NMDHB Annual Plan 2013/2014 by Nelson Marlborough District Health Board

2013/14 NMDHB ANNUAL PLAN WITH STATEMENT OF INTENT

July 2013

Contents MODULE 1: INTRODUCTION.................................................................................................... 1 MODULE 2: STRATEGIC DIRECTION ........................................................................................ 4 2.1

STRATEGIC DIRECTION .......................................................................................................................... 4

MODULE 3: ACTIONS TO ACHIEVE OUR OUTCOMES ............................................................... 10 3.1

NMDHB’S ANNUAL PLAN AND STATEMENT OF INTENT - 2013/14 PRIORITIES AND TARGETS .................. 10

3.2

PRIORITIES AND TARGETS: Policy and Service priorities and related targets – Government expectations.. 17

MODULE 4: STEWARDSHIP .................................................................................................. 36 4.1

MANAGING OUR BUSINESS................................................................................................................... 36 4.1.1 Leadership Capability............................................................................................................... 36 4.1.2 Clinical Leadership Capability ................................................................................................. 36 4.1.3 National Collaboration .............................................................................................................. 36 4.1.4 DHB Shared Services .............................................................................................................. 36 4.1.5 Regional Collaboration ............................................................................................................. 36 4.1.6 Cross-sectoral ........................................................................................................................... 36 4.1.7 Strategy and Planning Function .............................................................................................. 37

4.2

STRENGTHENING OUR WORKFORCE .................................................................................................... 37 4.2.1 Workforce Development and Organisational Health Capability ............................................ 37 4.2.2 Building Culture and Relationships Capability........................................................................ 37 4.2.3 2013/14 Workforce Improvements .......................................................................................... 38 4.2.4 Capability................................................................................................................................... 38

4.3

2013/14 REPORTING AND MONITORING FRAMEWORK ........................................................................... 39

4.4

INFORMATION SERVICES ...................................................................................................................... 39

4.5

FACILITIES AND EQUIPMENT ................................................................................................................ 39

4.6

QUALITY AND SAFETY .......................................................................................................................... 39

4.7

SUBSIDIARIES, OTHER INTERESTS OR COOPERATIVE ARRANGEMENTS ............................................... 40

4.8

STEWARDSHIP ROLE (OWNER OF CROWN ASSETS).............................................................................. 40

MODULE 5: FORECAST SERVICE PERFORMANCE................................................................... 42 5.1

MEASURING OUR PERFORMANCE ........................................................................................................ 42

5.2

OUTPUT CLASS: PREVENTION SERVICES ............................................................................................. 45 5.2.1 Outcomes Measures Long-term (5-10 years) ........................................................................ 46 5.2.2 Outputs and Performance Measures 2013/14 ....................................................................... 48

5.3

OUTPUT CLASS: EARLY DETECTION AND MANAGEMENT SERVICES ..................................................... 50 5.3.1 Impact Measures medium term (3 to 5 years) ........................................................................ 51 5.3.2 Outputs and Performance Measures 2013/14 ....................................................................... 52

5.4

OUTPUT CLASS: INTENSIVE ASSESSMENT AND TREATMENT SERVICES ............................................... 56 5.4.1 Outcomes Measures Long term (5-10 years)......................................................................... 57

5.4.2 5.5

Outputs and Performance Measures 2013/14 ....................................................................... 59

OUTPUT CLASS: REHABILITATION AND SUPPORT SERVICES ................................................................ 62 5.5.1 Outcomes Measures Long term (5-10 years)......................................................................... 63 5.5.2 Outputs and Performance Measures 2013/14 ....................................................................... 66

MODULE 6: SERVICE CONFIGURATION .................................................................................. 68 6.1

NMDHB STRATEGIC DIRECTION ............................................................................................................ 68

MODULE 7: FINANCIAL PERFORMANCE................................................................................. 69 7.1

Financial Performance ........................................................................................................................... 69

MODULE 8: PERFORMANCE MEASURES ................................................................................ 76 APPENDIX 1:

MONITORING FRAMEWORK PERFORMANCE MEASURES..................................................... 76

APPENDIX 2:

NMDHB ACCOUNTING POLICIES ......................................................................................... 81

APPENDIX 3:

GLOSSARY OF ACRONYMS, ABBREVIATIONS AND MAORI TRANSLATION ........................... 90

APPENDIX 4:

DEFINITIONS ...................................................................................................................... 96

APPENDIX 5:

SOUTH ISLAND ALLIANCE ................................................................................................ 100

MODULE 1: INTRODUCTION

The Nelson Marlborough District Health Board is one of 20 District Health Boards (DHBs) established on 01 January 2001 under the New Zealand Health and Disability Act 2000 amended in 2010 (the NZPHD Act). Each DHB is accountable to the Minister of Health under the NZPHD Act. Under the NZPHD Act each DHB is responsible for the health outcomes and services provided of a geographically defined community. DHBs were established to ensure that public funding made available through Government through an allocation under Vote: Health is utilised to achieve the most health benefit for the population of Nelson, Tasman and Marlborough. The NZPHD Act also requires us to assure access to high quality (including safe) health and support services, to promote the participation and independence of people with disabilities, to deliver equitable outcomes to Maori and disadvantaged people, and to do all of this within the funding provided by Government. Each DHB is also categorised as a Crown Agent under the Crown Entities Act 2004 and is accountable under this Act to both the Minister of Health and the Minister of Finance. This Annual Plan (including the Statement of Intent) [AP] has been prepared to meet the Minister of Health‘s expectations for DHBs as well as the requirements of sections 39 (8) and 42 of the NZPHD Act, section 139 (10 of the Crown Entities Act and the requirements of the Public Finance Act 1989 amended 2004. This AP sets out NMDHB‘s strategic direction, our aligned objectives and goals towards improving the health of the NMDHB population as well as positively influencing the health of the South Island Population. It also provides what we intend to do and deliver for the 2013/14 year and clarity of purpose (‗clear line of sight‘) between the funding provided to us by Government and the allocation of those funds to support optimal outcomes for the Nelson, Tasman and Marlborough population. It affirms our commitment as a partner in our operational alliances to deliver optimal utilisation of all our resources while increasing our productivity and our efficiency. To do this requires us to actively engage clinical leadership. We outline our support to improve the health of the Te Tau Ihau Maori population through the Maori Health Plan included in this AP. This AP outlines what we intend to do how we are organised to deliver high quality and safe services for our population that are sustainable both clinically and financially. The relevant modules of the AP are extracted to form a stand-alone Statement of Intent which is presented separately to Parliament. At the end of the 2014 financial year, the forecast service performance module of the Statement of Intent is used to compare planned with actual performance with results audited by Audit New Zealand who work on behalf of the Office of the Auditor General and reported publicly in NMDHB‘s Annual Report. We affirm our intention to deliver on Budget 2013 initiatives. The Minister of Health has been clear in setting his annual expectations for 2013/14. Progressing ‗Better, Sooner, More Convenient‘ health and support services through clinical and services integration while ensuring faster access to a range of services (shorter waits in Emergency Departments, shorter waits for cancer services, faster access to elective surgery) and working to prevent the development and progression of long term conditions (help to quit smoking), as well as episodes of illness and injury (increasing immunisation, access to primary care led services). Working together regionally and locally through strong joined-up partnerships and alliances is a key theme in this AP. To do this requires us to ‗live within our means‘ by working to reduce the need and reliance on hospitalisation, supporting our clinical workforce in delivering higher quality, safe care through improvements in process and use of information that enables better care, transfer of expertise ‗closer to home‘ and ensuring a better experience of care by people who access it. In signing this Annual Plan and Statement of Intent 2013/14, we are satisfied that it represents the intentions and objectives of the Nelson Marlborough District Health Board for the period of 01 July 2013 to 30 June 2014.

1.2 1.2.1

EXECUTIVE SUMMARY Background information and operating environment 1

The Nelson Marlborough District Health Board (NMDHB) under our Chief Executive and Board have every intention to fund, deliver and provide healthcare and support care services that address the ongoing health and support needs of the Nelson, Tasman and Marlborough populations within the funding provided by the taxpayer2. In September of 2012 the Board endorsed our overarching strategy for the ‗Top of the South‘ known as HEALTH 2030 3. This Annual Plan and Statement of Intent 2013/14 progresses the implementation of the HEALTH 2030 Strategy Action Plan. It lays out what we intend to do locally, regionally and nationally and how we expect our established partnerships both locally and regionally to work with us to support this work. It also demonstrates progress on our obligations under the Treaty of Waitangi. In early 2013, NMDHB undertook a major review of ‗Top of the South‘ services based on ‗best for patient, best for system‘ with the key principle being ‗one service two sites‘ particularly for hospital services. This aligns to our strategic direction as set out in HEALTH 2030 This Annual Plan 2013/14 (AP) signals the implementation of the agreed recommendations from this review to ensure high quality and safe services are consistently and sustainably accessed and delivered to patients according to need. This is one of the key initiatives outlined in this AP. This AP also sets out our commitment to achieve success with the re-focused Nelson Marlborough Health Alliance (NMHA). While this commitment is underpinned by the new Primary Health Organisation (PHO) Service Agreement, the key issue is that NMDHB, Kimi Hauora Wairau Marlborough PHO (KHW MPHO) and Nelson Bays Primary Health (NBPH) have entered into a formal Alliance Agreement to collectively share and deliver a range of health and support care services for our population. This is through getting more value for public funds in terms of the effective use of resources to achieve desired outcomes. We are already working collaboratively across settings of care to ensure better quality, safety, equity of access, effectiveness, acceptance and experience of care and services which should deliver on ‗the New Zealand Triple Aim‘ 4. This ‗gain share-pain share‘ relationship is critical to enabling us to progress a community and primary health care environment that addresses the Minister of Health‘s expectations, National Health Targets and each of our three Boards‘ goals and objectives. At the start of the 2013/14 year, NMDHB finds itself under Intensive Monitoring by the National Health Board. This has focused us on our sustainability, productivity and overall performance 5. It translates into an imperative to improve our ‗health‘6 to enable us to positively influence the Nelson Marlborough Health System7 (NMHS). High achievements in performance can only be delivered by a ‗healthy‘ organisation. Health today drives performance tomorrow and enables us to live within our means sustainably. The NMDHB Board through the Chief Executive ensures overall clarity of purpose and accountability to Government to do what we say we will do—to positively transform our organisation‘s performance not only in the short term but also in the longer term. NMDHB is clear on the need to meet the challenges of 2013/14 proactively. Our population is structurally the oldest in New Zealand. Due to the lovely environment in the ‗Top of the South‘ we have had a significant increase in older people migrating here to live. We have fewer young adults but recently experienced an increase in numbers in the 45 to 65 age group. We also employ one of the oldest health and support workforces and we have a Nelson Marlborough Health System (NMHS) that is distributed over large rural topographic and geographic boundaries. Over the last three years Nelson‘s refugee population (with acknowledged higher health need) has grown significantly and is now considered to be the fourth largest in the country. Through our partnerships and alliances collectively we are making best use of all the resources locally available along with minimising the cost of resources and ensuring regard to quality & safety (economy). Our intention is to have a transparent relationship between the NMHS outputs delivered and the resources the NMHS uses to produce them (efficiency). To be accountable, we must demonstrate the extent to which our objectives are achievable including the relationship between intended and actual impacts of a service (effectiveness). We believe this ensures optimal utilisation of resources to achieve all of the intended outcomes (cost-effectiveness) outlined in this AP.

Content required in the Statement of Intent CE Act s141 (1) (a) An overview of the Nelson Marlborough population can be found at: http://www.health.govt.nz/new-zealand-health-system/my-dhb/nelson-marlborough-dhb 3 the Board‘s HEALTH 2030 strategy is expected to be refined with both PHOs and the IHB during the 2013/14 year 4 The New Zealand Triple Aim: http://www.hqsc.govt.nz/news-and-events/news/126/ 5 ‗performance‘ in this context can be defined as what NMDHB delivers to stakeholders in financial and operations terms 6 ‗health‘ in this context can be defined as the organisation‘s ability to align, execute and renew itself faster to achieve more within our current resources to sustain exceptional performance over time. 7 The NMHS includes all of the provider and sector agents that contribute to the health of our population and for which NMDHB is a key accountable agent through our role under the NZPHD Act 2000. 1 2

NMDHB, working within the wider health system locally, regionally, and nationally is collaborating around ‗designing new models of care‘ to deliver services, and, assuring the ‗accounting for the value‘ achieved from these services. This is through closer monitoring of the performance of our NMHS.

1.2.2

Nature and scope of functions / intended operations

NMDHB, under the NZPHD Act, is organised under the following functions: 

Planning the strategic direction of the NMHS in partnership with clinical leaders, key stakeholders, our alliance partners, Maori Health Coalition and most importantly our community. We plan with other DHBs regionally through the South Island Alliance (SIA) with support from the South Island Alliance Programme Office (SIAPO). We also plan with other DHBs nationally through the District Health Board Shared Services Agency (DHBSSA). Nationally, we plan with the National Health Board and Ministry of Health as well as National Agencies (Health Benefits Limited, the National Health IT Board, Health Workforce New Zealand, PHARMAC, the Health Quality and Safety Commission and the National Health Committee.



Funding the majority of the health and support care service provided in Nelson Marlborough through our partnerships, alliances and key relationships with service providers. Our focus is on ‗best for patient, best for system‘ and achieving more health gain for dollar invested (value for money) by ensuring services are high quality, safe, responsive, coordinated, efficient and meet the expectation of the patient‘s experience of the care provided. This includes our share of funding for the SIA Service Level Alliance (SLA) and workstream outputs as well as audit and monitoring of service providers. We fund Service Developments sub-regionally (Capital & Coast DHB and Hutt DHB for plastic surgery services, cardiovascular services, genetic services, nephrology services and oncology and radiotherapy services. We also fund the national haemophilia services, the National Blood Service and a range of smaller agreements that are held under named District Health Boards (e.g. National Limb Service etc.). Along with other DHBs we collectively fund the support for national agreements developments for Age Related Residential Care (ARRC), Community Pharmacy Services (CPS), the National Dental Services (NDS), PHARMAC are the major ones.



Promoting, protecting, and improving the Nelson, Marlborough and Tasman population‘s health and wellbeing through evidence-based ‗whole of system‘ approaches including the provision of Public Health Services (Ministry of Health Funded) including working with our Local Authorities on health impact assessments as well as protection, and regulatory issues and health promoting interventions.



Providing hospital specialist and community services for the population of Nelson, Tasman, and Marlborough. The Nelson Marlborough Health Alliance oversees services that are either delivered in the community ‗close to home‘ and services that have been agreed to be shifted into a predominately community-responsive model of care. We provide our hospital specialist services to achieve the ‗one service two sites‘ approach recommended by the ‗Top of the South Review initiated in early 2013. We also provide an Intellectual and Physical Disability Support Service (funded by the Ministry of Health)



Corporate Support includes all of the necessary administrative support, facility and equipment support and procurement, information systems support, business and clinical intelligence support, human resources and organisational development (including quality and safety) support, Chief Executive Office and Board Support, Director of Nursing and Midwifery, Director of Maori Health and Whanau Ora and Chief Medical Officer (and Complaints) support as well as Finance support required for an organisation of the size of NMDHB.

MODULE 2: STRATEGIC DIRECTION

2.1 2.1.1

STRATEGIC DIRECTION NMDHB Strategic Vision – ‘Leading the Way to Healthy Families’

Our VISION is: “leading the way to healthy families” Our MISSION is to: “work with the people of our community to promote, encourage and enable their health, wellbeing and independence.” Our VALUES are: Respect We care about and will be responsive to the needs of our diverse people, communities and staff

Innovation We will provide an environment where people can challenge current processes and generate new ways of working and learning Teamwork We create an environment where teams flourish and connect across the organisation for the best possible outcome Integrity We support an environment which expects openness and honesty in all our dealings and maintains the highest integrity at all times

2.1.2

HEALTH 2030 and NMDHB’s Strategic Vision

HEALTH 20308 provides a guide to future planning and implementation of health and support services (services) so that NMDHB can continue towards delivering its strategic vision „Towards Healthy Families‟. It enables NMDHB to meet its statutory accountabilities, as required under the New Zealand Public Health and Disability Act 2000 9, the Health Act 1956, and the Crown Entities Act 2004 and any amendments to these Acts. It also aligns with the overall direction of the New Zealand Health Strategy and New Zealand Disability Strategy 10. HEALTH 2030 means patients and their families/whanau and the local population are at the centre of our local health and support delivery system. The strategy seeks to improve system efficiency through an approach that recognises the patient and their family/whanau as a co-producer of health outcomes. For NMDHB this means ensuring that services and the benefits received by patients and the Nelson, Tasman and Marlborough populations are organised around the patient‘s/population‘s experience of care and deliver on both patient and population health outcomes. Therefore, population and population-centred, HEALTH 2030 services are those services that:  keep groups of people healthy by working with communities and cross-sectorally (i.e. with other agencies – Government and non-government) in order to influence supportive environments that achieve wellness, resilience, independence and participation in society  ensure individuals receive the right treatment when ill or injured  utilise expanded, coordinated and networked providers , as well as patients and their families to deliver evidence-based programmes of integrated care that support people to get better and stay well over the course of their life  work to reduce disparities in health outcomes, particularly for Maori; ensuring a fair and equitable system of care locally  are affordable and sustainable. HEALTH 2030 presents a layered structure describing what kind of services can or should be funded and provided and how they interrelate. It is supported by a set of assumptions, concepts, values and practices that reflect our understanding of a future reality 9 New Zealand Public Health and Disability Act (NZPHD Act s38 2(a & b); 10 (NZPHD Act s38 2(d)). 8

The picture below depicts the future Nelson Marlborough Health System. It is used courtesy of the UK National Health Service (Redbridge NHS Trust). It depicts the organisation of health and support care as we envision it. The HEALTH 2030 Action Plan includes the objectives, definitions and descriptions of specific elements to be implemented over time.

At the centre of the approach is the patient, supported by information systems and community-based clinicians working within an integrated11 â&#x20AC;&#x2014;coordinated networkâ&#x20AC;&#x2DC; of providers to deliver better health outcomes for the patient, their whanau and the people of Nelson, Tasman, and Marlborough. Population and Patient-centred service delivery refers to the way in which people are cared for by themselves, their family, the community, by formal health services and by clinicians to ensure a shared care12 approach. In particular, patient-centred service delivery is directed by patients, while those doing the caring know and honour what matters to the patient. Healthy communities can be achieved by working together to improve overall wellbeing for all members of our community, improving access to high quality health and support care as close to where people live as safely as possible and ensuring that health and support services meet the needs 13 of people living within the Nelson Marlborough district. Core to achieving healthy communities are HEALTH 2030â&#x20AC;&#x2DC;s six quality dimensions: accessibility, acceptability, appropriateness, effectiveness, timeliness and patient-centredness.

2.2

NMDHB GOALS

The NMDHB Board has chosen the following four goals to achieve a results-based sustainable system: 1. Population Goal 1: Improved health, independence, participation and equity 2. Population Goal 2: Whole of person, whole of whanau, whole of system 3. Organisational Goal 1: Influence to reinvest 4. Organisational Goal 2: Optimal workforce (including all health workers - regulated and unregulated, informal caregivers, family members and volunteers).

Integrated care: includes both clinical and service integration to bring organisations and clinical professionals together, in order to improve outcomes for patients and service users through the delivery of integrated care. Integration is a key component of placing patients at the centre of the system, increasing the focus on prevention, avoidance of unplanned acute care and redesigning services closer to home. 12 Shared care is a term that denotes partnership approaches between a patient and the clinicians providing them with care. 13 Need in this context refers to the ability to significantly benefit from the intervention. 11

2.2.1

NMDHB JUMBO Framework and Strategic Initiatives

The 2013 NMDHB JUMBO Framework is below in a modified form to emphasise the key ‗system‘s components‘. VISION

“Towards Health Conscious Families” Community responsibility

General Protection

HEALTH 2030 Strategy

Partnerships & Alliances – Key Sector Organisations

Organising Strategy

Targeted Protection

Risk development

Accountable Sector

Nelson Marlborough Health System’s response

Risk reduction Healthy population

Health sector responsibility

Illness/Injury Prevention and Detection

Condition Management

Condition onset

Chronic Condition Population

Condition progression

Supportive & Palliative Care

Slow deterioration

Symptom reduction At risk population

Intensive Condition/Case Coordination

Complex Conditions Population

Condition progression

Improve Quality-of-life Population at End-of-Life

Health & Support Activities Health & Support Objectives Populations Grouped around Need

Population with Acute Condition(s) – rapid access, evaluation, triage, diagnosis and treatment

‘Whole of System’ Integrated Resources

Health & Support Resources

JUMBO incorporates ‗groups of the population based on need‘ (healthy, at risk, chronic condition, complex conditions, and people at the end of life). For each of these five population health need groups (HNGs) there is also a requirement to help people to recover from episodes of ill health or following injury generally referred to as acute conditions. JUMBO demonstrates that people can move from one group to another and that this ‗flexibility and ease of movement‘ is influenced by partnerships and alliances (the way key sector agencies organise locally, regionally and nationally). JUMBO incorporates objectives that are applied between each of the HNGs to address the particular needs of that group (e.g. risk reduction, symptom reduction, slowing of deterioration, and improvement of quality of life) as well as a set of evidence-based activities (general protection, targeted protection, illness/injury prevention and early detection, condition management, intensive condition management, and palliative care support) that the sector would deliver. JUMBO has as the foundation of the NMHS‘s response, all of the health and support resources we employ and the processes we use that integrate care around the needs of patients and communities. For the 2013/14 Annual Plan, NMDHB is focusing this on the dual themes of ‗prevention‘ and ‘integration’. Prevention spans preventing waste of all health care resources and acknowledges that we are currently NOT ‗living within our means‘. Integration spans clinical and system and aligns with the Minister‘s expectations and the ‗Better, Sooner, More Convenient‘ Government policy. Both inter-relate as you cannot have effective prevention without integration. From a context perspective, because of our structural deficit the National Health Board (NHB), our monitoring agency, placed us under Intensive Monitoring from the second half of the Annual Plan 2012/13 Year. This is due to NMDHB allowing our cost growth to greatly exceed our revenue growth—we are not living within our means. This is not continuing into 2013/14. This plan demonstrates our two-pronged approach: 1/ Through the Rutherford Programme14, (a line-by-line ‗value for money15‘ approach of all of our expenditure along with recommended changes to our cost structures) we intend to drive down production costs in the delivery of our DHB hospital based services; 2/ Through better integration of services we both fund and provide we are using our Alliances to focus on delivering better, more convenient, primary care-led, community-based, patient-centred services vs. a growth in hospital services. A recent review of our NMDHB Rutherford Programme indicated that not all of the recommendations had been implemented. For the AP 2013/14 the implementation of the Rutherford Programme recommendations has greater prominence and with no ‗stone unturned‘. As part of this approach, resources are being re-deployed to support the significant changes needed to return NMDHB to a sustainable financial position.

The Rutherford Initiative commenced in May 2009 to review line by line all services contracted for or provided by NMDHB. Value for Money: is the assessment of benefits (better health outcomes) relative to cost, in determining whether specific current or future investments/expenditures are the best use of available resource. NMDHB is assessing a range of processes including our diagnostic imaging, savings through Health Benefits Limited, our clerical administration, jobsizing for SMOs, and human resources management. 14 15

We are also working to reduce the cost of both provided and contracted services. Simultaneously we are organising a Top of the South services review that should result in improved productivity and efficiency of these services. This initiative involves implementing the recommendations from the review and re-aligning our health and support services delivery to ensure everything we do (resources and time) improves patient outcomes. Currently much of our cost infrastructure is invested in supporting the delivery of expensive secondary and tertiary services to members of our population. Arguably this is an imbalance, given we must invest in more community and primary care services that ensure people are healthier and their conditions are better managed using community resources. We are addressing this imbalance as a matter of urgency while also ensuring that the quality and safety of care we provide is not compromised. While most of our hospital and provider arm delivery is appropriate in meeting our population needs, the cost infrastructure (processes and inputs) of delivering these services has grown beyond our ability to fund them. We must ensure that all of our inputs and activities actively contribute to patient outcomes and have zero tolerance for activities that do not contribute. Quoting one of our clinical leaders, “we should be doing less of the things we should not be doing”. At the same time we are actively reducing our costs we are creating better integration of services and focusing on providing these primary care led services ‗closer to home‘. Care closer to home can be defined as shifting specialist care into community settings to provide more flexibility, accessibility and timely care with the aim is to encourage people to live independently to give them greater choice and control over their health, while reducing DHB costs and the demand for hospital resources. Integrated services are aimed at preventing illness, injury, and preventable death as well as care delays for our Top of the South population. Through our refocused Nelson Marlborough Health Alliance (NMHA), a collaborative partnership using shared resources, we see these improvements providing us with the ability and capability to reduce the need for expensive hospital care (reduce acute admissions and readmissions). In summary the main message for the NMDHB Annual Plan 2013/14 based on the two key themes of prevention and integration is that NMDHB is transforming the ‗health‘ of our delivery system while proactively reducing costs, matching costs to revenue and focusing on achieving value in terms of patient and system benefit per dollar invested. We acknowledge that delivering care ‗closer to home‘ for the Nelson Marlborough communities, requires NMDHB to implement significant and transformational service changes. The key principles we are following include: 1. making best use of resources (value for money) to improve health and wellbeing outcomes for the populations of Tasman, Nelson, and Marlborough 2. ensuring openness and transparency through an ‗open book‘ approach to reduce cost, reduce waste, and deliver better outcomes 3. empowering patients and consumers to have more control over their care packages, strengthen prevention, supported selfcare, and enhance well-being 4. working interdependently in partnership with KHW MPHO, NBPH, and the Maori Health coalition 5. incentivising integrated care through removing barriers and implementing mechanisms that reward outcomes using ‗Results Based Accountability‘ methods 6. targeting services for those patient (health need) groups most likely to benefit from ‗wrap around services‘ 7. keeping our communities informed, engaged and confident in our decision-making 8. reinvigorating the NMHA by collectively leading and jointly working with the primary and community environment and the Maori Health Coalition so that we deliver solutions that are both affordable and meet the needs of our communities. NMDHB intends to aggressively address our current cost growth through implementing transformational changes to the NMHS. For 2013/14 our focus is on ‗Living within our Means‘. In summary the following are the six 2013/14 priority initiatives: 1. Assuring an Integrated System of Care through the Nelson Marlborough Health Alliance 2. Accelerating implementation of actions to achieve the financial recovery programme Increasing our full time staff proportion while maintaining flexibility 3. Improving the quality, safety and efficiency of ‗Top of the South‘ services through implementing the review recommendations 4. Ensuring ‗value for money‘ in our diagnostic imaging services by implementing the recommendations from the district-wide review of Imaging (hospital and community). 5. Implementing ‗Top of the South‘ processes to eliminate inappropriate inter-district flow (IDF) to tertiary providers while progressing cost-effective, timely and productive South Island Alliance (SIA) Elective Services. It is important to note that measures of performance against each of these initiatives are outlined in modules 3 & 5.

2.2.2

NMDHB Maori Health Action Plan 2013-14

Our 2013/14 Nelson Marlborough Maori Health Plan strengthens the alliance framework between Nelson Marlborough District Health Board (NMDHB), Nelson Bays Primary Health (NBPH) and Kimi Hauora Marlborough PHO (KHW MPHO), to achieve the vision of ‗Kia korowaitia aku mokopuna kit e korowaitanga hauora‟, „We want to wrap out future generations in a korowai of health and wellness‟.16 By having greater ownership to Maori health and health inequalities, the responsibility will be shared by the alliance partners, across the continuum of care. There will be some major service transitional changes as the Maori health provider coalition work towards implementing the structural and service changes needed to achieve national policy direction in terms of Whanau Ora and Better, Sooner, More Convenient health services. The overall aim for approach is to achieve Whanau Ora outcomes through working collaboratively. The achievements will be seen through implementation of Whanau Ora centered services that seek to improve access, ensure services are appropriate, good quality management systems and best practice is in place and the services respond to whanau and are culturally appropriate.

2.3

GOVERNMENT PRIORITIES AND HEALTH TARGETS

The six 2012/13 Health Targets are confirmed as continuing into 2013/14: Shorter Stays in Emergency Departments Improved Access to Elective Surgery Shorter Waits for Cancer Treatment Increased Immunisation Better Help for Smokers to Quit More heart and diabetes checks

2.4

The 2013/14 AP Government priority areas (in addition to the Health Targets) are: Reducing rheumatic fever Clinical integration (including acute and unplanned care, primary care development, health of older people, long term conditions i.e. diabetes care improvement, stroke, child and maternity care Delivery of the mental health service development plan Delivery of the Prime Minister‘s Youth Mental Health Project Actioning the Children‘s Action Plan Faster cancer treatment Living within our means Whanau Ora Improved access to diagnostics

REGIONAL COLLABORATION17 THROUGH THE SOUTH ISLAND HEALTH SERVICES PLAN AND SUBREGIONALLY THROUGH THE CENTRAL REGIONAL HEALTH SERVICES PLAN

While working towards delivering our local initiatives under the themes of prevention and integration we are also addressing the goals of the South Island Alliance. More detail regarding this can be found in the South Island Health Services Plan (SI HSP) found on the NMDHB website. Additionally we are working sub-regionally with both Capital and Coast DHB and Hutt DHB particularly around some oncology services (particularly head and neck cancers and breast cancer reconstruction), genetics services, cardiology and cardiovascular services, renal services and plastic surgical services. These sub-regional approaches are mainly around creating more robust ‗hospital networks‘ of care and delivery.

2.5

COLLECTIVE WORK NATIONALLY THROUGH DHB SHARED SERVICES

2.6

STRATEGIC OUTCOMES TO ADDRESS LOCAL, REGIONAL AND NATIONAL POPULATION GOALS

DHBs are working collectively on national services (e.g. Health of Older People, InterRAI rollout; Oral Health (Dental Services Agreement); Community Pharmacy Services (Community Pharmacy Services Agreement implementation), the Laboratory Test List and guidance; Primary Health Organisation (PHO) Services Agreement and the PHO Performance and Incentives Framework, the New Zealand Blood Service; and, PHARMAC). The National Shared Services Agency also supports DHBs around collective activities including employment relations, the implementation of the national and regional Information Technology infrastructure, executive forums, data analysis, reporting and sharing, CEO Information group engagement, and representative engagement with Central Agencies such as Health Benefits Ltd, the NZ Quality & Safety Commission, the Health IT Board and the National Health Committee. The outcomes model on the following page demonstrates the connections between our local inputs, outputs, impacts and goals and the South Island Regional outputs, impacts and goals and the national sector outcomes to achieve the overarching health sector goal “all New Zealanders live longer, healthier and more independent lives”.

16 17

Nelson Marlborough Maori Health and Wellness Strategy 2008 Regional collaboration: means DHBs working together more effectively, whether regionally or sub-regionally

MODULE 3: ACTIONS TO ACHIEVE OUR OUTCOMES 3.1

NMDHB’S ANNUAL PLAN AND STATEMENT OF INTENT - 2013/14 PRIORITIES AND TARGETS

The following sections describe how NMDHB (including stakeholders) is addressing our local and regional Key Initiatives as well as the Government‘s health targets and priorities. Each initiative and priority is presented as a visual map, built using DoView (www.doview.com) outcomes software designed by Dr Paul Duignan (a NZ academic). Each visual map sets out the main actions needed to achieve the higher-level results (impacts and outcomes) NMDHB expects to achieve and identifies measures that provide evidence of the progress on each action18.

Colours in each of the visual maps represent: Yellow – NMDHB Initiatives; Blue – Actions; Pink – Government Targets/Priorities

Initiative 1: Assuring an Integrated System of Care through the Nelson Marlborough Health Alliance (NMHA) Context As of 1 July 2013 the new PHO Services Agreement comes into effect. Under the agreement Nelson Marlborough District Health Board, Nelson Bays Primary Health and Kimi Hauora Wairau Marlborough PHO have reinvigorated the Nelson Marlborough Health Alliance (NMHA). The NMHA takes a collaborative approach towards clinical and services integration by focusing on primary care including: strengthening PHO roles, functions, and results; ensuring accountability and alignment with Government priorities and National Health Targets; organising a Performance and Incentive Framework; bringing care closer to home. Attributes of â&#x20AC;&#x2DC;good clinical integrationâ&#x20AC;&#x2122; to be delivered include: coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patientfocused (acceptable). This is evidenced by the NMHA implementing an active and ongoing programme to evaluate and modify practice patterns by the Allianceâ&#x20AC;&#x2DC;s providers and to create a high degree of interdependence and co-operation to control costs and ensure quality. Objectives Reconfiguring primary and community system to deliver services improvements and value for money; reducing demand on acute hospital service; increasing access to a range of services in a primary and community setting to deliver care closer to home to specialist nursing, allied health professionals and medical services to primary care; accelerating achievement of the health targets.

Initiative 2: Accelerating implementation of actions to achieve the financial recovery programme, including Rutherford recommendations and the required ‘change management’ Context The Rutherford Initiative19, which began over four years ago to take a line-by-line ‗value for money‘ review of all of our expenditure, is a key component of the financial recovery programme. Objectives Implementing the financial recovery programme ensures that NMDHB achieves a breakeven financial result at 30 June 2014.

The Rutherford Initiative commenced in May 2009 to review line by line all services contracted for or provided by NMDHB.

Initiative 3: Increasing our full time staff proportion while maintaining flexibility Context NMDHB currently has a ratio of part time to full time staffing (particularly, for nursing, allied health and administrative clerical staff) which has a high percentage of part-time over full time employees. Analysis shows that it would be more appropriate from a quality, safety and financial perspective to employ a greater proportion of full time to part time staff. NMDHB has utilised Trend Care systems for capturing rostering data but has not extracted value from the investment in the system to its full extent. Objectives NMDHB is reconfiguring the current staffing model of part-time/full-time mix and type beginning with nursing staffing and progressing to allied health and administrative clerical staffing; implementing a centralised rostering system for NMDHB nursing services utilising Trend Care Systems and ensure maximum staff resource utilisation. Other groups such as Allied Health and Clinical Administration are also under consideration.

Initiative 4: Improving the quality, safety and efficiency of ‘Top of the South’ acute services Context NMDHB currently operates two 24/7 acute care hospital services in Nelson and in Wairau some of which are associated with quality of care issues at a high cost. A Top of the South Acute Services Review was initiated in May 2013, by the NMDHB Board. The Review supports:  Clinical quality/safety and financial sustainability  Cost effectiveness and maximising resources of acute services in the Nelson/Marlborough district  Consistent access to, and provision of, services across the district for patients based on need. Objectives The first services reviewed are orthopaedic surgery, general medicine, and general surgery (one service, two sites). Implementation of recommendations from the Review is subject to Board agreement (includes timeframes and benefits realisation). Any service changes that meet the definition of ‗significant‘ are to be agreed by both the NMDHB Board and the Minister (Operational Policy Framework – Significant Service Change).

Initiative 5: Ensuring ‘value for money’ in our diagnostic imaging services through implementing the recommendations from the review of these services Context As part of the Initiative 4, NMDHB is reviewing hospital-based imaging services, including those that are community referred. NMDHB currently has two differently provided hospital-based imaging services. Nelson hospital operates a gate-keeping approach using expert radiology and ensuring appropriateness of imaging referrals and timeliness of imaging reporting. Wairau hospital operates a feefor-service imaging production that has demonstrated a growth over the past two years that exceeds the population demographic growth of Marlborough. Other South Island DHBs (Southern, South Canterbury) are reviewing imaging services; NMDHB will align with the regional approach on imaging. Objectives Implementation of recommendations from the Review is subject to Board agreement (includes timeframes and benefits realisation). Any service changes that meet the definition of ‗significant‘ are to be agreed by both the NMDHB Board and the Minister (Operational Policy Framework – Significant Service Change).

Initiative 6: Implementing Top of the South controls to eliminate inappropriate inter-district flow (IDF) to tertiary providers Context NMDHB currently has experienced a growth in inter district flow procedures to other DHBs that exceeds our population growth. At the same time we continue to maintain the same cost structure despite our required elective target for the population not increasing. This has resulted in increased expenditure over revenue. Objectives NMDHB is accelerating the process for managing IDF flows in a sustainable way; reconfiguring our local cost structure and taking account of appropriate IDF growth.

3.2

PRIORITIES AND TARGETS: Policy and Service priorities and related targets – Government expectations

As part of the focus on ‗living within our means‘ the Minister‘s letter of expectations for DHBs 2013/14 requires NMDHB to lift productivity while keeping to budget. Our activities in NMDHB include: 

addressing the productivity of our services delivery model within all our hospitals to maximise the quality of our service and to reduce the cost of our services



matching our delivery capability and capacity to achieve the national health targets and to live within our means



ensuring consistency of delivery and access to services district-wide (this includes the following services in particular, acute surgery, secondary maternity, cardiology)



NMDHB, with our alliance partners, are strengthening service integration across the continuum of patient care delivery and across settings of care (facility, hospital, community, home, mobile, virtual etc). We are collectively working to broaden our planned activities and quicken our momentum towards fully integrated services. We are doing this through reducing waste and duplication of resources, through ensuring timely access and more importantly through addressing quality and safety of care provided. Our activities through the NMHA include: - coordinated management of people with long-term conditions including progressive implementation of ‗single point of coordination‘ through the NMHA to ensure more ‗wrap-around care‘ for those who might benefit including access to the new Community Pharmacist Services Long Term Condition Service, - management of the demand for urgent and unscheduled acute care and particularly readmissions through implementing the NM predictive risk score to address improved discharge planning, discharge medicines reconciliation, increased ability for GP practices to provide access to interventions to better manage the risk of readmission, continuing the free after hours care for under six-year-olds, ensuring rural after-hours delivery, enhancing access to Community Pharmacist Services, - supporting patients to be cared for better in their homes (this includes rapid response teams, use of new technologies and access to needs assessment, Community Pharmacist Services and progressively implementing a range of creative and responsive district nursing service delivery models, - supporting timely expert nursing and specialist access to community and primary care providers.

In the following DoViews, NMDHB has framed the Government Priorities and National Health Targets, with related key objectives described in the pink boxes. These Objectives, and related Actions and Measures, indicate our approach to achieve ‗better, sooner, more convenient‘ health and support services that meet the needs of New Zealanders within sustainable publicly funded delivery models. As can be seen these groupings involve systems improvement, services improvement, the work DHBs are expected to do to advance other Government Agency priorities, the Minister of Health‘s priority areas and the National Health Targets. Last but no means least we must do all of this while being financially responsible with the taxpayer funds entrusted to us..

Prime Ministerâ&#x20AC;&#x2122;s Youth Mental Health Project Context A significant number of young people in New Zealand will experience mental health problems during adolescence. Problems such as depression, anxiety and substance abuse can have life-long consequences. As part of the 22 initiatives identified within the project, the Ministry of Health is leading seven initiatives, of which DHBs will contribute to five. NMDHB is developing services that improve primary care responsiveness to youth with mild to moderate mental health issues, for example a single point of access for children and young people to both primary and specialist services. Objectives The Nelson Marlborough Health System ensures better mental health and wellbeing for young people â&#x20AC;&#x201C; including sub-groups of the population at comparatively higher risk of mental health issues, such as Maori and Pacific.

Maternal and Child Health Context Better Sooner More Convenient health services (BSMC) for mothers, babies and children and their families means families do not have to navigate multiple systems in order to access the services they need. Supporting vulnerable children contributes to the Governmentâ&#x20AC;&#x2DC;s overall priorities by improving services and reducing avoidable expenditure in the justice, health and welfare systems â&#x20AC;&#x201C; helping to deliver better public services within financial constraints and helping to build more competitive and productive economy. NMDHB is both supporting and contributing to actions outlined in the Better Public Services Action Plan, led by the Ministry of Education, to increase in the participation in quality early childhood education. Objectives For the Nelson Marlborough Health System this ensures that children and their families have improved access to services that maintain good health and independence and that all vulnerable children and families are identified and offered the services they need to enjoy good mental and physical health and wellbeing.

HEALTH TARGET - Cancer Services Context Better, Sooner, More Convenient health services for New Zealanders in relation to Cancer means all New Zealanders can easily access services, in a timely way to improve overall cancer outcomes. Objectives The Nelson Marlborough Health System ensures all patients, ready-for-treatment, wait less than four weeks for radiotherapy or chemotherapy. Patients with cancer have access to services that optimise good health and independence; patients with cancer receive equitable services wherever they are; services make the best use of available resources across the whole cancer pathway (screening, detection, diagnosis, treatment and management, palliative care).

Diagnostic Services Context The Nelson Marlborough Health System ensures appropriate access to hospital-based diagnostic imaging tests by primary care providers to support the optimal care for their enrolled population and ensures that the delivery of â&#x20AC;&#x2014;community-based imagingâ&#x20AC;&#x2DC; is evidence-based and affordable to NMDHB. Objectives Achieve identified waiting time targets by more efficient use of existing resources; making improvements to referral management and patient pathways; and investing in workforce and capacity as required.

HEALTH TARGET - Elective Services Context NMDHB aims to achieve its health target of elective discharges as part of the New Zealand health systemâ&#x20AC;&#x2DC;s approach to increase the number of elective discharges provided. The Nelson Marlborough Health System continues to: maintain elective discharges; ensure appropriate access to first specialist assessments; reduce waiting times for people requiring elective services; improve prioritisation and selection of patients; support innovation and service delivery; and, reduce follow up visits. Nelson Marlborough already achieves above or at the standardised discharge ratios for elective services and meets the national elective services targets. Objective People have shorter waiting times for elective services meaning they receive better health services, and can regain good health and independence sooner.

Cardiac Services and Acute Coronary Syndrome Context Better Sooner More Convenient Health Services for New Zealanders in relation to Cardiology and Cardiothoracic Services requires improved and more timely access to services. NMDHB is working regionally with the Central Network to achieve improved regional services. Nelson Marlborough already achieves above the standardised intervention rate for cardiac services and acute coronary syndrome patients. Objectives Within affordability constraints maintain appropriate cardiac surgery and ACS discharges; maintain needs-based access to cardiac diagnostic services and specialist assessments; reduce waiting times for patients requiring ACS and cardiothoracic services; and, improve prioritisation and selection of cardiac surgery patients.

NMDHB & NMHA Priorities under the National Mental Health and Addiction Service Development Plan Context: The national Mental Health and Addiction Service Development Plan (SDP) articulates prioritised service developments for the next 5 years. The Plan aims to ensure that across the spectrum of health promotion, primary, specialist treatment and support services access and responsiveness will be enhanced; integration will be strengthened while improving value for money and delivering improved outcomes for people using services. Objectives The Nelson Marlborough Health System continues to: actively use our resources more effectively; builds infrastructure for integration between primary and specialist services; cements and builds on gains in resilience and recovery; undertakes a gap analysis between the actions identified in the Service Development Plan and the current service provision model.

Contributing to Whanau Ora Outcomes Context: The Nelson Marlborough Health System continues to contribute to Whanau Ora by: maximising the opportunity to support and build capacity and capability of provider collectives to support the growth towards mature providers; working in a seamless and integrated way with other parts of the social sector and delivering improved outcomes and results for Whanau. Objectives: Contributing to Whanau Ora provider collectives to transform to a Whanau-centred integrated approach to deliver improved Whanau health and other social outcomes. Reporting: Nelson Marlborough is caught between two Whanau Ora catchments â&#x20AC;&#x201C; Central Region and Te Waipounamu. The DHB has three providers who are affiliated to the Te Waipounamu Whanau Ora Network. The quarterly updates to TPK will ensure they are informed about decisions in this district.

HEALTH TARGET - More Heart and Diabetes Checks and Diabetes Care Improvement Planning Context Demands on the health system are increasing with a tight fiscal situation. An aging population, long term conditions, and the needs of vulnerable populations are placing greater pressures on the health system. The Nelson Marlborough Health Alliance is working to develop district-wide service models of care, focussing on patients with long term conditions that ensure coordinated health care through multidisciplinary teams. Objectives The Nelson Marlborough Health System delivers care for patients with cardiovascular and diabetes by enhancing risk assessment and proactive primary care services. This approach requires: prompt identification of at-risk people; timely effective assessment and management of their risk factors in primary care; effective self management of their risk factors and their diagnosed conditions; and, close primary care and secondary care clinical integration centred on the patient.

HEALTH TARGET - Better Help for Smokers to Quit Context Better Sooner More Convenient Health Services for New Zealanders in relation to tobacco means more smokers make more quit attempts, leading to more successful quit attempts and a reduction in smoking prevalence (including pregnant women). A renewed impetus is required in order to achieve the Governmentâ&#x20AC;&#x2DC;s aspirational goal of a Smokefree New Zealand by 2025. Increased integration into all other aspects of health is critical to achieving Smokefree Aotearoa 2025 Objectives The Nelson Marlborough Health System proactively encourages patients who smoke to quit. All patients seen by a health practitioner in either Nelson or Wairau public hospitals or enrolled with primary care providers are offered brief advice and support to quit smoking, and pregnant women who smoke are offered advice and support to quit.

HEALTH TARGET - Shorter Stays in Emergency Departments Context The Nelson Marlborough Health System actively delivers reduced waiting times for patients in Emergency Departments with patients easily accessing appropriate services in a timely way to improve overall health outcomes. More people have improved access to services that maintain good health and independence. More people have shorter waiting times for emergency department services meaning people receive better health services. Objectives To meet acute care needs we: deliver and co-ordinate acute care services across hospital and community settings; improve the publicâ&#x20AC;&#x2DC;s confidence in being able to access services when they need to; ensure patients spend less time waiting and receiving treatment in the ED; move patients efficiently between phases of care; and make the best use of available resources.

Through the Nelson Marlborough Health Alliance (NMHA) improving care for people with multiple long-term conditions (MLTCs), Stroke Services & Improving Care for People with Dementia Context There is a need for integration of care for those with multiple long-term conditions. Objectives The Nelson Marlborough Health System ensures that people with multiple advanced conditions receive improved care management and care co-ordination to prevent deterioration and maintain current health and avoid acute hospitalisation; delivers equitable access through a single point of entry to multidisciplinary team management and ensures the right services are delivered to the right patients at the right time; and for patients with stroke, ensures best practice and organised stroke services that reduce functional disability.

Improving wrap around services for the Health of Older People Context Currently Nelson Marlborough has one in six people over 65 and this will grow to one in five over the next ten years. Many of these people require health care and community support services. The NMHA has a priority to ensure timely access to appropriate general practice services. Objectives The Nelson Marlborough Health System provides: wrap around services that enable older people to live in their homes for longer; more intensive community based support services for older people; supported hospital discharge; primary care access to specialists; and, comprehensive clinical assessments (InterRAI).

Stroke Context Nelson Marlborough DHB in conjunction with South Island region will embed organised stroke services consistent with evidence-based practice described in the New Zealand Clinical Guidelines for Stroke Management 2010. Objectives To improve the services provided to people who have, or who are at risk of diabetes, heart disease and stroke .

Dementia Pathway Context Nelson Marlborough DHB in conjunction with South Island region will progress the implementation of the National Dementia Framework. Objectives To deliver integrated health and support services that enable people with dementia, their family, and whanau, to maintain and maximise their abilities to practice described in the New Zealand Clinical Guidelines for Stroke Management 2010.

Community Pharmacy Services (CPS) Context In July 2012 all Community Pharmacies signed a new agreement (CPSA) which supports a ‗service-based patient-centred‘ model of care and incentivises community pharmacists as experts in medicines management. The CPSA has a three year timeframe to safely transition Community Pharmacy from the old ‗fee-per-dispensed item‘ business model to the new ‗service delivery‘ business model. Objectives The Nelson Marlborough Health System is committed to fully supporting the effective implementation of the three-year CPSA (1 July 2012 to 30 June 2015) in accord with the direction of the lead DHB CEO and Programme Director.

MODULE 4: STEWARDSHIP

4.1

MANAGING OUR BUSINESS

4.1.1 Leadership Capability NMDHB‘s Executive Leadership Team is being restructured in line with the DHB‘s future direction and the establishment of the NMHA. The intention of the new structure is to place clinical leadership, quality and safety, and managing within our revenue as priorities. The new leadership is key to achieving the Annual Plan 2013/14 initiatives, priorities, and Health Targets. 4.1.2 Clinical Leadership Capability The Chief Executive is also consulting with clinicians within all disciplines across hospital, primary, and community settings as to his approach to clinical governance. 4.1.3 National Collaboration The National Health Board is responsible for:  The funding, monitoring and planning of District Health Boards (DHBs), including the annual funding and planning rounds  The planning and funding of designated national services  Bringing together the various activities with strategic planning and funding of future capacity (Information Technology, facilities, workforce), so they can be better integrated and driven by future service requirements. Including: - The DHB regional service planning and funding, including arbitration over regional disputes - The process for deciding, which services should be planned, funded and provided at national, regional and local levels, and how that should change over time - How to best support the Government's initiative to reduce bureaucracy, so savings can be invested in front-line services. Along with DHBs nationally, NMDHB funds services for people with haemophilia and PHARMAC for community pharmaceuticals management. 4.1.4 DHB Shared Services Along with other DHBs, NMDHB collectively funds the National DHB Shared Services agency (DHBSS) to support national collective projects, programmes, national services agreements (i.e. Age Related Residential Care, Community Pharmacy Services Agreement, National Dental Agreement and the PHO Performance Programme). DHBSS also supports ‗functional groups‘ such as the Chief Executives and Boards Collective, the GMs P&F Forum, the COO Forum and the CFO Forum in particular are supported in their collective work programmes by the DHBSS team. 4.1.5 Regional Collaboration Along with other South Island DHBs, NMDHB collectively funds the South Island DHB Alliance Project Office (SIAPO) to support South Island (SI) collective planning and other projects. SIAPO also supports DHB management networks such as the South Island GMs Planning and Funding, Chief Operating Officers, Chief Information Officers, General Managers Human Resources, and is governed by the collective SI Chief Executives. SIAPO also manages the SI ARRC Audit Programme, the SI Mental Health Network, the SI Cancer Network, the SI Health of Older People Network and the SI Child Health Network. We are collectively involved in implementing the actions outlined in the appendix of the South Island Regional Health Services Plan20. For the 2013/14 year, the South Island DHB Alliance service priorities include Cancer Services, Cardiac Services, Elective Services, Child Health Services, Mental Health Services, Health of Older People Services, and Support Services including procurement and information systems. The workstream priorities include continuing actions by the Southern Cancer Network; and our collective approach to elective (scheduled) services production. 4.1.6 Cross-sectoral NMDHB works with three unitary local authorities (Nelson City, Tasman and Marlborough districts) through a variety of mechanisms including membership of key committees (civil defence, transport, disability access), environmental safety and sustainability (air, water, built environment, footpaths, cycle ways etc.) and undertakes ‗Health Impact Assessments‘ 20

For a copy of the SI Regional Health Services Plan go to www.nmdhb.govt.nz

collaboratively with other agencies. We contribute to the ‗Safe at the Top‘ initiative 21. Led by the Ministry of Social Development, NMDHB continues to be a member of the Strong Families Regional Governance Group and the Family Violence Intervention Programme. NMDHB is a partner in the Talking Heads initiative. This brings together the three district Mayors and heads of Government departments on local initiatives related to community well being, and includes governance of the WHO sponsored Safer Communities project. 4.1.7 Strategy and Planning Function Strategy and Planning (S&P) supports the wider organisation towards achievement of local, regional and national goals, objectives, impacts and services development. Located within the support arm of NMDHB, the role of the GM S&P is a comprehensive one, responsible for planning the strategic direction of services across the care continuum within the Nelson Marlborough district, in line with the Board‘s direction, organising the Board‘s accountability planning, monitoring and reporting requirements, overseeing the strategic allocation of the Board‘s Population Based Funding including Crown Funding Agreements, and proactive participation in regional and national service planning and funding initiatives. In order for this role to deliver performance, the Board allocates financial resources from Governance and Administration to sit within a ‗Strategic Expenditures‘ (StratEx) fund. This fund is under the administration of the GM S&P. For the 2013/14 Annual Plan year the following areas are StratEx fund investments: 1. Nelson Marlborough clinical pathways development costs 2. NMDHB initiatives, particularly to support alignment with regional and national approaches 3. deployment costs for InterRAI and for e-Prescribing 4. any other initiative related to emergent strategic issues as approved by the Chief Executive.

4.2

STRENGTHENING OUR WORKFORCE

4.2.1 Workforce Development and Organisational Health Capability Workforce development and strong organisation health22 are central to NMDHB to ensure that we provide high quality effective services and meet the continued challenges of the health needs of our community. Through supporting flexibility and innovation in work design; providing leadership and skill development opportunities; and being a Good Employer, NMDHB aims to be a preferred employer of health workers. As a ‗good employer‘ we have a number of policies that promote equity, fairness and a safe and healthy work environment these policies address:  fair, equal opportunity and transparent recruitment to ensure we meet current and future workforce needs and retain staff  equal employment opportunities as per our legislative requirements  zero tolerance of all forms of harassment and bullying  equitable training and development opportunities for all employees  the management and disclosure of adverse events to ensure a safe quality working environment. NMDHB is committed to developing our workforce including understanding its needs and expectations. We are committed to promoting leadership opportunities and a positive culture for our organisation and across the community NMDHB‘s workforce plan will see the continued development of all health disciplines. Clinical workforce planning and development will be carried out in conjunction with the South Island Regional Training Hub and non-clinically based development through collaboration with other South Island DHBs via the South Island GMs HR Group. The Nelson Marlborough District Health Board has the third oldest health workforce as at December 2012. The mean age of all staff is around 49 years; the national mean is 46 years. The mean length of service for all staff is 9 years; national mean is 8 years. 4.2.2 Building Culture and Relationships Capability NMDHB is committed to a culture of cooperation and collaboration that signals our role as a Crown Entity through promoting a ‗whole of sector‘ and ‗whole of Government‘ perspective. Our values ensure promotion of the standards of the State Sector‘s culture of integrity and conduct. Our culture is central to achieving our outcomes. As such, our leadership team is overseeing continuous processes to embed a ‗new way of thinking‘ which is consciously expressed in this Annual Plan. NMDHB is 21 22

Refer http://static.bewell.org.nz/gems/SafeAtTheTop.pdf Good Employer obligations as outlined in the Crown Entities Act 2004 (s 151 (1) (g))

continuously identifying, building and maintaining relationships to assist us in achieving our outcomes. We are working with local, regional, national and international networks to canvas new methods and to test new concepts. The virtual primary and community environment operates cohesively and collaboratively ensuring the ‗critical connectedness‘ with all service providers focused on the patient‘s care needs. It is committed to a new era of working to achieve the following:  Patient-centredness. Care that is patient-centred is delivered  Consistency of access. This relates not only to similar services being available across the Top of the South populations, but to measures and reporting of these services  Patient Deliverables. The application of funding by both PHOs results in a similarity of outcomes as perceived by both the patient and the general practice  Satisfaction of Providers. Mechanisms to evaluate and respond to the levels of satisfaction of General Practice with the support and services provided by their PHO  Timely Resolution of Differences. As the range of learning becomes evident through the collaborative approach these are shared together with a plan and realistic timeline to address them  Aligned Clinical Governance. Clinicians in both PHOs and NMDHB are expected to work collaboratively within the Nelson Marlborough Health System.  Minimise Administration and Overhead Costs. Use of common systems, processes and reporting whenever possible. The objective is to optimise the investment of funds in primary care across the district that focuses on the consistency and efficiency of the approach, access and outcomes. 4.2.3 2013/14 Workforce Improvements A key workforce improvement in the 2013/14 is to commence rebalancing the nursing full-time/part-time split within NMDHB secondary services. Over time we have reached a situation where at March 2013 only 20% of nurses worked full-time. This is the lowest percentage of full-time nursing staff in the South Island. The literature is clear that a balance in the mix of full-time/part-time has a positive impact on patient care quality and safety. NMDHB‘s goal is to increase the full-time nursing percentage to 40% over a three year period. This will enable the retention of flexibility for a predominantly female workforce and improve the opportunity for new entrants to the nursing workforce to gain full-time work at NMDHB. 4.2.4 Capability Growing the capability of the Nelson Marlborough and the South Island workforces will be the key to achieving a successful delivery of the Health 2030 strategy. Current capability will be challenged as models of service delivery change and the focus on ‗patient family centred care in a whole of system context‘ becomes common. Support required to enable the development of capability to meet new delivery systems will come from a variety of NMDHB and South Island initiatives. Addressing barriers that currently limit staff from working at the ‗top of their scope‘ and supporting core competency development are important. Nursing is recognised as a group with potential for development to meet the challenges of the future. The development of a district wide registered nurse professional and educational pathway is seen as one way to enable expansion of practice for this significant staff group. The Director of Nursing & Midwifery will take the lead in this initiative. HWNZ has identified that a key priority for 2013/14 for the Regional Training Hub is to improve regional standardisation of medical training opportunities for PGY1 and PGY2‘s. Career plans for all employees receiving HWNZ funding for training/education purposes is to be progressed. DHBs also need to assist with the implementation of the revised General Practitioner Employment Programme (GPEP) being rolled out in 2013/14. The South Island Regional Training Hub (SIRTH) takes a regional approach to clinical training. South Island General Manager‘s Human Resources support the implementation of a regional approach to co-ordinated human resource processes for the 2013/14 year. As more regional workforce initiatives are implemented it is important that sound employment processes underpin development. NMDHB will aim to support and encourage interdisciplinary workforce innovation as new models of service delivery are developed.

NMDHB is working regionally to address the Allied Health Assistant Programme. The systems and processes for implementing the programme will be established in 2013/14. NMDHB is working regionally in the review of qualifications in Disability, Social Services, and Whanau Ora sectors, which has been initiated by the NZ Qualifications Authority. The review of levels of 1 to 6 of the Framework will have implications for the unregulated workforce in this district.

4.3

2013/14 REPORTING AND MONITORING FRAMEWORK

As a NZ Crown Entity, NMDHB is required to report to our monitoring agency, the Ministry of Health, on a regular basis throughout the year. The Reporting and Monitoring Framework involves a number of measures within four dimensions reflecting NMDHB‘s functions as owners, funders, and providers of health and disability services. The four dimensions are: 1. Achieving Government‘s priority/goals and targets or ‗policy priorities‘ 2. Meeting service coverage requirements and supporting sector interconnectedness or ‗system integration‘ 3. Providing quality services efficiently or ‗ownership‘ 4. Purchasing the right mix and level of services within acceptable financial performance or ‗outputs‘ The Reporting and Monitoring Framework is designed to assist stakeholders ‗to see at a glance‘ how well NMDHB is performing across a range of activities but particularly focused on Government priorities.

4.4

INFORMATION SERVICES

NMDHB‘s Information Services are planned on a regional basis. This includes a move to a regional clinical workstation, patient administration system, radiology (imaging), and pharmacy systems. NMDHB is addressing an urgent requirement for a new Patient Administration System (PAS). A South Island regional selection process has contracted with Orion Health to develop the system and will go live on 30 June 2014.

4.5

FACILITIES AND EQUIPMENT

A capital investment programme is being developed in line with the South Island Alliance process, including earthquake strengthening.

4.6

QUALITY AND SAFETY

NMDHB is committed to improving services to the people it serves through the provision of safe and quality care. A new NMHS quality and safety group will develop a system that mirrors the requirements of the Health Quality and Safety Commission and the NZ Triple Aim, and reflect the establishment of a NMDHB Quality Report. There is extensive consumer involvement in the planning and evaluation of services. NMDHB has a Consumer Involvement Strategy which aims to develop and enable a culture of consumer involvement within the organisation. The strategy is supported by a Consumer Involvement policy which outlines the principles supporting consumer involvement in all aspects of care, organisational planning and service monitoring at NMDHB, and outlines the information and process available to staff to achieve consumer participation. NMDHB involves consumer representatives directly in organisational planning and service monitoring at NMDHB. For example, two consumers are on the steering group preparing the first Quality Report (Accounts) for publication in September 2013, two consumer representatives have recently provided feedback on patient education material, such as the ‗Ask 3 Questions‘ brochure, and the ‗Patient Safety‘ brochure. The brochures have been changed in response to feedback. Consumer involvement is being reflected in service development. The diabetes working group has, as part of its work programme, a task to develop a consumer engagement process. This is currently in draft and will be further developed and confirmed. The draft process involves the following steps:  Identifying the consumer stakeholders.  Identify the current known issues.  Determine how the consumer voice will be represented (survey, personal stories, literature review, existing consumer /patient groups).  Convene an initial consumer-only meeting.  Convene a joint meeting.  Determine ongoing engagement. NMDHB will continue whole of system continuous quality improvement utilising a range of proven quality improvement tools with the goal of transforming how we provide care to the people of the district. Integral to quality programmes is the measurement of both clinical and non clinical activity – people, process and structures – that lead to better outcomes. Clinical performance indicators have been agreed across the organisation, they are: falls, medication errors, incidence of pressure

areas, physical assaults on staff, hospital acquired infection rate. These five indicators are reported regularly through Directorates and the quality committee process to ELT and to the Board. The Patient/Family-Centred Strategy established in 2011/12 has achieved its foundation initiatives. In 2013/14 it plans to improve patient feedback mechanisms and educate patients how to be partners in their healthcare and staff how to engage and include patients and their families in health care decisions.

4.7

SUBSIDIARIES, OTHER INTERESTS OR COOPERATIVE ARRANGEMENTS

The Minister of Health has under sections 24 and 28 of the NZPHD Act 2000 approved the following arrangements:  Nelson Marlborough Hospitals‘ Charitable Trust, which holds trust funds for the benefit of public hospitals  Marlborough Hospital Equipment Trust, which provides equipment and other items from public donations raised by the trust  Churchill Private Hospital Trust, which provides private medical and surgical services in Marlborough  South Island Alliance Project Office (SIAPO), which supports the activities of the South Island DHBs by providing services, such as planning and funding audit, analysis and advice and contract management, as determined by the participating DHBs    

An agreement with Nelson Radiology Ltd, which covers a joint Magnetic Resonance Imaging (MRI) service from the Nelson Hospital site Golden Bay Health Alliance for an Integrated Family Health Centre with Nelson Bays Primary Health Trust NBPH and Golden Bay Community Health Trust – Te Hauora O Mohua Trust Appointment of a trustee to the board of the Golden Bay Community Health Trust – Te Hauora O Mohua Trust An agreement with Top of the South Cardiology Ltd which covers private cardiology services from Nelson Hospital.

NMDHB does not hold any controlling interests in a subsidiary company.

4.8

STEWARDSHIP ROLE (OWNER OF CROWN ASSETS)

Description

Physical Assets Buildings and Equipment:

FTEs People

Nelson Hospital delivering the full range of New Zealand Role Delineation Model level 4 secondary services including emergency, surgical and medical specialist (acute and elective), primary and secondary maternity, neonatal, paediatric, specialist health services for older people and support services including diagnostic imaging; also includes the Services Directorates of Medical Surgical Services, Clinical Support Services and Community Based Support Services. Wairau Hospital delivering the full range of New Zealand Role Delineation Model level 3 secondary services including emergency, surgical and medical specialist (acute and elective), primary and secondary maternity, neonatal, paediatric, specialist health services for older people, support services including diagnostic imaging, and mental health services. Mental Health and Addiction services with acute inpatient facilities and community facilities in Nelson and Wairau. Alexandra Hospital in Richmond delivering psycho-geriatric services for older people and aged residential care services for people with dementia. Note: NMDHB is currently in the process of both progressing an RFP for community beds and an alternative delivery model for specialist psycho-geriatric services that will see the closure of Alexandra Hospital over the 2011/13 timeframe.

Waimea Rd Nelson

620

Hospital Rd Blenheim

302.39

Tipahi St & Braemar Campus Nelson; Hospital Rd Blenheim Gilbert St Richmond

219.8

Murchison Hospital and Health Centre delivering the full range of primary care services including ‗Primary Response for Medical Emergencies [PRIME], district nursing services and aged residential care rest home and hospital services for Murchison residents. District Nursing Services located in Motueka. Intellectual Disability Support Services (IDSS) – Nelson community based residential and day activities for people with intellectual and physical disabilities. Needs Assessment and Coordination Services (Support Works) for people with lifelong, long-term conditions and age-related disabilities.

Fairfax St Murchison

11.24

Courtney St Motueka Tahunanui Drive Nelson plus 65 individual community homes Harley St Nelson and Blenheim Hospital Campus

5.5 231.36

NMDHB is a Crown Entity with ownership of:

28.37

30.24

Description

Physical Assets

FTEs

Public Health Unit providing a range of health promotion, health protection and Medical Officer of Health services for Nelson and Wairau. Specialist Dental, School Dental and Adolescent Health Services based in Nelson and Wairau Hospitals and in our communities. Corporate Offices in Nelson for the Chief Executive and members of the Executive Leadership Team (ELT) including the Board Secretary, GM Strategy and Planning, GM Organisational Development, GM Corporate Services; Director of Maori Health and Whanau Ora; Chief Medical Officer; Director of Nursing and Midwifery, with the Nursing and Midwifery Service Development Team. South Island DHB Alliance Project Office (SIAPO) â&#x20AC;&#x201C; ownership shared with Canterbury DHB, South Canterbury DHB, Otago DHB, Southland DHB and West Coast DHB to work collectively together for improved health for the South Island population. In 2013/14 NMDHB is selling the buildings for the Golden Bay Community Hospital to Golden Bay Community Health Te Hauora O Mohua Trust. The land continues to be owned by NMDHB. 20 District Health Boards Shared Services, a national arm of TAS, to ensure organisation and collective delivery of national strategies and the organisation of national service interests.

Franklyn St Nelson and Taylor Pass Rd Blenheim Various locations

48.12

Braemar Campus, Road, Nelson

Hazeldean Rd, Christchurch

Waimea

48.16

Addington,

Takaka Golden Bay TAS Building, L7, 186 Willis St, Wellington

MODULE 5: FORECAST SERVICE PERFORMANCE 5.1

MEASURING OUR PERFORMANCE

Over the longer term, two key roles of the health sector are to make positive changes in the health status outcomes of the population and to do this within the funding provided by Government. DHBs are not solely responsible for achievement of better population health outcomes. Government priorities and national policy and decision-making have a major part to play in making overall population health gains. However, the decisions NMDHB makes both as funder and as provider concerning the majority of health and disability services delivered in this district, has a significant impact on our population‘s health. Understanding the dynamics of our population and the drivers of demand is fundamental when determining which services will be delivered to our population where, by whom and at what level. One of the functions of this AP is to show how NMDHB will evaluate the effectiveness of the decisions we make on behalf of our population. We do this by providing a forecast of the services (outputs) to be funded and provided in 2013/14 (using associated performance measures and targets that reflect quantity, quality, timeliness and service coverage). Our performance is described against these in our end-of-year Annual Report.23 In order to present a representative picture of performance, our outputs have been aggregated into four ‗output classes‘ that are applicable to all DHBs, and are a logical fit with the specific stages of the continuum care depicted below in Figure 1. The four National District Health Board output classes (defined in the following Module) are:  Prevention Services  Early Detection and Management Services  Intensive Treatment and Assessment Services  Rehabilitation and Support Services. We have chosen a mix of measures focused on four key elements of performance:  Volume (V) - to demonstrate volumes of services delivered  Quality (Q) - to demonstrate safety, effectiveness and acceptability  Timeliness (T) - to demonstrate responsive access to services  Coverage (C) - to demonstrate the scope and scale of services provided. Wherever data is available we have included trends in performance (as baseline data) to outline our performance, and compare against national averages to give context in terms of what we are trying to achieve. 24 Over time, we expect to use this output class framework to demonstrate local changes in allocation of resources and quantum of activity and quality outcomes from across the continuum of care. Overall progress in achieving the desired health outcomes for our population will be demonstrated.

23 24

DHB performance is also measured by the Ministry of Health through quarterly reporting against the Performance Monitoring Framework (refer to Appendix 4). A copy of previous years‘ Annual Reports can be found on the DHB website: www.nmdhb.govt.nz Some measures being developed relate to new services for which there is no baseline data. A number also relate to NMDHB specific services for which there is no national comparison or national average available. These instances have been noted.

Figure 1: Scope of DHB Operations – Output Classes against the Continuum of Care DHB Scope of Operations Aggregated Health & Disability Needs

General Population

Population with Long Term Conditions

Population with Early Conditions

At Risk Population

Population with EndStage Conditions

The Populations’ ‘of need’ (Health Need Groups)

Population Health Continuum of Care

Objectives

Live Well and Be Health Literate

Access appropriate care & make healthy Choices

Support to selfmanage & access to expert guidance

Prevent avoidable deterioration & support to manage progression

Die with dignity & support for whanau post-bereavement

What the ‘Health Sector’ should enable them to do

Supported Self-management and care Health Promotion, Protection & Injury/Illness Prevention

Health Sector ‘Service’ Activities

Population & At-Risk Screening, Education & Early Detection Diagnosis, Curative Treatment, and Care Coordination and Case Management Recovery, Rehabilitation, Respite, Home & Residential Supportive care Palliative Care for end of condition / end of life , and support (patient/ whanau)

The ‘Health Services & Interventions’ we supply to meet the health & disability support needs of our people

Services & Products Delivered & Provided to the Population Aggregated Outputs

Output Class 1: Prevention Services

Output Class 2: Early Detection and Management

Output Class 3: Intensive Assessment and Treatment

DHB OUTPUT CLASSES

Output Class 4: Rehabilitation & Support

The ‘Products & Services’ we fund & deliver to meet the needs of our people 25

In setting performance targets we have factored in the growth of our population, the increasing demand for health services due to our ageing population and the rapid increase in health technologies and an assumption that increases in population based funding is limited into the future. Our performance involves measurable trends in quantity and quality of service outputs delivered. The Forecast Financials for each of the Output Class is detailed below. The rest of this module has the detail on the Statement of Service Performance outputs content. Achievement of Ministry of Health Monitoring Framework Performance Measures. In 2012/13 NMDHB has a target of achieving more than 80% of the MOH Monitoring Framework Performance Measures (outstanding, achieved, satisfactory ratings) for the 25 Monitoring Framework Performance Measures reported to the Ministry of Health in Appendix 4) 25

Output Class Statement of Financial Performance Forecast Prevention Services Output Class Statement of Financial Performance $000s Revenue Expenditure Personnel Costs Outsourced services Clinical Supplies Infrastructure Provider Payments Total Expenditure Net Surplus/(Loss)

2013_14 Plan 7,422 3,847 135 74 661 1,845 6,563 860

Forecast Intensive Assessment and Treatment Services Output Class Statement of Financial Performance

$000s Revenue Expenditure Personnel Costs Outsourced services Clinical Supplies Infrastructure Provider Payments Total Expenditure Net Surplus/(Loss)

2013_14 Plan 217,773 109,515 7,757 29,915 30,528 40,292 218,006 (233)

Forecast Early Detection and Management services Output Class Statement of Financial Performance $000s Revenue Expenditure Personnel Costs Outsourced services Clinical Supplies Infrastructure Provider Payments Total Expenditure Net Surplus/(Loss)

2013_14 Plan 111,200 20,972 1,809 1,140 6,644 80,632 111,197 2

Forecast Support Services Output Class Statement of Financial Performance

$000s Revenue Expenditure Personnel Costs Outsourced services Clinical Supplies Infrastructure Provider Payments Total Expenditure Net Surplus/(Loss)

2013_14 Plan 91,477 21,035 964 3,151 6,866 60,090 92,106 (629)

5.2

OUTPUT CLASS: PREVENTION SERVICES

Output Class Description2627 Preventative health services promote and protect the health of the whole population, or identifiable sub-populations, and influence individual behaviours by targeting population-wide changes to physical and social environments to influence and support people to make healthier choices. These services include:  education programmes and services that raise awareness of risk behaviours and healthier options  legislation, regulation and policy that protects the public from toxic environmental risks and communicable diseases  population-based immunisation and screening programmes that support early intervention to maintain good health. Funding and delivery of these services are the responsibility of many organisations across the district, including: the Ministry of Health; NMDHB Community Based Services Directorate Public Health Unit; primary care services and general practice; a number of non-government organisations; and local Government. A mix of public and private funding is used to provide these services .28

Why is this Output Class significant for NMDHB? These services support people to address any risk factors that contribute to long-term conditions development. They enable people to avoid, delay or reduce the impact of these conditions on their quality of life. High health need and atrisk population groups (low socio-economic Maori and Pacific) who are more likely to engage in risky behaviours and to live in environments less conducive to making healthier choices are targeted. Preventative services are our best opportunity to target improvements in the health of these high need populations to reduce inequalities in health status and improve population health outcomes. These services ensure that threats to the health of the community are detected early and prevented. These services also respond to emergency events such as pandemics or earthquakes.

What are the output class major sub-sets and how are they described? 

    

Health Promotion and Education Services: Health promotion has been defined by the World Health Organisation's 2005 Bangkok Charter for Health Promotion in a Globalised World as ‗the process of enabling people to increase control over their health and its determinants, and thereby improve their health‘. The primary means of health promotion occur through developing healthy public policy that addresses the prerequisites of health, such as income, housing, food security, employment, and quality working conditions. Health Education services inform people about health matters and support them to be healthy. Success is measured by greater awareness, engagement and the volume of programmes that support people to maintain wellness, and assist them to change personal behaviours. Statutory and Regulatory Services are services which sustainably manage environmental elements and risks in a way that supports people and communities to make healthier choices and maintain their health and safety. These services are frequently delivered by public health units and include effective quarantine and bio-security procedures, proper management of hazardous substances, assurance of safe drinking water, and compliance monitoring with liquor licensing and smoke environment legislation. Population Based Screening Services are services mostly funded and provided through the National Screening Unit that help to identify people at risk of illness earlier including breast screening, cervical cancer screening, newborn hearing testing, antenatal HIV screening, etc. The DHB‘s role is to encourage uptake, as indicated by high coverage rates. Immunisation Services are services which prevent the outbreak of vaccine-preventable diseases and unnecessary hospitalisations. The DHB works with primary care and allied health professionals to improve the provision of immunisations across all age groups both routinely and in response to specific risk. A high coverage rate is indicative of a well-coordinated and successful approach to immunisation delivery for our region. Well Child Tamariki Ora Services are a screening, surveillance, education and support services offered to all New Zealand children and their family or whanau from birth to five years. It assists families and whanau to improve and protect their children‘s health. Services in our district are provided by Plunket, Maori Health Providers and the Public Health Service. Mental Health Promotion are services that promote a social and physical environment that enhances mental health and resiliency. These services promote mental wellbeing; raise knowledge of mental illness including recognition of early warning signs and availability of appropriate interventions; and reduce stigma and discrimination towards people who experience mental illness.

For a full definition of the output classes refer to Appendix 7 This SFSP uses 2009/10 data as our baseline and compares with expected performance in 2012/13 to provide the trend and progress for increasing the level of service delivery 28 A full description of NMDHB Prevention Services are contained in the Public Health Service Draft Annual Plan for July 2012 to June 2013 26 27

Measuring Our Performance Why is this outcome a priority?

Outcomes Measures Long-term (5-10 years)

Associated Outcome Measures – we will know we are succeeding when there is: A reduction in smoking rates particularly for youth. 

Tobacco smoking kills an estimated 5,000 people in New Zealand every year, including deaths due to second-hand smoke exposure. Smoking is also a major contributor to preventable illness and long-term conditions. It is a major cause of lung (and a variety of other) cancer, as well as chronic obstructive pulmonary disease, heart disease and stroke.



NMDHB is reducing smoking rates in its population. Data shows that in addition to an almost 50% reduction in the number of daily and regular smokers among Nelson Marlborough 14- and 15-year-olds over the last ten years, the number of ‗never smokers‘ has almost doubled (Figure 2).

90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

Never % Regular % Daily % 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 201…

5.2.1

Figure 2. Smoking by 14 & 15 year-olds in NMDHB

% of 14-15 year olds

New Zealand is experiencing a growing prevalence of long-term conditions such as diabetes and cardiovascular disease, which are major causes of poor health and morbidity and account for a significant number of presentations in primary care and admissions to hospital and specialist services. With an ageing population, the burden of long-term conditions will increase. The World Health Organisation (WHO) estimates more than 70% of health funding is spent on long-term conditions. Supporting people to reduce risk factors and make healthy choices will enable them to attain a higher quality of life and to avoid, delay or reduce the impact of long-term conditions. Tobacco smoking, inactivity, poor nutrition and rising obesity rates are major and common contributors to a number of the most prevalent long-term conditions and are avoidable risk factors, preventable through a supportive environment, improved awareness and personal responsibility for health and wellbeing.

Data sourced from the ASH Year 10 Snap shot Survey 2010 ASH Year 10 snapshot survey. The Year 10 survey is an annual questionnaire of around 30,000 students in New Zealand. It is conducted each year in schools throughout the country and is one of the biggest surveys of its kind. It has been going for a decade and gives us a valuable and robust insight into youth smoking. Each year ASH publishes a summary report showing youth smoking trends. Available at http://www.ash.org.nz/?t=139 1

Figure 3. NMDHB vs NZ Obesity Rates 60.0 50.0

A reduction in obesity rates locally in comparison to NZ rates

40.0



There has been a rise in the prevalence of obesity in New Zealand in recent decades and the 2006/07 NZ Health Survey found that 1 in 4 adults (26.5%)2 and 1 in 12 children (8.3%) were obese. This has implications for rates of cardiovascular disease, diabetes, respiratory disease, some cancers, poor psychosocial outcomes and reduced life expectancy.

30.0



NMDHB‘s Nutrition and Physical Activity (NPA) Programme is a 5-year district-wide strategy aimed at sustainable change to improve nutrition and physical activity. The results of the Baseline Survey (2008) shown in Figure 3 reveal that while the weight profile of NMDHB residents is better than that of NZ as a whole, more than 55% of Maori and 40% of non Maori are overweight or obese. The results of repeat study are expected in 2012.

20.0 10.0 0.0

NMDHB Maori NMDHB NonMaori NZ Maori

NZ Non-Maori

Data sourced from Nutrition and Physical Activity Survey 2011

Impact Measures medium term (3 to 5 years) associated with achieving regional outcomes

Weight Grouping Over the next three years, NMDHB will seek to make a positive difference (impact) on the health and wellbeing of its population and to contribute to longer-term regional outcome goals. The effectiveness of the services NMDHB funds and delivers, and the contribution they make, will be measured using the following impact measures:

An increase in the proportion of children who are fully breast-fed 

Breastfeeding helps lay the foundations of a healthy life for a baby, contributing positively to infant health and wellbeing, reducing the likelihood of obesity later in life, contributing to the health and wider wellbeing of mothers.



Although breastfeeding is natural, it sometimes does not come naturally which is why it is important that mothers have access to appropriate support and advice. As such, increased breastfeeding rates are seen as a good proxy measure of successful engagement and a change in the social and environmental factors that influence and support breastfeeding.

Data sourced from Plunket via the Ministry of Health .4 Breastfeeding data is reported annually on calendar rather than financial years, and is based on the national DHB performance indicator S17

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

70% 60%

50% Māori Pacific Other

40%

Māori

30%

Pacific

20%

Other

10% 0%

Rate

2008-09 2009-10 2010-11 2011-12

Figure 6. NMDHB Children Exclusively and Fully Breastfed at 6 Months

Figure 5. NMDHB Children Exclusively and Fully Breastfed at 3 Months

Figure 4. NMDHB Children Exclusively and Fully Breastfed at 6 Weeks

Rate

40% 35% 30% 25% 20% 15% 10% 5% 0%

Rate



Figure 7 shows that nearly 60% of infants in Nelson Tasman5 are enrolled with a GP by 8 weeks of age.



Linking newborns to primary care in this way would not only work synergistically with immunisation but also sets up the links to primary care at this crucial time in these children‘s lives.

Data sourced from Nelson Bays Primary Health and NMDHB.

Other Rate

Rate

2008-09 2009-10 2010-11 2011-12 Figure 7. Nelson Bays PHO - Percent Newborns enrolled with GP's - Jan to Dec 2011

An increase in the percentage of babies enrolled with a General Practitioner (GP) at 4 weeks of age NMDHB has begun work towards monitoring the percentage of babies enrolled with a GP at 4 weeks of age with the end of maximising this early enrolment. To date only one of the two Primary Health Organisations (PHOs) has information systems able to monitor this.

Pacific

Rate

2008-09 2009-10 2010-11 2011-12



Māori

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

An increase in the proportion of the adult population who have healthier diets 

Good nutrition is fundamental to health, the prevention of disease and disability. Nutrition-related risk factors (such as high cholesterol, high blood pressure, obesity and inadequate fruit and vegetable intake) jointly contribute to two out of every five deaths in NZ each year (approximately 11,000).



Appropriate fruit and vegetable consumption helps protect our population against obesity, cardiovascular disease, diabetes, some common cancers and contributes to maintaining a healthy body weight.



An increase in fruit and vegetable consumption is also seen as a good proxy measure of successful engagement and a change in the social and environmental factors that influence people to make healthier choices.

Data sourced from the national NZ Health Survey.

5.2.2

Outputs and Performance Measures 2013/14

Figure 8. Fruit & vegetable intake of NMDHB population 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Adequate fruit intake Adequate vegetable intake

2008

Output subset:

Health Promotion and Education Services

2011

2013 Estimate

Health promotion services work to develop public policy that addresses the prerequisites of health such as income, housing, food security, employment, and quality working conditions. Health Education services inform people about the risks and support them to be healthy. Success begins with awareness and engagement, reinforced by programmes that support people to maintain wellness or assist them to make healthier choice. Change is indicated by rates of positive or negative behaviours (such as smoking rates).

Output Subset:

Statutory Regulation Services

Output Subset:

Population-Based Screening Services

Output Subset:

Immunisation Services

Output Subset:

Well Child / Tamariki Ora Services

Output Subset:

Mental Health Promotion Services

These services sustainably manage environments to support people and communities to make healthier choices and maintain health and safety. They include compliance monitoring with Smokefree environment legislation, assurance of safe drinking water, proper management of hazardous substances and effective quarantine and bio-security procedures.

These services are mostly funded and provided through the National Screening Unit and help to identify people at risk of illness and pick up conditions earlier. They include breast and cervical cancer screening and antenatal HIV screening. The DHB‘s role is to encourage uptake, as indicated by high coverage rates.

These services reduce the transmission and impact of vaccine-preventable diseases. The DHB works with primary care and allied health professionals to improve the provision of immunisations across all age groups both routinely and in response to specific risk. A high coverage rate is indicative of a well-coordinated and successful service. Work with Plunket as the national provider to ensure high coverage and quality of Well Child services in the district, in line with service specifications. Well Child services delivered locally by Public Health services and Maori Health providers. Public Health Services under the Community-Based Services Directorate will deliver B4 School Checks to all children in their fourth year of age.

The Children of Parents with Mental Illness service is targeted to intervene earlier and facilitate access to community, primary and specialist health supports. The service is aimed at building resilience and averting future adverse outcomes for infants, children and youth.

5.3

OUTPUT CLASS: EARLY DETECTION AND MANAGEMENT SERVICES

Output Class Description

Early detection and management services cover a broad scope and scale of services provided across the continuum of care activities to maintain, improve and restore people‘s health. These services include:  detection of people at risk and with early disease  more effective management and coordination of people with long-term conditions. These services are by nature more generalist, usually accessible from multiple providers and a number of different locations. Providers include:  general practice services  primary and community services  personal and mental health services  Maori and Pacific health services  pharmacy services  diagnostic imaging services  diagnostic laboratory services  children and youth oral health and dental services. A significant proportion of these services are demand driven, such as pharmacy, community radiology and diagnostic laboratory services. These services are provided with a mix of public and private funding and may include copayments for general practice and pharmacy services.

Why is this Output Class significant for NMDHB?

New Zealand is experiencing an increasing prevalence rate of long-term conditions such as diabetes and cardiovascular disease, and some population groups suffer from these conditions more than others, for example, Maori and Pacific people, older people and those on lower incomes. The health system is also experiencing increasing demand for acute and urgent care services. For NMDHB cancer, respiratory disease, chronic pain and dementia are significant long-term conditions that are prevalent locally. Early detection and management services based in the community deliver earlier identification of risk, provide opportunity to intervene in less invasive and more cost-effective ways, reduce the burden of long-term conditions through supported selfmanagement (avoidance of complications, acute illness and crises). These services deliver coordination of care, supporting people to maintain good health. Below is the description of the sub-sets of services that make up this output class:  Primary Health Care (GP) Services are services offered in local community settings by a primary care team including general practitioners (GPs), registered nurses, nurse practitioners and other primary health care professionals aimed at improving, maintaining or restoring people‘s health. High levels of enrolment with general practice are indicative of engagement, accessibility and responsiveness of primary care services. 



Oral Health Services are services provided to assist people in maintaining healthy teeth and oral tissues and are provided by approved registered oral health professionals. High enrolments are indicative of engagement, while more timely examination and treatment of children will indicate a well functioning and efficient approach to delivery. Programmes of Integrated Care. Components of programmes integrated care29 include: - Self-management support and patient education: Self-management support involves collaboratively helping patients and their families acquire the skills and knowledge to manage their own illness, providing selfmanagement tools and routinely assessing problems and accomplishments. Education is giving the patients information (materials and/or instructions) regarding their condition and possible management.

Figure 9: Nelson Marlborough % of 5 year olds Caries Free 80%

Maori

70%

60%

Pacific

50% Total

40% 30%

Southern Region

20% 10%

National

0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

See ―Integrated Care Programmes for Chronically Ill patients: a review of systematic reviews. Marielle Ouwens, Hub Wollersheim, Rosella Hermens, Marlies Hulscher Richard Grol. Int J Qual Health Care (2005) 17 (2): 141-146. doi: 10.1093/intqhc/mzi016 First published online: January 21, 2005 29

Clinical follow-up: This means monitoring the patient after or during treatment on a close regular base. This is often done by a nurse case manager who uses a phone, mailings, or visits. Clinical follow-up can be seen as part of self-management support.

Case management: This means explicit allocation of coordination tasks to an appointed individual (a case manager) or a small team who may or may not be responsible for the direct provision of care. The case manager or team takes responsibility for guiding the patient through the complex care process in the most efficient, effective and acceptable way. A multidisciplinary patient care team: This is composed of a group of professionals who communicate with each other regularly about the care of a defined group of patients and participate in that care. Multidisciplinary clinical pathway: Clinical pathways or integrated care pathways are structured multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem and describe the patient‘s expected clinical course. Clinical pathways should be derived from evidence-based guidelines translated into practice. Figure 10: Adolescent Oral Health Service Utilisation by DHB in 2010 Feedback, reminders, and education for professionals: The aim of feedback, reminders, and education is to provide health care providers with information regarding appropriate care for patients. This information can come from clinical pathways, medical records, computerised databases, patients, or audits by colleagues. Feedback is given after the consultation; education is given before consultation; reminders are given before or during consultation. Additional requirements: (i) Supportive clinical information system; (ii) specialised clinics or centres; (iii) shared mission on integrated care; (iv) leaders with a clear vision on integrated care; (v) finances for implementation and maintenance; (vi) management commitment and support; (vii) patients capable and motivated for selfmanagement; (viii) culture of quality improvement.



Pharmacy Services are services aligned to requirements of the pharmaceutical schedule, including provision and dispensing of medicines. Pharmaceuticals are demand driven and we are likely to see an increased dispensing of pharmaceutical items, as more people engage with health services. To improve performance, NMDHB will target medication management for people on multiple medications to reduce potential negative interactive effects.



Community Referred Testing and Diagnostic Imaging Services are services30 to which a health professional may refer a person to help diagnose a health condition, or as part of treatment. They are provided by personnel such as laboratory technicians, medical radiation technologists and nurses. These services are demand driven and are likely to increase as more people engage with health services and respond to health promotion messages about early diagnosis. To improve performance, we will target an increase in the number of community referred radiological images (MRI, CT, Coronary angiography, Ultrasound), as an indication of improved primary care access to diagnostics, without the need for a hospital appointment.



Infection Control comprises services that are committed to prevention of infections and occupational exposures throughout the healthcare continuum. The programme manages and minimises the infection risk by incorporating measures/interventions that are required to prevent pathogen transfer between patients, staff and visitors and in safe-guarding patients from developing infections due to, or resulting from, medical interventions.



Primary and Mental Health Services are services that are delivered in a primary care setting for the assessment, treatment and when needed the ongoing management of people with mild to moderate mental health and/or addiction issues. This includes promotion, prevention, early intervention and ongoing treatment.

5.3.1

Impact Measures medium term (3 to 5 years)

Over the next three years, NMDHB will seek to make a positive difference (impact) on the health and wellbeing of its population and to contribute to longer-term regional outcome goals. The effectiveness of the services NMDHB funds and delivers, and the contribution it makes, will be measured using the following impact measures:

An increase in the proportion of children who have good oral health



Regular dental care has life-long benefits for improved health and wellbeing, demonstrating the need for early contact with health promotion and prevention services and reduced risk factors, such as poor diet, which has benefits in terms of improved nutrition and healthier body weights.



Oral health is also an integral component of lifelong health and includes a person‘s comfort in eating (and ability to maintain good nutrition in old age), their self esteem, mental wellbeing and quality of life.

Laboratory, imaging procedures, cardiology/physiological procedures, audiology services, neurology services, endocrinology services

Maori children are three times more likely to have decayed, missing or filled teeth, and improved oral health is a good proxy measure of equity of access to services and the effectiveness of mainstream services in targeting those most in need.



While water fluoridation can significantly reduce tooth decay across all population groups, no children in our district have access to fluoridated water. Achievement against this measure indicates the accessibility and effectiveness of publicly-funded oral health programmes.

Data sourced from Ministry of Health. 7 Oral health data is reported annually for the school year (i.e. calendar year) and is based on the national DHB performance indicator PP11

An increase in the percentage of eligible adolescents engaging with the Adolescent Oral Health service The percent of eligible adolescents engaging with Adolescent Oral Health services was greater than 80% in 2010. This is an indicator for better oral health for adolescents which predetermines adult oral health. Oral health is important in achieving better health outcomes. An increase in adolescents utilising DHB-funded oral health services should translate in better overall oral health and health in general. Data sourced from Ministry of Health http://www.moh.govt.nz/moh.nsf/indexmh/oralhealth-statistics/#adolescent

The rate of engagement with the service in Nelson Marlborough has increased substantially since 2001 (Figure 11). NMDHB aims to meet the agreed health target. This graph illustrates that our district is achieving its goal in ensuring better oral health outcomes for adolescents and, by abstraction, adults.

Figure 11: Adolescent Oral Health Service Utilisation Over Time % of eligible adolescents using services



100%

Nelson/ Marlborough

90% 80%

All DHBs

70% 60% 50% 40% 30%

Data sourced from Ministry of Health http://www.moh.govt.nz/moh.nsf/indexmh/oralhealth-statistics/#adolescent

An increase in the proportion of eligible people receiving Vascular Risk Assessments  ‗Long term conditions‘ comprises the major health burden for New Zealand now and into the foreseeable future. This group of conditions is the leading cause of morbidity in New Zealand, and disproportionately affects Māori, Pacific and South Asian peoples. As the population ages, and lifestyles change, these conditions are likely to increase significantly.  Cardiovascular disease (CVD) includes heart attacks and strokes – which are both substantially preventable with lifestyle advice and treatment for those at moderate or higher risk. Diabetes tests are included as part of the overall CVD risk assessment.  More people receiving vascular risk assessments means more people are given the opportunity to prevent adverse health events from CVD and diabetes. Source MoH website document "Health Targets quarter one 2011/12 interactive spreadsheet" & "Health Targets quarter one 2010/11 interactive spreadsheet” http://www.health.govt.nz/new-zealand-health-system/health-targets/how-your-dhb-performing/how-your-dhb-performing-2011-12

5.3.2

Outputs and Performance Measures 2013/14

Output Subset:

Primary Health Care (GP) Services

These services are offered in local community settings by teams of general practitioners (GPs), registered nurses, nurse practitioners and other primary health care professionals, aimed at improving, maintaining or restoring people‘s health. High levels of enrolment with general practice are indicative of engagement, accessibility and responsiveness of primary care services.

Figure 12: The percentage of the eligible population who have had their cardiovascular risk assessed in the last five years 80%

2011/12 Q1

70%

60%

2012/13 Q1

50% 40%

2013/14 Q1 Estimate

30% 20%

2012/13 Target

10% 0% Maori

Other

Total

Keep more people well by:  intervening early to detect, manage and treat existing health conditions  better education and advice so people can manage their own health  reaching those at risk of developing long-term or acute conditions.

Output Subset:

Oral Health Services

Output Subset:

Primary and Community Programmes of Care

Output Subset:

Community Pharmacy Services

Output Subset:

Community Referred Testing and Diagnostics

Output Subset:

Infection Control

Output Subset:

Primary Mental Health

These services are provided by registered oral health professionals to assist people in maintaining healthy teeth and gums. High enrolments are indicative of engagement, while more timely examination and treatment indicates a wellfunctioning and efficient service. We are influencing the oral health status of young children through:  Implementation of the new model of care for primary school and pre-school children through the Community Oral Health Hubs, including  Targeting children and adolescents living in disadvantaged areas with oral health promotion programmes  Work with Well Child Tamariki Ora providers to increase the enrolment of preschool children with the service We maintain utilisation of dental service for adolescents through maintaining access to services and ensuring dental service providers operate effective recall systems. We are improving access to dental services for low income adults.

These services are targeted at people with high health need due to long-term conditions and aim to reduce deterioration, crises and complications. Success is demonstrated through identification of need, regular monitoring and outcomes that demonstrate successful management of conditions. A focus on early intervention strategies and additional services available in the community will help to reduce the need for hospital appointments. The services provide:  community programmes that support keeping people well and address inequalities  targeted interventions for people to support areas of key inequality such as clinical interventions for people with asthma and other respiratory conditions, and podiatry services.

These services include provision and dispensing of medicines and are demand-driven. As long-term conditions become more prevalent, we are likely to see an increased dispensing of pharmaceutical items. To improve service quality we will introduce medication management for people on multiple medications to reduce potential negative interactive effects. We are:  implementing safe and effective pharmacy services across settings of care (hospital and community) assisted by the Rutherford Performance Programme.  implementing the first phase of the new community pharmacy service model  working with PHO and NMDHB hospital prescribers on chronic non-malignant pain pharmacological best practice approaches.

These are services to which a health professional may refer a person to help diagnose a health condition, or as part of treatment. They are provided by personnel such as laboratory technicians, medical radiation technologists and nurses. To improve performance, we will target improved primary care access to imaging diagnostics to improve clinical referral processes and decision making. We are further maximising utilisation of diagnostic tests and procedures to ensure early detection and diagnosis of a patient condition and to assist effective assessment and treatment of a patient condition under treatment.

These services:  minimise and manage the infection risks by incorporating measures and interventions required to prevent pathogen transfer between patients, staff and visitors  monitor and refine systems used to manage the infection risks within NMDHB as per NZS 8134:2008  safeguard patients from developing infections due to, or resulting from medical interventions  participate in three national programmes including hand hygiene, central line associated blood stream infections, and surgical site infection reduction.

These services are targeted to those general practice patients with mild to moderate mental health problems/symptomology. Target populations are Maori, Pacific and lower socio economic incomes. A range of services are provided including extended general practice consultations, packages of care, brief intervention clinical services and an anxiety disorder programme. Outcomes expected are improved access and flow through community, primary and specialist mental health services; and improved mental health wellbeing. .

5.4

OUTPUT CLASS: INTENSIVE ASSESSMENT AND TREATMENT SERVICES

Output Class Description

Intensive assessment and treatment services are services that are complex and provided by specialists and other health care professionals working closely together in multi- and interdisciplinary teams. These services are therefore usually (but not always) provided in hospital settings that enable the co-location of clinical expertise and specialist equipment. These services include ambulatory services, inpatient and outpatient services, and emergency or urgent care services. As the local provider of hospital and specialist services, NMDHB provides an extensive range of intensive treatment and complex specialist services to our population. NMDHB also funds some tertiary and quaternary intensive assessment and treatment services for our population provided by other DHBs, private hospitals and private providers. A proportion of these services are driven by demand, such as unplanned (acute) and maternity services. However, others are planned (elective) services for which access is determined by capability, capacity, resources, clinical triage, national service coverage agreements and treatment thresholds.

Why is this Output Class significant for NMDHB? Equitable timely access to intensive assessment and treatment can significantly improve people‘s quality of life, either through early intervention (i.e. removal of an obstructed gallbladder so that the patients does not have repeat attacks of abdominal pain/ colic, increased risk of cancer and/or infection) or through corrective action (i.e. major joint replacements to relieve pain and improve activity). Flexible and responsive assessment and treatment services can also support improvements across the whole system, enabling people to be supported in the community with confidence that complex intervention will be available when needed. It would then be expected that our population is able to establish greater lifestyle stability, based on improved public confidence in the health system and utilisation overall. As an owner and provider of these services, the DHB is also concerned with the quality of the services being provided. Adverse events in hospital, as well as causing harm to patients, drive unnecessary costs and redirect resources away from other services. Quality improvement in service delivery, systems and processes will improve patient safety, reduce the number of events causing injury, and provide improved outcomes for people in our services. Government has set clear expectations for the delivery of increased elective surgical volumes, a reduction in waiting times for treatments and increased clinical leadership to improve the quality of care being delivered. The changes being made to meet Government expectations are providing unique opportunities to introduce innovative clinically led service delivery models and improve productivity within our hospital services.

Description of the sub-sets of services that make up this output class 

 

Inpatient Planned and Unplanned Services are services that include: - Planned (Elective) Services are services for people who do not need immediate hospital treatment and are ‗booked‘ services. This includes elective surgery, but also non-medical interventions (such as coronary angioplasty) and specialist assessments (either first assessments, follow-ups or preadmission assessments). National Elective Services Patient Flow Indicators (ESPIs) are indicative of a successful and responsive service, addressing increasing needs and matching commitments to capacity. - Unplanned (Acute) Services are services for illnesses that have an abrupt onset and are often of short duration and rapidly progressive, creating an urgent need of care (NB: they may or may not lead to a hospital admission). Hospital-based acute services include emergency departments, short-stay acute assessments and intensive care services. Performance against clinical triage guidelines is used to demonstrate the capacity and responsiveness of the system. Productivity measures such as length of stay rates are balanced with outcome measures such as readmission rates to indicate the quality of service provision. - Specialist Mental Health Services are services for people who are most severely affected by mental illness or addictions and include assessment, diagnosis, treatment and rehabilitation, as well as crisis response when needed, and as required under the Mental Health Act. Currently the expectation established in the National Mental Health Strategy is that specialist services (including psychiatric disability services) will be available to 3% of the population. Utilisation rates will be monitored across age groups and ethnicities to ensure service levels are maintained and to demonstrate responsiveness. Maternity Services are services provided to women and their families through pre-conception, pregnancy, childbirth and for the first months of a baby‘s life. These services are provided in home, community and hospital settings by a range of health professionals, including midwives, GPs and obstetricians and include: specialist obstetric, lactation, anaesthetic, paediatric and radiology services. We will monitor volumes in this area to determine access and responsiveness of services. Specialist Assessment, Treatment, and Rehabilitation Services are services provided to people who experience disability or age-related disorders to restore people‘s functional ability and enable them to live as independently as possible. Services are delivered in specialist inpatient units, outpatient clinics and also in home and work environments. Specialist geriatric and allied health expertise and advice is also provided to general practitioners, home and community care providers, residential care facilities and voluntary groups. An increase in the rate of people discharged home with support, rather than to residential care or hospital environment (where appropriate) will be indicative of success and of the responsiveness of services.

Secondary-level hospital and specialist services meet people‘s complex needs, are responsive to episodic events and support the provision of quality community-based care. By providing appropriate and timely access to high quality complex services, health outcomes and quality of life are improved and untimely deaths reduced.

Why is this outcome a priority? Timely access to high quality hospital and specialist services improves health outcomes, and shorter waiting lists and wait times are indicative of a well functioning system matching capacity with demand - managing the flow of patients through its services and addressing the needs of its population. Our Government is concerned that patients wait too long for hospital diagnostic tests, for cancer treatment and for elective surgery. The expectation around reducing waiting times, coupled with the current fiscal situation, means DHBs need to develop innovative ways of assisting more people and reducing waiting times with limited resources. This outcome reflects the importance of ensuring that hospital and specialist services are sustainable and the South Island has the capacity to provide for the complex needs of its population now and into the future. Typically, an organisation‘s capacity is considered to be the means through which an outcome is achieved and not an outcome itself. However, as providers of hospital and specialist services who are operating under increasing demand and workforce pressures, the South Island DHBs have included the provision of timely and appropriate complex care as a Strategic Outcome.

5.4.1

Figure 13. Standardised Unplanned (Acute) Readmission Rate Standardised Acute Reradmission Rate

Regional Strategic Goal 3: People with complex conditions have improved or stabilised health and optimal quality of life expectation

9.00% 8.80% 8.60% 8.40% 8.20%

8.00% 7.80% 2010/11 Q2

2010/11 Q3

2010/11 Q4

2011/12 Q1

Outcomes Measures Long term (5-10 years) Figure 14. Unplanned (acute) readmission rates across all 20 DHBs

13.00

Associated Regional Outcome Measures - We will know we are succeeding when there is: 12.00



Unplanned acute readmission rates are a measure of quality of care, efficiency and appropriateness of discharge for hospital patients. They are also a quality counter-measure to balance improvements in productivity and reduced lengths of stay, at the same time as our population is ageing and people are presenting with more complex conditions.  Improved patient-focused and clinically driven pathways will support early intervention and planned readmission where clinically appropriate, and deliver improvements in care across the whole continuum. Responsive intervention will also enable people, their families and caregivers to establish more stable lives. Unplanned (acute) readmission rates across all 20 DHBs for the 12 months ending 30 Sept 2010 are shown in Figure 14. The figure shows that NMDHB comes in second, after West Coast. Work to explore reducing this rate further continues.

Acute readmissions (%)

- a reduction in unplanned (acute) readmissions to hospital and specialist services

11.00

10.00

9.00

8.00

7.00

Data sourced from Ministry of Health: http://www.nsfl.health.govt.nz/apps/nsfl.nsf/pagesmh/317?Open



Lakes

Whanganui

Capital and Coast

Taranaki

MidCentral

Northland

Hawkes Bay

Auckland

Waitemata

Bay of Plenty

Waikato

South Canterbury

Tairawhiti

Hutt Valley

Canterbury

Southern

Wairarapa

Counties Manukau

Mortality rates are a measure of clinical outcomes for hospital patients and are related to the safety and efficacy of treatment. Maintaining or improving our current mortality rates will demonstrate maintenance of clinical quality standards and a balance against productivity gains such as reduced length of stay. System and process changes being made to the way we deliver services to patients, such as changes intended to reduce the incidence of falls, pressure ulcers, pneumonia and hospital-acquired infections, will lead to a measurable change in patient mortality.

Nelson Marlborough



West Coast

6.00

- a reduction in mortality (deaths) rates within 30 days of discharge from hospital and specialist services

DHB standardised acute readmission rate

unstandardised acute readmission rate

average

Data sourced from NMDHB Patient Management System

Figure 15. Standardised Mortality Rate within 30 days of discharge

Over the next three years NMDHB will seek to make a positive difference (impact) on the health and wellbeing of the Nelson Marlborough population and to contribute to longer-term Regional Outcome Goals. The effectiveness of the services the DHB funds and delivers, and the contribution it makes, will be measured using the following impact measures.

Meeting the planned (elective) surgical needs of the Nelson Marlborough community through phased production planning and delivery   

Elective surgical procedures have been shown to increase people‘s quality of life, independence and length of life The Minister of Health requires DHBs to deliver an agreed volume of elective surgical discharges each year. NMDHB has funded and delivered more than that volume over the past 5 years within funding provided Production planning enables optimal use of specialist skills, equipment and infrastructure to deliver the most appropriate care

Standardised Mortality Rate

Impact Measures medium term (3 to 5 years) associated with achieving regional outcomes

1.6% 1.4% 1.2% 1.0%

0.8% 0.6% 0.4% 0.2% 0.0% 2008/09

Data sourced from Ministry of Health

Deliver NMDHB share of national increase in access to planned (elective) surgical services   

Elective (non-urgent) services are an important part of the health care system, as these services improve the patient‘s quality of life by reducing pain or discomfort, and improving independence and wellbeing. Timely access to elective services is considered a measure of the effectiveness of the health system. Improving access and reducing waiting times will not only improve health outcomes for our population, but will increase community confidence that the health system will meet their needs. Improved performance against this measure is also indicative of the improved hospital productivity required to ensure the most effective use of resources so that year-on-year growth in elective services can be achieved.

Data sourced from NMDHB Patient Management System

2009/10

2010/11

2011/12 2012/13 Est

Figure 16. Elective surgery discharges per Capita (2011/12) 8,000 7,000 6,000 5,000 4,000

3,000 2,000 1,000 0

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Cumulative Base Planned Electives Cumulative Additional Planned Electives Cumulative Elective Discharges

A reduction in wait times for Urgent Care   

Long stays in emergency departments (EDs) are linked to overcrowding of the ED, negative clinical outcomes and compromised standards of privacy and dignity for patients. Reducing the time spent waiting to receive treatment in the emergency department is indicative of improved service provision and hospital productivity (ensuring resources are being used effectively and efficiently). It is also indicative of a more unified health system, because a coordinated, ‗whole of system‘ response is needed to address the factors that influence ED length of stay. Improved performance against this measure will not only improve outcomes for our population, but will improve the public‘s confidence in being able to access services when they need to, increasing their level of trust in health services.

Data sourced from the NMDHB Patient Management System

Mental Health Measure: PP6 - Service Access Rates by Age and Year - All Mental Health & Addictions Services  

This measure monitors Service access on the basis that sufficient access to specialist mental health services will lead to improvement in quality outcomes for service users/tangata whaiora. NMDHB has the seventh highest total access rate (3.85%) across the 20 DHBs according to PP6 Standing Order Report – Access Rates July 2010 - June 2011.

Data sourced from NMDHB Mental Health & Addictions Service via PRIMHD.

Figure 17. Access to Planned (Elective) Service Measures (From 1 July 2013 no Patients will wait over 5 months) 3.00% 2.00% 1.00% 0.00% Jun-09

Jun-10

Jun-11

Jun-12 1/06/2013 (Est)

ESPI 2: Waiting >6 mths to FSA ESPI 5: Percentage of patients given commitment to treatment, but not treated within six months.

Figure 18. Percent of ED patients admitted, discharged or transferred within 6 hours

Mental Health Measure: Percent of long-term clients with up-to-date relapse plans

Clients of Mental Health Services with long-term and up-to-date relapse plans have been shown to have better outcomes than those who do not. Better outcomes mean a focus on wellbeing and ability to be part of society. This results in reduced acute admissions and avoidance of deterioration in mental health. The graph demonstrates that NMDHB has been able to achieve 95% of long-term clients with these plans since the last quarter of 2007/08. Data sourced from NMDHB Mental Health Service

5.4.2

Outputs and Performance Measures 2013/14

Output Subset:

97.8% 97.6% 97.4% 97.2% 97.0% 96.8% 96.6% 96.4% 96.2%

97.6%

97.4%

97.3%

97.2% 97.0% 96.8%

Inpatient Planned (A – Elective) and Unplanned (B – Acute) Services including Mental Health

A. These are services for people who do not need immediate hospital treatment and are ‗booked‘ or ‗arranged‘ services. This includes elective surgery, but also non-surgical interventions and specialist assessments. B. These are services for illnesses that have an abrupt onset, are often of short duration and rapidly progressive, for which the need for care is urgent. Hospital based acute services include emergency departments, short-stay acute assessments and intensive care services. There are also a number of community-based acute demand programmes and packages of care unique to Nelson Marlborough, established to reduce acute demand.

Output Subset:

Figure 19. Service access rates by age and year - all mental health & addiction

Maternity Services

These services are provided to women and their families through pre-conception, pregnancy, childbirth and for the first months of a babyâ&#x20AC;&#x2DC;s life. These services are provided in home, community and hospital settings by a range of health professionals, including midwives, GPs and obstetricians and include specialist obstetric, lactation, anaesthetic, paediatric and radiology services. We will monitor volumes in this area to determine access and responsiveness of services.

Output Subset:

Assessment Treatment and Rehabilitation

These are services provided to restore functional ability and enable people to live as independently as possible. Services are delivered in specialist inpatient units, outpatient clinics and also in home and work environments. Specialist geriatric and allied health expertise and advice is also provided to general practitioners, home and community care providers, residential care facilities and voluntary groups. An increase in the rate of people discharged home with support, rather than to residential care or hospital environments (where appropriate), is indicative of the responsiveness of services. Establish a comprehensive Specialist Health Service for Older People (SHSOP) team, which consists of health professionals with geriatric and psycho-geriatric expertise, and which will use documented links and pathways with acute mental health, acute medical and surgical services and community providers who have an older personsâ&#x20AC;&#x2DC; client base. The SHSOP service has inpatient as well as community teams.

Figure 20. Percent of long-term clients with up-to-date relapse plans 100.0%

95.0% 90.0% 85.0% 80.0% 75.0% 70.0% Q2 Q4 Q2 Q4 Q2 Q4 Q2 Q4 Q2 2007/08 2007/08 2008/09 2008/09 2009/10 2009/10 2010/11 2010/11 2011/12

5.5

OUTPUT CLASS: REHABILITATION AND SUPPORT SERVICES

Output Class Description

Rehabilitation and support services provide people with the support and assistance they need to maintain maximum functional independence, either temporarily while recovering from illness/disability, or over the rest of their lives. These services are delivered following a ‗needs assessment‘ process coordinated by Needs Assessment and Service Coordination (NASC) services and include domestic support, personal care, community nursing and community services provided in people‘s own homes and places of residence and also long and short-term residential care, respite and day services. Services are provided mostly for older people, mental health clients and for personal health clients with complex health conditions.Support services also include palliative care services for people who have end-stage conditions. It is important that they and their families are appropriately supported, enabling the person to live comfortably, have their needs met in a holistic and respectful way and die without undue pain and suffering. Delivery of these services may require coordination with other organisations and agencies, and may include public, private and part-funding arrangements.

Why is this Output Class significant for NMDHB? Services that support people to manage their needs and live well, safely and independently in their own homes are considered to provide a much higher quality of life, as a result of staying active and positively connected to their communities. People whose needs are adequately met will also be less dependent on hospital and residential services and less likely to experience acute illness, crisis or deterioration of their conditions. Even when returning to, or maintaining full health is not possible, timely access to responsive support services enables people to maximise function with the greatest independence. In preventing deterioration and acute illness or crisis, these services have a major impact on the sustainability of hospital and specialist services and on the wider health system in general. Effective and responsive delivery of support services will help to reduce demand for acute services and improve access to other services and interventions. It will also free up resources for investment into early intervention, health promotion and prevention services that will help people stay healthier for longer. NMDHB has taken a restorative approach and has introduced individual packages of care to better meet people‘s needs, including complex packages of care for people assessed as eligible for residential care who would rather remain in their own homes. With an ageing population, it is vital that we ascertain the effectiveness of services in this area and that NMDHB uses the InterRAI (International Residential Assessment Instrument) tool to ensure people receive support services that best meet their needs and, where possible, support them to regain maximum functional independence.

Description of the sub-sets of services that make up this output class 

Palliative Care Services are services that improve the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early intervention, assessment, treatment of pain and other supports. The DHB will target an increase in the number of sites that support the ‗Liverpool Care of the Dying‘ pathway as this reflects best-practice care.



Support Services: - Needs Assessment and Services Coordination Services are services that determine a person‘s eligibility and need for publicly funded support services and then assist the person to determine the best mix of supports based on their strengths, resources and goals. The supports are delivered by an integrated team in the person‘s own home or community. The number of assessments completed is indicative of access and responsiveness. - Age Residential Care comprises services provided to meet the needs of a person who has been assessed as requiring long-term residential care in a hospital or rest home indefinitely. With an ageing population, a decrease in the number of subsidised bed days alongside an increase in the number of home-based support service hours is seen as indicative of more people being successfully supported to continue living at home. - Respite, Carer Support and Day Programmes are services providing people with a break from a routine or regimented programme so that crisis can be averted or so that a specific health needs can be addressed. Services are provided by specialised organisations and are usually short-term or temporary in nature and may also include support and respite for families, caregivers and others affected. Services are expected to increase over time, as more people are supported to remain in their own homes. - Home-Based Support Services are services designed to support people to continue living in their own homes and to restore functional independence. They may be short or longer-term in nature. Examples include domestic support, personal care and community nursing services. An increase in the number of people being supported is indicative of increased capacity in the system, and success is measured against a decreased or delayed entry into residential or hospital services. - Community Support Services – Mental Health comprises services that support tangata whaiora/service users‘ recovery journey. This includes a wide range of services such as Home Based Support, Residential Housing, Planned and Crisis Respite, Day Activity and Living Skills, Peer Support, Vocational Support and Community Support Work to tangata whaiora/service users living in the community. - Community Support Services – Intellectual Disability Support Services and Physical Disability Support Services are services that provide residential support in community home settings for people with intellectual and physical disability needs. This support is provided on a 24-hour-basis to support the person to maintain as ordinary life as possible to achieve their goals.

Regional Strategic Goal 2: People are supported to Stay Well in their Own Homes and Communities Expectation Primary and community services support people to access intervention, diagnostics and treatment and to better manage their illness or long-term conditions. By providing a point of ongoing continuity and care and assisting people to detect health conditions earlier, treatment and interventions are easier and the complications of disease, injury and illness are reduced. Fewer people need hospital-level or long-stay interventions, and those who do have a greater chance of returning to a state of good health and slowing the progression of disease and illness.

Why is this outcome a priority? For most people, their GP is their first point of contact with health services. Primary care can deliver services closer to home and is one of the most effective ways to prevent disease through screening, early detection and provision of the most effective treatment as soon as possible. Primary care is also vital as a point of continuity and effective coordination across the continuum of care and for improving the management of care for people with long-term conditions. Supporting primary care are a range of health professionals including midwives, community nurses, allied health, aged residential care providers, Maori health providers and pharmacists who work in the community, often with the neediest families. These providers deliver beneficial services to people in the community and have prevention and early intervention perspectives that link people with other services and community agencies and further improve the management of illness and long-term conditions. Studies show that countries with strong primary and community care systems have lower rates of death from heart disease, cancer and stroke, and that they achieve better health outcomes for lower cost, than those countries with systems that focus only on specialist or tertiary level care. With an ageing population, the South Island will require strong primary care systems and strong support services delivered in the community, including residential care, respite and responsive short-term and home-based support. If long-term conditions are managed effectively, crises and deterioration can be reduced and health outcomes improved. Even where returning to full health is not possible, access to flexible, responsive, needs-based services can support people to maximise function with the least restriction and dependence. A strong community and primary base will reduce the rate of hospital admissions, particularly acute and unplanned admissions, and will not only improve health outcomes for our population but will free up health resources, allowing them to be directed to other priority areas

5.5.1

Outcomes Measures Long term (5-10 years)

Associated Regional Outcome Measures - We will know we are succeeding when there is:

An increase in the proportion of the population who are supported to better manage their long-term conditions resulting in a reduction in acute hospital discharges. 

The impact of long-term conditions in terms of quality of life and cost to the health system is significant. By improving the management of long-term conditions and reducing the deterioration of conditions, people are supported to live more stable healthier lives, without the complications that lead to acute illness and crisis.



Acute admissions can be used as a proxy measure of the improved management of long-term conditions by indicating that conditions are being better managed earlier, without escalation to an event needing urgent and complex intervention.



Reducing acute admissions also has a significant effect on productivity in hospital and specialist services - enabling the DHB to redirect resources and avoided costs into the provision of elective services which can otherwise be ‗crowded out‘ by demand for urgent and acute care.

Data sourced from NMDHB Patient Management System

While living in Age Related Residential Care (ARRC) is appropriate for a small proportion of our population, Nelson Marlborough rates are above national averages. When people receive adequate support for their needs to be managed, remaining in their own homes is considered to provide a much higher quality of life as a result of staying active and positively connected to their communities. Living in ARRC facilities can be associated with a more rapid functional decline than ‗ageing in place‘. It is also a more expensive option, and resources could be better spent providing appropriate levels of support to people in their own homes. The aim is to support older people to stay well as long as possible rather than entering ARRC facilities. Data sourced from SIAPO

#'s vs proportion of population

A reduction in the number of people supported in Age Related Residential Rest Home Level Care in comparison to other SI DHBs

Figure 21. Reduced proportion of people over 65 years in ARRC Dementia

Hospital Care

Psychogeriatric

Rest Home

2000% 1500% 1000% 500% 0% Canterbury

An increase in the proportion of the population aged over 65 who need support are supported to live well, in their own homes, with a decrease in rest home clients The graph opposite outlines the trend in NMDHB following the introduction of restorative Home Based Support Services ‗packaged interventions‘ for people with complex and non-complex needs. High needs complex clients are at risk of requiring age residential care but are being supported to remain at home. Respite care is part of this approach in order to enable ‗caregivers‘ in the home to have appropriate break to preserve their health and wellbeing. Data sourced from Support Works

Nelson South Marlborough Canterbury

Southern

West Coast

Figure 22. NMDHB Rest Home clients per capita of population

0.50% 0.48% 0.46%

2009/2010

0.44%

2010/2011

0.42%

2011/2012

0.40% 0.38%

2012/2013 2013/14

A reduction in the number of people admitted with malnutrition Discharges following admissions with malnutrition are shown in Figure 23. The figure shows that admissions of people with malnutrition have fallen since 2008/09. This is probably due to a combination of factors, such as the Nutrition and Physical Activity Programme, the new model of goal-orientated Home Based Support Services and the increased level of nursing care in aged residential care facilities.

Data sourced from NMDHB

Figure 23. Reduction in number of people aged 65+ admitted with malnutrition

0 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011 2011/12

Maintain people aged over 65 years healthily in the community People aged over the age of 65 years achieve optimal quality of life for themselves when supported to live in their own home in the community. NMDHB currently supports 55% of its over 65 home based support clients with goal based home based support. The Ambulatory Sensitive Hospitalisation (ASH) admission rate per 1000 goal based home based support (HBSS) are monitored by NMDHB with the aim of reducing these rates by 5% over the next two years. This will involve investigating, understanding and addressing the variances throughout the year shown in Figure 24. Data sourced from NMDHB

Figure 24. ASH rate per 1000 goal based HBSS clients per month 12 10 8 6 4 2 0

An increase in the proportion of people aged over 75 who are supported to maintain their functional independence measured through a reduction in admissions from falls in the number of people aged over 75. 

Around 12,000 older New Zealanders are hospitalised annually as a result of injury due to accidental falls. Compared to elderly people who do not fall, those who fall experience prolonged hospital stay, loss of confidence, restriction of social activities, loss of independence and an increased risk of institutional care.



With a significantly increasing older population, a focus on reducing falls will help to reduce the relative demand on acute and residential services. Reducing the average hospitalisation rate for falls by 1% would mean 550 fewer hospitalisations among people aged 75 and over across the country.



Achievement against this measure will indicate improved health service provision for older people, as the initiatives used to reduce falls will address various health issues and risk factors associated with falls including: osteoporosis, lack of physical activity, poor nutrition, medications, impaired vision and environmental hazards.

Data sourced from Nationwide Service Framework Library via http://www.nsfl.health.govt.nz/apps/nsfl.nsf/pagesmh/401 at http://www.nsfl.health.govt.nz/apps/nsfl.nsf/pagesmh/401/$File/PP15+Admissions+from+falls.xls

Figure 25: Admission to Hospital from community dwelling from falls per 100 people aged 75 and older 9.00% 8.50% 8.00% 7.50% 7.00% 6.50% 6.00% 5.50% 5.00% 4.50% 4.00% 2006/07

NM DHB

2007/08

2008/09

Total NZ

2009/10

2010/11

2011/12

Total NZ 08/09 Standardised

5.5.2

Outputs and Performance Measures 2013/14

Output Subset:

Palliative Care Services

Services that:  improve the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early intervention, assessment, treatment of pain and other support services  ensure people have timely access to quality, culturally appropriate palliative care services  co-ordinate care across hospital, community and support services  implement the ‗Liverpool Care Pathway‘ for palliative care services  deliver a responsive system that supports a person‘s choice to die at home.

Output Subset: Needs Assessment & Support Services – NASC, Age Residential Care, Respite, Carer Support, Day Programmes & Home Based Support InterRAI ensures that older people, who have an assessed need, receive support services in their homes whenever possible. NMDHB uses:  regionally agreed service specifications for HBSS  regionally agreed eligibility criteria and standardised approach to access  locally agreed and expanded options for respite and day programmes for older people and their family/carers.

Output Subset: Community Support Services – Mental Health

These services are targeted to improve service user recovery. Accessing specialist mental health and addiction services early prevents deterioration in mental health.

Output Subset: Community Mental Health Older Persons Specialist health of older people services are for people with complex physical and / or cognitive conditions associated with older age that provide:  a holistic inter-professional team approach to the health and disability support needs of older people,  integrated specialist geriatric and psychiatry of old age assessment, treatment and rehabilitation, incorporating a palliative approach when necessary,  a consultation and liaison service for other health and disability support services,  a setting for the training and education of health practitioners, and evaluation of innovation.

Output Subset: Geriatric ATR Specialist health of older people services plans for HOP specialists to consult with health professionals in primary care and ARC.

MODULE 6: SERVICE CONFIGURATION

6.1

NMDHB STRATEGIC DIRECTION

In order to deliver on the changes required, NMDHB continues to evolve its Strategic Management System through a Balanced Scorecard that outlines our planned initiatives including the Ministers Priorities and Health Targets. Why good management of service change and consultation matters Implementing health policy is complex and challenging, with a multitude of difficult and potentially contradictory policy choices for DHBs. There is also considerable public pressure to expand public spending on new medical technologies and greater levels of care and interventions. Service change is best managed in a planned and staged manner to avoid adverse financial, resource and clinical impacts on the Nelson Marlborough population. Well managed service change provides the Government and the Nelson Marlborough Health System with confidence that a robust process is followed31 (as per the Minister‘s expectations of NMDHB), that there are sufficient controls in place to avoid unnecessary service instability, and the change is clinically appropriate/safe, affordable, financially sustainable, and public confidence is managed by the DHB. NMDHB is undertaking a number of key initiatives as outlined in Module 3, of these the following could trigger the service change protocol.  Accelerating implementation of actions to achieve the financial recovery programme, including Rutherford recommendations and the required ‗change management‘  Improving the quality, safety and efficiency of ‗Top of the South‘ acute services  Ensuring value for money in our diagnostic imaging services by implementing the recommendations from the districtwide review of Imaging. We expect these services changes not to be completed in the 2013/14 year; they may take as long as 2015/16 to be fully implemented. The establishment under the new PHO Services Agreement of the NMHA requires NMDHB within the Alliance to collectively discuss and agree resourcing for the Nelson Marlborough Health System to achieve care closer to home. NMDHB is undertaking an initiative to combine all DHB-owned Needs Assessment Co-ordination Services ‗function‘, i.e., Mental Health, Health of Older People, Long-Term Chronic Conditions, Maori Health, and Whole of Life Disability, into a single, integrated team. This integrated team will use the NMHA process and progress innovation in home-based support services.

2013-14 Operational Policy Framework (13 Feb. 2013), Section 4, Service Change, pp. 48-58

MODULE 7: FINANCIAL PERFORMANCE 7.1

Financial Performance

Financial Performance NMDHB has prepared these prospective financial statements in line with the accounting policies adopted by the Board, as provided in Appendix 2. In addition, these financial statements also comply with the New Zealand Institute of Chartered Accountants FRS-42 â&#x20AC;&#x201C; Prospective Financial Statements standard. The purpose of the prospective financial statements is to inform the Crown and the public. They are also required to meet legislation, specifically the New Zealand Public Health and Disabilities Act 2000 and the Crown Entities Act 2004, and are the accountability statements for NMDHB. The information in these statements may not be appropriate for purposes other than those described. Actual results achieved for the period covered may vary from the information presented in these statements. The DHB faces considerable uncertainty with regards to future demand for services - that and uncertainties in wage growth assumptions make it possible that any variation in the actual financial results from these prospective financial statements may be significant. The prospective financial statements include the audited 2011/12 results. The 2012/13 prospective financial statements include five months actual results and a forecast for the remainder of the financial year. The assumptions are sourced from the best information available at the time. The prospective financial statements for the purposes of this document are not intended to be updated subsequent to the date of issue. Forecast financial statements We have an objective of strong financial performance and plan to return to a breakeven or better than breakeven position and to minimise cyclical deficits. The following table sets out our key financial information.

Table: Summary of Financial Information 2011/12

2012/13

2013/14

2014/15

2015/16

$000

PLANNED

ACTUAL FORECAST PLANNED Revenue

408,291

418,524

427,873

437,360

447,555

(5,228)

(3,000)

1,030

2,025

168,264

167,049

182,674

186,287

177,077

Net Assets

93,888

90,341

89,795

90,278

91,756

Term Borrowings and Provisions

(68,665)

(61,060)

(60,137)

(58,906)

(68,100)

Net Surplus/(Deficit) Total Fixed Assets

Our Rutherford Initiative process remains a key plank of our actions to return to a breakeven or better situation and the results of this programme is included in these prospective financial statements. To date, this process has identified significant savings, however still more are required. A number of new initiatives have been commenced to improve service delivery, introduce efficiencies and reduce costs. Initiatives are being managed nationally through Health Benefits Ltd, regionally through the South Island Alliance, and locally using NMDHB resources.

Table: Statement of Prospective Comprehensive Income

2011/12 $000 ACTUAL

2012/13

2013/14

$000 $000 FORECAST PLANNED

2014/15

2015/16

$000 PLANNED

REVENUE Government & Crown Agency Non-Government

394,911 13,380

407,347 11,177

417,093 10,780

426,935 10,425

436,783 10,772

TOTAL REVENUE

408,291

418,524

427,873

437,360

447,555

EXPENSES Personnel Outsourced Services Clinical Supplies & Patient Costs Infrastructure & Non-Clinical Supplies Interest Depreciation Capital Charge Payments to Non-Health Board Providers

152,238 11,932 31,083 24,722 2,659 12,070 6,792 172,022

152,258 11,011 30,762 24,312 2,844 12,542 6,728 181,068

155,369 10,665 30,856 26,062 2,844 11,742 7,475 182,859

158,036 10,772 30,596 23,352 2,873 15,474 7,475 187,754

161,192 10,987 31,013 23,170 2,899 16,141 7,475 192,653

TOTAL EXPENSES

413,519

421,524

427,872

436,330

445,530

1,030

2,025

1,030

2,025

SURPLUS/(DEFICIT)

(5,228)

Property revaluation

9,268

TOTAL COMPREHENSIVE INCOME

4,040

(3,000) 0 (3,000)

Table: Statement of Prospective Financial Position

CROWN EQUITY CURRENT ASSETS: Bank balances, deposits and Cash Receivables Inventory Assets held for Sale CURRENT LIABILITIES: Short T erm Loans Payables and Accruals Payroll Accruals

NET WORKING CAPITAL: NON CURRENT ASSETS: Fixed Assets Investments Non Current Prepayments NON CURRENT LIABILITIES: Payroll Liabilities T erm Loans

NET ASSETS

2011/12

2012/13

2013/14

2014/15

2015/16

$000 ACTUAL

$000 FORECAST

$000 PLANNED

93,888

90,341

89,795

90,278

91,756

30,082 13,261 2,246 2,045

28,291 13,250 2,400 3,546

12,947 13,250 2,400 1,500

10,292 13,250 2,400 0

20,942 13,250 2,400 0

47,634

47,486

30,097

25,942

36,592

1,045 19,966 32,343

7,972 25,700 31,935

8,223 25,700 31,935

9,232 25,700 31,935

0 25,700 31,935

53,354

65,607

65,858

66,867

57,635

(18,121)

(35,761)

(40,925)

(21,043)

(5,720)

168,264 7 3

167,049 2,473 0

182,674 3,019 0

186,287 3,822 0

177,077 3,822 0

168,273

169,522

185,693

190,109

180,899

12,296 56,369

12,600 48,460

12,600 47,537

12,600 46,306

12,600 55,500

68,665

61,060

60,137

58,906

68,100

93,888

90,341

89,795

90,278

91,756

Table: Statement of Prospective Cash flow 2011/12 2012/13 2013/14 $000 $000 $000 ACTUAL FORECAST PLANNED

2014/15 $000 PLANNED

2015/16 $000 PLANNED

OPERATING CASH FLOWS Cash received from Crown Agencies and other income

405,522

416,660

426,668

436,605

446,550

Cash paid to employees, suppliers and payment of finance charges

(397,745)

(400,431)

(413,198)

(417,895)

(426,400)

7,777

16,229

13,471

18,711

20,150

3,033 (22,070)

1,733 9,988

3,252 (27,915)

2,269 (19,904)

1,005 (6,932)

(19,037)

11,721

(24,663)

(17,635)

(5,927)

8,478 (4,213)

0 (4,459)

0 (4,151)

0 (3,731)

0 (3,573)

4,265

(4,459)

(4,151)

(3,731)

(3,573)

(6,995) 11,795

23,491 4,800

(15,344) 28,291

(2,655) 12,947

10,650 10,292

4,800

28,291

12,947

10,292

20,942

INVESTING CASH FLOWS Cash received from assets and equity Cash paid to purchase assets and term deposits

FINANCING CASH FLOWS Cash received from borrowing and equity Cash repaid for borrowing and equity

Net increase/(decrease) in cash Opening Cash balances Closing Cash Balances Table: Statement of Prospective Movements in Equity

2011/12

2012/13

2013/14

2014/15

$000 $000 $000 ACTUAL FORECAST PLANNED

2015/16

$000 $000 PLANNED PLANNED

Crown Equity at start of Year

89,805

93,888

90,341

89,795

90,278

Surplus/(Deficit) for the year

(5,228)

(3,000)

1,030

2,025

Increase in Revaluation Reserve

9,268

Equity Injections from Crown

478

Distributions to Crown Other Equity Movements

(547)

113

93,888

90,341

89,795

90,278

91,756

Crown Equity at end of Year

Capital Expenditure/Investment New capital expenditure projects budgeted for the next three years are:

Table: Statement of Capital Expenditure 2011/12 2012/13 2013/14 $M $M $M ACTUAL FORECAST PLANNED Land Buildings & Plant Clinical and other Equipment IT/IS Motor Vehicles Total Capital Expenditure

0.0 4.0 3.3 1.0 0.5 8.9

0.3 5.2 4.5 2.6 0.3 12.8

0 9.8 7.7 9.8 0.1 27.4

2014/15 2015/16 $M $M PLANNED PLANNED 0 12.7 3.7 2.5 0.2 19.1

0 1.2 3.3 1.4 1.0 6.9

All capital plans, including any redevelopment of Nelson Hospital, will be subject to normal business case processes and availability of cashflow. A formal asset management plan has been developed in accordance with Ministry of Health requirements. The following table sets out the financing plan for proposed capital projects: Table: Statement of Financing of Capital Expenditure 2011/12 2012/13 2013/14 $M $M $M ACTUAL FORECAST PLANNED

Internal Financing Surplus/(Deficit) Depreciation Sale of fixed assets Other - includes cash reserves External Financing CHFA Debt Equity Injection Total Capital Financing

2014/15 2015/16 $M $M PLANNED PLANNED

(5.2) 12.1 1.4 6.3

(3.0) 12.5 0.0 1.5

0.0 11.7 2.1 (1.8)

1.0 15.5 1.5 (1.6)

2.0 16.1 0.0 (0.6)

0 0.5 15.1

0 0 11.0

0 0 12.0

0 0 16.4

0 0 17.6

Asset Revaluation Land and buildings are revalued at least every three years to fair value as determined by an independent registered valuer by reference to the highest and best use. The last revaluation was undertaken as at 30 June 2012. The next revaluation is planned to take place as at 30 June 2015, at which time no material difference between carrying value and fair value is expected. Disposal of Land The procedure for disposal of surplus land is subject to due process with regard to the New Zealand Public Health and Disabilities Act 2000, including Ministerial approval, Public Works Act 1981, S.40, the Office of Treaty Settlements Protection Mechanism and any other interests registered on the title or under any other applicable legislation. There are plans to sell assets with a market value of $3.5m in 2012/13 or the outer years. NMDHB Borrowings We have the following existing financing facilities: ď&#x201A;ˇ Debt Management Office of $48.2 million ď&#x201A;ˇ Finance leases of $1m

Fund Equity No assumption has been made on the use of the Fund equity. This equity could be used to assist with capital developments, one off service purchases or assisting with the change management required to be sustainable. How these transactions are completed may have an impact on the prospective financial performance of NMDHB. Other measures and standards necessary to assess DHB performance The following tables set out the planned financial performance by division.

Table: Prospective Financial Targets and Measures DHB Provider 2011/12 2012/13 2013/14 2014/15 2015/16 $000 $000 $000 $000 $000 ACTUAL FORECAST PLANNED PLANNED PLANNED REVENUE Government & Crown Agency Non-Government TOTAL REVENUE

218,529 12,403 230,932

225,468 10,739 236,207

226,756 10,780 237,536

231,444 10,425 241,869

236,118 10,772 246,890

EXPENSES Personnel Outsourced Services Clinical Supplies & Patient Costs Infrastructure & Non-Clinical Supplies Internal Recharges TOTAL EXPENSES

151,309 11,670 34,268 40,083 (1,857) 235,474

151,416 10,569 34,363 39,719 (1,867) 234,200

154,468 9,844 34,280 40,666 (1,628) 237,631

157,122 9,942 34,623 41,073 (1,644) 241,116

160,264 10,141 35,135 41,451 (1,659) 245,333

SURPLUS/(DEFICIT)

(4,542)

2,007

Table: Prospective Financial Targets and Measures DHB Governance 2011/12 2012/13 $000 $000 ACTUAL

(95)

754

1,557

2013/14 2014/15 2015/16 $000 $000 $000 PLANNED PLANNED PLANNED

REVENUE Government & Crown Agency Non-Government TOTAL REVENUE

6,010 14 6,023

7,147 0 7,147

7,382 0 7,382

7,461 0 7,461

7,544 0 7,544

EXPENSES Personnel Outsourced Services Clinical Supplies & Patient Costs Infrastructure & Non-Clinical Supplies Internal Recharges TOTAL EXPENSES

929 262 0 2,975 1,857 6,023

842 442 0 3,104 1,867 6,256

900 821 0 4,033 1,628 7,382

914 829 0 4,073 1,644 7,460

927 846 0 4,112 1,659 7,544

891

SURPLUS/(DEFICIT)

Table: Prospective Financial Targets and Measures DHB Funding 2011/12 2012/13 2013/14 2014/15 2015/16 $000 $000 $000 $000 $000 ACTUAL FORECAST PLANNED PLANNED PLANNED REVENUE Government & Crown Agency Non-Government TOTAL REVENUE

369,409 964 370,373

382,045 438 382,483

390,321 0 390,321

400,113 0 400,113

409,912 0 409,912

EXPENSES Governance Administration Personal Health Mental Health Disability Support Public Health Maori Services

5,948 263,221 37,403 59,697 1,995 2,795

7,104 279,594 38,141 59,815 1,045 2,682

7,344 278,913 38,574 61,578 1,025 2,793

7,422 285,801 38,907 63,810 1,033 2,864

7,505 292,732 39,184 66,048 1,041 2,934

TOTAL EXPENSES

371,059

388,381

390,226

399,838

409,445

(686)

(5,898)

276

467

SURPLUS/(DEFICIT)

Any significant assumptions The following are the key assumptions used in the build-up of the 2013/2014 budget and the out years: Key assumptions

CFA revenue growth assumptions are in line with information provided in the funding envelope and include cost pressure and demographic growth Employee agreement assumptions

2012/13

2013/14

2014/15

2.71%

2.53%

3.32%

Increase by committed salary steps plus provision for settlement

0 to 1% 0 to 3%

Increases between 0% and 5%

0 to 3.5%

Per asset base plus capital programme

Interest received (per annum)

4.2%

Interest payments (per annum) Capital charge (per annum)

4.7% 8.0%

Payments to NGOs Contribution to Costs Demographics Payments to suppliers Depreciation

Any significant assumptions The following are the key assumptions used in the build-up of the 2013/2014 budget and the out years:

Risks Risk

Mitigation strategy

There is a risk that NMDHB will not achieve planned financial performance if we do not achieve the planned savings through our Rutherford and other Initiatives.

 Chief Executive led work streams  Regular and detailed internal monitoring of performance

The Minister of Health approved on 17 November 2011 NMDHB leasing the land on which the current Golden Bay Community Hospital to a community property trust who will purchase the existing building. NMDHB will lease the expanded building from the property trust for a term of 35 years. Service provision and use of the facility will be integrated under one provider (Nelson Bays PHO) under a contract for 10 years. The effects on the financial statements will be recognised when the leases and other contracts are in place

 This will involve a write down of the existing book value of approximately $630,000 against the revaluation reserve. The change is planned to be implemented in the first quarter of 2013/14. .

The Aged Related Residential Care (ARC) forecasts are based on forecasted demographic change in the over 65s. Risks are that the forecast will not match the market and the eagerness of ARC providers to build additional beds. The DHB has no control over the number of beds and if residents meet the needs assessment and qualify for subsidy then the DHB may face a situation where the costs of aged residential care exceed forecasts.

 Use of the InterRAI (International Residential Assessment Instrument) tool to ensure people receive support services that best meet their needs.

The employee relations environment presents uncertainty in terms of potential increases in employee remuneration packages. Although a wage increase percentage has been included in the assumptions, some employee representatives may have an expectation of wage increases that differ from the budgeted levels.

Potential strategies include:

There is risk that cost increases for provider arm purchasing of goods and services will exceed the assumed percentage increases based on the inherent uncertainty of future inflationary pressures.

 Review contracting arrangement and negotiate more favourable terms.  Participate in national procurement initiatives to take advantage of bulk purchasing

There is financial risk in terms of the inherent uncertainty as to the total amount of funding that will be appropriated to health beyond the current year and how this funding will be allocated by the Population Based Funding (PBF) formula. In addition, PBF is a fixed annual funding allocation in an environment where the District Health Board funds demand driven contracts that have the risk of the demand exceeding the forecast levels

 Continuous monitoring of demand-driven expenditure.

The Board will provide funding to Health Benefits Limited (a Crown company) of $845,000 in 2013/14 to finance the implementation of transformational changes to the delivery of support services. There is a risk that the savings and benefits envisaged will not be delivered, or be delivered late and that the change programme will disrupt the delivery of support services in the interim.

 Close liaison with the HBL implementation team.

 The number and scale of national and regional initiatives is growing significantly

 Services are delivered to meet assessed need (not the market demand).  Restorative services are deployed to delay preventable decline.  Robust processes adopted (ATR, NASC, PHO etc) are all aligned.  Negotiate lower than inflation or close to 0% increases.  Use containment mechanisms to constrain FTEs.

 Active involvement in the implementation process.  Regular and open communication with affected staff.

MODULE 8: PERFORMANCE MEASURES APPENDIX 1:

MONITORING FRAMEWORK PERFORMANCE MEASURES

2013/14 PERFORMANCE EXPECTATIONS The DHB monitoring framework aims to provide the Minister with a rounded view of performance using a range of performance markers. Four dimensions are identified that reflect DHBs functions as owners, funders and providers of health and disability services. The four identified dimensions of DHB performance cover: • achieving Government‘s priority goals/objectives and targets or ‗Policy priorities‘ • meeting service coverage requirements and Supporting sector inter-connectedness or ‗System Integration‘ • providing quality services efficiently or ‗Ownership‘ • purchasing the right mix and level of services within acceptable financial performance or ‗Outputs‘. It is intended that the structure of the framework and associated reports assists stakeholders to ‗see at a glance‘ how well DHBs are performing across the breadth of their activity, including in relation to legislative requirements, but with the balance of m easures focused on government priorities. Each performance measure has a nomenclature to assist with classification as follows: Code Dimension PP Policy Priorities SI System Integration OP Outputs OS Ownership DV Developmental – Establishment of baseline (no target/performance expectation is set) Performance measure 2013/14 Performance expectation/target PP1: Workforce – Improving clinical leadership PP6: Improving the health status of people with severe mental illness through improved access PP7: Improving mental health services using relapse prevention planning

PP8: Shorter waits for non-urgent mental health and addiction services

Report progress of DHB work to improve clinical leadership and engagement across all levels of the DHB and the Regional Training Hubs. Maori 4.2% Age 0-19 Total 4.2% Maori 6.5% Age 20-64 Total 4.34% Age 65+ 0.9% Child and 95% Youth Adult 20+ 95% Mental Health Provider Arm <= 3 Age <=8 weeks weeks 0-19 70% 85% 20-64 70% 85% 65+ 70% 85% Total 70% 85% Addictions (Provider Arm and NGO) <= 3 weeks 0-19 70% 20-64 70% 65+ 70% Total 70% Ratio year 1 Age

PP10: Oral Health- Mean DMFT score at Year 8 PP11: Children caries-free at five years of age PP12: Utilisation of DHB-funded dental services by adolescents (School Year 9 up to and including

<=8 weeks 85% 85% 85% 85% 1.10

Ratio year 2

1.00

Ratio year 1 Ratio year 2 % year 1

65% 70% 85%

% year 2

85%

age 17 years)

PP13: Improving the number of children enrolled in DHB funded dental services

PP18: Improving community support to maintain the independence of older people

PP20: improved management for long term conditions (CVD, diabetes and Stroke)

Focus area 1: Cardiovascular Disease

Focus area Services

Stroke

Focus area 3: Diabetes – Management (STATINS)

0-4 years - % year 1 0-4 years - % year 2 Children not examined 0-12 years % year 1 Children not examined 0-12 years % year 2 The % of older people receiving long-term home support who have a comprehensive clinical assessment and an individual care plan 70 percent of highrisk patients will receive an angiogram within 3 days of admission. (‗Day of Admission‘ being ‗Day 0‘) 80 percent of ACS patients receiving a risk assessment and classification within 24 hours of presenting 80 percent of nonhigh risk ACS patients undergoing further risk stratification tests within 2 days of admission. 6 percent of potentially eligible stroke patients thrombolysed

60% 66%

15%

10%

100%

70 percent of high-risk patients will receive an angiogram within 3 days of admission. (‗Day of Admission‘ being ‗Day 0‘)

80 percent of ACS patients receiving a risk assessment and classification within 24 hours of presenting

80 percent of non-high risk ACS patients undergoing further risk stratification tests within 2 days of admission.

80 percent of stroke patients admitted to a stroke unit or organised stroke service with demonstrated stroke pathway

80%

Maintain or Improve appropriate access to statins or lipid lowering medication for people with diabetes and CVD risk assessment greater than or equal to 15 percent

NMDHB will maintain or Improve appropriate access to statins or lipid lowering medication for people with diabetes and CVD risk assessment greater than or equal to 15 percent over 5 years.

Focus area 3: Diabetes – Management (ANTIHYPERTENSIVES)

Focus area 3: Diabetes – Management (MICROALBUMINURIA AND ON AN ACEi OR ARB) PP21: Immunisation (previous health target)

coverage

over 5 years. Maintain or Improve appropriate access to antihypertensive medications for people with diabetes and a CVD risk assessment greater than or equal to 15 percent. Maintain or improve appropriate management of microalbuminuria or overt nephropathy in patients with diabetes. 95 per cent of two year olds are fully immunised

NMDHB will maintain or Improve appropriate access to antihypertensive medications for people with diabetes and a CVD risk assessment greater than or equal to 15 percent.

NMDHB will maintain or improve appropriate management of microalbuminuria or overt nephropathy in patients with diabetes.

95%

PP22: Improving system integration

Report on delivery of the actions and milestones identified in the Annual Plan.

PP23: Improving Wrap Around Services – Health of Older People

Report on delivery of the actions and milestones identified in the Annual Plan.

PP24: Improving Waiting Times – Cancer Multidisciplinary Meetings

Report on delivery of the actions and milestones identified in the Annual Plan.

PP25: Prime Minister‘s youth mental health project PP26: The Mental Health & Addiction Service Development Plan

PP27: Delivery of the children‘s action plan

Provide a written stocktake, gaps analysis and actions being considered, Provide gaps analysis and report against SDP milestones Demonstration site DHBs to report on actions and progress to support the successful establishment and on-going operation of Children's Teams

All DHBs to report on stocktake of service , gaps analysis and actions being considered across the care continuum to support vulnerable pregnant women, children and parents All DHBs to provide updates on actions to help reduce child assaults identified in the Annual Plan

Provide a progress report against DHBs‘ rheumatic fever prevention plan

PP28: Reducing Rheumatic fever

SI1: Ambulatory sensitive (avoidable) hospital admissions

Hospitalisation rates (per 100,000 DHB total population) for acute rheumatic fever are 10% lower than the average over the last 3 years Age 0-4 Age 45-64 Age 0-74

0.5 per 100,000

<151% <119% <136%

SI2: Delivery of Regional Service Plans

A single progress report on behalf of the region agreed by all DHBs within that region

SI3: Ensuring delivery of Service Coverage

Report progress achieved during the quarter towards resolution of exceptions to service coverage identified in the Annual Plan , and not approved as long term exceptions, and any other gaps in service coverage

SI4: Standardised Rates (SIRs)

major replacement

Intervention

joint

an intervention rate of 21.0 per 10,000 of population

cataract procedures cardiac surgery (a target intervention rate of 6.5 per 10,000 of population) If previous rate of 6.5 per 10,000 or above -maintain this rate.

SI5: Delivery of Whanau Ora OS3: Inpatient Length of Stay OS8: Reducing Readmissions to Hospital

Acute

6.5 per 10,000

percutaneous revascularization (a target rate of at 11.9 per 10,000 least 11.9 per 10,000 of population) coronary angiography services (a target rate of at 33.9 per 10,000 least 33.9 per 10,000 of population) Report progress on planned activities with providers to improve service delivery and develop mature providers. ≤3.0 days. Elective LOS . Acute LOS 3.29 days % total pop ≤6.3% % 75 plus ≤8.63% National Health Index (NHI) duplications Greater than 3.00% and less than or equal to 6.00%

OS10: Improving the Quality of Data Submitted to National Collections

an intervention rate of 27.0 per 10,000

Ethnicity set to ‗Not stated‘ or ‗Response Unidentifiable‘ in the NHI. - Greater than 0.50% and less than or equal to 2% Standard vs. edited descriptors -Greater than or equal to 75.00% and less than 90.00% Timeliness of NMDS data - Greater than 2.00% and less than or equal to 5.00% late NNPAC Emergency Department admitted events have a matched NMDS event Greater than or equal to 97.00% and

National Health Index (NHI) duplications - Greater than 3.00% and less than or equal to 6.00%

Ethnicity set to ‗Not stated‘ or ‗Response Unidentifiable‘ in the NHI. Greater than 0.50% and less than or equal to 2%

Standard vs. edited descriptors -Greater than or equal to 75.00% and less than 90.00%

Timeliness of NMDS data - Greater than 2.00% and less than or equal to 5.00% late

NNPAC Emergency Department admitted events have a matched NMDS event - Greater than or equal to 97.00% and less than 99.50%

less than 99.50% PRIMHD File Success Rate Greater than or equal to 98.0% and less than 99.5%

Output 1: Mental health output Delivery Against Plan

PRIMHD File Success Rate - Greater than or equal to 98.0% and less than 99.5%

Volume delivery for specialist Mental Health and Addiction services is within: a) five percent variance (+/-) of planned volumes for services measured by FTE, b) five percent variance (+/-) of a clinically safe occupancy rate of 85% for inpatient services measured by available bed day, and c) actual expenditure on the delivery of programmes or places is within 5% (+/-) of the year-to-date plan

APPENDIX 2:

NMDHB ACCOUNTING POLICIES

REPORTING ENTITY Nelson Marlborough District Health Board (NMDHB) is a Health Board established by the New Zealand Public Health and Disability Act 2000. NMDHB is a Crown Entity in terms of the Crown Entities Act 2004, owned by the Crown and domiciled in New Zealand. Nelson Marlborough DHB is a reporting entity for the purposes of the New Zealand Public Health and Disability Act 2000, the Financial Reporting Act 1993, the Public Finance Act 1989 and the Crown Entities Act 2004. The Group consists of NMDHB and its subsidiary, Nelson Marlborough Hospitals Charitable Trust. NMDHB's activities involve the delivery of health and disability services and mental health services in a variety of ways to the community. Therefore, NMDHB has designated itself and its subsidiaries as public benefit entities, for the purposes of the New Zealand equivalents to International Financial Reporting Standards (NZ IFRS). BASIS OF PREPARATION (a) Statement of Compliance The consolidated financial statements have been prepared in accordance with the requirements of the NZ Public Health & Disability Act 2000 and the Crown Entities Act 2004, which includes the requirement to comply with Generally Accepted Accounting Practice in New Zealand (NZ GAAP). They comply with New Zealand equivalents to International Financial Reporting Standards (NZ IFRS), and other applicable Financial Reporting Standards, as appropriate for public benefit entities. (b) Measurement Base The financial statements are prepared on the historical cost basis modified by the revaluation of certain assets and liabilities as identified in the statement of accounting policies. (c) Functional and Presentation Currency The financial statements are presented in New Zealand Dollars (NZD), rounded to the nearest thousand. The functional currency of NMDHB is New Zealand dollars. (d) Management Judgements, Estimates and Assumptions The preparation of financial statements in conformity with NZ IFRS requires management to make judgements, estimates and assumptions that affect the application of policies and reported amounts of assets and liabilities, income and expenses. The estimates and associated assumptions are based on historical experience and various other factors that are believed to be reasonable under the circumstances, the results of which form the basis of making judgements about carrying values of assets and liabilities that are not readily apparent from other sources. Actual results may differ from these estimates. The estimates and underlying assumptions are reviewed on an ongoing basis. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period, or in the period of the revision and future periods if the revision affects both current and future periods. (e) Standards, Amendments and Interpretations Issued that are not yet Effective and have not been Early Adopted Certain new standards, amendments and interpretations to existing standards have been published that are not effective for the year ended 30 June 2012 and have not been applied in preparing these financial statements. The following standards, amendments and interpretations which are relevant to NMDHB are: ď&#x201A;ˇ NZ IFRS 9 NZ IFRS 9 Financial Instruments will eventually replace NZ IAS 39 Financial Instruments: Recognition and Measurement. NZIAS 39 is being replaced in three main phases. The first phase on the classification and measurement of financial assets has been completed and has been published in the new financial instrument standard NZ IFRS 9. NZ IFRS 9 uses a single approach to determine whether a financial asset is measured at amortised cost or fair value, replacing the many different rules in NZ IAS 39. The approach in NZ IFRS 9 is based on how an entity manages its financial instruments and the contractual cash flow characteristics of the financial assets. The financial liability requirements are the same as those of NZ IAS 39, except for when an entity elects to designate a financial liability at fair value through the surplus/deficit. The new standard is required to be adopted for the year ended 30 June 2014. NMDHB has not yet assessed the effect of the new standard and does not expect to early adopt it. (f) Changes in Accounting Policies There have been no changes in accounting policies during the financial year.

ACCOUNTING POLICIES Basis of Consolidation Subsidiaries are those entities controlled by NMDHB. Control exists when NMDHB has the power, directly or indirectly, to govern the financial and operating policies of an entity so as to obtain benefits from its activities. Nelson Marlborough Hospitals Charitable Trust is a subsidiary of NMDHB. The financial results of the Trust are not material and have not been consolidated. Therefore, the financial results disclosed for both the parent and group are the same. Information relating to the Trust is separately disclosed in the notes to the financial statements. Borrowing Costs Nelson Marlborough DHB has elected to defer the adoption of NZ IAS 23 Borrowing Costs (Revised 2007) in accordance with its transitional provisions that are applicable to public benefit entities. Consequently, all Borrowing costs are recognised as an expense in the period in which they are incurred. Capital Charge The capital charge is recognised as an expense in the period to which the charge relates. Cash and Cash Equivalents Cash and cash equivalents means cash on hand, call deposits held with banks, short term deposits that have maturities of three months or less, and bank overdrafts. Creditors and other payables Creditors and other payables are initially measured at fair value and subsequently measured at amortised cost using the effective interest method. Payables of short duration are not discounted. Debtors and other receivables Debtors and other receivables are initially measured at fair value and subsequently measured at amortised cost using the effective interest method, less any provision for impairment. Receivables of short duration are not discounted. Impairment of a receivable is established when there is objective evidence that NMDHB will not be able to collect amounts due according to the original terms of the receivable. Significant financial difficulties of the debtor, probability that the debtor will enter into bankruptcy, and default in payments are considered indicators that the debtor is impaired. The amount of the impairment is the difference between the asset's carrying amount and the estimated recoverable amount. The carrying amount of the asset is reduced through the use of an allowance account, and the amount of the loss is recognised in the surplus or deficit. When the receivable is uncollectable, it is written off and the allowance reversed. Employee Entitlements (a) Defined Contribution Plans Obligations for contributions to defined contribution pension plans, such as Kiwisaver and the State Sector Retirement Savings Scheme, are recognised as an expense in the surplus or deficit when they are incurred. (b) Defined Benefit Plans NMDHB does not make contributions to defined benefit pension plans. (c) Long Service Leave, Sabbatical Leave, Sick Leave, and Retirement Gratuities NMDHB's net obligation in respect of long service leave, sabbatical leave, sick leave and retirement leave is the amount of future benefit that employees have earned in return for their service in the current and prior periods. The obligation is valued on an actuarial basis. Those entitlements expected to be settled within 12 months of balance date are classified as a current liability. Where settlement is expected more than 12 months after balance date, the entitlements are classified as non-current liabilities. (d) Annual Leave, Conference Leave and Medical Education leave Annual leave, conference and medical education leave are short-term obligations and are calculated on an actual entitlement basis at current rates of pay. NMDHB accrues the obligation for paid absences when the obligation both relates to employees' past services and it accumulates.

Equity Equity is measured as the difference between total assets and total liabilities. Equity is disaggregated and classified into the following components: ď&#x201A;ˇ Crown equity ď&#x201A;ˇ Retained earnings ď&#x201A;ˇ Revaluation reserves Revaluation reserves are related to the revaluation of land and buildings to fair value. Financial Instruments Non-derivative financial instruments Non-derivative financial instruments comprise investments in equity securities, debtors and other receivables, cash and cash equivalents, loans and borrowings, and creditors and other payables. (a) Recognition A financial instrument is recognised if NMDHB becomes a party to the contractual provisions of the instrument. Non-derivative financial instruments are initially recognised at fair value plus transaction costs unless they are carried at fair value through other comprehensive income in which case the transaction costs are recognised in the surplus or deficit. Subsequent to initial recognition, non-derivative financial instruments are measured as described below. Purchases and sales of financial assets are recognised on trade-date, the date on which NMDHB commits to purchase or sell the asset. Financial assets are derecognised when NMDHB's rights to receive cash flows from the financial assets have expired or if the DHB transfers the financial asset to another party without retaining control or substantially all risks and rewards of ownership. Financial liabilities are derecognised if NMDHB's obligations specified in the contract expire or are discharged. Cash and cash equivalents comprise cash balances, call deposits, and other deposits with original maturities of no more than three months. Bank overdrafts that are repayable on demand and form an integral part of NMDHB's cash management are included as a component of cash and cash equivalents for the purpose of the Statement of Cash Flows. NMDHB classifies its financial assets into the following categories: Fair Value through other comprehensive income, loans and receivables, fair value through profit and loss, and amortised cost. (b) Measurement Fair Value through other comprehensive income NMDHB's investments in equity securities are classified as fair value through other comprehensive income. Subsequent to initial recognition, they are measured at fair value and changes therein, other than impairment losses, and foreign exchange gains and losses are recognised in other comprehensive income. When an investment is derecognised, the cumulative gain or loss in equity is transferred to surplus or deficit. The fair value of financial instruments traded in active markets is based on quoted market prices at balance date. The quoted market price used is the current bid price. NMDHB classifies its investment in equity securities as fair value through other comprehensive income. However, the shares have been recorded at cost as they do not have a quoted price in an active market and their fair value cannot be reliably measured. Loans and Receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments that are not quoted in an active market. They are included in current assets, except for maturities greater than 12 months after balance date, which are included in non-current assets. After initial recognition they are measured at amortised cost using the effective interest method less impairment. Receivables of short duration are not discounted. Gains and losses when the asset is impaired or derecognised are recognised in the surplus or deficit. NMDHB classifies debtors and other receivables, and cash and cash equivalents as Loans and Receivables.

Instruments at fair value through surplus or deficit An instrument is classified at fair value through surplus or deficit if it is held for trading or is designated as such upon initial recognition. NMDHB does not have any financial instruments classified at fair value through other comprehensive income. Other Financial Instruments Financial instruments that are not classified as fair value through other comprehensive income or fair value through surplus or deficit are measured at amortised cost using the effective interest method, less any impairment losses. NMDHB classifies creditors and other payables, finance leases, and secured loans as Other Financial Instruments. Derivative financial instruments NMDHB does not have any derivative financial instruments. Goods and Services Tax All items in the financial statements are exclusive of goods and services tax (GST) with the exception of receivables and payables which are stated inclusive of GST. Where GST is irrecoverable as an input tax, then it is recognised as part of the related asset or expense. The net amount of GST recoverable from, or payable to, the Inland Revenue Department (IRD) is included as part of receivables or payables in the Statement of Financial Position. The net GST paid to, or received from the IRD, including the GST relating to investing and financing activities, is classified as an operating cash flow in the Statement of Cash Flows. Commitments and contingencies are disclosed exclusive of GST. Impairment (a) Recognition NMDHB considers at each balance date whether there is any indication that its assets other than investment property, inventories and inventories held for distribution may be impaired. If any such indication exists, the asset's recoverable amount is estimated. Given that the future economic benefits of the DHB's assets are not directly related to the ability to generate net cash flows, the value in use of these assets is measured on the basis of depreciated replacement cost. If an asset's carrying amount exceeds its recoverable amount, the asset is impaired and the carrying amount is written down to the recoverable amount. For revalued assets the impairment loss is recognised against the revaluation reserve for that class of asset. Where that results in a debit balance in the revaluation reserve, the balance is recognised in the surplus or deficit. For assets not carried at a revalued amount, the total impairment loss is recognised in the surplus or deficit. For intangible assets that have an indefinite useful life and intangible assets that are not yet available for use, the recoverable amount is estimated at each balance date and was estimated at the date of transition. When a decline in the fair value of an available-for-sale financial asset has been recognised directly in equity and there is objective evidence that the asset is impaired, the cumulative loss that had been recognised directly in equity is recognised in the surplus or deficit even though the financial asset has not been derecognised. The amount of the cumulative loss that is recognised in the surplus or deficit is the difference between the acquisition cost and the current fair value, less any impairment loss on that financial asset previously recognised in the surplus or deficit. Impairment losses on an individual basis are determined by an evaluation of the exposures on an instrument by instrument basis. All individual trade receivables that are considered significant are subject to this approach. For trade receivables which are not significant on an individual basis, collective impairment is assessed on a portfolio basis based on number of days overdue, and taking into account the historical loss experience. Impairment gains and losses, for items of property, plant and equipment that are revalued on a class of assets basis, are also recognised on a class basis. (b) Recoverable Amount The estimated recoverable amount of receivables carried at amortised cost is calculated as the present value of estimated future cash flows, discounted at their original effective interest rate. Receivables with a short duration are not discounted.

The estimated recoverable amount of other assets is the greater of their fair value less costs to sell and value in use. Given that the future economic benefits of the DHB's assets are not directly related to the ability to generate net cash flows, the value in use of these assets is measured on the basis of depreciated replacement cost. (c) Reversals of Impairment Impairment losses are reversed when there is a change in the estimates used to determine the recoverable amount. An impairment loss is reversed only to the extent that the asset's carrying amount does not exceed the carrying amount that would have been determined, net of depreciation or amortisation, if no impairment loss had been recognised. An impairment loss on an equity instrument investment classified as fair value through other comprehensive income or on items of property, plant and equipment carried at fair value is reversed through the relevant reserve. All other impairment losses are reversed through the surplus or deficit. The reversal of an impairment loss on a revalued asset is credited to the revaluation reserve. However, to the extent that an impairment loss for that class of asset was previously recognised in the surplus or deficit, a reversal of the impairment loss is also recognised in the surplus or deficit. For assets not carried at a revalued amount the reversal of an impairment loss is recognised in the surplus or deficit. Income Tax NMDHB is a Crown Entity under the New Zealand Public Health and Disability Act 2000 and is exempt from income tax under section CW38 of the Income Tax Act 2007. Accordingly, no charge of income tax has been provided for. Intangible Assets (a) Software acquisition and development Computer software licenses acquired by NMDHB are capitalised on the basis of the costs incurred to acquire and bring to use the specific software. Costs that are directly associated with the development of software for internal use by NMDHB are recognised as an intangible asset. Direct costs include the software development, employee costs and an appropriate portion of relevant overheads. Staff training costs are recognised as an expense when incurred. Costs associated with maintaining computer software are recognised as an expense when incurred. Costs associated with the development and maintenance of NMDHB's website is recognised as an expense when incurred. (b) Amortisation Amortisation is recognised in the surplus or deficit on a straight line basis over the estimated useful lives of intangible assets unless such lives are indefinite. Intangible assets with an indefinite useful life are tested for impairment at each balance sheet date. Other intangible assets are amortised from the date they are available for use. The estimated useful lives are as follows: Type of Asset Software

Estimated life 3 â&#x20AC;&#x201C; 10 years

Amortisation Rate 10 â&#x20AC;&#x201C; 34%

Inventories held for distribution Inventories classified as held for distribution are stated at cost (calculated using the weighted average cost method) adjusted, where applicable, for any loss of service potential. The loss of service potential of inventory held for distribution is determined on the basis of obsolescence. Where inventories are acquired at no cost or for nominal consideration, the cost is the current replacement cost at the date of acquisition. Any write-down from cost to current replacement cost is recognised in the surplus or deficit in the period when the write-down occurs.

Investments Bank Deposits Investments in bank deposits are initially measured at fair value plus transaction costs. After initial recognition, investments in bank deposits are measured at amortised cost using the effective interest method, less any provision for impairment. At each balance date, NMDHB assesses whether there is any objective evidence that an investment is impaired. Leases (a) Finance Leases Leases which effectively transfer to NMDHB substantially all the risks and benefits incident to ownership of the leased asset are classified as finance leases. At the commencement of the lease, NMDHB recognises finance leases as assets and liabilities in the Statement of Financial Position at the lower of the fair value of the leased asset or the present value of the minimum lease payments. The finance charge is charged to the surplus or deficit over the lease period so as to produce a constant periodic rate of interest on the remaining balance of the liability. The amount recognised as an asset is depreciated over the shorter of its useful life and the lease term. (b) Operating Leases Leases where the lessor effectively retains substantially all the risks and benefits of ownership of the leased items are classified as operating leases. Payments under these leases are recognised as expenses in the periods in which they are incurred. Loans and borrowings Loans and borrowings are recognised initially at fair value less attributable transactions costs. Subsequent to initial recognition, loans and borrowings are stated at amortised cost with any difference between cost and redemption value being recognised in the surplus or deficit over the period of the borrowings on an effective interest basis. Borrowings are classified as current liabilities unless NMDHB has an unconditional right to defer settlement of the liability for at least 12 months after balance date. Non-current assets held for sale Non-current assets held for sale are classified as held for sale if their carrying amount will be recovered principally through a sale transaction rather than through continuing use. Non-current assets held for sale are measured at the lower of their carrying amount and fair value less costs to sell. For revalued assets, any impairment losses for write-downs of non-current assets held for sale are recognised in other comprehensive income to the extend the impairment loss does not exceed the amount in the revaluation reserve in equity for that same class of asset. For assets not carried at a revalued amount, the total impairment loss is recognised in the surplus or deficit. Any increases in fair value (less costs to sell) are recognised up to the level of any impairment losses that have been previously recognised. Non-current assets held for sale (including those that are part of a disposal group) are not depreciated or amortised while they are classified as held for sale. Property, Plant and Equipment (a) Classes of property, plant and equipment. The major classes of property, plant and equipment are as follows:  Freehold Land  Freehold Buildings  Plant and Equipment  Motor Vehicles  Work in Progress

(b) Recognition & Measurement Under section 95(3) of the New Zealand Public Health and Disability Act 2000, the assets of NM Health Services Limited (a Hospital and Health Service) vested in NM District Health Board on 1 January 2001. Accordingly, assets were transferred to NMDHB and their net book values recorded in the books of the Hospital and Health Service. In effecting this transfer, the health board has recognised the cost and accumulated depreciation amounts from the records of the Hospital and Health Service. The vested assets have since been revalued and are depreciated over their remaining useful lives. Except for land and buildings and the assets vested from the Hospital and Health Service (see above), items of property, plant and equipment are stated at cost, less accumulated depreciation and impairment losses. Cost includes expenditures that are directly attributable to the acquisition of the asset. The cost of self-constructed assets includes the cost of materials and direct labour, any other costs directly attributable to bringing the asset to a working condition for its intended use, and the costs of dismantling and removing the items and restoring the site on which they are located. Purchased software that is integral to the functionality of the related equipment is capitalised as part of that equipment. Where an asset is acquired at no cost, or for a nominal cost, it is recognised at fair value when control over the asset is obtained. When parts of an item of property, plant and equipment have different useful lives, they are accounted for as separate items (major components) of property, plant and equipment. (c) Subsequent Costs Subsequent costs are added to the carrying amount of an item of property, plant and equipment when that cost is incurred if it is probable that the service potential or future economic benefits embodied within the new item will flow to NMDHB and the cost of the item can be reliably measured. All other costs are recognised in the surplus or deficit as an expense as incurred. (d) Revaluation of land and buildings Land and buildings are revalued every three years to fair value as determined by an independent registered valuer by reference to the highest and best use. Assets for which no open market evidence exists are revalued on an Optimised Depreciated Replacement Cost basis. Additions between revaluations are recorded at cost. The results of revaluing land and buildings are credited or debited to an asset revaluation reserve for that class of asset and other comprehensive income. Where a revaluation results in a debit balance in the asset revaluation reserve, the debit balance will be expensed in the surplus or deficit. Any decreases in value relating to a class of land and buildings are debited directly to other comprehensive income and the revaluation reserve, to the extent that they reverse previous surpluses and are otherwise recognised as an expense in the surplus or deficit. The carrying values of revalued assets are reviewed annually to ensure that those values are not materially different to fair value. If there is evidence supporting a material difference, then the asset class will be revalued. (e) Depreciation Depreciation is provided on a straight-line basis on all Property, Plant and Equipment other than freehold land, at rates which will write off the cost (or valuation) of the assets to their estimated residual values over their useful lives. The estimated useful lives of major classes of assets and resulting rates are as follows: Type of Asset Buildings & Building Fitout Plant & Equipment Motor Vehicles Leased Assets

Estimated life 10 – 76 years 2 – 20 years 5 – 16 years 2 – 7.25 years

Depreciation Rate 1.3 – 10% 5 – 50% 6.25 – 20% 13.79 – 50%

The residual values and useful lives of property, plant and equipment are reassessed annually at financial year end.

(f) Capital Work in Progress Capital work in progress is not depreciated. The total cost of a project is transferred to buildings, building fitout and/or plant and equipment on its completion and then depreciated. (g) Leased Assets Leases where NMDHB assumes substantially all the risks and rewards of ownership are classified as finance leases. The assets acquired by way of finance lease are stated at an amount equal to the lower of their fair value or the present value of minimum lease payments. (h) Disposal of Property, Plant and Equipment When Property, Plant and Equipment is disposed of, any gain or loss is recognised in the surplus or deficit and is calculated as the difference between the net sale price and the carrying value of the asset. When revalued assets are sold, the amounts included in revaluation reserves in respect of those assets are transferred to general funds. Provisions NMDHB recognises a provision for future expenditure of uncertain amount or timing when there is a present legal or constructive obligation as a result of a past event, it is probable that an outflow of economic benefits will be required to settle the obligation and a reliable estimate can be made of the amount of the obligation. Provisions are measured at the present value of the expenditures expected to be required to settle the obligation. Provisions are not discounted if the effect of the time value of money is not material. (a) Restructuring A provision for restructuring is recognised when NMDHB has approved a detailed and formal restructuring plan, and the restructuring has either commenced or has been announced publicly. Future operating costs are not provided for. (b) ACC Partnership Programme NMDHB belongs to the ACC Partnership Programme under which it accepts the management and financial responsibility for employee work-related illnesses and accidents. Under the programme, NMDHB is liable for all its claims costs for a period of four years up to a specified maximum. At the end of the four year period, NMDHB pays a premium to ACC for the value of residual claims, and from that point the liability for ongoing claims passes to ACC. The liability for the ACC Partnership Programme is measured using actuarial techniques at the present value of expected future payments to be made in respect of the employee injuries and claims up to balance date. Consideration is given to anticipated future wage and salary levels and experience of employee claims and injuries. Expected future payments are discounted at a rate that approximates the average gross yield on Government Bonds of short to medium term durations consistent with the duration of the liabilities. Revenue Revenue is measured at the fair value of consideration received or receivable. (a) Crown Funding The majority of revenue is provided through an appropriation in association with a Crown Funding Agreement. Revenue is recognised monthly in accordance with the Crown Funding Agreement payment schedule, which allocates the appropriation equally throughout the year. (b) ACC Contracted Revenue ACC contract revenue is recognised as revenue when eligible services are provided and any contract conditions have been fulfilled. (c) Inter-District Patient Flows Inter district patient inflow revenue occurs when a patient treated within the Nelson Marlborough district is domiciled outside of the region. The Ministry of Health credits NMDHB with a monthly amount based on estimated patient treatment of non-NM residents. An annual wash up occurs at year end of reflect the actual non-NM patients treated at NMDHB.

(d) Rental Income Lease income under an operating lease is recognised as revenue on a straight-line basis over the lease term. (e) Goods Sold Revenue from goods sold is recognised when NMDHB has transferred to the buyer the significant risks and rewards of ownership of the goods and NMDHB does not retain either continuing managerial involvement to the degree usually associated with

ownership or effective control over the goods sold. (f) Provision of Services Revenue from services is recognised, to the proportion that a transaction is complete, when it is probable that the payment associated with the transaction will flow to NMDHB and that payment can be measured or estimated reliably, and to the extent that any obligations and all conditions have been satisfied by NMDHB. (g) Interest Income Interest income is recognised using the effective interest method. (h) Donated Assets Where a physical asset is gifted to or acquired by NMDHB for nil or nominal cost, the fair value of the asset received is recognised as income. Such assets are recognised as income when control over the asset is obtained. (i) Volunteer Services Certain operations of NMDHB are reliant on services provided by volunteers. Volunteer services received are not recognised as revenue or expenditure by NMDHB due to the difficulty of measuring their fair value with reliability. Trust and Bequest Funds Donations and bequests are made for specific purposes. The use of these funds must comply with the specific terms of the sources from which the funds were derived. All donations and bequests are assigned to and managed by the Nelson Marlborough Hospitals Charitable Trust (NMHCT) which has an independent Board of Trustees. The funds are held separately by NMHCT and not included in NMDHB's Statement of Financial Position. The revenue and expenditure in respect of these funds are also excluded from NMDHB's surplus or deficit. Donations and bequest to the NMDHB from the NMHCT are recognised as income when received, or entitlement to receive money is established. Expenditure subsequently incurred in respect of these funds is recognised as an expense in the surplus or deficit.

APPENDIX 3: ABC A4HC A&D / AOD ACC ACNM ACU AE AEP AIR ALOS AOD AOHS AP ARC ARF ARCC ASD ASMS AT&R BSCQ BA B4SC BCTI BFCI BFCI BS BSI BSMC C CAMHS CBAC CBF CBSD CDHB CCDHB CCDP CCF CCT CCU CDEM CDHB CDM CE (CEO) CEA CEG CeTas CFA CFO CHFA CHS CIMS CIO CME CMI CMS CNM Concerto CO

GLOSSARY OF ACRONYMS, ABBREVIATIONS AND MAORI TRANSLATION Ask about their smoking status; brief advice to quit; cessation Action for Healthy Children Alcohol and Drug / Alcohol and Other Drugs Accident Compensation Corporation Associate Charge Nurse Manager Ambulatory Care Unit Alternative Education Accredited Employer Programme Agreed Information Repository Average Length of Stay Alcohol and Drug Adolescent Oral Health Services Annual Plan with Statement of Intent Aged Residential Care Audit Risk and Finance Aged Residential Care Contract Autism Spectrum Disorder Association of Salaried Medical Specialists Assessment, Treatment & Rehabilitation Balanced Score Card Quadrant Business Analyst Before School Checks Buyer Created Tax Invoice Breast Feeding Community Initiative Baby Friendly Community Initiative Business Support Blood Stream Infection Better, Sooner, More Convenient Coverage Child and Adolescent Mental Health Services Community Based Assessment Centres Capitation Based Funding Community Based Service Directorate Canterbury District Health Board Capital & Coast District Health Board (also called C & C) Care Capacity Demand Planning Chronic Conditions Framework Continuing Care Team Coronary Care Unit Civil Defence Emergency Management Canterbury District Health Board Chronic Disease Management Chief Executive (Chief Executive Officer) Collective Employee Agreement Coordinating Executive Group (for emergency management) Central Technical Advisory Support Crown Funding Agreement or Crown Funding Agency Chief Financial Officer Crown Health Financing Agency Community Health Services Coordinated Incident Management System Chief Information Officer Continuing Medical Education Chronic Medical Illness Contract Management System Charge Nurse Manager IT system which provides clinicianâ&#x20AC;&#x2DC;s interface to systems Carbon Monoxide

COO COPMI CPHAC CPIP CPNE CPO CPU CRISP CSR CSSD CTA CTC CTANAG CTU CVD CVDRA CWD CYAERG CYF CYFS DAP DAR DHB DHBNZ DHBRF DIFS DiSAC DGH DMH DNA DoView DRG DSP DSS DWCSP EAP EBID ECWD ED EDA EFI ELT EMPG ENT EOI EQP ESA ESOL ESPI ESR ESU EVIDEM FF&E FFT FMIS FOMHT FOUND FRC FSA FST

Chief Operating Officer Children of Parents with Mental Illness Community and Public Health Advisory Committee Community Pharmacy Intervention Project Continuing Practice Nurse Education Controlled Purchase Operations Critical Purchase Units Central Region Information Systems Plan Contract Status Report Clinical Support Services Directorate Clinical Training Agency Contributions to Cost Clinical Training Agency Nursing Advisory Group Combined Trade Unions Cardiovascular Disease Cardiovascular/Diabetes Risk Assessment Case Weighted Discharge Child Youth Advisory & Expert Reference Group. Child, Youth and Family Child, Youth and Family Service District Annual Plan Diabetes Annual Review District Health Board District Health Boards New Zealand District Health Boards Research Fund District Immunisation Facilitation Services Disability Support Advisory Committee Director General of Health Director of Maori Health Did Not Attend A visual map used in modules 3 and 5 using DoView outcomes software. Each map sets out the main actions needed to achieve higher-level results (impacts and outcomes) Diagnostic Related Group District Strategic Plan Disability Support Services District Wide Clinical Services Plan Employee Assistance Programme Earnings Before Interest & Depreciation Equivalent Case Weighted Discharge Emergency Department Economic Development Agency Energy for Industry Executive Leadership Team Emergency Management Planning Group Ears, Nose and Throat Expression of Interest Earthquake Prone Building Policy Electronic Special Authority English Speakers of Other Languages Elective Services Patient Flow Indicators Environmental Science & Research Enrolled Service Unit Evidence and Value: Impact on Decision Making Furniture, Fixtures and Equipment Future Funding Track Financial Management Information System Friends of Motueka Hospital Trust Found Directory is an up-to-date listing of community groups and organisations in Nelson/Tasman Fee Review Committee First Specialist Assessment Financially Sustainable Threshold

FTE FVIP GM GMS GP GRx HAC HBI HBSS HBT H&DC / HDC HDSP HDU HEA He Kawenata HEeADSSS HEHA HEP HESDJ HFA HHS HIA HM HMS HODs HOP HP HPI HPV HR HR & OD IANZ IBA IDF IDSS IFRS IFHC IHB iLTCF IM InterRAI IPAC IPC IPC Units IPG IPU IS ISSP IT JIFH JAMHWSAP JOG KIM Kotahitanga KPI KHW MPHO LA LCN LIS LMC

Full Time Equivalent Family Violence Intervention Programme General Manager General Medical Subsidy General Practitioner Green Prescription Hospital Advisory Committee Hospital Benchmarking Information Home Based Support Services Home Based Treatment Health and Disability Commissioner Health & Disability Services Plan Programme High Dependency Unit Health Education Assessments Covenant, agreement, treaty, testament (PM Ryan Maori Dictionary pg 104) Psychosocial tool â&#x20AC;&#x201C; Home, Education, eating, Activities, Drugs and Alcohol, Sexuality, Suicidality (mood), Safety Healthy Eating Healthy Action Hospital Emergency Plan Ministries of Health, Education, Social Development, Justice Health Funding Authority Hospital and Health Services Health Impact Assessment Household Management Health Management System Heads of Department Health of Older People Health Promotion Health Practitioner Index Human Papilloma Virus Human Resources Human Resources and Organisational Development International Accreditation New Zealand Information Builders of Australia Inter District Flow Intellectual Disability Support Services International Financial Reporting Standards Integrated Family Health Centre Iwi Health Board InterRAI Long Term Care Facility Assessment Information Management Inter Residential Assessment Instrument Independent Practitioner Association Council Intensive Patient Care Intensive Psychiatric Care Units Immunisation Partnership Group In-Patient Unit Information Systems Information Services Strategic Plan Information Technology Jack Inglis Friendship Hospital Joint Action Maori Health & Wellness Strategic Action Plan Joint Oversight Group Knowledge and Information Management Unity, accord, coalition, solidarity (PM Ryan Maori Dictionary pg 127) Key Performance Indicator Kimi Hauora Wairau Marlborough PHO Local Authority Local Cancer Network Laboratory Information Systems Lead Maternity Carer

LOS Length of Stay LSCS Lower Segment Caesarean Section LTC Long Term Care LTCCP Long Term Council Community Plan LTO Licence to Occupy LTS-CHC Long Term Supports – Chronic Health Condition LTSFSG Long Term Service Framework Steering Group Manaakitanga Goodwill, show respect, or kindness to ((PM Ryan Maori Dictionary pg 172) Manawhenua Power, prestige, authority over land (HW Williams Maori Dictionary pg 172) Manawhenua O Te Tau Ihu O Te Waka A Maui – Referring to the eight iwi who hold tribal authority over the top of the South Island (no reference) MHDSF Maori Health and Disability Strategy Framework MHFS Maori Health Foundation Strategy MPDS Maori Provider Development Scheme MA Medical Advisor MCT Mobile Community Team MDC Marlborough District Council MDO Maori Development Organisation MDS Maori Development Service MDT Multi Disciplinary Team MECA Multi Employer Collective Agreement MHAU Mental Health Admission Unit MHC Mental Health Commissioner MHD Maori Health Directorate MHINC Mental Health Information Network Collection MHWSF Maori Health and Wellness Strategic Framework MOH Ministry of Health MOH Medical Officer of Health MOA Memorandum of Agreement MOSS Medical Officer Special Scale MOU Memorandum of Understanding MOW Meals on Wheels MRI Magnetic Resonance Imaging MRT Medical Radiation Technologist (or Technician) MSD Ministry of Social Development NMDHB Nelson Marlborough District Health Board NPA Nutrition and Physical Activity NRAHDD Nelson Region After Hours & Duty Doctor Limited NRT Nicotine Replacement Therapy MRSA Methicillin Resistant Staphylococcus Aureus MSSD Medical Surgical Service Directorate NHBIT National Health Board IT NASC Needs Assessment Service Coordination NBPH Nelson Bays Primary Health Trust NCC National Capital Committee NCC Nelson City Council NCSP National Cervical Screening Programme NETP Nursing Entry to Practice NGO Non Government Organisation NHCC National Health Coordination Centre NHI National Health Index NIR National Immunisation Register NMDHB Nelson Marlborough District Health Board NMDS National Minimum Dataset NMHA Nelson Marlborough Health Alliance NMHS Nelson Marlborough Health System NMIT Nelson Marlborough Institute of Technology NPA Nutrition and Physical Activity (Programme) NPV Net Present Value NRAHDD Nelson Regional After Hours and Duty Doctor Ltd NSU National Screening Unit

NTOS NZHIS NZMA NZNO NZPH&D Act OAG OIA OIS OPD OPF OPJ OSH OT PACS PAS P&F PANT PBF(F) PC P&C PCI PCO PCT PDR PDRP PDSA PFG PHS PHCS PHI PHO PHOA PHONZ PHS PHU PIA PN POA POETIC PPP PSAAP PT PTAC PRIMHD PVS Q QA QHNZ QIC QIPPS Rangatiratanga RDA RDA RIF RFI RFP RICF RM RMO RN ROI

National Terms of Settlement NZ Health Information Services New Zealand Medical Association NZ Nurses Organisation NZ Public Health and Disability Act 2000 Office of the Auditor General Official Information Act Outreach Immunisation Services Outpatient Department Operational Policy Framework Optimising the Patient Journey Occupational Health and Safety Occupational Therapy Picture Archiving Computer System Patient Administration System Planning and Funding Physical Activity and Nutrition Team Population Based Funding (Formula) Personal Cares Primary & Community Percutaneous Coronary Intervention Primary Care Organisation Pharmaceutical Cancer Treatments Performance Development Review Professional Development and Recognition Programme Plan, Do, Study, Act Performance Framework Group (formerly known as Services Framework Group) Public Health Service Primary Health Care Strategy Public Health Intelligence Primary Health Organisation PHO Alliance PHO New Zealand Public Health Service Public Health Unit Performance Improvement Actions Practice Nurse Programme of Action (Whanau Ora nationally) Primary Options for Extended Therapy interventions in the Community PHO Performance Programme PHO Service Agreement Amendment Protocol Patient Pharmacology and Therapeutics Committee Project for the Integration of Mental Health Data Price Volume Schedule Quality Quality Assurance Quality Health NZ Quality Improvement Council Quality Improvement Programme Planning System Autonomy, evidence of greatness (HW Williams Maori Dictionary pg 323) Resident Doctors Association Riding for Disabled Rural Innovation Fund Request for Information Request for Proposal Reducing Inequalities Contingency Funding Registered Midwife Resident Medical Officer Registered Nurse Registration of Interest

RSE RSL SAN SCBU SCN SD SDB SHSOP SI SIA SIAPO SICF SICSP SI HSP SI RHSP SIRCC SISSAL SLH SLT SMO SNA SOI SOPD SOPH SPOE S&P T TDC TIA TLA TOW TOR TPOT TRTT TWWOC UG V VLCA VRA WAM WAVE (Project) WCTO WEll WIP YTD YTS

Recognised Seasonal Employer Research and Sabbatical Leave Storage Area Network Special Care Baby Unit Southern Cancer Network Service Director/Directorate Special Dental Benefit Services Specialist Health Services for Older People South Island Services to Improve Access South Island Alliance Project Office South Island Chairs Forum South Island Clinical Services Plan South Island Health Services Plan; now SI RHSP South Island Regional Health Services Plan South Island Regional Capital Committee South Island Shared Service Agency SouthLink Health Strategic Leadership Team Senior Medical Officer Special Needs Assessment Statement of Intent Surgical Outpatients Department School of Population Health Single Point of Entry Strategy and Planning Timeliness Tasman District Council Transient Ischemic Attack Territorial Local Authority Treaty of Waitangi Terms of Reference The Productive Operating Theatre Te Roopu Tupu Tahi Te Waipounamu Whanau Ora Collective User Group Quantity Very Low Cost Access Vascular Risk Assessment Wairau Accident & Medical Trust Working to Add Value through E-Information Well Child Tamariki Ora Whanau Engagement, Innovation and Integration Work in Progress Year to Date Youth Transition Service

May 2013

APPENDIX 4:

DEFINITIONS

Activity

What an agency does to convert inputs to outputs.

Capability

What an organisation needs (in terms of access to people, resources, systems, structures, culture and relationships), to efficiently deliver the outputs required to achieve the Government's goals. A Crown entity that must give effect to government policy when directed by the responsible Minister. One of the three types of statutory entities (see also Crown entity; autonomous Crown entity and independent Crown entity). A generic term for a diverse range of entities within one of the five categories referred to in section 7(1) of the Crown Entities Act 2004, namely: statutory entities, Crown entity companies, Crown entity subsidiaries, school boards of trustees, and tertiary education institutions. Crown entities are legally separate from the Crown and operate at arm‘s length from the responsible or shareholding Minister(s); they are included in the annual financial statements of the Government. Reducing costs or cost growth in general, whether through improved efficiency, or other means such as contract negotiation/consolidation, changes to budget management, changes in structure etc. Reducing the cost of inputs relative to the value of outputs.

Crown agent Crown entity

Cost containment Efficiency Effectiveness

Impact

Impact measures

Input ntegrated care

Intervention Intervention logic model

Intermediate outcome

The extent to which objectives are being achieved. Effectiveness is determined by the relationship between an organisation and its external environment. Effectiveness indicators relate outputs to impacts and to outcomes. They can measure the steps along the way to achieving an overall objective or an outcome and test whether outputs have the characteristics required for achieving a desired objective or government outcome. Means the contribution made to an outcome by a specified set of goods and services (outputs), or actions, or both. It normally describes results that are directly attributable to the activity of an agency. For example, the change in the life expectancy of infants at birth and age one as a direct result of the increased uptake of immunisations. (Public Finance Act 1989). Impact measures are attributed to agency (DHBs) outputs in a credible way. Impact measures represent near-term results expected from the goods and services you deliver; can often be measured soon after delivery, promoting timely decisions; and may reveal specific ways in which managers can remedy performance shortfalls. (http://www.ssc.govt.nz/upload/downloadable_files/performance-measurement.pdf page 13). The resources such as labour, materials, money, people, information technology used by departments to produce outputs, that will achieve the Government's stated outcomes. (http://www.ssc.govt.nz/glossary/) Includes both clinical and service integration to bring organisations and clinical professionals together, in order to improve outcomes for patients and service users through the delivery of integrated care. Integration is a key component of placing patients at the centre of the system, increasing the focus on prevention, avoidance of unplanned acute care and redesigning services closer to home. WHO definition of health service integration: Bringing together common functions within and between organisations to solve common problems, developing commitment to a shared vision and goals and using common technologies and resources to achieve these goals. An action or activity intended to enhance outcomes or otherwise benefit an agency or group. (Refer (http://www.ssc.govt.nz/glossary/). A framework for describing the relationships between resources, activities and results. It provides a common approach for integrating planning, implementation, evaluation and reporting. Intervention logic also focuses on being accountable for what matters – impacts and outcomes (Refer State Services Commission ‗Performance Measurement – Advice and examples on how to develop effective frameworks: www.ssc.govt.nz). See Outcomes.

‘Living within our means’

Providing the expected level of outputs within a break even budget or National Health Board (NHB) agreed deficit step toward break even by a specific time.

Management systems

The supporting systems and policies used by the DHB in conducting its business.

Measure

A measure identifies the focus for measurement: it specifies what is to be measured.

Objectives

Is not defined in the legislation. The use of this term recognises that not all outputs and activities are intended to achieve ―outputs‖. For example, increasing the take-up of programmes; improving the

Outcome

Output agreement

Output classes

Output class definitions

retention of key staff; improving performance; improving Governance etc. are ‗internal to the organisation and enable the achievement of ‗outputs‘. Outcomes are the impacts on or the consequences for, the community of the outputs or activities of government. In common usage, however, the term 'outcomes' is often used more generally to mean results, regardless of whether they are produced by government action or other means. An intermediate outcome is expected to lead to an end outcome, but, in itself, is not the desired result. An end outcome is the final result desired from delivering outputs. An output may have more than one end outcome; or several outputs may contribute to a single end outcome. (Refer http://www.ssc.govt.nz/glossary/) . A state or condition of society, the economy or the environment and includes a change in that state or condition. (Public Finance Act 1989). Output agreement/output plan - See Purchase Agreement (refer to http://www.ssc.govt.nz/glossary/). An output agreement is to assist a Minister and a Crown entity (DHB) to clarify, align, and manage their respective expectations and responsibilities in relation to the funding and production of certain outputs, including the particular standards, terms, and conditions under which the Crown entity will deliver and be paid for the specified outputs (see s170 (2) Crown Entities Act 2004. An aggregation of outputs, or groups of similar outputs. (Public Finance Act 1989) Outputs can be grouped if they are of a similar nature. The output classes selected in your nonfinancial measures must also be reflected in your financial measures (s 142 (2) (b) Crown Entities Act 2004). It is proposed that all DHBs use the following new output class definitions for 2012/13: Prevention 1. Preventative services are publicly funded services that protect and promote health in the whole population or identifiable sub-populations comprising services designed to enhance the health status of the population as distinct from treatment services which repair/support health and disability dysfunction. 2. Preventative services address individual behaviours by targeting population wide physical and social environments to influence health and wellbeing. 3. Preventative services include health promotion to ensure that illness is prevented and unequal outcomes are reduced; statutorily mandated health protection services to protect the public from toxic environmental risk and communicable diseases; and, population health protection services such as immunisation and screening services. 4. On a continuum of care these services are public wide preventative services. Early Detection and Management  Early detection and management services are delivered by a range of health and allied health professionals in various private, not-for-profit and government service settings. Include general practice, community and Maori health services, Pharmacist services, Community Pharmaceuticals (the Schedule) and child and adolescent oral health and dental services.  These services are by their nature more generalist, usually accessible from multiple health providers and from a number of different locations within the DHB.  On a continuum of care these services are preventative and treatment services focused on individuals and smaller groups of individuals. Intensive Assessment and Treatment Services 4 Intensive assessment and treatment services are delivered by a range of secondary, tertiary and quaternary providers using public funds. These services are usually integrated into facilities that enable co-location of clinical expertise and specialized equipment such as a ‗hospital‘. These services are generally complex and provided by health care professionals that work closely together. 5 They include: 5.1 Ambulatory services (including outpatient, district nursing and day services) across the range of secondary preventive, diagnostic, therapeutic, and rehabilitative services 5.2 Inpatient services (acute and elective streams) including diagnostic, therapeutic and rehabilitative services 5.3 Emergency Department services including triage, diagnostic, therapeutic and disposition services

Outputs Ownership

P5 Health

Performance measures

Priorities Productivity Purchase agreement

Regional collaboration

On a continuum of care these services are at the complex end of treatment services and focussed on individuals. Rehabilitation and Support  Rehabilitation and support services are delivered following a ‗needs assessment‘ process and coordination input by NASC Services for a range of services including palliative care services, home-based support services and residential care services.  On a continuum of care these services provide support for individuals. Final goods and services, that is, they are supplied to someone outside the entity. They should not be confused with goods and services produced entirely for consumption within the DHB group (Crown Entities Act 2004). The Crown's core interests as 'owner' can be thought of as: Strategy - the Crown's interest is that each state sector organisation contributes to the public policy objectives recognised by the Crown; Capability - the Crown's interest is that each state sector organisation has, or is able to access, the appropriate combination of resources, systems and structures necessary to deliver the organisation's outputs to customer specified levels of performance on an ongoing basis into the future; Performance - the Crown's interest is that each organisation is delivering products and services (outputs) that achieve the intended results (outcomes), and that in doing so, each organisation complies with its legislative mandate and obligations, including those arising from the Crown's obligations under the Treaty of Waitangi, and operates fairly, ethically and responsively. (Refer http://www.ssc.govt.nz/glossary/). A change in focus rooted in new science that considers the convergence of systems approaches to disease, new measurement and visualisation technologies and tools to allow the current, largely mode of health care, to be replaced by a Predictive, Preventive, Personalised, Participatory and Patientcentred health care focused on cost-effectiveness and wellness. Selected measures must align with the DHBs Regional Service Plan and Annual Plan. Four or five key outcomes with associated outputs for non-financial forecast service performance are considered adequate. Appropriate measures should be selected and should consider quality, quantity, effectiveness and timeliness. These measures should cover three years beginning with targets for the first financial year (2012/13) and show intended results for the two subsequent financial years. (Refer to www.ssc.govt.nz/performance-info-measures). Statements of medium term policy priorities. Increasing outputs relative to inputs (i.e.: either more outputs produced with the same inputs, or the same output produced using fewer inputs). A purchase agreement is a documented arrangement between a Minister and a department, or other organisation, for the supply of outputs. Some departments piloting new accountability and reporting arrangements now prepare an output agreement. An output agreement extends a purchase agreement to include any outputs paid for by third parties where the Minister still has some responsibility for setting fee levels or service specifications. The Review of the Centre has recommended the development of output plans to replace departmental purchase and output agreements. (Refer http://www.ssc.govt.nz/glossary/). Regional collaboration refers to DHBs across geographical ‗regions‘ for the purposes of planning and delivering services (clinical and non-clinical) together. Four regions exist.  Northern: Northland DHB, Auckland DHB, Waitemata DHB and Counties Manukau DHB  Midland: Bay of Plenty DHB, Lakes DHB, Tairawhiti DHB, Taranaki DHB and Waikato DHB  Central: Capital and Coast DHB, Hawkes Bay DHB, Hutt Valley DHB, MidCentral DHB, Waitemata DHB and Whanganui DHB  Southern: Canterbury DHB, Nelson Marlborough DHB, South Canterbury DHB, Southern DHB and West Coast DHB Regional collaboration for some clinical networks may vary slightly. For example Central Cancer Network contains eight DHBs, Taranaki DHB and Tairawhiti DHB in addition to the Central Region DHBs.

Results

Sometimes used as a synonym for 'Outcomes'; sometimes to denote the degree to which an organisation successfully delivers its outputs; and sometimes with both meanings at once. (http://www.ssc.govt.nz/glossary/).

Standards of Service Measures

Measures of the quality of service to clients which focus on aspects such as client satisfaction with the way they are treated; comparison of current standards of service with past standards; and appropriateness of the standard of service to client needs.

Statement of service performance (SSP)

Government departments, and those Crown entities from which the Government purchases a significant quantity of goods and services, are required to include audited statements of objectives and statements of service performance with their financial statements. These statements report whether the organisation has met its service objectives for the year. (http://www.ssc.govt.nz/glossary/).

Strategy

See Ownership (http://www.ssc.govt.nz/glossary/).

Sub regional collaboration

Sub regional collaboration refers to DHBs working together in a smaller grouping to the regional grouping, typically in groupings of two or three DHBs and may be formalised with an agreement. For example a Memorandum of Understanding. Examples of sub regional collaboration include DHBs in the Auckland Metropolitan area, MidCentral and Whanganui DHBs (CentralAlliance), Capital and Coast, Hutt Valley and Wairarapa DHBs and Canterbury and West Coast DHBs.

Targets

Targets are agreed levels of performance to be achieved within a specified period of time. Targets are usually specified in terms of the actual quantitative results to be achieved or in terms of productivity, service volume, service-quality levels or cost effectiveness gains. Agencies are expected to assess progress and manage performance against targets. A target can also be in the form of a standard or a benchmark. The collectively shared principles that guide judgment about what is good and proper. The standards of integrity and conduct expected of public sector officials in concrete situations are often derived from a nation's core values which, in turn, tend to be drawn from social norms, democratic principles and professional ethos. (http://www.ssc.govt.nz/glossary/). The assessment of benefits relative to cost, in determining whether specific current or future investments/expenditures are the best use of available resource.

Values

Value for money

APPENDIX 5:

SOUTH ISLAND ALLIANCE

SOUTH ISLAND HEALTH SERVICE PLAN 2013/16 PRIORITIES

100

101

102

103