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West Auckland Locality Plan “A journey towards self-directed care”
2013
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A Patient Story
A 45 year old woman came into my surgery. She had noticed a growing redness and pain on her Right Breast.She had cellulitis in her breast tissue and needed intravenous antibiotics.She was frightened that she would need to go to hospital for treatment, in particular, she did not want to go to Hospital.I told her about Primary Options for primary care that would fund the practice to give her intravenous antibiotics in the community.She was so relieved to face the prospect of treatment in the community without the need to be admittedHowever, she was allergic to penicillin and the ‘permitted’ intravenous antibiotic had a significant risk of cross allergy.This was the beginning of her problems.I phoned the medical registrar at one of the local hospitals and asked him to take her for intravenous therapy.I was told that breast infections often need surgical intervention and were admitted under the surgeons at another larger hospital.The patient was going to end up having the hospital treatment she would like to avoid.If we were ‘permitted’ to use other iv antibiotics ( according to guidelines) this admission would have been avoidedshe was seen by the surgical registrar. He agreed that she needed intravenous antibiotics. She emerged from hospital 24 hours later.
She could have been treated in the community It would have been easy to give the recommended iv antibiotic in the practice It would have made her happier and would have prevented an unnecessary
admission.
Dr Jonathan Simon West Auckland GP and West Auckland Locality Clinical Director
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Table Of Contents
EXECUTIVE SUMMARY..............................................................................................................5Background................................................................................................................................6
The Locality Approach............................................................................................................7Description Of The West Auckland Locality...........................................................................8
Locality And Cluster Level Analysis....................................................................................9Governance And Structures To Support The West Locality Development (To Be Confirmed)..................................................................................................................................................10
West Auckland Health Network (WAHN).........................................................................10Operational Framework Within The West Locality..............................................................11
Funding.............................................................................................................................11Locality Governance (agnostic to the DHB/PHO) - this function will led by West Auckland Health Network................................................................................................12Clusters operations – this function will be led by the nominated cluster lead PHO.......12
Community...............................................................................................................................14Increasing The Capability And Capacity Of General Practice...................................................15
Forming Clinical Clusters And Networks..............................................................................15Practice Re-Engineering.......................................................................................................16Development Of Cluster Integrated Family Health Centres................................................17
New Lynn IFHC – New Lynn Cluster.................................................................................17Whanau House – Henderson Cluster...............................................................................18Westgate Medical Centre - Massey Cluster.....................................................................18
Integrated Models of Care.......................................................................................................19Clinical Work streams...........................................................................................................19
Diabetes...........................................................................................................................19Child Health......................................................................................................................22Urgent Care......................................................................................................................22
Workforce................................................................................................................................24Inter-Disciplinary Workforce............................................................................................24
Actions for 2013/15..................................................................................................................25Appendices...............................................................................................................................27
Appendix 1...........................................................................................................................27Appendix 2...........................................................................................................................30Appendix 3...........................................................................................................................30
Bibliography...............................................................................................................................1
List of Figures
FIGURE 1: VISION, FUNDING AND INCENTIVE ALIGNMENT......................................................6Figure 2: Map Of The West Auckland Clusters..........................................................................8Figure 3: The functions of the West Auckland Health Network..............................................11Figure 4: GP Practices In The West Auckland Clusters.............................................................16Figure 5: The Diabetes Quality Improvement Team................................................................21
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Figure 6: Guiding Principles For Service Design.......................................................................27Figure 7: Process Principles for service review and redesign..................................................29Figure 8: Principles of Engagement and Consultation.............................................................30
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Executive Summary
“A locality approach will create the conditions in which people, families/whanau and communities
can take greater control over their lives to maximise their health and wellbeing”
During the initial phases of the West Auckland locality planning the emphasis has been on increasing
the capacity and capability of primary care. The reason for this focus has been because of the
emerging crisis faced by West Auckland, caused by five contributing factors:
1. The population of West Auckland is growing. There is an estimated increase of 87,000
people between 2006 and 2026 (Martin, Zhou 2012).
2. The population of West Auckland is ageing. The 65+ age group is expected to increase from
9% of the total population to 14% between 2006 and 2026 (Martin, Zhou 2012).
3. The health workforce of West Auckland is also ageing. The majority of current West
Auckland general practitioners (GPs) (Waitemata District Health Board 2010) and practice
nurses (Ryan et al 2012) will retire within the next 10 years.
4. 65% of the West Auckland population live in high deprivation areas (Martin, Zhou 2012). It is
widely acknowledged that deprivation has a significant impact on health outcomes.
5. The funding for healthcare is finite, the demands of new technology and an ageing
population will create increasing tensions.
This plan details the beginning of the journey of service integration and delivering healthcare
through a localities approach. A joined up healthcare system focused around the population of a
locality will create an environment where patients are more empowered to take control of their own
health and well being.
The West Auckland Health Network has been established to act as an independent body to facilitate
integration across the health sector and the development of localities and clusters in West Auckland.
Sapere, the integration support group has been contracted to independently support to the
development of Integrated Family Healthcare Centres.
Future actions have been identified to continue to strengthen the alliance between the Waitemata
District Health Board, its PHO and Iwi partners to integrate health service planning in order to deliver
better healthcare to the communities of West Auckland.
5
Background
Primary Health Care In West Auckland
Primary health care in West Auckland has been transitioning through a period of change. In 2010
Waitemata District Health Board, its PHO and Iwi partners agreed on a series of process and service
design principles to implement the Better, Sooner, More Convenient BSMC strategy (appendix 1).
In 2011 to support greater regional collaboration, Waitemata DHB implemented a two district wide
PHO policy, this reduced the number of PHOs from six to two, Waitemata PHO and ProCare
Networks Limited. Subsequently additional PHOs including Auckland PHO, Tamaki HealthCare and
the National Hauora Coalition began providing clinical services within Waitemata under the umbrella
of either Waitemata or Procare PHO. In addition three business cases have been implemented
across greater Auckland to separately progress the BSMC strategy. Building strong relationships
across the sector is a critical component of this plan while moving towards an integrated system.
Planning healthcare services around the population in a geographical area aligns the vision, funding
and incentives of different healthcare providers around the patient and the community.
Figure 1: Vision, Funding and Incentive Alignment
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The Locality Approach
A locality is defined as a geographical area that encompasses all people that usually reside in the
area. There are a number of reasons why health services should be planned around locality
populations:
- Localities are strong natural communities of interest
- Health services are by their nature geographically located and deliver services within
a locality
- Primary care is by nature generalist and comprehensive and tends to provide these
services within a limited geographic area rather than providing services to more
specific groups over a larger area
- Primary care is strongly linked with local communities. Enhancing this linkage can
lead to better involvement with the community and improved access
- Primary care clinicians need to work closely with other people caring for their
patients. This is most easily enhanced through a locality population.
(Robinson, Selak 2010)
It is recognised that there is not one locality size that is best for all functions that a locality may have.
The West Auckland locality has therefore been sub-divided further into clusters. A cluster covers a
population of between 40,000 – 100,000 people. The advantages of this size include:
- Small enough to define communities of interest with distinctive demographics and
health needs
- Of sufficient size to justify some local planning of health services
- Sufficient size to support at least one IFHC and the surrounding practices it supports
- Sufficient size for satellite delivery of common secondary care services such as
paediatric, cardiology and diabetes outpatient clinics, community mental health
services, and district nursing
- Sufficient size for local delivery of PHO provided community services
- Small enough to create networks of primary care clinicians, yet few enough to make
the support of these networks and their linkage with secondary services not too
onerous
- Large enough for most measurements of performance and quality to be statistically
reliable and informative
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Description Of The West Auckland Locality
For West Auckland, the term “locality” refers to the domiciled population based within the defined
geographical boundaries of the Waitakere and Whau local government wards. Following the
formation of Auckland super city, local government, after consultation with public, framed up its
geographical area into wards. Within each ward are local boards for smaller defined geographical
areas. Other central government service providers such as MSD are working to these boundaries.
To enhance potential future collaboration WDHB has chosen to work with these boundaries as our
“localities”. As far we possible the localities have aligned the local board areas to define a cluster of
health service providers.
West Auckland includes the Henderson-Massey, Waitakere Ranges and Whau local boards. The
West Auckland locality covers a domiciled population of 241,780 people (2011 census). There are
three clusters within the West Auckland locality; Henderson, New Lynn and Massey. It is proposed
that each cluster will contain one IFHC.
Figure 2: Map Of The West Auckland Clusters
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HENDERSON
NEW LYNN
MASSEY
Locality And Cluster Level Analysis
A locality and cluster level analysis of West Auckland provides some detail of the challenges faced in
delivering healthcare to this population. (Martin, Zhou 2012). A brief summary of the analysis is
presented below:
The Waitakere Locality contains approximately 16% of the total population in the Auckland region.
West Auckland is diverse in ethnicity with higher proportions of Maori (12%), Pacific (14%), Asian
(18%). The ‘Other’ ethnicity group is 57% in West Auckland and 71% in Waitemata DHB.
Approximately 65% of the population live in NZdep2006 scores 6 to 10. It is recognised that
deprivation has a significant contribution to the socio-economic determinants of health including
poor living conditions, low educational achievement and increased barriers to accessing health
services.
Key findings of the West Auckland locality and cluster level analysis include:
- There is inequity of health outcomes and disease burden for Maori and Pacific ethnic
groups in comparison to European, other ethnic groups
- There are relatively high rates of potentially avoidable hospitalisations due to chronic
diseases compared to the total Waitemata population. In particular for diabetes,
asthma, respiratory illness, and cellulitis.
- There is high attendance rates at Waitakere Hospital ED especially in the under 4 years
age group
- There are poor health outcomes for West Auckland children across a range of clinical
conditions
Another challenge to healthcare delivery in West Auckland is the low ratio of general practice
doctors in relation to the size of the population. There are currently 43 general practices in the West
Auckland locality with a total of only 173 doctors. 11 of the 43 practices have ‘closed books’ and
were not accepting any patients at July 2012 (Healthpoint 2012). Approximately 23,000 people
living in West Auckland are not enrolled with a PHO. Based on population and disease growth it is
estimated that there will need to be an additional 20 general practice patient appointments per GP
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per week by 2026. Additionally, the number of beds in Waitakere Hospital will need to increase by
150% to meet the increase in demand.
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Governance And Structures To Support The West Locality Development (To Be Confirmed)
Locality Establishment Governance Group
A governance group will be established to provide the strategic direction of the West Locality
development. It is yet to be determined if this group will provide governance to the Central, North
and West Localities or solely the two localities in the Waitemata District.
This group will assume high level governance and monitoring role across the developing networks,
this alliance will include a Memorandum of Understanding and Data Sharing Agreement as well as an
agreed framework and funding models to progress the journey to self-directed care. The
membership core will include DHB, PHO and community representatives as well as representatives
from our Memorandum of Understanding partners Te Runanga o Ngati Whatua and Te Whanau o
Waipareira Trust along with other key leaders from community and hospital care settings.
West Auckland Health Network (WAHN)
The West Auckland Health Network (WAHN) is the Integrated Health Network for the West Auckland
locality. It consists of a selection of primary and secondary care clinicians as well as community and
Whanau Ora representation.
This is a whole of system, provider only, group. The individuals attend as individuals and not as
representatives of their respective organisations. The role of WAHN is to guide the West locality
activity towards a smarter, safer and sustainable integrated health system. A significant focus of the
WAHN is to address the issues of quality, performance, equity and accountability it is required to
have structures that support the whole of the sector.
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Figure 3: The functions of the West Auckland Health Network
Operational Framework Within The West Locality
In addition to the governance structures outlined to support the development of the localities and
clusters, it is proposed that the additional locality operational functions are also required:
- Funding - at a regional level
- Leadership - at a locality level
- Operations - at a cluster level
Funding
Existing funding organisations will be utilised to allocate funding through the locality. It is important
to involve an inter-sectorial approach and include funders outside of health to have a greater
influence on the social determinants of health. The opportunity to work with other funding groups
will be scoped in the next stage of the locality development by Waitemata District Health Board
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The funders will continue to provide the following functions at a regional level
Commissioning
DHB management support to provider
PHO management to primary care
DHB/PHO interface to develop whole of sector solutions
Planning
Locality Governance (agnostic to the DHB/PHO) - this function will led by West Auckland Health
Network
Whole of community
Whole of sector
Measurement of quality
Performance management
Value added
Health gain
Design of primary and secondary care interface pathways
Practice re-engineering for new business models
Peer review/collaborative
Clusters operations – this function will be led by the nominated cluster lead PHO
Development of the co-operatives (working out how practices can work together)
Supporting implementation of the existing IFHCs with cluster practices
Service Level Agreement between practices in co-operatives
Management support
Cluster based purchasing plans
Co-management of nominal budgets e.g. access to diagnostics budgets
Incorporation of cluster pharmacy and allied health providers
Community engagement
At the cluster level, co-operative groups will initially align via a service level agreement. In the future
more formal agreements could be made sharing resources and expertise, joint appointments
between practices or alignment of practice systems.
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Enablers
The following enablers have been identified and agreed to support the continued development of
the West Auckland locality:
Reviewed economic and financial models
Information technology
Sharing data
Agreed model of change management
Measures of quality, impact and outcomes
Communicating performance to the communities
Defining and engaging with communities of interest
Development of partnerships with communities
Whanau Ora – measurement and accountability framework
A whole of sector quality management and clinical governance
Enhanced health literate communities
Consistent approach to communication and engagement
Commissioning outcomes framework
Evaluation commitment and capacity
Robust change management processes
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Community
Waitemata DHB funds two community NGOs to liaise with communities in a variety of ways. One of
the NGOs is sited in West Auckland (Waitakere Health Link) and is a unique enabler to further
enhance and explore the process of redesigning of health services.
A number of engagement models were drawn upon including the International Association for Public
Participation (IAP2) to brief and inform the West Auckland community of the opportunities
encompassed within collaborative conversations.
One on one meetings and presentations have taken place with:
- Local boards, (Henderson/Massey and Waitakere) - Community Response Forum West (Ministry of Social Development), - Whanau Ora providers (i.e. Waipareira Trust), PHOs,(ProCare and Waitemata PHO), Mana
Whenua (Ngati Whatua) , - local primary care health providers including GPs and pharmacies. - NGO forums
These events have provided a number of unique stories and examples of access to urgent care,
concerns for child health/ poverty and questions regarding diabetes programmes were raised by the
attendees.
Regular updates on locality planning continue to be provided to Waitakere Health Link who
reproduce these updates in monthly newsletters including online newsletters to a significant
database (NGOs, public, stakeholders) in the West Auckland locality.
The capture of consumer voice is not always easy. Waitemata DHB and Auckland DHB have agreed
on principles for community engagement for locality planning. These are attached as appendix 1.
In addition, the three workstreams all have community voice representation. These individuals are
either themselves service users or who are key stakeholders who access sectors of the community
whose needs and experiences (patient stories) are feeding into service design.
It is acknowledged that further development is needed to extend the reach into the West Auckland
community. This will include ensuring that all impacted communities of all cultures are being
supported and engaged with including the “hard to reach” populations. A variety of methodologies
about how this achieved are under consideration and include public/NGO forums, forums at
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community centres/houses/marae, Mana whenua, Asian and Pacific engagement through
established forums , patient surveys, public gatherings, established community networks.
A communication plan will be developed, which will include communication strategies for all sectors.
Aspects of the plan will be implemented alongside the community engagement strategies to
enhance community awareness and participation, including media releases, feature articles, and
the exploration of the use of social media.
(A brief history of health sector development in primary care is provided in appendix 3)
Increasing The Capability And Capacity Of General Practice
It is recognised that primary care delivery in West Auckland faces a serious workforce challenge. GP
numbers are the lowest in the country and they have a particularly high workload. The majority of
West Auckland GPs are likely to retire within the next ten years. Increasing the capacity and
capability of general practice within West Auckland is critical to the meet the increase in healthcare
demands and support integration with hospital services.
Three interrelated mechanisms have been identified to deliver this objective:
- Forming clusters and networks
- Individual practice re-engineering
- IFHC development
Forming Clinical Clusters And Networks
The West Auckland Clinical Director and the Waitemata Clinical Director of Primary Care have
engaged individually with all 43 general practices in West Auckland. This confirmed the natural
cluster boundaries. GP cluster groups have been established in Henderson, Massey and New Lynn to
allow GPs a forum in which to plan service development in the clusters.
16
Figure 4: GP Practices In The West Auckland Clusters
Cluster Practices
Henderson
Family Practice + Medical Centre Swanson Medical CentreHenderson Medical Centre T L Care LimitedLincoln Rd Medical Centre Te Atatu South Medical CentrePalomino Medical Centre Valley Medical CentrePeninsula Medical Centre Waitakere Union Health CentreRanui Medical Centre West Fono Health TrustRatanui Medical Centre Whanau Centre (Wai Health)
Massey
Hobsonville Medical Centre Upper Harbour Medical CentreLuckens Road Medical Centre West Harbour Medical CentreMassey Medical Centre Westgate Medical CentreRoyal Heights Medical Centre
New Lynn
Avondale Family Doctor Kinross Medical CentreAvondale Family Health Centre Lynnmall Medical CentreAvondale Health Centre McLaren Park Med CentreAvondale Medical Centre New Lynn Medical CentreBlockhouse Bay Medical Centre New Windsor Road SurgeryDonovan Street Medical Centre Pacific Horizon HealthcareGlenavon Doctors Surgery Rosebank Road Medical ServicesGolf Road Medical Centre The Doctors Ltd. (New Lynn)Green Bay Medical Centre Titirangi Family HealthcareIntegrated Medical - Dr Doering Titirangi Medical CentreKelston Medical Centre Westview Medical Centre
Some practices within West Auckland have developed good models of nurse led clinics and multi-
disciplinary teamwork. It has been suggested that specific nurse cluster groups would support the
sharing and development of ideas across the clusters. Wider cluster meetings including allied health
providers and inter-sectoral stakeholders will be explored to enhance the development and capacity
of the clusters.
Practice Re-Engineering
For practices to be able to increase capacity and integrate within the cluster and with hospital
services it is critical that the practices change the way they work. Sapere, the Integration Support
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Group (ISG), leads the practice re-engineering process within the West Auckland clusters. Practice
re-engineering involves the development of strategic business cases or business models which:
- informs practice decisions on how to proceed with different ways of working including
organisation structures that make better use of staff time and skills
- models the likely effects of the above changes in terms of staff time, service capacity and
the financial impact
- identifies opportunities for collaboration within the cluster and key barriers and enablers
The first phase of practice re-engineering is complete with initial GP cluster engagement meetings
and strategic business cases finalised for the New Lynn and Henderson IFHCs. The second phase of
practice re-engineering is scheduled to begin with the development of a strategic business case for
the Westgate Medical Centre in the Massey cluster, A number of other practices undergoing
business model development to support integration and co-operatives within the cluster is also
included in the second phase. The co-operative development allows smaller groups of practices
within the clusters to work together to pool resources for increased efficiency such as of specialist
nurses, allied health professionals, administration and technology.
Development Of Cluster Integrated Family Health Centres
IFHCs are a central part of the Government’s BSMC strategy and an opportunity where a variety of
services can be located alongside general practice. Additional services maybe provided by private
organisations, NGOs, PHO’ or Waitemata DHB. It is planned to have one IFHC per cluster. New Lynn
IFHC has been selected as the IFHC in New Lynn, Whanau House in Henderson and Westgate
Medical Centre in Massey. The IFHC provides a hub for the integrated services that are offered
within the cluster.
New Lynn IFHC – New Lynn Cluster
The New Lynn IFHC plans to open in March 2013 in a new purpose built facility. The IFHC will merge
the existing practices of Golf Road Medical Centre, New Lynn Medical Centre and Titirangi Family
Healthcare. The new centre will service approximately 15,000 patients and will initially have 10.7
full time equivalent (FTE) GPs and 6.4 FTE nurses. New Lynn IFHC is actively looking at ways to
increase capacity by increasing the nurse FTE and increasing the responsibility of the nursing
workforce. This will include more nurse lead clinics for stable chronic conditions, specialist nurses as
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the first point of contact for children under six and specialised urgent care capability with nursing
triage overseen by a GP.
The IFHC will have a range of co-located health providers including a pharmacy and x-ray services.
Specialist paediatrics clinics are planned to be delivered from the New Lynn IFHC alongside other
child health services. In conjunction with providing clinics, the onsite paediatrician’s will also
provide support and mentoring to the New Lynn cluster GPs to manage their challenging paediatric
patients.
Planning is underway for a jointly appointed paediatric nursing position between Waitemata DHB
and New Lynn IFHC. This role will deliver specialist nurse clinics, support practice nurses within the
cluster as well as triaging the paediatric clinics at New Lynn IFHC. Child health services have been
the early adaptors for secondary services to develop new models of care. Engagement continues
with other DHB services, including Whanau Ora, to be integrated into the New Lynn cluster.
Whanau House – Henderson Cluster
Whanau House is the IFHC for the Henderson cluster. Waitemata DHB has committed to leasing a
floor of Whanau House for five years. Whanau House is shared with an East Tamaki Healthcare
general practice as well as Te Whanau o Waipareira Trust which provides a range of community
services. There is a monthly co-located Waitemata DHB specialist paediatric clinic being delivered
from Whanau House and options for other paediatric support services are being explored. Ongoing
work is required between Whanau House and the practices in the Henderson cluster to ensure the
services are able to be fully integrated into the cluster and not only co-located. Other Waitemata
DHB services have also been approached to plan additional services to be integrated into the
Henderson cluster.
Westgate Medical Centre - Massey Cluster
Westgate Medical Centre has been identified as the preferred option for the IFHC in the Massey
cluster. They currently have some nurse lead clinics, Accident and Medical services an onsite
pharmacy and co-located radiology and laboratory collection services. The strategic business case
for Westgate Medical Centre will begin with the second phase of practice re-engineering in 2013/14.
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Integrated Models of Care
Clinical Work streams
Three clinical areas have been prioritised to begin developing new integrated ways of working.
diabetes (a chronic disease), child health (a population group) and urgent care (a suite of services)
were selected based on the following rationale:
- Consultation at the West Auckland clusters meetings
- The alignment to the priorities in the Northern Region Health Plan
- The current health statistics and future modeling which predicts significant increases in
future demand
- A suitable platform for primary and secondary care clinicians to work together
In addition to the above work streams a small collaborative wound care pilot has been running in
two West Auckland practices.
Culturally and cognitively diverse communities have expressed the need for simple, clear, culturally
appropriate conversations between themselves, their families (whanau) and health professionals.
This aspect of health is an essential component of health services planning, implementation and
evaluation in localities. Currently there is a collaborative project between Waitemata DHB and
Health Links. Each workstream will identify barriers and mitigating strategies to health literacy for its
target populations.
Diabetes
This work stream aims to consistently provide better care for people living with diabetes in West
Auckland
The diabetes work stream aligns with the Health Targets (Better diabetes and cardiovascular
services) and links to the Northern regional health plan.
Diabetes care is not provided consistently across the West Auckland general practices. This is
evidenced by only 51% of people diagnosed with diabetes across Waitemata DHB are recorded as
having an annual review in primary care. Historical West Auckland general practice audits have
20
shown similar annual review results alongside significant variation of blood glucose, blood pressure
and renal function monitoring. Large numbers of people with diabetes are admitted to hospital.
Between 2009 and 2011 there were 2,400 West Auckland hospital admissions with diabetes as the
primary diagnosis.
This work stream aligns closely to a specific initiative in the Northern Region Health Plan of the
implementation of a Quality Improvement Team (QIT) to work with individual practices to develop
action plans to improve the quality of diabetes care. The QIT will be made up of a GP and practice
nurse who will engage with West Auckland locality practices to benchmark best practice across the
locality, implement best practice guidelines and support the development of practice nurse lead
clinics. The QIT will improve the linkages between the hospital diabetes service, other diabetes care
providers and general practice. Another function of the QIT will be to gather practice diabetes data
across the locality.
Consumer voice for the diabetes work stream has been provided by Waitakere Health Link. The
consumer nominated for this work stream, delivers a number of patient support groups in West
Auckland and has strong links to Diabetes NZ. Self directed care is a key element of good
management of all chronic diseases including diabetes. The work stream will explore opportunities
to change the way diabetes services are delivered so that patients are better able to manage their
condition.
The primary indicator for this work stream will be an improvement in the percentage of diabetes
annual reviews in the practices that are supported. Secondary measures of patient blood glucose
control, blood pressure control and renal monitoring and CVD checks will also be used.
This approach reflects the key focus of quality improvement processes for the clinical pathways.
21
Figure 5: The Diabetes Quality Improvement Team
A working group has been established which is led by primary and secondary clinicians. The group
has identified the key factors for improved diabetes care and gathered baseline data for the current
state of diabetes care.
It is envisaged the information gathered from this work stream will inform how we review the
management of other chronic diseases in the West Auckland locality.
22
Child Health
This work stream aims to collaboratively develop and implement better ways of working for child
health priority areas
The child health work stream aligns to the Northern Region Health Plan and the Auckland DHB and
Waitemata DHB Child Health improvement Plan. It will also link to the immunisation health target
and the Greater Auckland Integrated Health Network (GAIHN) business case.
Across a range of indicators, West Auckland has poor child health outcomes relative to Waitemata
DHB as a whole. As child health covers a broad range of services and conditions, specific identified
areas are needed for the working group to focus the work stream.
The established working group will include the community, child health providers including NGOs
and hospital and general practice clinicians. The purpose of the working group is to:
- implement best practice, guidelines and pathways for the prioritised conditions
- to develop better integrated ways of working
The working group has identified the following clinical areas to target:
- asthma - developing better management of the chronic condition
- rheumatic fever – implementing best practice guidelines
- skin infections – implementing best practice treatment and prevention guidelines
- the interface between maternal, well child and child health providers
The specific evaluation measures of success are still to be defined by the working group. The
Waitemata DHB Community Engagement Co-ordinator sits on the working group and will help to
inform this ongoing process and allow for further stakeholder/consumer input as needed. The
Whanau Ora Co-ordinator from HealthWest NGO is also part of this working group and provides a
community perspective as well as a working knowledge of Whanau Ora.
Urgent Care
The work stream aims to improve the provision of urgent care in West Auckland
The urgent care work stream is aligned to the shorter stays in emergency department health target
and the Greater Auckland Integrated Health Network (GAIHN) business case .
23
Initial analysis shows that urgent care in West Auckland is delivered in an episodic way and takes
little account of long term conditions management or prevention. There appears to be a general
lack of co-ordination across the system and an overuse of the Waitakere Hospital ED by patients that
could be seen in their medical home. It has been estimated that up to 35,000 non-urgent patients
are seen each year in the hospital ED. Success of the urgent care workstream will be measured by
the:
- reduction in the number of non-urgent patients seen in Waitakere Hospital ED
- increased capacity of urgent care appointments within West Auckland general practices
and Accident and Medical clinics
Key stakeholders including Waitakere Hospital ED, Accident and Medical Centres, pharmacy, St John
Ambulance and general practice have been brought together for a series of six meetings to
determine the desired state of how urgent care should be delivered in West Auckland and to identify
key enablers and barriers to achieving the desired state.
A large face-to-face patient survey being conducted at Waitakere Hospital to determine the main
reasons individuals choose to attend the Waitakere Hospital ED with non-urgent conditions. Once
completed this survey will be provided to the working group and inform urgent care planning
Waitakere Health Links representatives are members of the urgent care working group and have
connections to a broad range of community groups to consult with to inform decision making.
The six urgent care meetings have been completed and a recommendation report is being drafted.
This report will provide a basis for planning and contract re-negotiation in 2013. It is expected that
the implementation of the recommendations will be a phased approach over a minimum of five
years.
Wound Care Pilot
Waitemata DHB is piloting an integrated model of care for complex lower leg wounds in West
Auckland. This project commenced in September 2012 with two pilot practices West Fono and
Kelston Medical Centre. This project brings together the general practice staff, DHB district nursing
and dietetic services. Initial feedback from the patients, practice nurses and district nurses is very
positive. An evaluation of this project will be completed to determine the clinical effectiveness of
the intervention and future roll out.
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Workforce
Inter-Disciplinary Workforce
It is widely recognised that inter-disciplinary teamwork is an effective way to improve health
outcomes and to use scarce health sector resources more effectively.
Allied health practitioners provide diagnostic, therapeutic and preventative health interventions.
Allied health providers have a strong focus on development of inter-professional education and
collaborative practice to ensure better health outcomes for their clients and families in accordance
with WHO principles ( WHO 2012).
Within the West Auckland locality primary healthcare setting, allied health services are provided
through private practitioners, NGOs and DHB departments. Audiologists, counsellors, dietitians,
occupational therapists, pharmacy, physiotherapists, podiatrists, psychologists, psychotherapists,
radiology, speech language therapists, social workers as well as others may be employed in one or
more of these settings.
Waitemata DHB Allied Health Services are currently reviewing models of care used in emergency
care, child health and the management of chronic diseases such as diabetes. In collaboration with
primary health, their objective is to identify how allied health services may be best aligned with
IFHCs to ensure the best health outcomes for the West Auckland population.
In future, a skilled allied health workforce specifically focused on early intervention and prevention is
required to work with GPs and other primary care providers (Boyd, Horne 2008)
Developing a strong primary care nursing workforce is integral part of increasing the capacity of the
primary care sector. Building the capability of primary care nurses to work at the top of their scope
will help to meet the predicted service demand. Nurses are particularly effective in the area of self
directed care including the management of long term conditions, health of older people and child
and youth health.
25
To build capacity, Waitemata DHB provides the Nurse Entry to Practice (NETP) programme in
primary health care with new graduates working in a variety of primary care settings which includes
general practice, Plunket and age residential care. They are being supported in their workplace by
the Primary Health Care Nursing Development Team. In addition, clinical placements are provided
in primary care settings for student nurses and return to practice nurses.
To enhance the capability of current primary care nurses, Waitemata DHB provides professional
development and recognition programme (PDRP) and career coaching. Postgraduate study is
supported with funding available from Health Workforce New Zealand.
Actions for 2013/15
Over the next two years the following actions are proposed to continue on the journey to self
directed care:
Finalise a jointly agreed governance and infrastructure to support further locality
development
Progress the Alliance between PHO’s and DHB to progress locality and cluster development
Deliver a robust 5 year business case which will include financial, time and risk management
Determine the resources required (including funding, staff and technology) to deliver the on
the actions in the West Auckland locality plan and to prepare the subsequent business case
Complete the clinical work streams of Diabetes, Child health and Urgent care and develop
implementation plans of the actions identified including evaluation.
Progress community engagement models within the clusters alongside a communication
strategy
Establish a working party to develop a collaborative approach to enhance primary care
access to diagnostics and elective procedures in general practice (O’Malley 2013)
To work with PHO and relevant NGO’s to agree on ways to improve performance of the
National Immunisation Register Administration, Co-ordination and Out reach services.
(O’Malley 2013)
To review the usage of Primary Options to Acute Care services in West Auckland
Define and prioritise additional workstreams including additional chronic conditions and
gerontology
26
Prepare a strategic business case and open a Integrated family Healthcare Centre within the
Massey cluster
Develop a quality and performance framework to be administered by the West Auckland
Health Network
Auckland District Health Board, Waitemata District Health Board and PHO partners to work
together to develop a commission and outcomes framework
Continue primary care nursing development
Review allied health opportunities
Scope the need for a health literacy intervention in West Auckland
Develop a locality communications plan for the community and health providers
West Auckland Health Network to hold public meetings within each cluster to begin direct
communication with community
Greater involvement of Primary Health Organisations (PHOs) in working as co-
commissioners and co-managers of nominal budget management for pharmacy, laboratory
testing and imaging
Scope the management of PHO Performance Programme (PPP) payments at a locality level:
Work at a practice level measuring baseline performance and agreeing three year quality
improvement plans for practices
Increase practice capability and capacity by re-engineering business models and the
formation of co-operatives within the clusters
27
Appendices
Appendix 1
Figure 6: Guiding Principles For Service Design
Service Design Principles What this principle means
Service Design Principle 1
Patients are supported to manage their health and well-being
Patients are given the knowledge and tools to be experts in their own health
Health systems are designed, and health professionals are trained, to support patients to be experts in their health
Service Design Principle 2
Services are accessible and address inequalities – particularly for Maori and other high-need and minority groups
Access includes: location, time, language, culture and cost
More services are delivered in primary care and community settings - closer to where people live, work and play
Primary health care services are broadened (more comprehensive) and better “wrapped” around whanau/families
PHO membership is not a barrier to access (people with similar needs can access a common set of services)
Health works with other agencies and NGOs
Service Design Principle 3
Primary and secondary services are integrated
DHB specialist services support primary care teams to manage their patients within primary care settings
Supporting co-ordination of care within primary care and minimizing “hand offs” to other providers
Diagnostic services and specialist advice are available to primary care teams to avoid unnecessary referral to secondary care
Service Design Principle 4
Workforce effectiveness and capacity is maximized through multidisciplinary team-working, education and good systems
Workforce substitution and delegated functions within the team
Specialists are part of the “virtual” primary health care team
Service models incorporate the training and education of all health professionals (undergraduate & postgraduate: doctors, nurses, pharmacists & allied health)
Services are attractive to the current and future workforce
Career pathways for the primary care workforce identifying opportunities and mechanisms for achievement
28
Service Design Principles What this principle means
Service Design Principle 6
Relevant patient information is available to providers involved in their care
Providers involved in a patient’s care can access relevant and current clinical information in different settings at any time
29
Figure 7: Process Principles for service review and redesign
Process Principles What this principle means
Process Principle 1
Service planning is “joined up” and aligned with geographic communities of interest (localities)
PHOs and the DHB work collaboratively to develop integrated service plans around geographic communities of interest
Planning is aligned with National Health Targets and priorities, PHO Performance Programme, and district priorities
Individual organisations contribute to an overall locality plan
Health services work collaboratively with NGOs and other sectors on the wider determinants of health
Process Principle 2
Information is used to reduce inequalities and improve the patient journey
Collective data is used to improve the health status of the district; to measure and reduce inequalities; to improve patient pathways; improve quality and safety; for service analysis and re-design.
Information is used for a collective understanding of the whole system/process/care pathways
A “virtual” health needs analysis function (Health Intelligence) for the district with PHO and DHB participation
Process Principle 3
Funding and contracting supports good clinical practice and service integration
More integrated and global budgets with accountability for outcomes
Funding and contracting supports the Service Design Principles
Remove incentives to cost-shift and transfer patient care (“hand-offs”)
Process Principle 4
Clinicians are actively involved in service improvement
Create opportunities for clinician involvement in service analysis, review and re-design
Integrated district clinical governance (across PHOs and between PHOs and WDHB)
30
Appendix 2
Figure 8: Principles of Engagement and Consultation
Principles of Engagement and Consultation ADHB/WDHB Consultation and Engagement Policy, May 2012
• Acknowledge our Treaty of Waitangi-based relationship with iwi and the MOU between the ADHB, WDHB and Te Runanga o Ngati Whatua
• Acknowledge the relationship between Waitemata DHB and Te Whanau o Waipareira under their MOU
• Assess the importance of the matter from the ADHB, WDHB and our patients, service providers and wider community stakeholders’ points of view
• The scale of engagement and consultation undertaken should correspond to: - The significance or importance of the matter, and - The amount of resources the DHB has available
• Have genuine intent and an open mind• Engage and consult as early as practicable• Engagement and consultation should be aligned to the decision-making process• Because different communities communicate in different ways, engage and consult
stakeholders in a way that is focused on their needs for meaningful participation. • Provide clear, comprehensive and balanced information. Use simple language and avoid
jargon. We will provide translated material and interpreters and seek advice as to appropriate cultural practices in our consultation/engagement where needed.
• Allow sufficient time for stakeholders to consider the information required to make an informed response
• Close the loop by informing decision-makers and the people engaged and/or consulted about the engagement and/or consultation outcomes
Appendix 3
Brief History Of The West Auckland Community
There has always been a strong sense of community in West Auckland. Over the past 30 years there
have been good collegial relationships between the GPs across West Auckland. In the 1970s the
Emergency Medical Services (EMS) were set up based in Glendene. The EMS required all the local
GPs to contribute towards an out of hours roster for West Auckland.
31
In the early 1990s the first wave of health reform hit the New Zealand health sector with the
creation of Independent Practitioners Associations (IPAs). As the doctors in West Auckland had
worked together for long time, they were able to rapidly set up a value based organisation that was
rooted within the local community. The initiative was led by two enthusiastic doctors; Clive Stone
and Lannes Johnson who set up Integrated Primary Care Services Ltd (IPCS). The idea was clear: to
set up an integrated health system in West Auckland. Over the next 20 years the following was
achieved:
- West Kids was established
- WestCare was set up for out of hours coverage
- Waitakere Health Link was set up to lobby for a hospital for West Auckland. This was
supported by the Waitakere Council, local MPs and the local population
West Auckland has developed strong networks and the ability to get things done. In the early 2000s
the PHOs came into being. IPCS was transformed into HealthWest Limited, a small, cost effective
local PHO. The PHO held the local health professionals together and it took on an even stronger
community direction. The directors consisted of:
- 4 GPs
- Practice nurse
- Chair of Waitakere Health Link, Community representatives
- Pharmacy representative
- Iwi representative
- 3 Pacific representatives
It was connected by long term trusting relationships with many of the local communities.
By 2010, HealthWest was spending a proportion of its Services to Improve Access (SIA) funding to
deliver services to the whole population. These services were:
- Whanau Ora social services
- Schools based clinics
- Managing the National Immunisation Register (NIR)
- Managing the hard to find patients for immunisation
- Youth mental health
32
These services were available, locality wide and based on patient need, not PHO affiliation. This was
characteristic of West Auckland.
- In 2010 Waitemata DHB announced its two PHO policy. As a result of the policy, HealthWest
lost its PHO status. The community and provider networks were transferred into the West
Auckland Health Network to preserve these important long term relationships.
The West Auckland Health Network is being used as the foundation for the West Auckland locality.
Locality planning provides unique opportunities for the healthcare providers to be informed by
services users. This approach enhances service design for better, sooner and more convenient
outcomes in primary care for our communities.
The West Auckland Health Network is committed to working with Waitemata DHB, primary care, and
the community. Part of this collaboration is to explore working in a self-directed model, meaning
patients are more involved in the management of their care. This will be a new model of working
and will require a change in focus for all. Enablers for this change will be required for all parties.
Some of the enablers for our communities are patient centred care model, community engagement,
consumer representation, culturally specific engagement and co-design.
33
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