully understand the problems within the system by asking individuals, their families and the wider community what they are “hearing and seeing and feeling and thinking.” The process of identifying their deeply felt needs and priorities is referred to as human-centered design or co-value creation. It also identifies the needs and priorities of the providers within the system.

Feasibility asks all stakeholders to look at what improvements are possible, in terms of existing and potential capacity, human resources, processes, and technology. It also asks where this problem has been solved or partially addressed. In addition, we can look more broadly across the care provider network in Northland to find the bright spots or shining stars where the model of care or system change has been effective and apply the learning.

Viability is a key component of any change process. We need a robust improvement process so that the desired change can be implemented and sustained over time. Change can be hard and therefore part of the planning process needs to consider how to make it easy to do the right thing every time for every provider and for every patient. We need to consider how the new MOC can be easily built into the new normal of the day to day functioning of the team to ensure it has a higher likelihood of continuing long past the point of implementation.

Ultimately this will result combined to create a district primary health care plan in conjunction with Northland DHB.

The key questions for this paper and the Mahitahi Hauora planning process are described in a Prioritisation Framework used by the Northern Region which provides a set of clear and agreed criteria against which investments can be measured.

The framework will support the Region to assesses and ranks potential investments across the Region against four questions:

Must we?

Indicates areas where there is a clear mandate, be it a Ministerial directive, legislative mandate or statutory requirement. Investment proposals that meet the ‘must we’ criteria will be undertaken, regardless of the ‘should we’, ‘would we’, or ‘could we’ criteria.

Should we?

Identifies the strategic alignment of each proposed investment to the regional investment objectives to ensure the investment will result in the Region moving toward the desired future state.

Would we?

This component of the framework outlines the benefits and risks of the investments. The benefits address the financial, patient experience and health outcomes of the investment whereas the risks assess both the risk the project is addressing as well as the functional risk of failure.

Could we?

Prompts consideration of achievability of the project, noting the degree of regional support for the project, the technical and business complexity of implementation and the change management required.

52

Rautaki / Whakamahere (Strategy and Planning)Mahitahi Hauora will grow alignment of resourcing, services and ways of working with the needs and aspirations of patients, whānau and communities. The Northland DHB Governance Board has an expectation that the single primary care entity will allocate resources in light of the priorities that whānau, communities and providers identify via locality-driven planning.

The new planning model is not yet fully defined. It is expected to be an iterative process starting with whānau and community, and clinicians through a locality advisory group. There will be a shared planning process with partners who provide care in that area to develop the locality health plan for that population and for that geography that they will be responsible for delivering. Ultimately this will result combined to create a district primary health care plan in conjunction with Northland DHB.

Mahitahi Hauora: Evidence based population health approaches and prioritiesWhile interventions focused on individuals and integrating care services for key population groups are important, these must be part of a broader focus on promoting health and to addressing the determinants of health inequalities across whole populations (see figure 7 below).

Figure 7

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• Mahitahi Hauora needs to continue to work with the health and social care providers to promote healthy behaviours that will help reduce amenable mortality such as smoking, alcohol, diet and physical activity

• We also know that unhealthy lifestyles are increasingly clustering and polarising within the population, with the relative risk increasing in parts of our community who are from lower socioeconomic backgrounds and /or Maori. How effective are our programs? Do we need to place a larger emphasis on this part of our community to address inequities?

• As early life experiences in the womb, home and school are critical to health and wellbeing over the life course how effective are we in working to improve the health and wellbeing of Mama Kōhungahunga and Tamariki Ora?

What are some of the benefits of growing collaborations with other practices/health and social care providers? Managing activity with greater coordination and effectiveness

The paper outlines why we need an entirely new model of primary and community care to deliver future services. As discussed if we are to develop a sustainable healthcare system we need to support and grow new models of care, leverage the growing role of technology and associated opportunities to improve productivity, and grow and use the skills and capabilities of the wider healthcare team to deliver care closer to home and avoid hospital care (see table below).

Ten Evidence-based Community Interventions to Avoid Hospital Care

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Understanding the gearing of the systemAs shown below it is essential in the planning associated with the change agenda to recognise that the vast majority of urgent care is already delivered in primary care.

A publication by the Royal College of General Practitioners (RCGP UK) in the UK4F4F3 found that 95 percent of urgent care is accessed in the UK in primary care, with 5 percent in secondary care. As a result, a 1 percent increase in primary care causes a 20 percent decrease in secondary care. A study published in the New Zealand Medical Journal5F5F4 considered that 37 percent of all ED presentations (49.7 percent of those not admitted) ‘primary care appropriate,’ and 50 percent of all ED presentations (68.1percent of those not admitted) ‘primary care appropriate,’ if laboratory and radiological facilities were immediately available.

The sheer volume of this activity means that a small improvement in the gearing of primary care will have a significant impact on secondary care. This is why investing time, money and effort to redesign the care team and process is a critical enabler to achieving the quadruple aim of good outcomes for patients and whānau, and a great place to work for staff. The work underway under the umbrella of Innovation Support (formerly The Northland Initiative) will be making this their focus. There is also additional funding to support the process of care being delivered closer to home called the Primary Option Acute Demand Management Service.

Solutions lie in thinking as one system focused on improving the coordination of care across the whole patient, whānau journey through better integrated care systems and processes. However many of the above described initiatives that are evidence based increasingly rely on primary care services to do more than ever before.

This means that the scale of the workforce challenge in the Northern region is much bigger than simply meeting the needs of projected population growth which is already estimated at an additional 29 GPs/year. With an overburdened and older workforce grappling with the increased demands of more complex patients such an increased expectation can only be delivered if we use the workforce more imaginatively, making the most of multi-disciplinary teams.

3, ’Guidance for commissioning integrated urgent and emergency care; A whole system approach’ Royal College of General Practitioners UK http://www.rcgp.org.uk/policy/rcgp-policy-areas/urgent-and-emergency-care.aspx

4, ‘Can primary care patients be identified within an emergency department workload?’ Raina Elley et al, June 2017

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In the Tier 1 Health and Disability review the discussion taking place concerning the introduction of new roles and/or changing the skill mix of existing teams indicate that there are a number of factors to bear in mind including:

• building roles and teams based on the care that actually needs to be delivered and is important to our patients and whānau

• focus on developing broader skillsets to deliver the care rather than working within the narrow boundaries of what various professional roles have traditionally delivered.

While at first glance this process seems simple enough it is important to allow enough time and resource to support and enable the change; current evidence suggests that achieving efficiencies, extending services, and improving clinical outcomes takes at least two years.

The example shown below sets out how a future model of primary and community care might look, taking into account the core aspects of new integrated models as well as key enablers.

Example: Future model of primary and community care

A summary of some of the key innovations that will free up more time in primary care include:

• Use of alternative methods of consultation, such as phone, email and Skype may improve productivity as they are usually quicker than face-to-face consultations, although as noted above, they may lead to increases in activity. Practices are also encouraged to consider the use of group appointments for patients with long-term conditions, which can not only make more efficient use of practice resource but can enable patients to provide peer support to each other. Studies suggest that group appointments can enhance patient experience, improve outcomes and reduce A & E attendance and hospital admissions.

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• Reducing ‘did not attends’ or DNAs e.g. through text reminders as well as making it easy for patients to rearrange appointments reduces wasted clinical and administrative resource. There may also be opportunities for more significant redesign to the appointment system such as reviewing the balance of same day and book ahead slots. This review should take place as part of any attempt to introduce online appointment booking systems.

• Reviewing skill mix across primary care teams and connecting patients directly with an appropriate professional can reduce the burden on other professionals. By “deconstructing” a primary care physician’s time, it is recognised that a significant proportion of their work could be allocated to others in the primary care team which could include paramedics and pharmacists.

See Reshaping the Workforce (Imison et al., 2016a)

A number of practices identified in Making Time in General Practice had developed new roles within the practice team which were able to reduce pressure on GPs. These included:

• Practice pharmacist • Nurse practitioner • Paramedic • Physician assistant • Health advisor/community coordinator • Health trainer • Clinical personal assistant.

Where practices are small, such roles may operate very effectively working across more than one practice. For example, paramedics based in general practice were able to see and treat two-thirds of the patients referred.

Increasing efficiency regardless of activity levels

The Nuffield Trust’s Is bigger better? report identified a number of productivity and efficiency benefits from collaboration between practices on as in this case the establishment of a single PHE Mahitahi Hauora. These include:

• pooling staff • better staff training and development • more flexible opening hours • more efficient back office functions • investment in IT• Improved use of the skills and contributions of the wider workforce.

• Developing quality improvement expertise in the practice. This supports ongoing service redesign and continuous quality improvement within the practice. However, unless practices are very large, it is likely that this is expertise better shared across a number of practices.

• Improving workflow within the practice – using techniques such as LEAN to introduce new ways of working which enable staff to work smarter rather than harder such as is occurring with the HCH initiatives.

• Personalised productivity improvement for each staff member, based on the specific skills they need to enable them to undertake their particular role in the most efficient way possible.

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Benefits of the Proposal

“Success in improving healthcare will depend on the level of ambition or willingness from key providers, innovative ideas,

and effective change processes.”

Key benefits of the Mahitahi Hauora model include:• a single primary care entity will be in place to address and improve governance issues• improved allocation of resources to priorities that whānau, communities and providers

identify via locality driven planning and neighbourhood healthcare homes• establish a more streamlined primary health care planning process• ensuring patient and whānau needs and aspirations at the centre• establishment of a single primary health outcomes framework that will be used to monitor

progress in improving outcomes and closing the equity gap• single point of contracting and service planning responsibilities.

It is anticipated that the Neighbourhood Healthcare Homes will result in improvements in the following areas:

• equitable access to health services and health outcomes including a reduction in ambulatory sensitive hospitalisations and emergency department presentations

• timely access to acute and unplanned care for patients• proactively managing the care for high needs patients be it complex social and/or health

needs• the standard of routine care received by patients• the standard of preventative care received by patients• better population health outcomes, and • improved business efficiency.

 CURRENT STATE FUTURE STATE

Ministry of Health

Northland DHB

Manaia Health PHO

Te Tai Tokerau PHO

Ministry of Health

Northland DHB

Mahitahi Hauora

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Your Feedback

“We are seeking your input on how the challenges can be met and the vision realised.”

This document recognises that while you may have or at least are now aware of the establishment of the Mahitahi Hauora as the single entity that the DHB will work with from 1 July 2019. Now you have an opportunity to contribute your thoughts and ideas on how we can ensure the transformation agenda for the Mahitahi Hauora will be successful.

1. Tell us your thoughts and ideas as to how we can ensure we can be successful in thetransformation programme?

2. Describe what approaches you believe have been, or are effective that we can learn from?

3. Explain how you individually and within your team would like to contribute to making thevision a reality for all who live in Northland?

4. In your response you can choose to respond to some or all questions posed.

Online Form We have setup a feedback website for you to submit your thoughts and ideas online.

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