Improving Our Health - The Challenge for New Zealand - Te Whai Ora : Te Wero mo Aotearoa - Ministry of Health
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Improving Our Health Te Whai Ora : Te Wero mo Aotearoa The Challenge for New Zealand
Mission Statement
To allocate resources that secure the best health and independence
for all New Zealanders.
HFA Improving Our Health 1Mihi (greetings)
Tiheewa! Mauri! Ora,
Ki nga tini aitua, nga mate huhua, mai I muri whenua,
Tika tonu atu, ki te rerenga wairua haere, haere, haere
Ki a tatou te hunga ora tena koutou
Kia kaha tonu tatou ki te hapai I nga ahuatanga
Katoa mo te iwi Maori ara nga iwi katoa o
Aotearoa na reira kia u mai.
Kia ora huihui mai ano tatou
2Foreword The Health Funding Authority has had the role since October 1998 of contracting, funding and monitoring public health services that the Government provides for the benefit of New Zealanders. From July this year the Government is introducing structural changes to the health sector that will widen the functions of the Ministry of Health to incorporate HFA functions, and establish District Health Boards. Though the planned change more appropriately reflects the Government’s vision for the health system, I feel that it is important to build on the substantial good work expert staff members within the HFA have been doing, and to acknowledge what they have achieved. I thank them for their efforts. I am pleased that this document, Improving Our Health: The Challenge For New Zealand, has been produced as an information resource for the health sector. It outlines some of the issues and the exciting and innovative initiatives in Personal Health that the HFA has undertaken, and provides valuable and enlightening funding information. The new District Health Boards, as they come on stream, will be able to build on much of the work done by the HFA. Meanwhile, I do not want to lose any of the momentum for improvement in the health arena and I look forward positively to continuing those worthwhile partnerships that exist already. Hon Annette King Minister of Health HFA Improving Our Health 3
Personal Health Almost every New Zealander has used health services purchased by the Personal Health operating group of the Health Funding Authority. General practitioners, midwives, laboratories, pharmacists, dentists, hospitals, hospices, nurse practitioners, and ambulance services are just some of the health care providers funded by Personal Health on behalf of the Crown. Personal Health is the largest of the HFA’s operating groups, responsible for about two- thirds ($3.8 billion) of the HFA budget allocated to fund public health services. It comprises: the Service Strategy Team, the Change Management Team, and Locality Teams, who manage and contract health services in 11 Locality areas around the country. Personal Health Locality Teams have had a local focus within national frameworks, based in five HFA offices: Auckland, Hamilton, Wellington, Christchurch, and Dunedin. They arrange most of the approximately 1100 health services contracts with the various health service providers. For example, the HFA has contracts and funding arrangements with doctors, independent Maori health providers, hospitals, laboratories, pharmacies and midwives. The Personal Health Service Strategy Team has developed national frameworks for purchasing public health services to guide localities and ensure the public can get the same level of health service around the country. The Locality Team has assessed community needs and the effectiveness of local services as the basis of a Locality health plan. The Personal Health Change Management Team has ensured that changes to health services worked for the health sector, that the community could see the benefits, and that national change projects were implemented in a timely manner. This document, Improving Our Health: The Challenge for New Zealand, outlines the challenge that the Personal Health operating group of the HFA accepted and what has been done during the 1999 year to improve the health of New Zealanders, within the resources available, to fulfil the Crown’s health objectives. The HFA is required to provide information to stakeholders. Here we offer a snapshot of: health issues in the four main localities, issues of major focus, progress made working with the many health providers, and important clinical issues. The work of the Personal Health group, as a high performance organisation, has made a huge and positive difference to publicly-funded health services, by promoting innovation, equity, accountability, quality and integrity, and by valuing people. David Moore General Manager, Personal Health 4
Maori Health As the Government moves to implement its change programme within the health sector, it is timely to reflect upon what the Health Funding Authority (HFA) has achieved in terms of Maori health. This document forms part of that review. Clearly, the Personal Health group has been a major contributor to a rapidly growing awareness within the sector that Maori health needs are complex and substantial. Some of the complexities include the need to carefully select providers who are well equipped to deliver effective services to Maori. The quality of working relationships between the Personal Health and Maori Health groups of the HFA has contributed significantly to sound selections of a wide variety of capable providers. Moreover, the sharing of HFA resources between the various Operating Groups of the HFA, both of human and technological natures has provided a focused perspective on Maori health issues, which has helped to identify priorities. This focus on priorities has in turn called for innovative funding agreements to be developed with providers in ways which match Government’s policies. Some of those innovations are expanded upon later in this document. Also touched upon is the growing capacity of the HFA to identify gaps in services to Maori, particularly within what are often referred to as “mainstream services”. This growing capacity will become an essential feature of organisational competence within the public sector as Government policies on eliminating disparities and Maori developments become translated into action. Consequently, the experiences learnt in the HFA’s Personal Health Group, in regard to Maori health, are experiences which can contribute to the health sector as a whole, especially for the benefit of Maori. Rob Cooper General Manager, Maori Health HFA Improving Our Health 5
In New Zealand every day...
150 babies are born
40,000 laboratory tests are analysed
6800 outpatients visit hospitals for care
460 people have surgical operations
68,000 prescriptions for medicines are filled
6Contents
Foreword 3 Clinical Issues and What We are Doing 27
Personal Health 4 Waiting Times: Patient Focused Care 27
Maori Health 5 Complex Medicine: Managing the Issue 29
The Challenge: Diabetes: Moving Forward 29
Improving Health for all New Zealanders 8
Asthma: a High Priority 30
Localities: The Face of Personal Health 11
Heart Disease: Preparing the Way 30
Auckland Locality 11
Oral Health: Focus on Youth 31
Hamilton Locality 12
Immunisations: Revamp in Action 32
Wellington Locality 14
Hepatitis B: Screening Introduced 32
South Island Locality Offices 15
Sexual and Reproductive Services:
Our Focus 17 Under the Microscope 33
Maori Health: Action Oriented Strategy 17 Oncology: Reviewing Drugs
and Radiation 33
Pacific Island Health:
Growing and Young Population 18 Palliative Care: Studied for the
First Time 34
Child Health: High Levels of Activity 19
Cervical Screening Investigation:
Rural Health: Continual Focus 19
Gisborne 34
Service Gaps: Being Addressed 20
Paediatric Speciality Services:
Working with Providers 21 Review Underway 35
Hospitals: Purchasing Strategy Personal Health Financial Information 36
and Issues 21
Primary Care: Well Advanced 21 Relationships With Communities 44
Telephone Advice: Personal Health Senior
A New Concept in New Zealand 22 Management Team 44
Pharmacy: Needs to Adapt 22 Personal Health -
External Advisory Groups and Committees 50
Laboratory Contracts: Poised to
Move Forward 23 Technical Working Groups within
Health and Hospital Services 51
Maternity: Direction Correct but
Improvements Required 23 Health - What’s Driving the Future? 56
Accident Insurance Reform:
Significant Risks 24
Quality: Transforming the Sector? 24
HFA Improving Our Health 7The Challenge:
Improving Health for all New Zealanders
The challenge to the HFA’s Personal Health group has been to improve health status within a given budget.
The challenge is complicated - we cannot affect all of the determinants of health, we cannot do everything at
once - but it has been important to us.
Accepting this challenge required a mind shift from most of the activities of a health purchaser. For instance,
in the days of the RHAs it was largely acceptable to contract for services, and manage to budget, without
feeling responsible for outcomes. Implicit in accepting this challenge is that, in a very New Zealand way,
there needed to be a fair chance for all and a need to focus resources where they would make the most
difference.
The biggest challenge is improving Maori health. Maori health is significantly under par - the table below
dramatically shows the additional burden of disease carried by Maori, compared to the non-Maori population.
Age Standardised DALY Rates for Cause Groups by Ethnicity
Non Maori Maori
Musculoskeletal
Infection
Infant peri-natal conditions
Other chronic
Endocrine
Neurosensory
Respiratory
Injury
Mental
Cancer
Cardio Vascular Disease
0.0 10.0 20.0 30.0 40.0 50.0 60.0
rate per 1,000
Note: The Disability Adjusted Life Year (DALY) is a standardised Quality Adjusted Life Year (Qaly) type measure equal to the
sum of Years Lost to Premature Mortality (YLL) and Years Lost to Disability (YLD).
8The increased mortality associated with the difference in health outcomes is demonstrated in the graph
below. This graph is for the Wellington region but is broadly indicative of the pattern nation-wide.
Proportion of Deaths Occurring at Different Ages in Wellington
Residents 1990-94, by Gender and Ethnicity
Maori Male Non Maori Male
Maori Female Non Maori Female
100%
Proportion of Deaths 1990-94
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%Adoption of health outcome targets
The fourth Labour Government introduced health outcome targets according to disease or high health
risk behaviour.
Personal Health has been implementing these measures. We accepted the targets and devolved the measures
to localities, off the back of the analytical work highlighted in the Wellington locality section, together with
appropriate, revised budget measures. Work will continue measuring management performance against
the targets.
One set of targets is shown below, with comments on the trends.
Target Indicator Target Level (year) Current Level Base Line Level Future Trend Historical Trend Comment/Trend
(year) Required
Hearing Loss
Hearing Loss - all Test failure rate at 5 percent (2000) 8.4 percent 10.5 percent (1991) -12 percent pa -4 percent pa Tracking toward
children school entry 1996/97 health but slow
Hearing Loss - Test failure rate at 5 percent (2000) 13.0 percent 14.8 percent (1991) -21 percent pa -3 percent pa Tracking toward
Maori children school entry 1996/97 health but slow
Hearing Loss - Test failure rate at 5 percent (2000) 16.1 percent 14.0 percent (1991) -25 percent pa +3 percent pa Tracking away
Pacific children school entry 1996/97 from health
One of the major findings from attempting to apply this framework as an operational environment is the
lack of timely, accurate information.
Extension of existing frameworks
Our current work has been based on existing frameworks. The following is an example of how the table can
be extended in the near future.
Possible Health Indicators and Targets
Indicators Targets
Maori Health Separate reporting by ethnicity for all indicators listed below
Reduction in:
Maori smoking rates
Maori asthma admissions
Rate of maori low birth rate babies (Localities : The Face of Personal Health
The community responsive arm of Personal Health has been organised in five locality offices (with two in
the South Island). These offices are small (15 people in Auckland and in the South Island, 12 for
Wellington and Hamilton).
They manage contracts for local needs by running the budget, managing relationships with communities
and providers, and implementing change through nationally consistent contracting frameworks. Much of
the work has been done in moving to national consistency but less has been done in local innovation.
There are notable positive exceptions, and all localities have dealt with issues in their own particular context.
Auckland Locality
Area served: Auckland, Northland
Total population: 1.2 million
Population Characteristics Less visible, but equally critical, are issues in
Northland. One example is its burgeoning need
The Auckland localities include the poor rural
for dialysis services. There are many others. Our main
Northland area and the large urban area of Auckland.
focus has been to maintain and enhance the energy
• About a quarter (129,195) of all Maori live in the previously put into Northland by working with
Auckland locality. community groups, supporting Northland Health
and seeking innovative ways of getting to the needy
• 80 percent of New Zealand’s Pacific Islands
population lives in the Auckland locality. (e.g. mobile clinics).
Poor health is not just a Maori issue, but also a Pacific
• The Auckland population is increasing at a faster
Islands one. Auckland has most of the country’s
rate than other parts of the country.
Pacific Islands peoples so most of our Pacific Islands
• South Auckland has a high deprivation rating and team is based in Auckland.
poor health status
An example of the size of the issue is immunisation.
• 72 percent of Maori in Counties Manukau live in Among two-year-olds with complete immunisation:
the highest deprivation areas (deciles 8 -10). tamariki Maori have a 45 percent immunisation rate,
• 90 percent of Pacific Islands people in Counties Pacific Islands children rate 53 percent, and 72 of
Manukau live in the highest deprivation areas other children are immunised (last available figures
(deciles 8 -10). are 1996).
Specific Locality Issues There is also considerable reshaping of hospital
services in Auckland. Auckland Healthcare is
Rapidly growing population and critical health status
constructing a new 710 acute bed tertiary facility
are the issues that most concern the Auckland locality.
and decreasing its secondary care. We are seeking
The critical situation in South Auckland has caught to expand significantly (over the next 5 - 10 years)
the attention of the public. Currently acute medical the range of secondary services delivered close to
admissions are growing at 9 percent (the national home on the North Shore and South Auckland,
average is 3 percent). Our team in Auckland has but particularly West Auckland. There is a great
been working hard on solutions for both the short deal of tension between the three hospitals over
and the long-term. We expect to implement these the timing and size of the service adjustments.
initiatives in time for this year’s winter peak. The Auckland office has been leading a significant
The longer-term solution will take three to five years. project to help this adjustment.
HFA Improving Our Health 11Service projections 15 years forward have been its primary care providers on the nationally
prepared by Personal Health to help inform consistent contract, and regular forums are held with
decisions around hospital configuration in the primary care providers to oversee development of
Auckland region. those contracts.
A major part of the Auckland locality’s work has Asian health is an emergent issue. The HFA
been to build a positive relationship with providers. contracts with Waitemata Health for Asian health
In particular, its predecessor (North Health) was support services to identify health care needs,
known for its acrimonious relationships with provide access to health information, provide
primary care providers, mostly caused by differences in-service and meet the Asian community’s
in interpretation of the North Health primary care health needs.
contract. Now, the Auckland office has almost all of
Major achievements for personal health in Auckland and Northland locality
Better provider relationships The HFA established better relationships with primary care organisations and hospitals,
greatly enhancing opportunities for increasing the role of primary care providers in
prevention and management of chronic and acute diseases.
Primary care dispute resolved Settled a long outstanding major claim from previous administration regarding ProCare’s
claim for settlements under budget share arrangements. Agreement by ProCare to
implement a programme for Pacific Islands peoples was a significant outcome of the
negotiated settlement.
Long-term contract with Agreed to a 13-year contract with Auckland Healthcare, in which the HFA guarantees a
Auckland Healthcare decreasing revenue stream and Auckland Healthcare agrees to generate positive health
or financial gains for the HFA.
Service reconfiguration Moved paediatric neurosurgical services from Auckland Hospital to Starship.
Moved dermatology from Auckland Hospital to Greenlane Hospital.
15-year service projections described.
Regional configuration process begun.
Regional Trauma Centre Auckland Hospital established as regional trauma centre
Northland Rural GP Consortium Developed to address locum coverage and Continuing Medical Education needs of
rural GPs.
Plunket services Extra funding allocated to provide WellChild facilitation and support services.
Pacific Islands health The HFA developed new child health services, and funded a mobile hearing testing
service in the Auckland.
Hamilton Locality
Area served: Waikato, Taranaki, Bay of Plenty
Total population: 678,000
Population Characteristics • Almost one-third of people aged over 65 live
on their own.
The Hamilton localities are characterised by:
• Large sparsely populated areas. • Incomes within the region are lower than
national average, indicating greater disparity
• A younger age structure than New Zealand as a
between high and low incomes
whole, and a higher proportion of Maori than
the national average. Specific Locality Issues
• Large proportions of families with young and Rural health is a key concern as 40 percent of the
school-aged children, a significant number locality’s population live in communities of less
headed by single parents. than 10,000. There is a high proportion of Maori.
12The hospital network in this locality is highly There have been substantial issues around the
efficient. Health Waikato operates a ‘hub and spoke’ nature of primary care contracts from its
provider network with its four rural facilities predecessor, Midland RHA. In reviewing and
(Thames, Tokoroa, Te Kuiti and Taumarunui) as modifying the contact relationships, we have
the spokes, and Waikato Hospital the hub. Health preserved some of the very positive aspects and
Waikato is the second largest hospital in eliminated the negative.
New Zealand and represents 10 percent of
One good aspect is the extent of capitation.
hospital funding. This hub and spoke ensures that,
Capitation provides an incentive for doctors
as far as possible, services are delivered where
to manage themselves for the benefit of
people live and all people have equitable access to
their population, rather than just collecting
specialist services.
fees for services. About 75 percent of all
Thames Hospital has been in the spotlight with calls doctors in this region are capitated. The result of
for a return to 24-hour, seven days a week surgery. capitation has been a change of practice to using
The current service is 24 hours, five days a week. nurses more and GPs less. We have continued to
The HFA does not support a return to seven days, review and enhance the quality review
as the volume of cases from Thames admitted to programmes.
Waikato over a weekend do not justify the increased
The Hamilton office leads the renegotiations of the
costs.
First Health contract. The contract is on a nationally
All hospitals in the region have made significant consistent basis. Now, any surplus from managing
progress toward reducing waiting times through pharmaceuticals can be measured, and applied to
the booking system, becoming more efficient and the purchase of health services, rather than being
reducing historical deficits. gathered as a private profit.
Major Health achievements for personal health in Hamilton locality
Essential dental care extended Meeting the needs for low-income adults over the entire region with more than 100
dentists involved.
New mobile dental service Catering for three new schools, and nearly 2000 children in the Western Bay area.
KidZNet Software development for child health information service. It is a provider-driven, joint
HFA project & due to go live in February 2000. There has been interest from South
Auckland, Wellington, Taranaki and Dunedin child health groups and IPAs wanting to
use KidZNet system.
Integrated child health pilots New Traditions is a national site and has successfully integrated primary and secondary
New Traditions - Rotorua services. It is looking at specific projects across primary and secondary services. Rotorua
has all but one GP as part of one IPA, which makes this possible.
Plunket WellChild services Moving towards one single national contract that will allow dollars to move to where
people chose to go for their WellChild. There are a significant number of new providers
introduced into this service.
Abortion services Midland women can now obtain an abortion within the region, with the extension
of the service at Waikato and Thames hospitals and a new service at Tokoroa Hospital
this year.
Pharmaceuticals Personal Health contracted 32 community pharmacies to provide greater and user-
friendlier access.
$2 million increase in oncology Allocated an additional $2 million to Health Waikato for 1572 chemotherapy treatments
and 5508 radiotherapy treatments, to meet increasing demand.
Maori Development Organisation The Midland region has two Maori development organisations - Poutiri Trust (Bay Of
Plenty) and Tui Ora (Taranaki) leading the way toward better service co-ordination,
access and quality for Maori. The Midland region also has the highest number of
independent Maori providers reflecting higher population rations of Maori and iwi/
hapu structures.
HFA Improving Our Health 13Wellington Locality
Area served: Wellington, Manawatu, Wanganui,
Hawkes Bay, Gisborne, and Wairarapa
Total population: 821,619
Population Characteristics Specific hospital service issues include:
The Wellington office serves a diverse set of • The Wellington area hospital plan for the
localities. It ranges from the urban, relatively Porirua/Kapiti Coast areas. Cabinet decisions
well-off Wellington City to rural, poor Tairawhiti. regarding accident and emergency services at
There are several populations with a high Porirua will cost an estimated extra
percentage of Maori. $500,000 annually.
The Wellington population is generally wealthier • Hospital performance: HealthCare Hawkes Bay
and healthier than the national norm. There are (financial viability because of depreciation
pockets, however, of considerable poverty and poor costs); Capital Coast Health (performance
health status. Within Hawkes Bay and Tairawhiti issues); and some small HHSs such as Wairarapa
there are particular areas that have a lower health Health (clinical viability issues).
status, due to the high proportion of Maori.
• Rural hospital service issues need resolving in
These include the East Coast (95 percent Maori)
Horowhenua, Taihape, Wairoa and Raetihi
and Wairoa (58 percent Maori). There are a large
regions.
number of rural health centres in areas with
declining populations and decreasing client • We have ensured the viability of Capital
numbers. Coast Health by contracting for higher
prices beginning next year. This was done
Specific Locality Issues
to facilitate the new hospital and help with
The Wellington locality is most advanced with the current financial situation of Capital
development of the analytical base of health Coast Health. The locality carries a $5 million
services. The locality has completed, and seeks to risk next year, which should be covered from a
consult on, a substantial review of its population’s re-allocation of money from the tertiary
health. The work is particularly comprehensive and adjuster.
takes health, and the costs of lack of health, down
The Government is scoping an integrated care
to the finest level of definition we have ever
initiative for the Porirua/Kapiti area. The initiative
achieved. We are now almost able to tell the average
is being led by the MoH.
health of a person depending on where they live.
Pacific Islands health services are being developed
We expect this work, ‘Improving our Health in
in the region and will continue to expand.
Wellington’ to be a substantial vehicle in guiding
health purchasing.
There are six hospitals in this region. If a hospital
network were devised from scratch it would
probably have the same number, but with a different
arrangement of services.
14Major achievements for personal health in Wellington locality
Models of care pilot with Wellington Focus on chronic obstructive pulmonary disease and congestive heart failure - two major
IPA and Capital Coast Health causes of acute medical admissions.
Dental health The new mobile children’s dental service for the Wellington region is to start soon.
Dental health promotion service in Wanganui, Wellington, Hawkes Bay, Tairawhiti
and the Manawatu. Contracts with a range of providers including four Iwi contracts.
An Oranga Niho contract for Maori teenagers and low income adults in the Hawkes
Bay region.
Primary Maori Health A primary medical service in the Wairarapa by a Maori provider
Te Puia Springs Transfer of health services at Te Puia Springs to the local iwi based health provider,
Ngati Porou Hauora.
Child health Provision of paediatric surgery outreach clinics.
Development of child health facilitation and support services in Wanganui.
HHS financial solvency Capital Coast Health, Good Health Wanganui and MidCentral Health are now on the
road to solvency.
Medical/surgical initiatives Contract incentives for Capital Coast Health to work more closely with primary care
organisations on the management of people with chronic diseases.
Utilisation of Wairarapa Health’s spare capacity to provide general surgery operations.
Significant reduction in waiting times for elective surgery at Hutt Valley Health and
Wairarapa Health.
An integrated sexual health service Free access to young people between the ages of 19-25 with a community services card.
in the Wellington region
South Island Locality Offices
Area served: Nelson/Marlborough, Canterbury/
Westland, Otago/Southland
Total population: 899,472
Population Characteristics it covers a large regional area. This means the
southern region faces different management
• Most rural areas are slowly losing population
problems. The region operates through two offices,
• Dunedin, Christchurch (and its commuter belt), and manages a service budget that isn’t growing as
Nelson/Marlborough and the Wakatipu basin fast as that of other offices.
are growing. The West Coast is neither
increasing nor decreasing. There are substantial viability issues around rural
hospitals. HHSs have signalled their wish to exit
• Small rural population is scattered over vast from at least two, possibly six, rural hospitals.
territory meaning access problems. The long-term viability of the newly established
• Low Maori and Pacific Islands population. Central Otago Community Trust is an issue, as is
the availability of some GP services in rural areas.
• Lower health status in inner cities and poor
West Coast, Nelson /Marlborough, Queenstown
suburbs, the West Coast (especially Buller),
Lakes and Invercargill areas have economic scale
and in some small rural towns.
problems because of their rural nature and small
• There are more elderly in the South Island than populations.
other localities.
An ageing population also poses challenges.
Specific Locality Issues
There is increasing pressure to fund palliative care
The South Island locality is characterised by services more fully, reflecting a nation-wide trend.
declining population, other than Christchurch, but Further, there is growing pressure on the cost and
HFA Improving Our Health 15volume of community service, as more people leave Otago and Southern Health ($1.3 million and
hospital earlier and with more complex problems. $3 million).
In addition, acute medical volumes continue to Christchurch is emerging as the major tertiary
grow faster than population, especially in institution. Clinical viability of specific medical and
Christchurch, particularly in respiratory, cardiology surgical services (e.g. neurosurgery at Healthcare
and general medical. Otago, ophthalmology at Southern Health) is an
The South Island has been wrestling with issue, largely because of retention and recruitment
a significant budget problem. Personal Health of clinical staff in this area.
has a significant shortfall on purchasing Waiting times in surgical services are still high in
emergency department attendances at Healthcare some specialities.
Major achievements for personal health in the South Island locality
Pegasus contract An innovative contract including a project to manage acute demand growth.
Community trust contracts Put in place with new community trusts in the Waitaki, Central Otago, Gore and Balclutha
areas, following the withdrawal of service provision by Healthcare Otago and Southern
Health.
Emergency ambulance service A three-year emergency ambulance contract with the Order of St John close to finalisation,
for whole South Island including delivery of the primary response in a medical emergency (PRIME) scheme to
assist in provision of emergency services in geographically remote areas.
New community hospice Established by the Nelson Hospice Trust with the co-operation of Nelson Marlborough
Health.
Director of Rural Health Dr Pat Farry was appointed to this post earlier this year.
Innovative support packages for The HFA has worked with district councils, health trusts and centres to locate new GPs,
rural health centres build a locum database and provide support packages and retain general medical and
nurse practitioners.
Pacific Islands health service Additional child health funding was taken up by a new organisation, expanding services
for the Pacific Islands community in Christchurch.
Integrated care project - The HFA is working with Marlborough Health Trust, the Nelson Marlborough Health
Marlborough Services and the community on various projects to improve health services in the area.
Health action plans The HFA is working with South Link Health on developing diabetes and cardiovascular
disease plans.
16Our Focus
Maori Health: Action Oriented way we fund and support preventative health
Strategy education (with the Public Health group);
the funding of primary care (GP services,
Issues pharmaceuticals, nursing services, sexual health,
Disparities in health status are a major concern and WellChild services); and the access and treatment
our focus is evident in the work being done in of Maori in secondary care. We are seeking to
Maori health. We have been focusing on identified increase Maori access to secondary care to ensure
geographical areas (such as larger Maori populations necessary treatment in some areas (complex
with lower socio-economic status) and on particular diabetes treatment, cardiac surgery) but in others
service areas where Maori have poorer health. we are aiming to reduce hospitalisation (acute
admissions for asthma).
The total Maori population is 523,365 (nearly 15
percent of the population). Some localities are Personal Health’s Action
densely populated by Maori where health status is
All the plans developed integrate cultural factors
particularly poor - notably Wairoa, South Auckland,
that improve access, equity, effectiveness and
East Coast, Hutt Valley, Northland, Bay of Plenty.
ultimately health outcome. Examples of these
Many of these areas also have significant rural
include:
health issues. Funding plans for these localities
emphasise the higher numbers of Maori, who often Preventative Programmes
have greater need for more appropriate services in
• Supporting smokefree and smoking cessation
a diversity of settings - marae, Maori health clinics,
initiatives (which impact on cancer, respiratory
mobile services. Often the diversity of providers
conditions, diabetes, heart disease, child health
needs to be greater to promote choice and access
and life expectancy).
so in these areas we have worked hard to ensure
the number of Maori providers is greater. • Increasing funding to Maori providers to
provide education in nutrition, exercise, oral
Our funding plan gives full regard to HFA Maori
health, smoking cessation.
health policy of:
• Greater Maori participation at all levels of the • Ensuring programmes have implicit Maori
health sector health gain targets, such as the programmes for
Hepatitis B, breast screening, cervical screening,
• Mainstream enhancement
and diabetes.
• Maori Provider development
• Integrating health and education services with
Our projects place a heavy emphasis on Maori clinically based services.
health gain and in particular the eight key priority
Primary Care Programmes
areas identified and endorsed by the HFA Board.
The key priority targets relevant to Personal Health • Integrating the role of Maori providers.
are: immunisation, diabetes, oral health, hearing
• Development of funding formulae which
and asthma. The choice of diabetes, asthma and
incorporate a measure of deprivation and
oral health for disease management programmes
ethnicity considerations.
was driven by these key priorities. Plans for
improvement in hearing and immunisation for • Promoting better integration between IPAs,
Maori are being driven through the child health HHSs and Maori provider organisations,
strategy. e.g. the Auckland Healthcare/Ngati Whatua
joint venture for Hepatitis B screening
We are acutely aware any plans for improving Maori
health status must address the continuum of care - • Supporting workforce development to train
preventative programmes and improving access to Maori in key areas (child health, nurse
primary and secondary care. This impacts on the educators).
HFA Improving Our Health 17Secondary Care Programmes critical component of our methodologies in the
process of shaping future-funding models.
• Ensuring Maori need is identified in an
equitable way through Access Criteria for
surgery (Booking Systems project). Pacific Island Health: Growing
• Identifying Maori utilisation of secondary care and Young Population
services and comparing this to prevalence of
Issues
disease in the population.
The estimated population of 227,000 (6 percent of
• Paying a Maori Health Adjuster to hospitals to
3.8 million) is young and diverse with a projected
provide an incentive to improve service delivery
growth to 600,000 (12 percent of 4.8 million)
to Maori, and contracting for quality measures
by 2051. It comprises Samoan (50 percent),
with explicit Maori health requirements.
Cook Islands (22.5 percent), Tongan (15.5
Improving Access to Services percent), Niuean (9.0 percent), Fijian (2.0 percent)
and Tokelau (1.0 percent). Some 58 percent of
• Family Start programme targeting Maori in key
Pacific Islands resident in New Zealand in 1996
localities.
were born in New Zealand. Some 80 percent of Pacific
• Maintaining the important role of Maori Islands people live in cities, mainly Auckland.
Community Health Workers and Support
Pacific Islands people often have lower health status
Workers in health care provision and advocacy
than Maori with different behavioural patterns from
for Maori whanau.
the mainstream population, requiring a different
• Ensuring Maori needs are met through approach. The four member HFA Pacific Islands
telephone helplines (Healthline, Plunketline, health team is based in Auckland and Wellington.
Maternity Helpline).
The socio-economic status of Pacific Islands people
• Improving the way information is disseminated is low. The strategy ‘For Pacific by Pacific’ is based
to Maori. on these facts and the priority areas are: child and
Monitoring Service youth, maternity, primary care, and medium to
long-term preventative health.
• Identifying and monitoring resource allocation
for Maori. Personal Health’s Action
• Evaluating quality audit programmes measuring • In the past year new child services targeting
the effectiveness of services for Maori. Pacific Islands children have been purchased
In 1999/2000 Personal Health is reviewing in Auckland, Wellington, Christchurch and
maternity and child health services. Hastings. A mobile hearing testing service in
Auckland (targeting Pacific Islands children)
• Collecting ethnicity data to support analysis for
has been bought from the National Audiology
decision making and resource allocation. This
Centre and has been operational since July
is a significant area for development through
1999. Child health and primary care services
primary care, child health, immunisation and
have been bought in Newtown (Wellington)
disease management projects. Currently we are
and the Hutt. Provider organisations have been
able to report ethnicity specific information for
established in Christchurch, Hastings and
most hospital services but the error rates (Maori
Hamilton.
recorded as non-Maori) in the figures produced
can be as high as 50 percent in some hospitals. • Joint ventures between Maori and Pacific
Islands providers for services targeting children
• Feedback and participation of Maori (at the
have been entered into in west and south
levels of governance, provider and consumer)
Auckland, Porirua and the Hutt.
in projects provides direct evidence of service
effectiveness. This will produce better • Multiple initiatives are aimed to produce benefit
outcomes for Maori. Involvement of Maori for the large numbers of Pacific Islands people
(both internal and external to the HFA) is a in South Auckland.
18Child Health: High Levels of Family Health Initiatives
Activity Strengthening Families is a joint initiative to
Issues improve outcomes for children and young people
at high risk. There are three programmes: Family
New Zealand has one million children aged 14 or Start, Local Co-ordination and Preventative
younger, with 57,000 babies born annually. Initiatives.
Disparities of health outcome for Maori and Pacific
Islands children are well documented. The Child • Personal Health is meeting regularly with
Health Strategy (1998) and Strengthening Families health, education and social services policy staff
Strategy provide the basis to address disparities and to ensure effective national implementation.
improve all children’s health. • Personal Health is the lead purchaser on a
number of programmes. Four further
Personal Health’s Action programmes have been put in place by Personal
Child Health Information System Health.
• In some areas there has been resistance to local
Quantitative information on children’s health is not
co-ordination programmes. Personal Health is
available in any easily retrievable form.
developing strategies accordingly.
• Personal Health has been developing the Child
Health Information Strategy (CHIS) which will
Rural Health: Continual Focus
be implemented progressively. Some aspects
have already begun, such as the perinatal Issues
information system and immunisation coverage
Retention and recruitment of doctors in rural areas
(using HBL data)
is one of the most significant problems facing the
• The KidZNet pilot is underway, involving health sector. Rural communities, particularly
information transfer between providers. small ones, have difficulty attracting and retaining
This will govern the way a national information health services. They can often support only one
system is established. National consistency will doctor who is constantly on call, isolated and has
be ensured during implementation between difficulty finding locums. The doctor-to-patient
providers and a range of systems. ratio in rural areas is lower than that of other areas.
On-going professional development is critical for
WellChild and Youth Service the safety of practice and to overcome professional
isolation.
The key issues for WellChild are access and
coverage. Rural communities have specific needs which must
be taken into account: the disparity of health status
• A technical advisory group of clinicians,
of Maori; lower socio-economic groups; people
providers, and Personal Health is considering
with disabilities who require assistance; children
future directions for WellChild services,
and older adults; and the high injury rate.
including the possible linkage of funding
Access to services by Maori is a particular concern.
mechanisms for WellChild and immunisation
For non-Maori, the rural health status measures
services.
compare favourably with urban.
• Integrated child health service approaches
(facilitating co-ordination and information Personal Health’s Action
sharing between providers) have been We have developed initiatives over the past year to
developed in West Auckland, Rotorua, address these problems. These include:
Hamilton and Christchurch.
• Improving the retention of health professionals
• The development of a youth strategy focusing through the change from the rural bonus to the
on sexual and reproductive health will rural ranking scheme; expansion of the Centre
commence in 2000. for Rural Health to a national role and the
HFA Improving Our Health 19funding for Rural Directors. In the North Island Medical Surgery- elective
there is a specific requirement to forge links and
Funding required to sustain level of elective surgery.
work to improve the health of Maori.
Palliative Care
• Developing appropriate skills and knowledge
Fully funding hospices.
among rural professionals to improve Maori
health disparities, through modification and Laboratories
review of existing contracts. Ensuring consistent pricing of outpatient
• Introducing the PRIME (Primary Response in laboratories across New Zealand.
a Medical Emergency) programme in the North Maternity and Neo-natal
Island to improve access to treatment in rural
Infertility services (including diagnostics).
medical emergencies. This has involved funder
collaboration (HFA and ACC) as well as Oral Health
provider (ambulance services, GPs and nurses) Dental services for low income adults. Increase in
collaboration. utilisation for children and adolescents. Dental
• Encouragement and support of rural education and examinations for pregnant women
practitioners to develop networks and multi- and mothers of pre-schoolers in at risk areas.
disciplinary teams to maximise the benefits of Dental Brush-ins for pre-schoolers in at risk areas.
the available resource. Regional Inconsistency
Regional inconsistencies also need addressing.
Service Gaps: Being Addressed Auckland funds sexual abuse services, Wellington
does not. Auckland provides good access to
Issues
infertility services, but they are poor elsewhere.
The budget bidding process, carried out in Community referred radiology is restricted to
November, highlighted (to a greater level of detail) Community Service Card holders in Wellington
service gaps. Identifying these gaps and identifying and the Hutt Valley. Insulin pumps are funded in
a way to meet the needs of our people is a key some areas only. Some areas have no hospices, for
challenge for Personal Health. Sometimes not example the Midland region. Emergency dental
meeting needs means waste and inefficiency as services are not available in Hawkes Bay or the
more is spent treating later. Often it means lost Hutt Valley.
quality and quantity of life.
Personal Health’s action
The gaps that we have identified include: • We are prioritising what we can do with the
Immunisation of Maori and Pacific Islands Children available money. For instance, we are moving
very quickly on some key immunisation issues
Only 45 percent are currently immunised and it (discussed below).
will require a 55 percent increase in funding to
• Medical surgery is being prioritised to those
target the hard to reach. Existing contracts are not
most in need, who can benefit from the surgery.
meeting demand.
• Clinical and service reviews are revealing some
Medical Surgery areas where substantial changes mean we can
Increased funding is required for emergency deliver more, for less money (eg. the developing
departments to reduce waiting times to acceptable dental strategy). Many of these issues are
levels. Increased oncology volumes has led to discussed further under clinical management.
increased vascular surgery requirements. Radiology • We continue to identify gaps by mapping our
volumes need increasing. There is a shortfall in service coverage document against locality
oncology radiation therapy. Renal and urology contacts, by service reviews and by locality
inpatient services need additional resources. needs assessment.
20Working with Providers
Hospitals: Purchasing Strategy book that has prices for different types of operations
and Issues described in a standard unit (called a cost weight).
Important adjustments to the standard cost weight
Issues are payments for complexity (e.g. Starship) and
One of the biggest areas of our work ($3.2 billion payments for rurality (e.g. Wairarapa hospital).
from all operating groups) is shaping relationships The sector faces important, unresolved questions:
with hospitals. The services provided are complex,
• Prices should be higher for mental health, lower
significant and one of the traditional areas of service
for personal health?
provision. The institutions are well resourced,
complex and in considerably better order than a • Capital costs should be included, but how?
few years ago. • A price path should be paid, but at what level?
Before Personal Health was established, the A significant further issue is the growth in acute
relationship between purchaser and provider was medical volumes, an issue that needs to be resolved
acrimonious, time consuming and negative. by primary care, but working in partnership with
More recently issues about hospital purchasing hospitals.
strategy and issues have been debated and analysed
in joint technical working groups before being Primary Care: Well Advanced
escalated for policy decision making.
Issues
Personal Health’s Action
This is the public’s first point of contact with the
We have implemented ‘relationship contracting’. health sector. The current delivery of care is based
Both the HFA and hospitals explicitly recognise our on an episodic approach responding to patient
interests are indelibly linked and are working demands. There is an increasing demand on
together to achieve the wider goal of benefit to services, which have historically grown at 5 - 10
patients. We try to put our differences in a strategic percent annually, without demonstrable health
contracting context, although there is significant gain. Technological advances, ageing population
tension for hospitals and purchaser to achieve their and shorter hospital stays are increasingly requiring
respective goals. a greater level of care.
In operational terms that means: Primary care expenditure is $1.26 billion. Much of
• Evergreen contracts (lasting forever) versus this is indirect spending through referred services.
annual negotiations. In the current financial year Personal Health is
forecast to spend $631 million on pharmaceuticals,
• Continuous improvement of services (instead
$251 million on General Practice subsidies
of once-off, forced changes).
(including practice nurses), $178 million on
• Commitment to joint problem resolution and laboratory tests, $20 million on primary care
strategic planning. organisation services, and $10.6 million on
Some hospitals have found it easy to work in this immunisation.
environment. Others haven’t. Those that haven’t There is a lack of co-ordinated and monitored care
are often under considerable pressures, such as between providers - between hospital and primary
substantial capital investment programmes, care and between different primary care
which bring them up against ownership interests. providers. Good information is a key to addressing
In short, the sector is still learning to work in a this issue.
co-operative way.
The HFA has agreement from the sector on
The most controversial element is about money, as specifications for shared information. We regard
always. Hospitals are paid from a national price this as a major accomplishment.
HFA Improving Our Health 21Privacy issues are significant. We plan to consult Telephone Advice: A New Concept
with the public on the increased use of National in New Zealand
Health Indicator (NHI) on health data and
appropriate processes to ensure privacy legislative Issues
obligations are met. The consultation is made up Telephone triage is a relatively new concept built
of three parts: 1) introducing NHI numbers onto on the system introduced by the United Kingdom
all claims; 2) explaining to the public the purpose Labour Government to the National Health Service
and use of ‘individual data’ (and in specific purposes (NHS). Telephone triage services assess the
when the HFA will have access to ‘identified’ data); urgency of callers’ health problems and advise
3) the proposed processes to be used for the which service they should contact (such as
collection, storage and access of confidential patient ambulance, emergency department, GP, or self-
information. care) plus the appropriate timeframe within which
Personal Health’s Action this should be done. The intention is to reduce cost,
by treating the matter over the telephone, and to
Our gains in this area are well beyond what we
reduce morbidity by getting those in need to GPs
believed possible.
or emergency services faster.
• Relationships with the sector have improved
Patients are connected to the appropriate service
over the past year with the new focus on
and, with the patient’s agreement, can have the
co-operation and openness. Almost all GPs in
information collected during the call forwarded.
primary care organisations have moved to the
The assessment and advice process are supported
new national contract.
by a computer-based system designed to identify
• The new national contracts provide for a the cause of the complaint that is riskiest for the
consistent information schedule, passive patient (rather than the most common or most
enrolment moving to active enrolment, cross- likely cause).
matching of registers and Maori quality
Personal Health’s Action
standards (in other words, all the infrastructure
to move to population based primary care). The provider of New Zealand’s telephone triage
system, Healthline, is a partnership of High
• Contracts with IPAs include action plans for
Performance Healthcare (HPH) and Access Health.
additional services, particularly for Maori.
St John’s Ambulance is also part of the group. HPH
These will address areas of high health need or
is based in Australia and Access Health provides
deliver important health outcomes.
nurse telephone triage services as part of NHS
• Establishment of a joint working party to Direct in England. Between them they have
analyse issues relating to capitation. substantial experience at providing this kind of
• A range of integration projects - Personal Health service.
has some 20 projects running with greater or Healthline will provide a telephone triage service
lesser degrees of integration. to 650,000 people in four identified pilot areas
We are consolidating on moves to greater national (Northland, Gisborne/East Cape, Canterbury and
consistency: West Coast/Buller).
• Electronic claiming - by July 2000. Pharmacy: Needs to Adapt
• Internal Systems - making sure we can monitor Issues
and implement contract requirements.
The current regulatory environment is outdated.
• NHI Implementation - for all claims, including
Pharmacists no longer produce medicines and are
ethnicity on General Medical Subsidy (GMS)
largely reduced to dispensing pre-packaged
and immunisation.
product. The current system is costly for both
A key issue is consultation on privacy of pharmacists and us. Pharmacists are strongly
information issues. A work-stream is established unionised by the Pharmacy Guild, which continues to
and we are ready to discuss the issue. promote the small business owner aspect of pharmacy.
22Contracts are currently provider-focused with poor Personal Health’s Action
links to health gain. The technical skills of
• Developed and implementing strategies to
pharmacists are under-utilised.
manage demand, driven by contracting with
Personal Health’s Action primary care organisations and tendering for
supply of a best practice advisory service.
• We have significantly cleared the backlog of
contractual issues, including settlement of • Consultation on comprehensive supply side
outstanding maximum dispensing queries and strategies is complete and is waiting on the new
the southern pharmacy contract price pool Government before proceeding. As part of that
reviews for 1998/99, 1999/2000 and 2000/01. strategy, we are working towards opening the
market to competition from HHS laboratories.
• We have driven improvements in HBL payment
processes, and are close to implementing • There is no single answer - each case will need
electronic claiming. a tailored solution.
• We are working with the sector to identify roles
for pharmacy to make use of their clinical skills Maternity: Direction Correct but
in patient medicine management.
Improvements Required
• We have linked development of a pharmacy
strategy with developments in integrated care The National Health Committee’s maternity
and primary care strategies. services review this year aimed ‘to consolidate,
refine and render consistent what is already a
workable and potentially equitable structure’.
Laboratory Contracts: Poised to The recommendations made by the NHC did not
Move Forward reverse the existing maternity framework.
Issues Issues
The HFA has consulted on strategies aimed at The major issue is poor relationships between
managing expenditure on laboratory tests. The providers. Access is also an issue - some women
reasons for wanting to introduce change include: have difficulty accessing unbiased information on
maternity services. Emergency specialist services
• Lack of evidence that prices are at the correct for women in rural areas also need to be addressed.
level and some evidence that they are too high. The HFA has concerns about poor performance by
• Lack of competition in the community some Leader Maternity Careers (LMC) and some
laboratory sector over price. Sonic Healthcare, hospitals.
an Australian company, now owns 65-70
Personal Health’s Action
percent of the New Zealand community
laboratory sector. • We are exploring the development of regional
primary maternity networks to provide
• Regional discrepancies in availability of tests
information to patients and manage
and standard contract terms and conditions,
relationships with other providers.
including quality requirements.
• Increasing utilisation at a higher level than the • We are finalising referral guidelines for specialist
increase in health funding. Expenditure has services
increased from $116 million (1993/94) to • We have established a maternity ‘Roadside to
$172.5 million (99/00). Bedside’ focus group, and are addressing
• A desire by hospital laboratories to enter the emergency services for rural women
community laboratory business.
• We are finalising a comprehensive audit
Developing a strategy has not been easy. None of programme that complements the LMC audit
the RHAs managed. We have, and we are poised to programme and the cultural audit currently
implement it. being conducted on all hospitals.
HFA Improving Our Health 23Accident Insurance Reform: actual volumes is improved. Another priority is
Significant Risks improving the transparency of information on the
cost/volumes of accident-related treatment to
Issues enable informed decision making on future funding
The Accident Insurance Act has required us to of acute accident treatment.
identify costs to insurers of accident services. We are improving the information on accident
The reform has several significant risks, all of which volumes/costs for the calculation of the public
get carried by Personal Health: health acute services levy through:
• Risks of providers shifting accident costs from • Surveying compliance costs to assess the
ACC to the HFA due to higher compliance costs additional compliance costs imposed on
associated with lodging claims with ACC. hospitals and assessing funding options.
• Comparability of the levy paid by ACC ($221 • Monthly communication with hospitals to
million, 1999/00) and the actual costs of ensure information in implementing the new
delivering accident-related public health acute regime.
services.
• Analysis of hospitals’ routine reporting to
• Poor quality of information collected and calculate the Public Health Acute Services Levy
managed by hospitals to inform the purchase for 2000/01.
of accident related services.
We endorse the direct purchase by an accident Quality: Transforming the Sector?
insurer of primary based services, except for Issue
pharmacy and laboratory. The Crown currently
A focus on the quality of provision of health services
has exemption under the Commerce Act for fixing
has become a feature of health systems
pharmaceutical and laboratory prices. The Crown
internationally. A culture of quality and self-
gains negotiating leverage by including those
improvement is rapidly being established.
volumes related to accidents.
Some argue that the health sector is the sector
Future options for funding accident-related where up-to-date ideas about quality management
treatment must take into account the following have gained least traction. Partly, this is because of
issues: the sector’s reliance on management by medical
• Transaction costs for providers and funders colleges.
increase in direct relation to the number of
There are very major issues in quality improvement.
purchasers and purchasing frameworks.
Those issues include: the setting of standards for
• Hospital information management systems are all providers; continuous quality improvement;
in transition from bulk purchasing (which did provider self-improvement programmes; and
not require detailed information on the tracking credentialling of providers.
of individual patient costs). Changes putting
pressure on hospital information systems must The future thinking quality programmes under
be managed with the sector, giving clear signals development internationally, and being kick-started
on information needs. in Personal Health, are evidence-based health
indicators and monitoring programmes. The belief
• The public is confused about their entitlements,
is the development of these clinical indicator
particularly the variation between accidents and
frameworks will provide territory for radical
illnesses. Changes varying the criteria and
transformation of clinical services in the future.
access to publicly funded services must be
clearly communicated. Personal Health’s Action
Personal Health’s Action Our key objectives during the past year have been:
We are working to improve the tagging of accident- • Development of initiatives to respond to major
related scripts and tests to ensure information on quality and safety issues which will arise, with
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