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

Counties Manukau District Health Board Community & Public Health Advisory Committee Meeting Agenda Wednesday, 11 November 2015 at 1.30 – 4.30pm, Manukau Boardroom, CM Health Board Office, 19 Lambie Drive, Manukau Time Item

1.30pm 1. Welcome

1.30 – 1.40pm 2. Governance 2.1 Attendance & Apologies 2.2 Disclosure of Interests/Specific Interest 2.3 Confirmation of Public Minutes (30 September2015) 2.4 Action Items Register

1.40 – 2.00pm 2.00 – 2.10pm

3. Population Health Updates 3.1 Over-Diagnosing (Dr Wing Cheuk Chan) 3.2 The Likely Effects of Acculturation

2.10 – 2.45pm

4. Director of Primary Health & Community Services Report (Benedict Hefford) 4.1 Glossary & Executive Summary 4.2 National Health Targets 4.3 Adult Rehabilitation & Health of Older People 4.3.1 Needs Assessment Services (Lynda Irvine) 4.4 Primary Health 4.5 Child Youth & Maternity

Afternoon Tea 2.55 – 3.45pm Director of Primary Health & Community Services Report (continued)

4.6 Mental Health & Addictions 4.7 Intersectoral Initiatives 4.8 Progress with Systems Integration 4.9 Locality Reports (Kathryn du Luc) 4.10 Financial Report

5. Resolution to Exclude the Public

3.45 – 4.00pm 4.00 – 4.20pm 4.20 – 4.30pm

6. Confidential Items 6.1 Integrated Services Strategy (Riki Nia Nia) 6.2 Social Services Investment (Geraint Martin) 6.3 Confirmation of Confidential Minutes (30 September 2015)

Next Meeting: Wednesday 16 December 2015 Manukau Boardroom, CM Health Board Office, 19 Lambie Drive, Manukau

Counties Manukau District Health Board – Community & Public Health Advisory Committee 11 November 2015 2

BOARD MEMBER ATTENDANCE SCHEDULE 2015 – CPHAC Name

21 Jan Feb 4 Mar 15 Apr 27 May June 8 July 19 Aug 30 Sept Oct 11 Nov 16 Dec

Lee Mathias (Board Chair)

No

Mee

ting

No

Mee

ting

No

Mee

ting

Colleen Brown

X X

Sandra Alofivae (CPHAC Chair)

X X

David Collings

George Ngatai

X X X X X

Dianne Glenn

X

Reece Autagavaia

X

Mr Sefita Hao’uli

X

Ms Wendy Bremner

X X

Mr Ezekiel Robson

Mr John Wong**

X

** Newly appointed to Committee from 15 April.


COMMITTEE MEMBERS’ DISCLOSURE OF INTERESTS

11 November 2015

Member Disclosure of Interest

Dr Lee Mathias, Chair • Chair Health Promotion Agency • Chairman, Unitec • Deputy Chair, Auckland District Health Board • Director, Health Innovation Hub • Director, healthAlliance NZ Ltd • Director, New Zealand Health Partners Ltd • External Advisor, National Health Committee • Director, Pictor Limited • Advisory Chair, Company of Women Limited • Director, John Seabrook Holdings Limited • MD, Lee Mathias Limited • Trustee, Lee Mathias Family Trust • Trustee, Awamoana Family Trust • Trustee, Mathias Martin Family Trust

Colleen Brown • Chair, Disability Connect (Auckland Metropolitan Area)

• Member of Advisory Committee for Disability Programme Manukau Institute of Technology

• Member NZ Down Syndrome Association • Husband, Determination Referee for Department of

Building and Housing • Chair IIMuch Trust • Director, Charlie Starling Production Ltd • Member, Auckland Council Disability Advisory Panel

Sandra Alofivae

• Member, Fonua Ola Board • Board Member, Pasefika Futures • Board Member, Housing New Zealand • Member, Ministerial Advisory Council for Pacific

Island Affairs Dianne Glenn

• Member – NZ Institute of Directors • Member – District Licensing Committee of Auckland

Council • Life Member – Business and Professional Women

Franklin • Member – UN Women Aotearoa/NZ • Vice President – Friends of Auckland Botanic

Gardens and Member of the Friends Trust • Life Member – Ambury Park Centre for Riding


Therapy Inc. • CMDHB Representative - Franklin Health

Forum/Franklin Locality Clinical Partnership • Vice President, National Council of Women of New

Zealand • Member, Disabled Women’s Group • Member, Pacific Women’s Watch (NZ) Ltd • Justice of the Peace

George Ngatai

• Arthritis NZ – Kaiwhakahaere • Chair Safer Aotearoa Family Violence Prevention

Network • Director Transitioning Out Aotearoa • Director BDO Marketing • Board Member, Manurewa Marae • Conservation Volunteers New Zealand • Maori Gout Action Group • Nga Ngaru Rautahi o Aotearoa Board

Reece Autagavaia • Member, Pacific Lawyers’ Association

• Member, Labour Party • Member, Auckland Council Pacific People’s Advisory

Panel • Member, Tangata o le Moana Steering Group • Employed by Tamaki Legal • Board Member, Governance Board, Fatugatiti Aoga

Amata Preschool • Trustee, Epiphany Pacific Trust

Sefita Hao’uli

• Trustee Te Papapa Pre-school Trust Board • Member Tonga Business Association & Tonga

Business Council • Member ASH Board • Board member, Pacific Education Centre Advisory roles: • Tongan Community Suicide Prevention Project (MoH) • Tala Pasifika (NZ Heart Foundation Pacific Tobacco

Control) • Member Pacific People’s Advisory Panel, Auckland

Council Consultant: • Government of Tonga: Manage RSE scheme in NZ • NZ Translation Centre: Translates government and

health provider documents. • Promotus GSL on Rheumatic Fever campaign (HPA) • Taulanga U Society Rheumatic Fever Innovation

project (MoH). • Member, Ministerial Advisory Council for Pacific

Island Affairs


Ezekiel Robson

• Department of Internal Affairs Community Organisation Grants Scheme Papakura/Franklin Local Distribution Committee

• Be.Institute/Be.Accessible ‘Be.Leadership 2011’ Alumni

• Member, CM Health Patient & Whaanau Centred Care Consumer Council

Wendy Bremner

• CEO Age Concern Counties Manukau Inc • Member of Health Promotion Advisory Group (7 Age

Concerns funded by MOH) • Member Interagency Suicide Prevention Group

John Wong

• Director, Asian Family Services at The Problem Gambling Foundation of New Zealand (PGF), also part of the PGF national management team

• Member, National Minimising Gambling Harm Advisory Group

• Chairman and Trustee, Chinese Positive Ageing Charitable

• Chairman, Chinese Social Workers Interest Group of the Aotearoa New Zealand Association of Social Workers

• Chairman, Eastern Locality Asian Health Group • Founding member and council member, Asian

Network Incorporation (TANI) • Board member, Auckland District Police Asian

Advisory Board • Member, Auckland and Waitemata DHBs Suicide

Prevention Advisory Group • Board member, Manukau Institute of Technology

(MIT) Chinese Community Advisory Group • Member, CADS Asian Counselling Service Reference

Group • Member, Waitemata DHB Asian Mental Health &

Addiction Governance Group • Member, Older People Advisory Group (ACC) • Member, University of Auckland Social Work Advisory

Group • Member, Community Advisory Group of Health Care

New Zealand • Member, Auckland Regional Public Health Service –

Asian Public Health External Reference Group David Collings

• Chair, Howick Local Board of Auckland Council • Member Auckland Council Southern Initiative


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

Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 11 November 2015 Director having interest Interest in Particulars of interest Disclosure date Board Action Mr George Ngatai

CMH Quit Bus Mr Ngatai is a Director of Transitioning Out Aotearoa who is a partner provider along with CMDHB and Waitemata PHO in the Quit Bus.

26 March 2014 That Mr Ngatai’s specific interest is noted and the Committee agree that he may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Mr Sefita Hao’uli

Rheumatic Fever national campaign

Mr Hao’uli is currently undertaking some work with the Ministry of Health on the Pacific campaign on Rheumatic Fever.

Updated 21 January 2015

That Mr Hao’uli’s specific interest is noted and the Committee agree that he may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Mr Geraint Martin

Renewal of the Regional After Hours Agreement

Mr Martin’s wife is the Executive Director of Takanini Care Medical Services Limited Partnership. The company comprises 2 A&M clinics and 2 general practices at the same location.

21 May 2014 and 20 August 2014

That Mr Martin’s specific interest is noted and the Committee agree that he may participate in the deliberations of the Committee in relation to this matter because he is able to assist the Committee with relevant information, but is not permitted to participate in any decision making.

Ms Colleen Brown Richmond NZ Trust Ltd Ms Colleen Brown has been involved with the family involved with this Trust.

22 October 2014 That Ms Brown’s specific interest is noted and the Committee agree that she may remain in the room and participate in any deliberations of the Committee in relation to this matter because she is able to assist the Committee with relevant information, but is not permitted to participate in any decision making.


Director having interest Interest in Particulars of interest Disclosure date Board Action Mr Sefita Hao’uli Alliance Health+

Mr Hao’uli is currently undertaking some work for AH+.

4 March 2015 That Mr Hao’uli’s specific interest is noted and the Committee agree that he may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Dr Lee Mathias Otahuhu Boundary Change Dr Mathias is the Deputy Chair of ADHB.

4 March 2015 That Dr Mathias’ specific interest is noted and the Committee agree that she may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Ms Dianne Glenn

Auckland Region Public Health Service update report

Ms Glenn is a member of the District Licensing Committee of Auckland Council

15 April 2015 8 July 2015

That Ms Glenn’s specific interest is noted and the Committee agree that she may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Ms Margie Apa Integrated Home & Community Support Services Redesign – Minister’s Briefing

Ms Apa is Chair of the Northern Presbyterian Support Services Network who are a current provider of home-based services.

8 July 2015 Ms Apa specific interest is noted and the Committee noted that she will excuse herself from the room whilst this item is discussed.


Minutes of Counties Manukau District Health Board Community & Public Health Advisory Committee Held on Wednesday, 30 September 2015 at 1.30 – 4.30pm, Manukau Boardroom, CM Health Board Office, 19 Lambie Drive, Manukau Present: Dr Lee Mathias (Board Chair), Ms Sandra Alofivae (Committee Chair), Ms Colleen

Brown, Ms Dianne Glenn, Mr David Collings, Apulu Reece Autagavaia, Mr Sefita Hao’uli, Mr Ezekiel Robson, Ms Wendy Bremner, Mr John Wong.

In attendance: Mr Geraint Martin (Chief Executive), Mr Benedict Hefford (Director, Primary Health

& Community Services), Ms Karyn Sangster (Chief Nurse Advisor, Primary Care) and Ms Dinah Nicholas (Minute Taker).

Apologies: Mr George Ngatai, Ms Margie Apa, Dr Campbell Brebner, Sefita Hao’uli and Apulu

Reece Autagavaia (for leaving early). 1. Welcome

The Chair opened the meeting and welcomed present. 2. Governance

2.1 Attendance & Apologies Noted.

2.2 Disclosure of Interest/Specific Interests Noted with no amendments.

2.3 Confirmation of Public Minutes – 19 August 2015 Resolution That the Public Minutes of the Counties Manukau District Health Board Community & Public Health Advisory Committee meeting held on Wednesday 19 August 2015 were taken as read and confirmed as a true and accurate record. Moved: Dr Lee Mathias Seconded: Ms Dianne Glenn Carried: Unanimously

2.4 Action Item Register Public Noted.


3. Resolution to Exclude the Public

Individual reasons to exclude the public were noted. Resolution That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000, the public now be excluded from the meeting as detailed in the above paper. Moved: Ms Sandra Alofivae Seconded: Ms Dianne Glenn Carried: Unanimously

1.42pm Public Excluded session. 2.09pm Open meeting resumed. 5. Director of Primary Health & Community Services Report (Mr Benedict Hefford)

5.2 National Health Targets

Going forward, cervical screening coverage and the change to the smoking target are the main

issues. Smoking – with the adjustor removed for 15/16, the target is now 90%. All PHOs are working

on sustainable quality improvement plans including both opportunistic and proactive initiatives that will enable us to reach this target.

Dr Mathias advised that at the Finance & Audit Committee meeting this morning they talked about making the train and bus station areas at Middlemore smokefree and that Auckland Transport will be approached so our entire campus, including the stations are smokefree. There was talk in the past from Auckland Council (through the Southern Initiative) about having a ‘smokefree precinct’ from Manukau City centre out in a large rectangle however, nothing has come of this yet.

It was noted that we should work collaboratively with other agencies (ie) Auckland Council, Kiwi Rail, NZ Police so we are all promoting the same message. We all live in the same space and should interact where and when we can. Resolution That the Board determine how we can ensure a smokefree precinct which includes all of the Middlemore campus including the rail and bus stations. Moved: Ms Sandra Alofivae Seconded: Ms Colleen Brown Carried: Unanimously The Committee requested a presentation in December on the Smokefree 2025 Strategy.

(Ms Rachel Wattie, NZ Doctor arrived at 2.30pm) Cervical Screening – enrolled population up to 76% at year end with our resident population

on 71.5%. A Cervical Screening Coordinator has been employed to work full time to identify and engage high needs women to have a cervical screen. Some initiatives include working with clinics with a high Maaori population (including Manurewa and Clendon) to assist them to


improve systems and processes to improve invitation and recall; organising free smear clinics in high needs areas including free weekend clinics and working with the poorest performing PHOs to identify clinics with the least coverage.

September is Cervical screening month and posters developed by CM Health have been circulated to PHOs for use within practices.

5.3 Adult Rehabilitation & Health of Older People

Community Geriatric Services – we are currently looking at who is being admitted to hospital from rest homes and private hospitals over the winter (tracking through Middlemore Central) to see if any particular rest homes are identified as having an increase but also to look at how we can support residential care facilities to provide more care in place so admissions are only happening if absolutely essential.

Needs Assessment Services for Older People – the transition of inpatient Needs Assessment and Service Coordination teams to localities and Assessment Treatment & Rehabilitation teams was completed in late August. Access will remain the same (ie) the referral, triage, allocation process will still be run centrally but the Needs Assessors will be closer to their community health colleagues so they can have a more joined up team approach. We have also changed the access for home support which is now being run through POAC - they will put in home support very quickly and then the team will come in to do the assessment. Ms Dana Ralph-Smith was asked to attend the next CPHAC meeting (11 November) to give a fuller briefing on both these issues.

5.4 Primary Health

Advance Care Planning – part of this process is to look at strengthening the uptake of the Enduring Power of Attorney. Dr Mathias referenced the following programmes which are run through the Cerebral Palsy Society which are valuable models to look at: Get Structured: http://www.cerebralpalsy.org.nz/Category?Action=View&Category_id=97 Get This & That: http://www.cerebralpalsy.org.nz/Category?Action=View&Category_id=95 Get Physical: http://www.cerebralpalsy.org.nz/Category?Action=View&Category_id=94 Ethnicity Data Audit Toolkit – this was identified as a key action in the 15/16 Annual Maaori Health Plan, particularly to address the implications that arise from misclassification of Maaori in primary care data. Most PHOs and their practices have already attended training sessions on the toolkit and have either started or already completed the activities to assess the quality and compliance of their ethnicity data. Preliminary results show that there is considerable variability in the quality of the ethnicity data amongst our general practices.

5.5 Child Youth & Maternity The report was taken as read.

5.6 Mental Health & Addictions It was agreed that there would be a deep dive into Mental Health & Addictions early in 2016 looking at the breadth and scope and how well we are placed overall to address the needs of our population.

http://www.cerebralpalsy.org.nz/Category?Action=View&Category_id=97




Key Worker Review Implementation– traditionally our community mental health teams have had a Key Worker role where one member of the team carries out the case management function. It is a highly valued role but we have recognised that a lot of services tend to do the case management of particular clients themselves and often in isolation, so the review is actually about, in the context of at risk individuals, care coordinators and integrated care, how do we change/adapt that approach so it is more holistic and more connected to primary care practices. There needs to be one key coordinator for patients and that role needs to work across teams and settings, moving us away from a situation where someone might have a key worker in a community mental health team but that person may not necessarily look at the person’s physical health needs or connect back to a general practice, or vice versa. It was agreed that a fuller briefing on this review would be provided in a future report.

5.7 Intersectoral Initiatives

Housing Support for Vulnerable Youth – MSD have contracted with Affinity Services to provide a supportive housing model in both Counties Manukau and Auckland. Previously, Housing NZ has been the main first port of call for housing related issues but under the new housing reform set up, Housing NZ is just another social provider - MSD will administer the system. For youth and mental health there is not a lot of information available about how big the need is so the team is currently working on how, in terms of named individuals, we make it very clear how many people we have in this district that have this kind of housing need to ensure they are prioritised for access to social housing.

5.8 Progress with Systems Integration The report was taken as read.

5.9 Financial Report

15/16 financial reporting now includes the Home Healthcare and Needs Assessment and Service Coordination budgets in the Locality structure and also includes Pacific Health Nurses within the Child Youth & Maternity portfolio – all previously included within the Hospital Services Directorate reporting in 14/15.

5.10 Localities Reports Eastern Locality - Ms Penny Magud was appointed to the role of General Manager Integration,

Eastern Locality on 31 August 2015. She is currently completing a period of induction across the DHB & PHO provided services in the Eastern locality.

It was agreed that Penny would attend a future meeting to presentation the work she undertook in England around community care, aged residential care and hospital admissions.

(Mr Martin departed at 3.25pm)

Mangere/Otara Locality – Ms Sarah Marshall provided some background into social service integration provider networks and ways of working, particularly with Mangere East.

(Apulu Reece Autagavaia and Mr Sefita Hao’uli departed at 3.35pm)

6.1 Youth Health in Counties Manukau (Dr Pip Anderson & Dr Doone Winnard)


This update was provided to give the Committee an update regarding the health of young people living in our district and summarised key findings from the 2014 report ‘Young People’s Health in Counties Manukau – a profile of aspects of young people’s health in Counties Manukau’. This report draws primarily on data from the Youth 2012 survey although also includes data from MSD, MoE, a range of health databases and the NZ Health Survey. The demography data was updated to reflect the results of the 2013 census. It was noted that over 500 5-21year olds living in Counties Manukau attend special schools. In terms of priorities and population health initiatives, it would be interesting to see more detail about how what we do in health reaches these young people on an equal basis with other school students. Ms Ellis confirmed that regular updates will come back to CPHAC to keep them informed on what is happening in this area. Priorities for 15/16 and beyond:

• Comprehensive and integrated school-based health services Collaborative model for young people and their whaanau – complex health & social needs.

• Joined-up youth services o Secondary care

• Continuous quality improvement - ‘youth friendly’ o Ongoing in schools o Youth friendly primary care o Secondary care guidelines

Ms Brown noted that whilst these priorities are admirable, there are a lot of young people in high risk areas (Mangere, Otara, Manurewa and Papakura) that don’t actually go to school. She commented that kids in Mangere, Otara, Manurewa and probably Papakura have been asking for a place of their own where they can go to and feel safe about actually talking and participating in a lot of these things and wondered whether there is an opportunity to reach these kids so they get some support, advice and help in a way that is on their turf. Ms Ellis confirmed that this is definitely within the scope of the above work-streams and that they are also looking at different ways of delivering ‘one-stop shops’ but that will be up to the localities and community where the best place/s might be. There is also work being undertaken intersectorally across the sectors. Dr Anderson referenced the following two papers on Youth Health: Young People’s Health in Counties Manukau: http://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Child-and-youth-health/2014-Young-peoples-health-in-CM.pdf Populations who have received care for mental health disorders: http://www.countiesmanukau.health.nz/about-us/performance-and-planning/health-status-documents/ The Chair thanked Drs Anderson & Winnard for their presentation. The meeting closed at 4.23pm. The next meeting of the Community & Public Health Advisory Committee will be held on Wednesday, 11 November 2015 in the Manukau Boardroom, CM Health Board Office, 19 Lambie Drive, Manukau.

http://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Child-and-youth-health/2014-Young-peoples-health-in-CM.pdf

http://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Child-and-youth-health/2014-Young-peoples-health-in-CM.pdf

http://www.countiesmanukau.health.nz/about-us/performance-and-planning/health-status-documents/

http://www.countiesmanukau.health.nz/about-us/performance-and-planning/health-status-documents/


The Minutes of the meeting of the Counties Manukau District Health Board Community & Public Health Advisory Committee held on Wednesday, 30 September 2015 are approved. Signed as a true and correct record on Wednesday, 11 November 2015. (Moved: /Seconded: ) Chair 11 November 2015 Ms Sandra Alofivae Date

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


Community & Public Health Advisory Committee Meeting – Action Items Register – 11 November 2015

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

8.7.2015 4.0 Update from Auckland Regional Public Health Service every 6 months on current issues.

3 February 2016 Mr Hefford

26.11.2014 5.0 Mr Nia Nia to provide an update on the NHC integrated service agreement work.

11 November Mr Hefford/Ms Apa

Refer Item 6.1 on this agenda

15.4.2014 4.4 Mental Health & Addictions – 2016 suicide prevention plan to be presented when available.

16 December/20 January 2016

Mr Hefford/Ms Ahern

27.5.2015 3.2 Update on the ARI programme from the Franklin Primary Care Practices

Early 2016 Ms Sangster

8.7.2015 6.1 Population Health Update Over diagnosis, over screening & over prescribing = bad health. Paper to unpick the issues which will help inform us how to prioritise certain screening programmes (ie) bowel cancer screening.

11 November

Dr Winnard

Refer Item 3.1 on this agenda.

19.8.2015 4.1 Asian Health – look into the relationship between acculturation and how it impacts on the health statistics of this group.

11 November

Dr Winnard


19.8.2015 5.5 Child Youth & Maternity – undertake a deep dive into childhood oral health looking at service access, the sugar debate, links to immunisations, Plunket, Well Child checks etc.

11 November/ 16 December

Mr Hefford

19.8.2015 5.10 Localities – further presentations from each locality: Kathryn du Luc Lynda Irvine Update on how the Southern Initiative is working from a DHB perspective – what the issues and hurdles are.

11 November 16 December Date TBC

Mr Hefford Mr Hefford

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


DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

30.9.2015 5.3 ARHoP- full briefing on Community Geriatric Services and Needs Assessment Services for Older People.

11 November

Ms Dana Ralph-Smith


30.9.2015 5.6 Mental Health – deep dive into Mental Health & Addictions looking at the breadth and scope and how well we are placed overall to address the needs of our population. Key Worker Review Implementation – full briefing on this review.

Early 2016 – date TBC Date TBC

Ms Ahern Ms Ahern

30.9.2015 5.10 Localities – presentation from Penny Magud on the work she undertook in England around community care, aged residential care and hospital admissions.

Date TBC Ms Magud


Counties Manukau District Health Board Community & Public Health Advisory Committee

Over-Diagnosis Recommendation It is recommended that the Community & Public Health Advisory Committee: Receive this report and the corresponding presentation that discuss the concepts related to over diagnosis. Prepared and submitted by: Wing Cheuk Chan, Public Health Physician, Population Health Team Purpose To actively discuss the concepts related to over diagnosis and the list of questions that are helpful to ask as part of service planning to limit over diagnosis, over utilisation and over treatment. Background The concept of over diagnosis is not new but there is increasing awareness of the issue through the campaign of the BMJ group, with an annual conference and increasing number of publications on the topic across a wide number of specialities. Central to the concept of over diagnosis is a balanced consideration of benefits and harms. There are overlapping social and ethical dimensions to consider, as value judgements are often required to determine whether the benefits out-weight the harms. Over diagnosis can be associated with over utilisation and over treatment. Presentation summary Over diagnosis refers to a diagnosis that does not produce a net benefit to the person. However, many examples of over diagnosis are occurring passively, without active consideration of the benefits and harms or affordability at an organisational level. The presentation describes some of the scenarios where over-diagnoses are likely to be occurring. Common scenarios include

1. A rapid increase in the incidence of a disease without a corresponding fall in mortality. 2. Detection of incidental findings from sophisticated imaging or remote monitoring gadgets

without fully understanding the natural progression of disease or the implications of the findings

3. Over reliance on test results when the prevalence of disease in the population (or pre-test probability) is low

4. Use of inappropriate questionnaires that make self-diagnosis common 5. Promoting the use of over-the-counter devices that do not provide accurate results

The presentation uses cancer as an example to discuss the concepts related to over diagnosis. It is a common belief that malignant cancer always kills people. However, cancer diagnosed in 2015 using sophisticated imaging and sampling techniques may not always kill, even though the tissue looks


malignant under the microscope. There are increasing numbers of small malignant cancers being diagnosed that do not necessarily cause harm and some may even regress. Many people may die with the cancers rather than die because of the cancer, partly because there are many slowly growing cancers that do not cause harm and partly related to the fact there are other competing causes of death from co-morbidities (e.g. people who get smoking-related cancer are also more likely to die from a heart attack or stroke because of their smoking). However, prospectively at present it is difficult to tell which of the ‘small’ cancers would cause harm and which ones would not. In the case of uncertainty, doing nothing is often the most difficult thing to do clinically. Most people will be offered treatment in the case of uncertainty; some of them will receive treatment they don’t actually need, for a cancer that would never cause them harm. Therefore, retrospective audits of the outcomes of our local populations are important to inform clinical decisions where there are lots of uncertainties currently. It is important to understand that not all cancer screening programs are the same in regard to the benefits and harms they bring. E.g. a recent report in the reputed New England Journal of Medicine suggests there is limited value in screening for thyroid cancer considering mortality rates for thyroid cancer have not fallen despite the rapid increase in thyroid cancer incidence. In order to explicitly consider the benefits and harms of a cancer screening program, it would be helpful to consider the subgroups of people who may benefit and harm from the screening program.

Patients subgroups Benefit or harm from screening

Reasons

People with very rapidly progressive cancer

No Benefit from screening

Cancer would be missed by the cancer screening program or even if the cancer was detected at a slightly earlier stage the prognosis remains poor.

‘Indolent’ cancer that will grow slowly and not likely cause harm before death from other causes.

Harm from screening (over diagnosis and over treatment)

Treating cancers that would otherwise not cause harm to the person is not good use of resources. Subjects patients to side effects of treatment without the gain in benefits

False positive screen (test is positive but person turns out not to have the condition)

Harm from screening Subjecting patient to extra unnecessarily follow up and tests. Creates unnecessarily anxiety

False negative screen (test is negative but person does have the condition)

Harm from screening Potentially resulting in delay in appropriate diagnosis and treatment

Relatively slow growing and progressive cancer

Benefit from screening

Providing early diagnosis and treatment result in better outcomes/ prognosis

Allowing disease awareness campaigns to fuel over diagnosis There are increasing numbers of self-diagnosis or self-help internet websites are funded by companies to promote self-diagnosis of a condition. Promoting a diagnosis rather than a product is likely to be subjected to fewer restrictions from regulators and less public scrutiny and distrust. One has to cautious that many of the interactive questionnaires may not be adequately validated. Indeed, they may not be designed to give a robust objective diagnosis. Non-specific symptoms that are commonly experienced are often used to promote awareness of a relatively rare condition. Often the presentation of health information may not be balanced.


Therefore, having a good understanding of the key issues and drivers of over diagnosis are important. Asking some of critical questions discussed in the presentation as part of service planning and funding related to over-diagnosis is likely help our service planners to refine our services further to limit over diagnosis, over utilisation and over treatment.

Preventing Over Diagnosis Community & Public Health Advisory Committee

Meeting

Dr. Wing Cheuk Chan Public Health Physician, Population Health Team, Strategic Development

Counties Manukau Health

Date:27/10/2015 Created by: Wing Cheuk Chan 019

Over diagnosis

• Central to the idea of over diagnosis is about having a balanced consideration about benefits and harms

• Refers to a diagnosis that does not produce a net benefit to the person – Has overlapping social and ethical dimensions – Overlapping concepts

• Over treatment and over utilisation • Expanded disease definitions

– e.g. pre-diabetes • Over medicalisation

– e.g. vitamin supplement 020

Questions that are useful to ask to see if over diagnosis could be occurring

• If there is a rapid increase in incidence of disease, is there a correspondence fall in mortality? – e.g. thyroid cancer screening

• Do we know the natural progression of disease? – We often do not know what the incidental findings really mean?

• Is the program undertaking a screening test in populations where the prevalence is low? – E.g. HIV testing in general population

• Association does not necessarily mean causation. Explore the alternative explanations. – E.g. low levels of vitamin D with cardiovascular disease

021

Using cancer as an example

• Important to appreciate that cancers diagnosed in 2015 do not always kill

• More cancers may regress, and some small cancers do not ever cause harm

• However, treatment of cancers can cause harm

• Prospectively we cannot tell for sure which of the small cancers will kill and which ones will not

• Hence, considerations of overall cancer mortality and all cause mortality benefit are important

022

Benefits and harms related to cancer screening

• If rapidly progressive cancer: no benefit from screening, as they are missed by screening or adverse outcomes can occur even detected in an early stage

• ‘Indolent’ cancer: patients are harmed from screening (over diagnosis and over treatment)

• False positive screen: patients are harmed from screening (misdiagnosis) • False negative: patients are harmed (false reassurance) • Relatively slowly progressive cancer: benefit from screening

Note: Not all cancer screening programs are the same in regards to the degree of benefits and harm they bring

023

National lung screening trial in US

• Benefits: – Number needed to screen: 320 ‘sets of 3 screens’ needed to

prevent 1 lung cancer death – All cause mortality benefit of 6.7% relative reduction (74

deaths per 100,000 person years). • Harms:

– Almost 40% of the people screened have a lesion that is subsequently found not to be lung cancer (false positive)

– Over-diagnosis rate of 13 to 27%, i.e. detection of cancer that patients are likely to die with rather than die of (need to consider competing causes of death) (over diagnosis + over treatment)

– Cost effectiveness and affordability are major concerns

024

Allowing disease awareness campaigns to fuel over diagnosis

• Be aware that a company may be marketing a disease instead of a drug or an intervention. – Use of self diagnosis website, using clinically inappropriate

questionnaire

e.g. even replying on website with all normal responses, the website still recommends to see doctor about dry eyes

– Lowering the bar,

e.g. Having a eating disorder if over eat 4 times in a month

– Raise the stakes, e.g. do it for your family

– Spin the evidence, e.g. fail the mention the side effects!

• Caution with promotion of over the counter testing 025

Current actions in Counties Manukau Health

• There are examples of over diagnosis across a wide range of speciality areas.

• A Diagnostic User group is being set up to review diagnostic variation, and support evidence based care delivery

i.e. helping us to ‘choose more wisely’

026



An overview of the likely effects of acculturation on the health of Asian people who reside in the Counties Manukau Health district

Recommendation It is recommended that the Community & Public Health Advisory Committee: Receive this report as an overview of how acculturation is likely to influence the health status of Asian people who live in the Counties Manukau Health district. Prepared and submitted by: Simon Thornley, Public Health Physician, Population Health Team Purpose This paper has been prepared in response to questions from CPHAC about the influence of acculturation on the health status of Asian populations who live in the Counties Manukau Health district. Background Nearly a quarter of the Counties Manukau Health district population self-identify as ‘Asian’. This group is diverse and has differing health needs. Immigrants have lived in New Zealand for varied lengths of time, and it is unclear how living in their adopted country influences their health. This paper summarises the published data relating to this issue, focusing on Asian people who live in the district. Studies of the effects of acculturation on health are relatively few in New Zealand, so studies from Canada, the U. S. and U. K. are referenced, since similar patterns of Asian immigration have occurred in these countries. Summary Acculturation is a process in which members of one cultural group adopt the beliefs and behaviors of another group. This process can have both positive and negative influences on the health of different cultures. This paper focuses on the effect of acculturation on Asian health, particularly in the Counties Manukau Health region. The principal Asian ethnic groups in the district are Indian and Chinese. In the Counties Manukau Health district, from responses to the 2013 Census, about 80% of Asian migrants are overseas born and are therefore likely to be in the process of acculturating. From 2013 census figures, about 50% of Asian people (42% of Indian and 63% of Chinese) in Counties Manukau Health district have lived in New Zealand for ten years or more. As this relatively healthy population progressively acculturates, the evidence reviewed for this paper suggests immigrant populations are more likely to develop chronic disease, and for Chinese people particularly put on weight. The chronic diseases most associated with more time spent in the host country include: allergies, back pain, high blood pressure, migraines, arthritis, ulcers and bronchitis.


In one study, the self-reported prevalence of these diseases approached those of the Canadian-born population in immigrants who had spent at least twenty years in their host country. Studies from the UK indicate that immigrants from India have higher rates of all-cause mortality, cancer and cardiovascular disease, with longer time elapsed since they immigrated. Effects of acculturation on mental health and tobacco smoking are not so consistent, with some sectors of society improving and some showing adverse effects with higher acculturation scores. Part of the health effects of acculturation are likely to be mediated through dietary changes, demonstrated by the strong associations between measures of acculturation and obesity in immigrants from China, Japan and the Philippines. Report Detail Background In our recent report of Asian health in the district, we reported that Asian people in Counties Manukau Health district have higher life expectancy than people who identify as New Zealand European or other (between 85 and 90 years). This is in contrast to average life-expectancy from their countries of origin (e.g. India 64 years; People’s Republic of China 76 years; and Fiji 69 years).1 This has been attributed to the ‘healthy migrant effect’, in which healthy immigrants are most likely to have positive physical and financial qualities which leads to their migration, compared to counterparts from their country of origin.2 Concern is expressed in the scientific literature that ‘acculturation’, whereby the members of one cultural group progressively adopt the beliefs and behaviours of another group, may be the reason for the progressively poor health seen as these ‘healthy’ migrants spend more time in their host country. Acculturation is thought to consist of three basic elements:

(1) Cultural difference: at least two different cultures are compared; (2) Cultural contact: immigration produces new contact between the two cultures; (3) Cultural change: new traits are being added to or replacing previous ones.

The notion of “acculturation” has been criticised as overly simplistic, since it carries an assumption of a “mainstream” and “traditional” culture, which have had little contact, prior to immigration. The idea is that individuals are on a continuum between the two poles. There is also little description of what “Western culture” actually consists of. With the globalisation of Western culture, the idea of immigration being the only opportunity for contact between the two cultures is also challenged.3 In contrast with this simplistic definition, some researchers have considered acculturation as a complex experience where some values from a person’s culture-of-origin are strengthened for those who migrate, while values from the mainstream culture to which they move are adapted to or acquired. Measurement of Acculturation Acculturation therefore has a variety of meanings and so, is assessed in different ways. In academic studies, it is often measured using a 21-item questionnaire which assesses language, identity, friendship choice, behaviours and attitudes toward the culture of their country of origin.


Epidemiological Evidence Even though the validity of the concept of “acculturation” is questioned, there is some evidence that the longer migrants from non-English speaking countries reside in English speaking countries, the higher their prevalence of a range of chronic diseases becomes. A Canadian study2 which compared immigrant (not specifically Asian), to local born health from national surveys, showed evidence of a higher incidence of various diseases with increasing time since migration. For conditions which included allergies, back pain, high blood pressure, migraines, arthritis, ulcers and bronchitis (designated “type A” diseases): the incidence of any of these diseases increased to those of Canadian born nationals 24 years after moving to Canada, in both men and women. For more severe diseases, such as heart disease, cancer, Crohn’s disease, thyroid disease and diabetes (“type B diseases”): years since immigrating to Canada was an important factor in women, but not men. This increased incidence of disease with increasing years since migration was only present in those born in non-English speaking parts of the world, and not for migrants from English speaking countries. These findings were not attributed to barriers to health service use, as migrants reported high levels of contact with the medical profession and enrolment in primary healthcare services. The authors reported that their findings suggested convergence of health status between migrant and local populations after about twenty years spent in the host country. A limitation of this study was that disease status was not objectively recorded, but rather derived from self-report. All-cause mortality, cardiovascular disease and cancer Some studies report the incidence of overall mortality, cardiovascular disease and cancer increase with longer time spent in Western countries. For example, a longitudinal study of immigrants from the Indian subcontinent to England and Wales reported a 68% (95% confidence interval: 13% to 150%) increased risk of all-cause mortality in South Asian migrants who had immigrated before 1964, compared to those who had migrated afterward. Similar increases in risk were observed for cardiovascular disease, coronary heart disease and cancer outcomes.4 The authors speculated that part of the reason for this is due to the adoption of a “British-type” diet. Psychological factors, such as difference between expectations and actual achievement, and threat of unemployment were also suggested to play a role. Days spent in bed due to illness Similarly, a U. S. study which compared overseas to local born Asian (predominantly Chinese, Filipinos, Japanese and Indian) immigrants, found that immigrants with longer lengths of stay in the U. S. were more likely to report negative outcomes, such as activity limitation and number of bed days due to illness per year. Asian immigrants who had spent less than five years in the U. S. were half as likely to report ≥ one week spent in bed sick in the last year, compared to people of the same ethnic group from the same region who were born in the U. S. Obesity Epidemiological evidence suggests that immigrants from China, Japan and the Philippines develop unhealthy weight gain, the longer they live in the United States, after immigration. This was illustrated in a U. S. study reported cross-sectional findings from a health insurance database. Asians (Chinese, Japanese, Filipino, Other Asian) were 30 to 70% more likely to be of normal weight (≤ 25 kg/m2) if they were foreign born, compared to their U. S. born counterparts.5


Cigarette smoking Studies of the effects of acculturation on tobacco smoking suggest a variable effect of this phenomenon, depending on the age and ethnicity of migrants. Evidence from the United States, for example, provided by a cross-sectional study of 1,374 respondents in a multi-ethnic Asian-American sample, assessed the link between acculturation and smoking prevalence.6 Acculturation was measured by native language ability and frequency of preparing and eating native food. The findings suggested that acculturated youth and less acculturated male adults were more likely to smoke. Conversely, measures of acculturation were higher among adult females that smoked, compared to their non-smoking counterparts. Mental health Studies of mental health also show variable associations between measures of acculturation and mental health status. Three cross-sectional studies of Asian-Americans reported that increasing acculturation was associated with less mental distress.7 On the other hand, three studies of Asian-American populations have reported that greater degrees of acculturation are associated with increased substance use, dependence and lower levels of engagement with substance abuse treatment.7 A study of Asian-American students reported that higher levels of acculturation were more likely to recognise the need for psychological help, and were more tolerant of the stigma associated with psychological help.8 Relevance to the health of Asian people in Counties-Manukau district In Counties Manukau, from responses to the 2013 Census, about 23% of Chinese and 21% of Indian people were born in New Zealand. 41% of Indian people living in the Counties Manukau Health district were born in a Pacific Island nation (e.g. Fiji), whereas 34% born in Asia. Of Chinese people living in the district, 76% were born in Asia. Thus, about 70 to 80% of Asian migrants in the Counties Manukau Health district are likely to be in the process of acculturating. The relatively good health that Asian migrants bring with them on arrival to New Zealand is likely to decline with further time spent in their host country. The amount of time those born overseas have been in NZ varies considerably. At the time of the 2013 Census, 25% of those identifying as Indian and 17% of those identifying as Chinese in CM had been in NZ less than 5 years, while 42% and 63% of these respective ethnic groups have lived in this country a minimum of ten years or more. Therefore, Asian people in Counties Manukau Health will be at quite different stages on their trajectory of acculturation, which is likely to be accompanied by change in health status. As this relatively healthy population progressively acculturates, the evidence reviewed for this paper suggests they are more likely to develop chronic disease, and for Chinese people particularly put on weight. The chronic diseases most associated with more time spent in the host country include: allergies, back pain, high blood pressure, migraines, arthritis, ulcers and bronchitis. Studies from the UK suggest that immigrants from India develop progressively higher rates of all-cause mortality, cancer and cardiovascular disease, the longer the time since immigration. Effects of acculturation on mental health and tobacco smoking are not so consistent, with both beneficial and adverse effects reported for different strata of the community. Part of the effect of acculturation is likely to be mediated through dietary changes, demonstrated by the strong associations between measures of acculturation and obesity.


References 1. Wang H, Dwyer-Lindgren L, Lofgren KT, et al. Age-specific and sex-specific mortality in 187

countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2013;380(9859):2071-94.

2. McDonald JT, Kennedy S. Insights into the ‘healthy immigrant effect’: health status and health service use of immigrants to Canada. Social science & medicine 2004;59(8):1613-27.

3. Hunt LM, Schneider S, Comer B. Should “acculturation” be a variable in health research? A critical review of research on US Hispanics. Social science & medicine 2004;59(5):973-86.

4. Harding S. Mortality of migrants from the Indian subcontinent to England and Wales: effect of duration of residence. Epidemiology 2003;14(3):287-92.

5. Gomez SL, Kelsey JL, Glaser SL, et al. Immigration and acculturation in relation to health and health-related risk factors among specific Asian subgroups in a health maintenance organization. American Journal of Public Health 2004;94(11):1977-84.

6. Ma GX, Tan Y, Toubbeh JI, et al. Acculturation and smoking behavior in Asian-American populations. Health Education Research 2004;19(6):615-25.

7. Koneru VK, de Mamani AGW, Flynn PM, et al. Acculturation and mental health: Current findings and recommendations for future research. Applied and Preventive Psychology 2007;12(2):76-96.

8. Atkinson DR, Gim RH. Asian-American cultural identity and attitudes toward mental health services. Journal of Counseling Psychology 1989;36(2):209.



Director’s Report Recommendation It is recommended that the Community & Public Health Advisory Committee receive the report of the Director Primary Health & Community Services. Prepared and submitted by: Benedict Hefford, Director Primary Health & Community Services Glossary of Terms

Acronyms Description A&D / AOD Alcohol and Drug ACP Advanced Care Plan AH+ Alliance Health Plus ARDS Auckland Regional Dental Service ARI At Risk Individuals ARPHS Auckland Regional Public Health Service ARRC Aged Related Residential Care AT&R Assessment, Treatment and Rehabilitation AWHHI Auckland Wide Healthy Housing Initiative B4SC Before School Checks CCM Chronic Care Management COPD Chronic Obstructive Pulmonary Disease CSW Community Support Worker DHS Director Hospital Services DNA Did Not Attend EOI Expression of Interest GAS+ Group A Streptococcal Positive GP General Practitioner hA healthAlliance HBSS Home Based Support Services HBT Home Based Community Team HHC Home Health Care HOP Health of Older People IDF Inter District Flows IFHC Integrated Family Health Centre IPIF Integrated Performance & Incentives Framework LTCF Long Term Conditions Facilities MOH Ministry of Health NGO Non-government organisation PHN Public Health Nurse POAC Primary Options to Acute Care PRIMHD Project for the integration of mental health data PSAAP Primary Services Agreement Amendment Protocol SUDI Sudden Unexplained Death of Infant VHIU Very High Intensive User VLCA Very Low Cost Access


Executive Summary • On 30 June 2016 More Heart and Diabetes Checks will cease to be a health target. The goal of the health

target was to provide a sharp focus on cardiovascular disease risk assessments as a strategic priority. The primary care sector has been able to generate significant awareness of Cardio Vascular Disease risk factors, improvements in health literacy and self-management. In recent months a consensus emerged around having a stronger focus on risk factor management which also aligns with the goals of the long term conditions work being done in the primary care sector. There is an opportunity now that nearly 90 percent of the eligible population has been risk assessed under the health target to focus on that population’s risk factor management as well as adding to the number assessed.

• Performance over the last quarter continues to improve for the Better Help for Smokers to quit target, since the removal of the adjustor and change to the target definition. A Smokefree Co-ordination Service Specification has been offered to PHO’s which includes funding for the development of a smokefree plan, and reaching the target. A portion of funding has also been allocated for improvement in cessation support.

• A new Health Target is to be implemented from 1 July 2016 to support the package of initiatives in the Childhood Obesity plan. The target is: By December 2017, 95 percent of obese children identified in the Before School Check programme will be offered a referral to a health professional for clinical assessment and family based nutrition, activity and lifestyle interventions. The aim is that children will receive a comprehensive check before they start school and are referred to the services they need to support healthy eating and activity.

• Reviews have occurred at the one year mark following transition to the new Mental Health and Addictions Housing and Recovery model. The report identified a reduction in average length of stay with the housing and recovery service and a significant increase in service users exiting to independent living situations. The service user satisfaction surveys indicated service users identified their increased independence to be beneficial to their recovery and enabled them to better develop the skills necessary to live successfully within the community. There are plans to extend the service to an additional four service users within the existing funding allocation.

• The Reablement service is operating within the Manukau, Eastern and Franklin localities. More than 80 patients have been seen by the service overall, with 27 now transitioned back to standard general practice care. Manukau has enrolled 58% of the total patients onto Reablement to date. Referrals are slowing as the winter demand settles across Middlemore hospital. The Mangere/Otara locality reablement service will launch in March 2016.

• Data for 2015/15 shows that we have achieved our target for reduced rheumatic fever hospitalisations.

The Mana Kidz programme outcomes continue to contribute significantly to the national better public service target for Rheumatic fever reduction.


4.2 National Health and Integrated Performance & Incentives Framework Targets

Target

15/16 14/15 14/15 14/15

Sep 2015 On Track Target Q2 Q3 Q4 More Heart and Diabetes Checks 90% 91.3% 91.2% 92.3% 91.2% Yes

Better Help for Smokers to Quit 90% 95.5% 95.1% 96.1% 84.2% Improvement required

Increased immunisations - 8 months 95% 94.0% 93.0% 95.2% 95.4% Yes Increased immunisations - 24 months 95% 96.0% 95.0% 95.3% 94.0% Improvement

required

Cervical screening coverage 75% 71.5% 71.4.% 76.0% N/A Yes

Note: September results are provisional only, based on calculation from PHO data.

Better Help for Smokers to Quit is reporting on unadjusted numbers from 1 July 2015

PROGRESS Provisional Integrated Performance and Incentive Framework target results for September show an improvement against the ‘More heart and diabetes checks’ and ‘Better help for smokers to quit’ targets. The main focus continues to be on the ‘Better help for smokers to quit’ target and ‘Cervical screening coverage’. All PHOs are developing smokefree plans for the 2015-16 year and as a part of this work there will be a significant focus on improving the quality and quantity of cessation support provided. Smokefree Group Based Therapy courses will be expanded across a greater number of PHOs in order to accommodate the additional referrals expected. More Heart and Diabetes Checks

Historical Quarters Current Month

PHO 2015-Q2

2015-Q3 2015-Q4 Sep-15

Alliance Health Plus 89.9 92.0 93.9 90.8 East Health 91.1 90.4 91.5 91.7 NHC 88.6 87.7 89.8 89.9 ProCare 91.1 92.3 93.0 93.0 Total Healthcare 88.5 89.3 90.7 87.2 CMH 91.3 91.2 92.3 91.2 National 87.0 87.7 89.0 Target 90.0 90.0 90.0 90.0

September-15 results are provisional only, based on calculations from PHO data Quarterly data for PHOs is MOH published


Graph One: CM Health Cardiovascular Disease Risk Assessment Performance at September 2015 September 2015 results are provisional only, based on calculations from PHO data. Quarterly data for PHOs is MOH published

Progress • The Counties Manukau Health result for More Heart and Diabetes Checks for September was

91.2% for the total population, based on the PHO monthly data. Most PHOs have met or exceeded the target and the focus continues to be on sustainable initiatives to ensure performance is maintained each month.

• The PHOs have offered all practices a weekly report (or ability to generate weekly reports) to ensure they are aware of who and how many people are missing risk assessments.

• A focus on management of high risk patients continues to be a priority and this is supported by various quality frameworks. Further reporting is being developed to demonstrate practice performance around primary and secondary prevention for both high needs and total populations.

• MedTech practices are encouraged to use the appointment scanner tool which identifies patients who have a visit scheduled at the practice, who have not yet had a CVD risk assessment. This enables patients to be targeted opportunistically. Practices are also supported to use practice tools such as Dr Info to identify those patients who have lipid and HbA1c results which will enable a risk assessment to be completed

• Practices who have not yet met the target are supported and assisted to develop improvement plans. These plans may include:

o Development of nurse led clinics o Support to access education to upskill nurses o Sharing of successful initiatives from high performing practices o Provision of additional resource to assist with screening large numbers of patients

and providing management advice

80

82

84

86

88

90

92

94

2015-Q2 2015-Q3 2015-Q4 Sep-15

Perc

enta

ge

* 3 month data lag on National Performance due to national data assurance requirements

CM Health More Heart and Diabetes Checks CMH Performance Sep-15

CMDHB National Target


o Assessment of practice processes to determine if greater efficiencies can be realised o Data analyst/help desk staff deployed to determine and resolve data issues o Identification of any barriers and plans to overcome barriers o Fee for service for screening high needs patients and offering phlebotomy o Support to set up text messaging for patients who have not yet had a risk

assessment. • A marketing approach has been developed so specific areas and populations can be targeted.

This also includes targeting patients who do not access primary care often. • Parish Nurses and Community Health Coordinators are targeting Maaori and Pacific

communities. • The Counties Manukau Health monthly Integrated Performance and Incentive Framework

meetings include a focus on the More Heart and Diabetes Checks target, where PHOs share issues and learning to assist each other to achieve the targets.

• The Integrated Performance and Incentive Framework Clinical Champion has been meeting with the PHOs to discuss this role and how best Counties Manukau Health can support PHOs and Practices with achieving the target. Most PHOs have asked for support with resolving issues when these arise and providing clinical advice when needed.

• Counties Manukau Health provides a Cardio Vascular Disease risk assessment and management template (Predict) which requires regular updating to ensure it reflects the most up to date guidelines. Most PHOs continue to use this as the main electronic decision support template.

• On 30 June 2016 More Heart and Diabetes Checks will cease to be a health target. Sector performance after 30 June 2016 will continue to be monitored through DHB accountability measures, service coverage requirements and reporting processes. There is an expectation that the target will be achieved by 30 June 2016 and engagement with the Ministry (e.g. those DHBs on recovery plans and quarterly reporting requirements) will continue. The health target has been in place for three years. During that time results have improved from 46% in quarter three 2011/12 to 89% in quarter four 2014/15. The latest quarterly results show that approximately 1.2 million people have been risk assessed. 11 DHBs and 22 PHOs have achieved the 90% target. There is an expectation that beyond 30 June 2016 there will continue to be strong collaboration and coordination between primary and secondary care.

Better Help For Smokers To Quit

Historical Quarters Current Month

PHO 2015-

Q2 2015-Q3

2015-Q4 Sep-15

Alliance Health Plus 89.0 94.7 98.6 89.5 East Health 98.0 95.5 95.1 86.6 NHC 89.0 81.4 94.5 85.1 ProCare 99.0 99.7 100.2 88.5 Total Healthcare 93.0 90.1 89.2 75.3 CMH 95.5 95.1 96.1 84.2 National 89.0 88.6 90.5 Target 90.0 90.0 90.0 90.0

September-15 results are provisional only, based on calculations from PHO data


Quarterly data for PHOs is MOH published Better Help for Smokers to Quit reporting on unadjusted numbers from 1 July 2015

Progress Performance over the last quarter continues to improve (approximately 1% per month), since the removal of the adjustor and change to the target definition. ProCare has identified an issue whereby the query they were using for the first quarter was counting the number of smokers that had been given brief advice and/or referred to cessation support services in the last 18 months, however the correct timeframe is 15 months. This has resulted in a reduction in their performance as the issue has now been corrected. Practices have been notified and have been given up to date reporting and will be supported to target patients who require brief advice and cessation support. All PHOs have been offered a Smokefree Co-ordination Service Specification which includes funding for the development of a smokefree plan, and reaching the target. A portion of funding has also been allocated for improvement in cessation support to encourage primary care to provide cessation support, refer to an appropriate provider (including Quitline) or prescribe NRT/other pharmacotherapy. There is significant variability amongst the PHOs and the focus on quality cessation support will improve the numbers of people quitting and assist practices with meeting the health target. The provider ‘Inspiring’ is offering smokefree group based therapy training in November and a group of PHO staff and practice nurses have registered. After completing training each person will be supported by the CMH Smokefree Advisor – Primary Care to start running group courses for interested patients. October is Stoptober and all PHOs have implemented various marketing campaigns to make the most of the opportunity to reach people who smoke. Referral numbers for October have been higher than normal and CMH is running a competition to reward the practice who refers the largest number of people in October to our Living Smokefree Team, with a morning tea. The PSAAP Working Group is meeting in October to discuss the primary care target and how we can move to an outcomes-based measure. Potential options include an indicator based on cessation support or an indicator based on smoking prevalence. Other activities include;

• The use of practice level weekly reporting to identify those people who need to be contacted and using telephone and text messaging campaigns.

• Opportunistic strategies will be implemented so patients will be identified when they attend the practice and will be offered brief advice as well as information on the various smoking cessation support options. Reception staff have been encouraged to check the smoking status of patients who are smokers and update their details if required.

• Capturing referral data and feeding this information back to the PHO so they can analyse practice referral information and target practices with no, or low numbers of referrals. There has been a significant increase in referrals to our local cessation team which is a result of practice visits and the Stoptober campaign.

• Support from the Counties Manukau Health Integrated Performance and Incentive Framework clinical champion to encourage collaboration and sharing of success stories.

• All PHOs have representatives who attend the monthly Counties Manukau Health Integrated Performance and Incentive Framework meetings where the targets are discussed. Issues are identified and resolved in a timely manner.


• The Primary Care Smokefree Advisor is working closely with the PHOs and practices and raising awareness about local and national cessation support options.

Immunisations The immunisation target for the period ending June 2016 requires 95% of all eligible children eight months and two years of age to have completed their scheduled course of immunisation. After our achievement last year it is very pleasing to see continuing achievement of the target. We do however have continuing challenges with Maaori whaanau under achievement in immunisation compared to all other ethnicities. Counties Manukau Health continues to implement strategies to sustain and improve coverage. Actions to achieve this include:

• The Immunisation Coordinator / Nurse Leader is working with PHOs to improve the timeliness of immunisation by improving coverage at six months of age and earlier identification of potential declines and referral to outreach immunisation services

• To acknowledge the commitment and hard work to reach target in 2014/15 all GP practices and Outreach Immunisations services are being given a certificate of achievement and a BUZZY BEE arm device with chiller pad to help block sharp pain and provide distraction when giving injections to children. These have been well received and are in use.

• Collaborating with outreach immunisation services to plan for the delivery of the immunisation schedule and the challenge of the small window of opportunity for catch up; we are working to increase the window for catch up through earlier referrals.

• Providing ongoing education for practice nurses; promoting higher profile of immunisations through moving to PHO Cold Chain Accreditation

• Planned education for midwives in October to improve messaging for mothers both antenatal and postnatal

• Continued targeted approach to engage and support Maaori Whaanau to immunise on time with information to assist their decision making.

For the eight month target, Counties Manukau Health is reported at 95.4% for total population, 90.2% Maori and 97.3% for Pacific. The results by Deprivation for the eight month immunisation indicated by localities with the highest density deprivation nine and 10, Manukau, Mangere/Otara are especially encouraging.


Children fully immunised at 24 months

The coverage rate for 24 month old children is reported as 94.0% for Total Population, 91.0% for Maaori, 96.5% for Pacific and 99.2% for Asian children.


Cervical Screening Total 3 year

coverage at June 2015

Maori Pacific Asian European/Other

CMDHB PHO enrolled population

76.0% N/A N/A N/A N/A

CMDHB resident population

71.5% 62.9% 74% 62.6% 79.5%

National 76.3% 62.6% 73.5% 63.4% 82.2% Table Four CM Health 3 Yearly Cervical Screening Coverage to June 2015 Source: National Cervical Screening Programme Register – women aged 25-69 years for CMH resident population and Connex (DHB Shared Services for PHO enrolled population) Note: Monthly reporting on cervical screening coverage at PHO level is not able to be provided due to the inability of the National Screening Unit to provide the data. NSU has not yet provided screening coverage performance for the July – September 2015 period. Progress Over the past month Counties Manukau Health has been consolidating cervical screening activity across the district by continuing to work closely with PHOs and their practice teams to identify, engage and complete cervical smear taking for women who are overdue for a smear or who have never been screened. The Cervical Screening Awareness promotions for the month of September meant an increase in promotional activity at the national, district, PHO and practice level. Billboards, posters, t-shirts and practice-based events all contributed to raising awareness of the importance of cervical screening. Counties Manukau Health produced a billboard for the Middlemore Hospital site showing the faces of local women and reinforcing messages about the importance of cervical screening. Additional activities during September have included:

• A Counties Manukau Health team including colposcopy services, obstetrics and gynaecological services, Maaori and Pacific teams, primary care nursing and primary care Planning and Funding are working together to prepare a submission for the Primary Human Papillomavirus screening by the National Screening Unit which closes on 23rd October.

• A proposal by Counties Manukau Health has been submitted to the Auckland Regional

Cervical Screening Coordination service for a Community Health Worker and a Nurse smear-taker to work together in the poorest performing PHO to identify, contact and engage the PHO’s unscreened and underscreened women in the district and either transport them to a clinic to have a smear or perform smear taking in the home. Approval in principle for the initiative has been provided by the Regional Coordination Service.


4.3 Adult Rehabilitation and Health of Older People OBJECTIVE To support older people in their homes and communities with integrated, locality based services that maximise independence through rehabilitation and quality care. PROGRESS Primary Options for Acute Care A trial of collaboration of short term Home and Community Support Services and Primary Options for acute care to support short term discharge needs for people post hospital admission this winter has been successfully completed. We have now transitioned this trial process over to business as usual alongside the developing Reablement and Community Central workstreams led by Localities General Managers and Project Managers. Assessment and Coordination of Care for Older People At 13 August 2015 100% of Aged Related Residential Care facilities were either interRAI trained or booked for training - (Reported Quarterly in arrears)

• 75% (33) of facilities are fully competent (required number of nurses trained) • 23% (10) facilities are competent (at least one nurse competent) • 2% (1) one new facility is in the process of completing training.

Early Supportive Discharge – Supporting Life after Stroke Work is progressing with combining of the Early Supported Discharge and Community Based Rehabilitation teams into one seamless service. Regular planning meetings to drive this change process of combining the two teams are being held. As new staff start they will immediately begin working across both models of care. A scheduling process which involves a three week cycle has been formulated and will be tested with staff. Work to finalise the triage process is ongoing, looking at completing the triage process online using the electronic referral system. This will automatically send an updated copy of the referral form stating if the referral has been accepted or declined and when the visits will commence. As a result we may be able to look at reducing the need to use letters in Saprano Med Docs. The team are completing the Community Based Rehabilitation general assessment on the ward prior to inpatient discharge for both wards six and 23. National and Regional Spinal Strategy There have been 89 patients through the Acute Spinal Service since 1 July 2014. Work continues with Burwood Spinal Unit on the development of a consistent approach to service delivery to meet the objectives of the New Zealand Spinal Cord Impairment Action Plan, in particular in relation to collection of patient experience information to inform service improvement. Discussions are progressing around access to upper limb surgery, tendon and nerve transfer. Historically surgery has been delivered from Christchurch with follow up through Auckland Spinal


Rehabilitating Unit. Competency exists to manage these types of patients through Middlemore for surgery and Manukau Super Clinic hand therapy, with the support of the Auckland Spinal Rehabilitating Unit. Further discussions need to take place to explore the impact on delivering this service. In the interim patients already receiving support or who are scheduled to receive support from Burwood will continue. One patient has received surgery at Middlemore Hospital this month, and this case will be used as opportunity to develop pathways and identify resources required. The Auckland Spinal Rehabilitating Unit has made contact with the Melbourne spinal surgery unit, who have expertise in tendon and nerve reassignment to assist in building knowledge and skills. Recruitment to approved roles remains a challenge in particular for Physiotherapy and Psychology. Community Geriatric Services An important component of the Systems Integration/Locality development is to provide Geriatric support to primary care practices and aged residential care. As part of our annual plan, an opportunity has been identified to further utilise the admission data extracted. This date will be further analysed to identify presentation trends based on diagnosis, environmental factors, facility etc. This will enable the service to develop and provide customised support plans for Aged Residential Care Facilities based on these trends. This piece of work is currently in the planning and analysis stage, with reporting due to commence from quarter three. In addition, from the weekly avoidable admission data an action plan is developed to identify trends across facilities which are addressed either individually with clinical staff in the residential care facility or as an education topic for all staff. Reasons for admissions are also reviewed at an NHI level. Community Specialists Health of Older People Teams (reported quarterly) Continue to provide proactive support to Aged Related Residential Care and Primary Care by Gerontology Clinical Nurse Specialists and Geriatricians. The monthly Aged Related Residential Care education session for facility staff continues to be well attended, with 36 staff attending the Lymphoedema education forum held on 24th September. The ATRACT education program for Registered Nurses in facilities continues to be promoted by the Counties Manukau Community Geriatric team. • Target: Maintain Gerontology Clinical Nurse Specialist and Geriatrician support per month to five

primary care practices including clinics and education sessions with GPs – During the month of September support was provided to more than five practices.

• Target: Maintain Geriatrician support per month to six Age Related Residential Care Providers for medication review case conferences – During the month of September support was provided to more than six Aged Related Residential Care providers.

Percentage of Home and Community Support Services client interRAI assessments complete by locality Between June and August 2015 90.4% of patients receiving home based support services have had an InterRAI assessment.


Memory Team (Dementia Care Pathway) Refinement of processes continues with documentation and data collection review phase one completed. Phase two, involving the definition of refined documents and data is underway. The outreach programme in Franklin has commenced with the Cognitive Impairment framework and Memory Team support to Waiuku being established. Confirmation of the new office area as a result of the required decant from Ward 22 will enhance relationships and collaboration with Community Geriatric Services and Mental Health Services for Older People community teams. Long Term Support Chronic Health Conditions update on service mix provided (Reported Quarterly in arrears) Counties Manukau Health Long Term Support Chronic Health Conditions utilisation There are 202 clients receiving long term supports for chronic health conditions and who are receiving the following services:

Locality Clients w/InterRAI PercentageEastern 1034 849 82.1%Franklin 652 599 91.9%Mangere/Otara 566 542 95.8%Manukau 1466 1371 93.5%CM Health 3718 3361 90.4%

Community Residential Services:

Qtr Ended 31-03-15

Qtr Ended 30-06-15

YTD12-Month Running

Dementia 6 6 6 6Hospital and Specialised Continuing Care 23 23 32 32Rest Home 18 20 23 23Respite 6 1 7 7Rehab and Community 0 0 0 0Carer Support 13 15 37 37Household Management 40 39 59 59Personal Care 75 74 94 94Night Support 0 0 0 0Individualised Funding 17 20 21 21Dementia Day Care 2 4 29 29

Total: 200 202 308 308

Number of clients


4.4 Primary Health

Diabetes Care Improvement Counties Manukau Health Primary Health Organisations and general practices have been delivering the Diabetes Care Improvement Programme since 2012. The Programme aims to achieve improved health outcomes and quality of life for patients with diabetes, particularly those who are currently not well controlled. Recently there has been an assessment of the Diabetes Care Improvement Programme as part of a broader refresh of the overall Counties Manukau Health diabetes strategy. Approximately a quarter of all diabetics in Counties Manukau are considered poorly controlled and the number of people does not appear to be reducing significantly. The Counties Manukau Health Alliance has a goal for 85 per cent of people with diabetes to have good glycaemic control by 2017. It has been recognised that better alignment of the Diabetes Care Improvement Programme with other initiatives such as the At Risk Individuals programme is required. Primary and secondary care clinicians have been consulting with key stakeholders on how diabetes care can better support the general diabetes goal of reducing the impact of disease and slowing disease progression. Key recommendations include:

• A collaborative model of care between Counties Manukau Health and general practice clinicians to enable better targeting and improved management of poorly controlled diabetes patients. The general practice team will be the healthcare home / key provider of care and Counties Manukau Health diabetes specialist resources such as Nurse Specialists and Senior Medical Officers will provide clinical advice, input and liaison;

• Phased roll out of the model, beginning in January 2016 with a smaller number of practices and patients. This will enable learning from the initial phase to be used to enhance the model of care and better inform full implementation across the district.

The proposed model means that other people with diabetes who are eligible for the At Risk Individuals programme will continue to receive coordinated care and those who are poorly controlled will receive an appropriate level of targeted resources, allied health services and social services. Regional Work Programme – Clinical Pathways 54 regionally-approved pathways have now been developed and are located on Healthpoint, providing a comprehensive road map for the local management of patients with common conditions. The pathways site has over 5000 individual hits per month, up 300% on the previous year. The Auckland region community membership of the HealthPathways (Canterbury model) has been completed. The regional team has aligned the Healthpoint pathways and adapted an additional 106 pages of HealthPathways content, including 43 clinical pathways. The site went live for the Auckland region on 24th August 2015 with over 530 clinicians registered for access with over 8000 page views since this time.

The dynamic pathways pilot (Nexxt) continues with 1,291 patients enrolled on a pathway being utilised by 347 clinicians across the target of 92 practices. The pilot will continue until March 2016. An Evaluation Advisory group to ensure the programme delivers on its intentions through robust analysis of the measures of success is now well established with evaluation of the Nexxt pilot to date now completed.

Work is continuing on the preparation of the Business Case for the continuation of this Regional Work Programme. This is due to be presented to the Auckland Waitemata and Counties Manukau Alliances in November 2015.


4.5 Child, Youth and Maternity Services OBJECTIVE(S) To integrate maternal and child health services; reduce perinatal mortality; improve care in the First 2,000 Days of life; intervene early to support vulnerable children; reduce Rheumatic Fever by two-thirds to 1.4 cases per 100,000; and improve youth services. 1st 2000 days-Maternity The Annual Counties Manukau Health Maternity Quality and Safety report has been endorsed and acknowledged by the Ministry of Health as well as the National Maternity Monitoring Group. This year’s report captures all initiatives currently being implemented under both the Maternity Quality and Safety and Maternity Action Plans’. Link to report: http://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Maternity/2014-2015-Maternity-Quality-Safety-Programme.pdf 1st 2000 days - Te Rito Ora (formerly Infant Nutrition Project) This programme of work has a new name – Te Rito Ora. Our new project name Te Rito Ora comes from the harakeke (flax) plant which reflects a whanau or family group - the inner most leaf is the rito or pepi (baby), and these baby shoots are surrounded, supported and protected by the Awhi Rito (parent) and Tupuna (grandparents). The second part of the name is 'Ora' which means health. The health workers employed by the project at Papakura Marae and Greenstone Family Clinic will be known as Kaitipua Ora Workers, and our peer supporters as Kaitipua Ora Volunteers. Kai Tipua Ora means "person empowering and fostering health". Both the Community and Workforce Development Workstreams of Te Rito Ora are on track and progressing as per the project plan with the community lactation clinics on track to be operational by 1 November 2015, the Peer Supporter Programme having recruited their Kaitipua Ora Volunteers (Peer Supporters) and commenced the training programme, and Phase two of the workforce development currently being developed. 1st 2000 days -Sudden Unexpected Death in Infancy The safe sleep device programme continues to provide pepi-pods to whaanau with newborn babies in unsafe sleeping environments. All referrals receive safe sleep education with a range of safe sleep baby bed options being made available. Safe Sleep education will be a requirement for all staff and contracted organisations in maternity and child health with good support from providers. The online education module has had good uptake from external providers. Safe Sleep audits are being rolled out through all birthing units, maternity wards, Kidz First and Neonatal care. There is good compliance in audits to date.

http://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Maternity/2014-2015-Maternity-Quality-Safety-Programme.pdf

http://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Maternity/2014-2015-Maternity-Quality-Safety-Programme.pdf


Childhood Obesity Plan The Government announced their Childhood Obesity Plan on 19th October. This package of initiatives aims to prevent and manage obesity in children and young people up to 18 years of age. It has three focus areas made up of 22 initiatives which are either new or an expansion of existing initiatives: 1. Targeted interventions for those who are obese 2. Increased support for those at risk of becoming obese 3. Broad approaches to make healthier choices easier for all New Zealanders. The focus is on food, the environment and being active at each life stage, starting during pregnancy and early childhood. The package brings together initiatives across government agencies, the private sector, communities, schools, families and whaanau. Before School Checks Before School checks are conducted in Counties Manukau by Plunket and Well Child Tamariki Ora Maaori Providers. Plunket also provide clinical leadership and training to the Well Child/Tamariki Ora providers. The 2015/16 Ministry of Health targets for the 2015-2016 year are 8,025 Before School checks overall, and 3,565 of these need to be Quintile five. At the end of September quarter Counties Manukau Health Before School programme is at 31% overall and 26% for Quintile five (high deprivation). Counties Manukau Health has exceeded the quarterly target for this financial year to date as a total of 2470 checks have been closed/completed, 920 of these being Quintile five. All strategies implemented in 2014/15 will continue to ensure maintenance of coverage in 2015/16. Introduction of a new Health Target To support the package of initiatives in the Childhood Obesity plan, a new health target is to be implemented from 1 July 2016. The target is: By December 2017, 95 percent of obese children identified in the Before School Check programme will be offered a referral to a health professional for clinical assessment and family based nutrition, activity and lifestyle interventions The target was selected as the Before School Checks focus on intervening in the early stages to ensure positive, sustained effects on health. Children receive a comprehensive check before they start school and are referred to the services they need to support healthy eating and activity. Rheumatic Fever Prevention Programme The Ministry of Health Rheumatic Fever Prevention Programme was established in 2011 to prevent and treat streptococcal throat infections, which can lead to rheumatic fever. The Programme was expanded significantly from 2012 following the introduction of the rheumatic fever Better Public Services target. Data released from the Ministry of Health for 2014/15 shows that Counties Manukau Health has achieved its target for rheumatic fever hospitalisations. The rate achieved is 8.0 per 100,000, which


is lower than the 2014/15 target rate of 8.2 per 100,000. This equates to approximately 66 cases in 2013/14, down to 41 cases in 2014/15 therefore 26 fewer cases for the financial year. From 1 July 2016, the Ministry of Health will decrease its investment in the National Rheumatic Fever Prevention Programme with the expectation that it remains a priority for all high incidence DHBs. Respective high incidence DHBs are required to submit updated Rheumatic Fever Prevention Plans which capture ongoing activity and investment in the programme. Counties Manukau Health will review the current configuration of school based health services as a part of this process. Any proposed changes which result in additional investment will be included in the DHBs annual prioritization process. Oral Health -Preschool The key target is to increase enrolment of preschool children aged zero to four years to 95% by 30 June 2016. Current enrolment is 72% with the gap being children aged zero to two years, particularly Maaori and Pacific children. Target is 90% by 31 December 2015. Counties Manukau Health is working in collaboration with Auckland Regional Dental Service and a range of child health providers exploring a number of initiatives to increase early enrolment and engagement in Community Oral Health services. September update: Preschool enrolments by ethnicity Enrolments snapshot

Preschool Asian

Preschool Maaori

Preschool All Others

Preschool Pacific

Total Preschool

Dec-13 5,443 7,570 8,893 9,780 31,686 Dec-14 5,397 6,504 8,174 8,498 28,573 Sept-15 5,866 6,600 8,355 8,558 29,379 Eligible population (2014) 8,650 10,620 9,620 12,140 41,030

% Preschool enrolled by ethnicity at September 2015

68% 62% 87% 70% 72%

Oral Health Pilot for Women with Diabetes in Pregnancy The Ministry of Health funded low cost oral health pilot for 400 Women with Diabetes in Pregnancy to receive free dental care during pregnancy and up to one year post-partum over three years commenced in February 2013. The service will be completed in February 2016 and is undergoing evaluation by Ministry of Health. With a planned cohort of 400, we have had 392 participants out of 701 referrals. Referrals are now only being accepted for women in acute need so that we can complete treatment by the end of the pilot and complete a full evaluation. Youth Health The Youth Health Leadership Group has refined its vision and intended health outcomes for youth health. The vision is for all young people in Counties Manukau to be healthy, confident and reach their full potential, with the following health outcomes:


• Good mental health and a strong sense of personal and emotional wellbeing; • Healthy relationships and good sexual health; • Good physical health including taking regular exercise and eating a balanced and nutritious diet; • Less harmful use of substances including alcohol, drugs and tobacco; • A positive social and healthy lifestyle, including strong self-esteem, positive image of self,

cultural identity, connectedness to whaanau and community.

Work continues on the development of comprehensive and integrated school-based health services, support for young people with high and complex needs and a framework for youth-friendly primary care. All workstreams are on track, with no known risks.


4.6 Mental Health and Addictions OBJECTIVE: That the communities of Counties Manukau will support mental health and wellbeing and be able to get support when they need it, quickly and easily, in their local community. PROGRESS Service Access Rates and Waiting Times Note that there is a 3 month report lag due to national data assurance requirements:

Graph showing access rates for mental health services from July 2014 to June 2015 (NGO & DHB services). This Ministry of Health performance measure provides a view on the whole of population access to specialist Mental Health & Addiction services. This includes all Counties Manukau patients who access any of the following services: Counties Manukau provider arm specialist Mental Health services, regional specialist Mental Health and/or Addiction services (e.g. specialist Alcohol and Drug, Forensics) and Non Government Organisation services (both Mental Health and Addictions). What is evident is the increase in access to these services for the Counties Manukau population. The current challenge is to how to ensure adequate access to specialist services while enabling and supporting specialist services to enhance the capability and capacity of the primary care level services to provide Mental Health and Addiction services. This is being undertaken through integration initiatives, Information Technology developments and the work on enabling specialist clinicians and services to report on non NHI defined clinical consultation to other providers. There has been a large increase in the number of children and young people accessing services from 5121 in 13/14 to 6320 in 14/15. One of the factors contributing to the increase is improvements made to the specialist child and youth services point of entry which was intended to increase access and reduce waiting times.


Access to services for 0-19 year olds

The graph shows access rates from July 2014 to June 2015, with a filter for age range 0 – 19 years (NGO & DHB services). We were unable to meet the target for Non-Government Organisation Alcohol and Drug zero to 19 wait times for 2014 / 15 as we have one provider that has had data difficulties over three reporting quarters. We have been working with this provider alongside the NRA and the ministry to ascertain what the root causes have been. The outcome of this work identified a number of issues which have now been resolved and the provider has resubmitted correct data which is reflective of the providers practise. Mental Health and Addictions and Housing and Recovery service transition- one year on On 1 July 2014 Non Government Organisation providers of Residential Responsive Night Services transitioned to the new Housing and Recovery Model. The transition was a significant departure from traditional bed based funding to a model that clearly separated the funding of support and accommodation options. The expected benefits of funding conversion included:

• Funding for support service not housing or accommodation • Enabling increased service user self-determination and autonomy • Creating individualised and responsive service provision able to flex according to client

need.

One year on from the transition individual provider reviews have occurred. Whilst the process has not been without its challenges; a report provided to the DHB by the Non-Government Organisation, Affinity Services, and feedback from all stakeholders observed the following benefits:

• Reduction in average length of stay within the housing and recovery service • Significant increase in service users exiting to independent living situations • Service User satisfaction surveys indicated service user identified their increased

independence to be beneficial to their recovery and enabled them to better develop the skills necessary to live successfully within the community

• Plans to extend the service to an additional four service users within the existing funding allocation.

0%10%20%30%40%50%60%70%80%90%

100%

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2014 2015

Counties Manukau DHB - NGO AOD: All Ages

> 8 weeks

>3 and <=8 weeks

< 3 weeks

No wait


One service user that has transitioned from the service and is now receiving support in the community from Affinity stated:

“I’m liking having my own space, it’s peaceful and good to be independent, I’m thankful to the staff for helping me get my place, a job and now my driver’s licence – I got it this year. My parents are happy I’m living out in the community, I reminded them that I’m getting older and I need to be independent!”

Further work is being undertaken to look at the residential services that have not changed to the new model to identify opportunities for improvement within those services


4.7 Intersectoral Initiatives OBJECTIVE Target populations/communities with high health, housing, social, employment and education needs to improve the health status and reduce health inequalities. PROGRESS Project Outcomes for the Warm up – Counties Manukau Project (1 July 2015 to 30 September 2015)

Month

Total Number of Referrals

Total Number of Homes Insulated

Total Number of Home Visits completed post install

July 2015 217 39 28 August 2015 172 55 36 September 2015 121 68 28 Total number of referrals generated to date

510 162 92

Please note: There is a time delay between referrals being received by the provider and the completion of the insulation install. Self-identified ethnicity by household for the current financial year (total referrals received 1 September 2015 to 30 September 2015):

Ethnic Group Number of referrals Percentage of total referrals

Asian 13 9% European 33 24% Indian 23 16% Maori 37 26% Other 5 4% Pacific 29 21% Total 140 100%

Please note: Households may identify with more than one ethnicity The Providing Access to Health Solutions Programme The key objective of the Providing Access to Health Solutions Programme is to reduce health barriers to employment by providing an appropriate health intervention, which enables participants to return to employment. Total Number of Voluntary Participant Enrolled onto the PATHS Programme

Month Total Number of Participants enrolled

July 2015 18 August 2015 15

September 2015 16 Total Number 49


Housing Reforms Identifying further Opportunities for Social Housing A request for information has been issued jointly by Treasury and the Ministry of Social Development. The request for information has been issued to identify providers interested in participating in the transfer of existing Housing New Zealand properties in Tauranga and Invercargill. As well as identifying those providers with land/buildings that may be available for a mix of social and affordable housing options in the high demand areas of Auckland, Christchurch, Waikato, Wellington, Northland and the Bay of Plenty. Emergency Housing Provision The Ministry of Social Development seeks to engage providers to deliver temporary Emergency Housing Services in Auckland from 1 January 2016. The aim of the Emergency Housing Service is to provide short-term accommodation and individualised support services for individuals and households that have an emergency housing need. The providers will be contracted to provide support services that should assist households to transition to a stable personal and financial position and achieve a long-term housing solution within an expected maximum stay of 12 weeks. To help bed-in a sustainable housing solution, providers will also be expected to continue to work with individuals/households for three months following their transition out of the Emergency Housing Service. The Service will be delivered over a 24 month period with the Government contributing $2 million to participating non-government organisations.


4.8 Progress with Systems Integration OBJECTIVE: That by December 2019 every Counties Manukau resident will have a more local, integrated experience At Risk Individuals The transition to the At Risk model of care has been implemented across Counties Manukau, with the Chronic Care Management programme now phased out. 99 practices across the district are now working within the model of care. Enrolment volumes have slowed as practices have hit the minimum contracted volumes for year one of the programme, with 14,594 patients enrolled in the programme, representing 3.1% of the Counties Manukau Health population (as at 01.10.15). PHO and locality performance is indicated below:

Clinical data is now being shared between PHOs and Counties Manukau Health, enabling the monitoring of clinical outcome indicators. Initial analysis of demographic data shows that the cohort of patients being enrolled into the programme are primarily within quintile five and over the age of 45 years. The ethnicity spread is primarily European, and while Maaori are enrolled at a rate higher than the enrolled population, Pacific people are not represented in At Risk Individual enrolments at


the level at which we would expect. Discussions are being held with the Fanau Ola team to understand potential barriers.


Phase two of the programme is progressing in the following areas: Quality improvement: A district-wide approach to quality improvement within primary care is now being rolled out to all practices that have been operating within the At Risk Individuals model of care. Practices have begun to review care plans with a view to developing an improvement plan. Initial feedback from practices is positive with framework milestones achievable and adding value to their practice processes. Training workshops on Health Literacy are underway and a more detailed training programme is being developed. An initial District Wide Quality improvement learning session hosted by the Manukau Locality will be held in late November. Complex households: An internal working group has been established to discuss the development of an intersectoral approach to supporting families to build resilience and wellness. Current work focusses on identifying the barriers to access and engagement with primary care and draws on the experience of primary, community, whaanau ora and fanau ola teams. Work is currently underway with WINZ, Child Youth & Family, and the Ministry of Social Development to establish training sessions for practice nurses to understand how these agencies work, and better integrate. This will result in each general practice cluster having a named contact at each agency who can support the implementation of the care plan. Frail elderly: A primary falls prevention working group has been established. A workplan has been agreed that includes piloting the primary falls prevention pathway in the Eastern and Franklin localities. Diabetes: A proposal has been developed jointly by the Counties Manukau Health diabetes service and At Risk Individuals leads which involves a redesign of the current Diabetes Care Improvement Package to focus on people with poorly controlled diabetes. This model will be implemented at a limited number of practices for a six month period, with a full evaluation before being rolled out district-wide. Community Health Service Integration Objective: To increase the capability and capacity of community services, facilitating integration with primary, Non-Government Organisation and speciality services. Reablement Workstream The reablement service is operating within the Manukau, Eastern and Franklin localities. Over 80 patients have been seen by the service, with 27 now transitioned back to standard general practice care. The Mangere/Otara locality reablement service will launch in March 2016. Community Central Community Central will provide seamless access and intake for Counties Manukau Health community services, enabled by a mobile technology solution that supports a ‘first response’ request for services, triaging, allocation of resources and capacity planning. The service will launch in Eastern locality in November 2015 with a staged rolled out scheduled for all locality community teams by March 2016.


4.9 Locality Reports Eastern Locality

Performance The Eastern Locality continues to run a Joint Replacement Alternative Pathway programme, an Otago Exercise Programme, an Early Intervention Osteo Arthritis programme as well as an Early Onset Osteo Arthritis classes (Knees &/or hips) through the East Health Primary Health Organisation. Under the Joint Replacement Alternative Pathway programme 55 visits have taken place with eligible patients in the first quarter of 2015/2016. The Otago Exercise Programme saw 22 new patients in quarter one with 92 treatment visits being undertaken in that period. The Early Intervention Early Intervention Osteo Arthritis class programme accepted 15 new referrals in Quarter one with a total of 75 participants attending the exercise classes in Quarter one. The At Risk Individual Coordinators employed via East Health Primary Health Organisation continue to work with each practice to support the uptake of at risk patients to have an At Risk Individuals care plan. As a result of this work 21 out of the 23 East General Practices have a high uptake of the programme with 2390 patients enrolled on the At Risk Individuals programme with a shared care plan.

Strategic Community Central A draft implementation plan has been drawn up enabling the preparation for the Eastern Community

1. Acute Demand

Indicator Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15

CMDHB Avg Last 12 mths

1.1 Unplanned readmissions (28 days) 5.3% 5.4% 5.0% 5.3% 5.9% 5.0% 6.3%1.2 ASH rate (per 1,000 enrolled patients) 0.8 0.9 0.7 0.7 0.7 0.6 1.41.3 Average bed day usage in last 6 months of l ife 6.8 8.0 13.8 10.9 5.9 8.3 11.8Notes : Numbers for previous months may change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffect Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality



2.1 Children fully immunised at 8 months (Target = 90%) 95.1% 94.7% 95.5% 94.9% 95.6% 94.9% 94.5%2.2 Children fully immunised at 24 months (Target = 95%) 97.5% 96.2% 96.6% 94.7% 93.9% 93.9% 95.4%2.3 Middlemore Radiology < 6 week wait time for GP Referrals 92.2% 89.8% 88.8% 91.6% 94.2% 94.9% 91.8%

3. Shared Accountability Services

Item Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15Last 12

Mths3.1 ED presentations not admitted 214 234 227 207 229 250 29243.2 Acute medical bed days 1278 1359 1397 1275 1345 1193 166793.3 Acute casemix-funded non-medical bed days 972 1079 908 885 946 1040 118923.4 Medical outpatient attendances 2214 2063 2008 2109 2379 1899 25385Note : Al l SAS volumes for previous months may change as IDF updates are received and coding i s modi fied

4. Other



4.1 E-referrals as % of all referrals 23.4% 24.2% 26.2% 27.0% 25.5% 25.1% 20.7%4.2 Medical Outpatient DNA rate 3.5% 3.6% 2.1% 3.6% 2.8% 3.4% 8.9%Note : Numbers for previous months may change as coding i s modi fied for 4.2 , and additional referra ls are included for 4.1


Health Team to Go Live with a mobility enabled workforce as well as implementing new ways of working to roll out a single referral, clinical triaging, central rostering, central allocation and a first best response system in November 2015. A workshop with representatives of the Eastern Community Health Team has taken place to view the proposed mobility solution to be used for the demonstrator roll out. A workshop with Clinical Leads, Clinical Nurse Coordinators and Operational Managers from all four localities took place 15th October 2015, with local workshops planned with East staff planned for 30th October 2015 and 5th November 2015. These workshops will be supported by Clinical Nurse Coordinators and the Clinical Leads to ensure that the new ways of working and work flows are developed as a whole district solution and not based around four differing local ways of working. Contracting and service specification meetings are taking place with the regional Primary Options for Acute Care service to work in partnership with Counties Manukau to provide a coordination function alongside the clinical triaging function that is being designed to be delivered centrally for the demonstrator phase of implementation of community central by Counties Manukau clinical staff. Reablement By working with East Health Primary Health Organisation Reablement has been rolled out within the Locality. The Reablement Coordinator employed via East Health is working with patients discharged from Middlemore Hospital. This Reablement Coordinator is working with the Counties Manukau Health to develop the role, using external care providers to deliver the reablement programmes with each patient. Locality Visits completed by General Manager Community Visit’s with member’s of the East Community Health Team have taken place enabling the General Manager to see how mobilising the workforce will assist with providing better health outcomes for our patients. It also assisted with identifying how staff are currently delivering interventions and how through the development of a multi skilled interdisciplinary workforce this will enable a better patient experience and create greater efficiencies within our own workforce. We need to ensure reablement becomes a core process that all patients experience before any long term needs are determined. Meetings with the East Health staff who provide Elder Care, Rapid response/reablement coordination, the At Risk Individuals programme coordination; Primary Care Options for Acute Care, as well as General Practice Staff from a range of medical centres has occurred, these visits have assisted the new General Manager in understanding how the current structures are working and has enabled her to understand the priorities for change for the implementation of demonstrator phase of Community Central and wider Community Health Service Integration developments. Eastern Locality Leadership Group The Eastern Locality Leadership Group met on Monday 12th October 2015 for the first time since March 2015.The terms of reference and governance structures of the various groups were reviewed with the Chair, in order to ensure structure, and to ensure that the Locality Leadership group will agree and have oversight of the key priorities for change across the locality. The Eastern Clinical Advisory Committee will ensure that each of the key priorities agreed by the Eastern Locality Leadership Group for the locality are being addressed.


Ministry of Health Mobility Action Programme and ACC Falls Prevention The Eastern Locality (both PHO & CMH resource) assisted with the authoring of the Counties Manukau Registration of Interest for the Ministry of Health Mobility Action Programme. A project lead to lead the ACC Falls Prevention development on our behalf and to lead on the resubmission of the Counties Manukau Registration of Interest for the Ministry of Health Mobility Action Programme has been identified. Health Promotion It has been agreed to trail the Food Bank App as part of the wider Healthy Howick strategy. The aim of the trial is to see how the community can begin to influence the food outlets, schools and retailers in regards to the types of healthy foods on offer, enabling healthy affordable food easier to access for everyone. We are working with East Health Primary Health Organisation to launch the trial and wider initiatives around healthier eating and healthier communities within the Eastern Locality.


Franklin Locality

Winter Planning Early results of the Winter Initiatives show a 7% decrease in the Emergency Department attendances from the Franklin Locality for the winter months. A full evaluation and future planning session will be held next month. Winter Planning - Phase Two The focus on Pukekohe North School for the last initiative for the winter had a mixed response, the colouring–in competition was very successful and contributed to our information regarding home insulation within this area. In terms of parents attending the drop–in session, there were very few in attendance. The team presented to a group attending a social empowerment group which was well received. Locality Hub development Discussion and planning for the Locality Hub continue. Both the Locality Leadership Team and Clinical Advisory Network have endorsed the plans in principle. Dementia Pathway Outreach Pilot - Waiuku Medical Centre The Pilot is underway with Champions in the Practice working through the education material supplied by the Northern Regional Alliance. They will use the Dynamic Pathway and E-Shared Care for documentation,

1. Acute Demand



1.1 Unplanned readmissions (28 days) 5.9% 4.9% 6.6% 6.0% 4.7% 6.5% 6.3%1.2 ASH rate (per 1,000 enrolled patients) 1.2 1.0 1.0 0.8 1.0 1.0 1.41.3 Average bed day usage in last 6 months of l ife 20.3 9.8 14.4 14.0 17.1 21.4 11.8Notes : Numbers for previous months June change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffect Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality






Mths3.1 ED presentations not admitted 119 102 82 106 135 111 14523.2 Acute medical bed days 683 702 743 949 868 956 109433.3 Acute casemix-funded non-medical bed days 561 621 626 548 587 485 75473.4 Medical outpatient attendances 1180 1140 1226 1112 1210 1014 14584Note: Al l SAS volumes for previous months June change as IDF updates are received and coding i s modi fied

4. Other





and At Risk Individuals for funding. Alzheimer’s Auckland Charitable Trust is part of the design and has a key worker who is able to support the Practice and Carers with case management. The Memory Team will assist with orientation and mentoring. Multi-disciplinary team support will be provided by the Community Geriatrician and the Clinical lead for Mental Health Services for Older People.


Mangere/Otara Locality

The Locality Leadership Team Action Plan to improve population health continues to be implemented in the following workstreams: Create a health promoting environment Providers of public health services to Otara & Mangere are meeting with the Locality Leadership Team in November to share information about common areas of interest and explore the merit of collaboration. Representatives from Auckland Council Community Boards, Auckland University and providers of the Ministry of Health’s Healthy Families initiatives will be present. Key concerns are the food, environment, smoking, physical activity, alcohol, and housing. Better Support Self-Management How providers can work together to better support self-management of local people is the main concern of the self-management support working group whose collaboration started after the September co-design workshop. The group are drafting a service development plan which will be tabled at a follow-up stakeholder workshop in December 2015. Integrate and improve service delivery to at risk individuals Otara child health integration project A local midwife network meeting with a focus on pregnancy education and social services coordination was attended by 21 midwives working in Otara. A GP, practice nurse and mix and mingle CME evening with the topic diabetes in pregnancy was attended by 24 health professionals working in Otara. Data this released this quarter has shown that women who register with a midwife in the first trimester has increased from 21% to 42% between July 2014 and March 2015 (For all of Counties Manukau Health.

1. Acute Demand



1.1 Unplanned readmissions (28 days) 6.6% 7.1% 6.4% 6.8% 7.8% 8.8% 6.3%1.2 ASH rate (per 1,000 enrolled patients) 1.7 1.8 1.7 1.8 2.2 2.1 1.41.3 Average bed day usage in last 6 months of l ife 10.0 10.9 9.4 9.4 13.6 13.2 11.8Notes : Numbers for previous months may change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffect Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality






Mths3.1 ED presentations not admitted 703 671 641 652 721 769 86393.2 Acute medical bed days 1745 1868 2053 1827 2471 2635 272383.3 Acute casemix-funded non-medical bed days 1700 1316 1612 1546 1277 1405 187993.4 Medical outpatient attendances 3116 2611 2693 2784 2933 2611 35936Note : Al l SAS volumes for previous months may change as IDF updates are received and coding i s modi fied

4. Other





Twelve Tapuaki pregnancy and parenting drop in sessions were held in Otara. Low numbers attended these sessions despite significant effort spent promoting them. As a result, a pilot to provide home visiting Tapuaki education sessions is in progress. There has been progress to embed the use of social services coordination service by midwives working with Otara women. Sustainability of this pilot beyond the Otara project’s completion in February 2016 to be determined, but there are several funding options that are being considered. Integrated models of care for at risk individuals General Practice enrolments of people in the At Risk Individuals Programme continue to increase and we continue to develop “Enhanced General Practice Teams” in geographical areas where General Practices are clustered: Mangere Town, Mangere East, Otara Central and ETHC Otara/Mangere. Agreement has been reached with Taikura Trust as to how they may work in Enhanced General Practice Teams. The approach which includes workforce education on eligibility criteria for services, referral decision support tools, named contact people and attendance at Multi-disciplinary team meetings where the patient meets eligibility criteria for referral will be tested from November. How social service providers work in Enhanced General Practice is the subject of a service improvement effort, with a view to increasing capacity and sharing information in better ways. There is agreement to start the ETHC Enhanced General Practice Team Multi-disciplinary team meetings on November 19th 2015 and planning is underway to make that happen. The Locality Leadership Team is reviewing the whole schedule of Multi-disciplinary team meetings to create efficiencies. Virtual participation in Multi-disciplinary teams is being tested with web based technology. The Otara-Mangere Locality Leadership Team continues to sponsor the Integrated Foot Care Project with a view to reducing lower limb amputations for people with diabetes, living in the Otara & Mangere areas. Progress has been made on the design and development of an integrated way of working. Patient information brochures have been reviewed for wider distribution. This will be implemented with permission of the Mangere Health Resources Trust. Analysis of low foot check volumes has been completed and delivery and contracting solutions developed. Solutions have proven challenging however, foot check volumes are increasing as a result of the project. Clinical Governance and service delivery options are being considered in the next reporting period. There is agreement to learn and use the Ipswich Touch Test tool via existing Diabetes Self-Management Education and Self-Management Education programmes. Four of the five Primary Health Organisations are now using a foot assessment and risk stratification tool based on the New Zealand Society for Study of Diabetes guidelines which advances the objective to have a common foot assessment tool. The remaining Primary Health Organisation has agreed to implement a tool. The Counties Manukau Health Renal foot assessment form is also being adapted as a practice resource to complement the Primary Health Organisation foot assessment tool. There is agreement to use the New Zealand Society for Study of Diabetes guidelines for podiatry intervention thresholds. Podiatrists are now available in all localities. Options to better network providers and open up referral access are being considered under a new delivery model. Credentialing for competency in management of high risk feet will be addressed under the new Clinical Governance and delivery model being considered. Podiatrists are agreeable to setting up primary/secondary peer review and learning sessions within the district. Enablers: Service Hubs Certainty that the Haemodialysis Unit will open at 10 Waddon Place in February 2016 has meant that the Mangere Town service hub plan can be activated. A working group has formed to initiate the planning.


Manukau Locality

Healing at Home - Self-Management Project – Manukau Locality 2015-2016 The service’s vision for this project focuses on inspiring and enabling high service reliant patients with long term conditions, to self-manage in partnership with their primary care team. This project will support patients to spend more time well in the community and experience less service inputs. The project’s aim is to ensure that at least 500 high service reliant patients, with long term conditions in the Manukau locality, will have a personal self-care plan by 1st December 2016. Progress Staff are currently being trained in goal setting, care planning and health literacy to support their work with patients. Training progress has been affected by the ability of staff to be released from high winter work loads but will progress more favourably from now on. A wound care resource folder has been developed that contains the necessary information and tools to work with the patients during their visits. Clinical Priorities Diabetes Collaborative The diabetes project is proving to be a useful way to engage practice teams in multidisciplinary meetings. A number of meetings have been held with practice teams the locality had yet to engage with which is helpful. Initial meetings have focussed on medical reviews as they are initiated and lead by locality Senior Medical Officer’s and the next step will be to ensure good follow up and support with patients wider health and social needs from other community team members as appropriate. Project meetings are now

1. Acute Demand



1.1 Unplanned readmissions (28 days) 5.9% 5.8% 5.2% 6.3% 5.9% 7.0% 6.3%1.2 ASH rate (per 1,000 enrolled patients) 1.7 1.4 1.6 1.5 1.8 1.8 1.41.3 Average bed day usage in last 6 months of l ife 9.5 9.8 8.5 10.7 16.0 11.5 11.8Notes : Numbers for previous months June change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffect Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality






Mths3.1 ED presentations not admitted 686 671 653 630 737 702 86753.2 Acute medical bed days 2597 2347 2462 2439 3157 2767 332043.3 Acute casemix-funded non-medical bed days 2024 1944 1881 1950 1659 1605 237803.4 Medical outpatient attendances 4025 3472 3947 4060 4338 3748 49002Note: Al l SAS volumes for previous months June change as IDF updates are received and coding i s modi fied

4. Other





being held fortnightly to drive the project forward, stream line meeting set up and operational processes and review the outcomes of the meetings. Some observations to date include:

• Practices like the structure the process provides to identify patients who need to be reviewed • Practice team members are sometimes surprised at the patients with high HBA1c’s that they had

not recognised as not engaged or managing their health • Generally practices only identify patients to review in the preceding few days of the meeting from

recent engagements – once again this supports the process of searching for the “At Risk” patient Reablement Pilot - Locality Co-ordinators Manukau has enrolled 48 patients in total onto Reablement to date which is 58% of the total patients for the three participating localities. Referrals are slowing a bit as the winter demand settles across the hospital. Quote from Dawn on the Reablement Service 21/09/15 “I would recommend the service to other people in hospital – most definitely. I’ve had things done for me that I haven’t been able to do myself. I’ve managed to achieve my goal and that’s great. At the start I thought it would never happen – told my son to sell the car. I didn’t think I would get out there but I did the shopping on Sunday with my granddaughter.” Manurewa Community Expo Manukau Locality participated in the Manurewa Community Expo held on the 8th of October at the Manurewa South Mall. Over seventy organisations had stands at this expo, including social services, educational, environmental and health related organisations. The Manukau Locality project manager coordinated the 17 health related stands. A Healthpoint representative joined the Manukau Locality stand and supported expo attendees to identify General Practices and other health services close to their homes or work places. The theme for the Manukau Locality’s stand was health literacy and an interactive voting activity helped to engage expo visitors. Voting results indicated that the majority of the seventy three participants in the Manukau Locality stand , across all ethnicities, asked questions of their family doctor around their health problems and their prescribed medications. However, of the Maori and of Pacific participants approximately a third did not seek information on their health problems or on the medications prescribed. Discussions with participants highlighted an issue related to the cost of medications, particularly when a number of medications are prescribed. Service Planning and Hub Development The Sapere Manukau Locality Service Framework report has been presented to the Locality Leadership Group and a draft Community Hub Briefing Paper was presented by Marianne Scott, Master Planner for Counties Manukau Health. The Leadership group has supported the need to commence engagement with the three practice cluster groups within the locality for their views and input into:

• Community Health Service Integration program (including Reablement, Rapid Response- Admission Avoidance, Supported Discharge and Community Central)

• Development of enhanced primary care teams • Hub development and service organisation


It has been over two years since practice teams in the locality have engaged in any service planning meetings apart from broad Counties Manukau Health At Risk Individual development meetings so this is a significant step forward for the leadership group to support this engagement.


4.10 Primary & Community Finance Report Summary Primary & Community Services had a small favourable variance to budget for September ($182k). This included a correction for Community Pharmaceutical spend, based on a corrected Pharmac forecast. While most expenditure budget variances had matching contra revenue variances there are a few highlights noted below. 15/16 financial reporting now includes the Home Healthcare and Needs Assessment Services for Older People budgets in the Locality structure and also includes Public Health Nurses within Child, Youth and Maternity portfolio. All previously included within Hospital reporting in 14/15. Localities (YTD $9k unfavourable variance) In total the Locality budget only shows a small unfavourable variance but there are concerning trends in the Home Healthcare budgets in Mangere/Otara, East and Manukau. Their year to date unfavourable variances are $47k, $39k and $45k a total of $131k and when annualised amount to full year forecast of $524k greater than budget. These variances are largely driven by what has been a busy winter with higher acuity from earlier hospital discharge, high staff illness, higher use of casual nursing staff and budgets that have little allowance for vacancy backfill. Fortunately these have been offset by underspends elsewhere within the Locality area of responsibility. Community Pharmaceuticals (YTD $211k unfavourable variance) Pharmac’s updated forecast will bring us in on Budget for the 15-16 year. An accrual error in the month has resulted in the year to date variance not being cleared. This will be corrected in October. Health of Older People (HoP) (YTD $549k favourable variance) The 14/15 trend of flat growth against an over 65 population growth of over 4% continues albeit at a slower rate. When the next surge in demand will start is unknown but the budget savings here will fund the investment now underway in the Community Health Services Integration implementation. Primary & Community – Management (YTD $107k unfavourable) Increased activity relating, in particular to the Community Health Services Integration implementation, has meant spend above budget. This was anticipated and conditional on the continued budget underspend from over 65s Home based and aged residential care costs. See Health of Older People comment above. Mental Health ($1.683m favourable variance) A typical slow start in procuring mental health services to ensure our ring fence requirement is maintained. The below budget spend is matched by a corresponding deferral on the revenue line.


CPHAC Financial Report Mth Mth Mth YTD YTD YTD

As at 30 September 2015 Actual Budget Var. Actual Budget Var.

$000 $000 $000 $000 $000 $000 Total Revenue 33,419 34,000 (581) 99,994 102,001 (2,006)

Expenditure

Primary Care Demand Driven Costs

Pharmaceuticals 8,489 8,523 34 25,781 25,569 (211) PHO/GMS/Rural Retention 7,008 6,954 (53) 21,419 20,863 (556) Other PC Demand Driven costs 748 754 6 2,253 2,261 7

ARI / DCIP / Depression / VHIU Health Targets 1,014 1,036 21 3,068 3,107 39 POAC 179 181 2 542 544 2 Regional After Hours 702 607 (95) 1,940 1,821 (119) Access to Diagnostics 100 100 0 294 300 6 Primary Care NGOs 776 929 153 2,407 2,788 380 Primary Care - Management 183 274 92 595 823 228 Primary Care - Other Services 68 73 5 230 219 (11)

Locality - Franklin 167 178 11 500 533 33 Locality - Mangere/Otara 436 441 5 1,392 1,323 (69) Locality - Eastern 215 214 (1) 608 641 33 Locality - Manukau 339 325 (14) 1,008 976 (32) Locality - General 81 89 7 250 266 17

PATHS / Warm Up Campaign 59 69 10 197 207 11

Child, Youth & Mortality - Management 214 251 37 605 753 148 Maternity Services & Review Group 39 79 40 164 238 74 Mana Kidz 196 112 (84) 588 336 (252) HVT / HPV 101 100 (1) 304 299 (5) Child, Youth & Mortality - Other Services 284 244 (39) 773 733 (40) Public Health Nurses 282 230 (51) 735 691 (44)

Maori Health 350 554 204 1,058 1,663 605 Pacific Health 174 182 7 519 545 25

Primary & Community - Management 188 190 1 676 569 (107) 20k bed day Intiatives 172 102 (70) 304 307 3 Savings Initiatives (1,039) (1,053) (14) (3,018) (3,158) (140)

HOP - LTS CHC 466 345 (120) 991 1,036 45 HOP - Home Based Support Services 1,554 1,651 96 4,715 4,952 237 HOP - Rest Home 1,680 1,784 104 5,475 5,351 (124) HOP - Private Hospital 4,149 4,276 127 12,408 12,829 421 HOP - Other Services 607 380 (227) 1,133 1,140 7 HOP - Management 53 59 6 168 177 8

Mental Health NGOs 3,912 4,490 578 11,787 13,470 1,683 Mental Health - Management 44 29 (15) 129 88 (40)

Total Expenditure 33,991 34,755 763 102,001 104,264 2,263

Net contribution (572) (755) 182 (2,007) (2,264) 257


Counties Manukau District Health Board 5.0 Resolution to Exclude the Public Resolution: That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

6.1 Integrated Services Strategy

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)]

Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S9(2)(i)]

6.2 Social Services Investment

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)]

Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S9(2)(i)]

6.3 Minutes of CPHAC meeting 30 September 2015 with public excluded

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32(a)]

Confirmation of Minutes For the reasons given in the previous meeting.

Documents

Counties Manukau District Health Board Community & Public ... · 21 Jan Feb 4 Mar 15 Apr 27 May June 8 July 19 Aug 30 Sept Oct 11 Nov 16 Dec . ... Ms Wendy Bremner X X Mr Ezekiel