NMDHB Annual Plan 2014/2015

‘NMDHB Annual Plan 2014-15 & Statement of Intent 2014-18’ Pursuant to Section 38 of the New Zealand Public Health and Disability Act 2000; Section 139 of the Crown Entities Act 2004; Section 49 of the Crown Entities Amendment Act 2013; New CE Act s149C. Nelson Marlborough District Health Board, Private Bag 18, NELSON Note: This Annual Plan should be read in conjunction with the Nelson Marlborough District Health Board (NMDHB) Maori Health Plan, the NMDHB Public Health Service Plan, the NMDHB Mental Health and Addictions Plan, and the South Island Regional Health Services Plan. These plans are available on our website: www.nmdhb.govt.nz.

Office of Hon Tony Ryall Minister of Health Minister for State Owned Enterprises

2 JUL 2014 Ms Jenny Black Chair Nelson Marlborough District Health Board Private Bag 18 NELSON 7042

Dear Ms Black Nelson Marlborough District Health Board 2014/15 Annual Plan This letter is to advise you I have approved and signed Nelson Marlborough District Health Board's (DHB) 2014/15 Annual Plan for three years.

I appreciate the significant work that goes into preparing your Annual Plan and I thank you for your effort. I look forward to seeing your progress over the course of the year.

While recognising these are tight economic times, the Government is dedicated to improving the health of New Zealanders and continues to invest in key health services. In Budget 2014, Vote Health again received the largest increase in government spending, demonstrating the Government's on-going commitment to protecting and growing our publicly funded health services.

Better Public Services (BPS): Results for New Zealanders Of the ten whole-of-government key result areas, the health service is leading these result areas:  increased infant immunisation  reduced incidence of rheumatic fever  reduced assaults on children.

It is important that DHBs continue to work closely with other social sector organisations, including NGOs, on initiatives including Whanau Ora, Children's Action Plan and Youth Mental Health.

As you will be aware, in May the Government announced support for rollout of four new Children's Teams by March 2015, including one in Marlborough, in Nelson Marlborough DHB. The actions and milestones outlined in your Annual Plan will enhance this new initiative. DHB participation in crossagency governance partnerships and ongoing efforts to improve service coordination for vulnerable children and, particularly, children in State care, will be major contributions.

Preparation for the anticipated enactment of the Vulnerable Children's Bill next year should focus on those areas of activity highlighted in our expectations, namely:  maintaining and developing services for vulnerable children, particularly in Maternal and Child Health  supporting health's contribution to the establishment of Children's Teams  developing workforce training, vetting and screening and child protection policies.

Private Bag 18041, Parliament Buildings, Wellington 6160, New Zealand. Telephone 64 4 817 6804 Facsimile 64 4 817 6504

2 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

National Health Targets Your plan generally includes a good range of actions that will lead to improved or continued performance against the health targets. As you are aware, there will be one new addition to the target set for 2014/15. From quarter two, the 62 day Faster Cancer treatment indicator will become the cancer health target with a target achievement level of 85% by July 2016. I look forward to seeing your progress during the year. .., Although Nelson Marlborough DHB is performing well in most health target areas, I would like you to focus on improving recent results in the primary care component of the Better help for smokers to quit target, and the More heart and diabetes checks target. In addition I am asking all DHBs to ensure appropriate actions are implemented to support immunisation service delivery.

Improving Quality I understand guidance on Quality Accounts for 2014 was recently provided by the Health Quality and Safety Commission. My expectation is that the presentation of your quality accounts will follow as closely as possible to the release of your Annual Report. I expect that quality improvement initiatives will include evidence based staffing practice that accurately matches staffing resource to demand for patient care.

Care Closer to Home I am pleased to see an enhanced commitment to tangible actions in your Annual Plan demonstrating how you will broaden the scope of diagnostic and treatment services directly accessible to primary care. I look forward to seeing the results of your work to improve the breadth of services with direct access from primary care.

It is also important that the development of rural service level alliance teams (SLATs) progresses during the year. It is expected that a rural SLAT is established by the end of quarter one and the SLAT develops and agrees a plan for the distribution of rural funding in accordance with the PHO Services Agreement Version 2 (July 2014).

Health of older people The Government expects DHBs to continue to work regionally, and alongside clinical leaders, primary care, and community care to deliver integrated services and improve the quality of the care that older people receive.

This year, the Government is particularly focused on achieving results through your commitments to:  continue implementing dementia care pathways  support aged residential care facilities to use interRAI  use health of older people specialists to advise and train health professionals in primary and aged residential care  improve rapid response and discharge management services.

In addition, I am pleased with your commitments to continuing to implement your fracture liaison service, continuing price or volume increases in home and community support services, and using interRAl-based quality indicators.

Regional and National Collaboration Greater integration between regional DHBs supports more effective use of clinical, financial and other resources, such as technology, I expect DHBs to make significant contributions to delivering on regional planning objectives; and to priorities specific to your region that will contribute to your financial and clinical sustainability. This requires sharing of expertise as a region and working together to realise the benefits of regional and sub-regional collaboration. I look forward to seeing delivery on your agreed Regional Service Plan actions.

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Guidance on national entity priorities was provided to all DHBs in February 2014, for inclusion in Annual Plans, following the completion of the Health Sector Forum lead work between the Ministry, national entities and DHBs. DHBs have committed to work in partnership with HBL to progress its Food Services, Linen and Laundry Services and National Infrastructure Platform business cases; and to factor in benefit impacts for HBL's Finance Procurement Supply Chain Initiative (FPSC), where these are available. I expect that your DHB will deliver on these business cases within your bottom line.

Living within our means DHBs are required to budget and operate within allocated funding and to identify specific actions to improve year-on-year financial performance in order to live within their means. This includes seeking efficiency gains and improvements in purchasing, productivity and quality aspects of your DHB's operation and service delivery. Improvements through national, regional and sub-regional initiatives are expected to continue to be a key focus for all DHBs. I am pleased to see that your DHB is planning increasing surpluses for the four years of the plan and I expect that you will have contingencies in place, should you need them, to ensure that you achieve your planned net result for 2014/15.

Budget 2014 The expectation is that you will deliver on Budget 2014 initiatives. This includes extending free doctors' visits and prescriptions for children aged under six years to all children aged under 13 years from July 2015.

Annual Plan Approval My approval of your Annual Plan does not constitute acceptance of proposals for service changes that have not undergone review and agreement by the NHB. As you know I am aware of your 'top of the South' service review, the NHB will contact you in relation to the recommendations from the review. The NHB will also inform you where service change proposals are agreed subject to particular conditions.

You are reminded that you need to advise the NHB of any proposals that may require Ministerial approval as you review services during the year.

I would like to thank you, your staff, and your Board for your valuable contribution and continued commitment to delivering quality health care to your population and wish you every success with the implementation of your 2014/15 Annual Plan. I am looking forward to seeing your achievements.

Please ensure that a copy of this letter is attached to the copy of your signed Annual Plan held by the Board and to all copies of the Annual Plan made available to the public.

Yours sincerely

Hon Tony Ryall Minister of Health

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CONTENTS

MODULE 1: INTRODUCTION AND STRATEGIC INTENTIONS....................................................................... 8 1.1 1.2 1.3

EXECUTIVE SUMMARY ................................................................................................................. 8 CONTEXT ......................................................................................................................................10 OUR STRATEGIC PRIORITIES......................................................................................................12

MODULE 2: DELIVERING ON PRIORITIES AND TARGETS..........................................................................20 2.1

HEALTH PRIORITIES AND TARGETS ...........................................................................................20

MODULE 3: STATEMENT OF PERFORMANCE EXPECTATIONS.................................................................46 3.1

MEASURING OUR PERFORMANCE BY OUTPUT CLASS ............................................................46

MODULE 4: FINANCIAL PERFORMANCE .....................................................................................................63 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8

FISCAL SUSTAINABILITY .............................................................................................................63 MEETING OUR FINANCIAL CHALLENGES ...................................................................................63 ASSUMPTIONS .............................................................................................................................64 ASSET PLANNING AND SUSTAINABLE INVESTMENT.................................................................64 DEBT AND EQUITY .......................................................................................................................66 ADDITIONAL INFORMATION AND EXPLANATIONS .....................................................................66 ACCOUNTING POLICIES ..............................................................................................................67 PROSPECTIVE FINANCIAL STATEMENTS...................................................................................67

MODULE 5: STEWARDSHIP ..........................................................................................................................73 5.1 5.2 5.3 5.4 5.5 5.6

INFORMATION TECHNOLOGY .....................................................................................................73 INFRASTRUCTURE/CAPITAL .......................................................................................................73 QUALITY ASSURANCE AND IMPROVEMENT ..............................................................................73 OUR WORKFORCE .......................................................................................................................75 SUBSIDIARIES, OTHER INTERESTS OR COOPERATIVE ARRANGEMENTS ..............................77 STEWARDSHIP ROLE AS OWNER OF CROWN ASSETS .............................................................78

MODULE 6: SERVICE CONFIGURATION ......................................................................................................79 6.1 6.2 6.3

SERVICE COVERAGE...................................................................................................................79 SERVICE CHANGE .......................................................................................................................79 SERVICE ISSUES..........................................................................................................................79

MODULE 7: PERFORMANCE MEASURES ....................................................................................................80 7.1

MONITORING FRAMEWORK PERFORMANCE MEASURES ........................................................80

APPENDIX 8.1 GLOSSARY OF ACRONYMS .................................................................................................84 APPENDIX 8.2 DEFINITIONS .........................................................................................................................86

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MODULE 1: INTRODUCTION AND STRATEGIC INTENTIONS 1.1

EXECUTIVE SUMMARY

1.1.1

FORWARD FROM NMDHB CHAIR, DEPUTY CHAIR, AND CHIEF EXECUTIVE

The Nelson Marlborough District Health Board (NMDHB) is one of 20 DHBs nationally, established under the New Zealand Public Health and Disability Act 2000 (including subsequent amendments). DHBs are each Crown Entities under the Crown Entities Act 2004, responsible to the Minister of Health and the Minister of Finance for the health and independence of their populations; NMDHB is responsible for the population of Nelson, Tasman, and Marlborough. This Annual Plan has been prepared to meet the requirements of both governing Acts and the relevant section of the Public Finance Act. This Plan sets out NMDHB‟s goals and objectives and describes what NMDHB intends to achieve in 2014/15 in terms of improving the health, wellbeing, and independence of our population and in delivering on the expectations of the Minister of Health.

This Annual Plan also contains services and financial statements of forecast expectations for the 2014/15 year and the three subsequent years. Modules of this Annual Plan are extracted to form a stand-alone Statement of Intent (SOI) which is presented to Parliament. As a public accountability document, the SOI is used at the end of every financial year to compare NMDHB‟s planned performance with our actual performance with the audited results presented in NMDHB‟s Annual Report.

NMDHB is committed to addressing a number of key issues to ensure the overall improvement in the health, wellbeing, and independence of the Nelson Marlborough population, and better outcomes for individuals including improved experience of the care funded by NMDHB and improvement in NMDHB‟s use of public funds.

Over the past 24 months Nelson Marlborough District Health Board has been through considerable challenges with respect to financial sustainability. This has resulted in a need to take steps to ensure we live within our means. As an organisation we have risen to this challenge, and it is pleasing that this plan sets out a number of areas where we are able to invest in our future. This includes: 1. Investment in initiatives that will strengthen our commitment to our „One-Service/Two-Sites‟ approach for 24/7 acute, and elective services in Nelson and Wairau Hospitals. The first investments are focused on workforce. The investment this year is the first steps of many to be taken in the future 2. Investment in initiatives that will provide the opportunity to enhance the integration of primary, community, and secondary services under the umbrella of the Top of the South / Te Tau Ihu o Te Waka a Maui Health Alliance (ToSHA) 3. Investment in significant initiatives through the Information Systems Alliance under the South Island Alliance umbrella which will make significant inroads in enhancing the integration of clinical information both across our district and regionally.

We are investing significant effort and energies to strengthen our approach to Clinical Leadership and Clinical Governance ensuring that this is integrated at all levels of the organisation, and across the Nelson Marlborough Health System.

During the year we will be undertaking a review of the Board‟s vision, goals, and HEALTH 2030 Strategy and Action Plan, a Health Service Plan, and a broader Facility Master Plan. Our financial plan as outlined in this Annual Plan is based on ensuring that NMDHB positions itself in a manner to support the future facility developments, particularly Nelson Hospital in the future, and to ensure it does not generate fiscal challenges associated with increased capital related charges. All of these activities are being done within the parameter of making certain that we achieve this while maintaining, and where possible enhancing, access to services across the system and across the district.

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NMDHB is committed to ensuring equity of outcomes for the Nelson Marlborough population through the ToSHA partnership with Kimi Hauora Wairau Marlborough Primary Health Organisation (KHW MPHO) and Nelson Bays Primary Health (NBPH). ToSHA‟s transformational, „whole of system‟ focus is our key vehicle for achieving integration of our community, primary and secondary care providers across the continuum of health, and support care, to enable high quality, safe, patient-centred delivery. Through ToSHA, NMDHB shall deliver the Minister‟s priorities as well as NMDHB Board‟s vision, goals, and HEALTH 2030 Strategy and Action Plan. For this Annual Plan, the key objectives NMDHB outlines, present a picture of our intentions and our commitment to the ToSHA partnership. This is expressed through physical co-location of all three ToSHA partners in terms of community care activities, plans, and approaches, both in NelsonTasman, and Marlborough.

In partnership with the Iwi Health Board, over the past few years we have been reviewing how Maori Health services are provided for the Iwi in Te Tau Ihu. During the early part of 2014 this culminated in a business case being received by the Iwi/Maori Coalition supporting the establishment of Te Piki Oranga. This organisation is being established and will commence providing services from 1 July 2014. Te Piki Oranga will focus on ensuring that services are provided across the entire district in a manner which works within the Whanau Ora framework and targets those Maori with the greatest needs.

NMDHB is also a partner with other South Island DHBs in the South Island Alliance. The full South Island Regional Health Services Plan (of which NMDHB is a signatory) can be found on the South Island Alliance Programme Office website: www.sialliance.health.nz.

NMDHB also has a series of operational Action Plans that provide operational detail as to who, when, what, and how we will deliver on the high level objectives outlined in this Annual Plan. These Action Plans cover the full range of our activities and interventions, and include the measurements of our expected performance. These Action Plans include the Maori Health and Public Health Service Action Plans for 2014/15. All of this Annual Plans aligned Action Plans can be found on our website: www.nmdhb.govt.nz.

In signing this Annual Plan, we are satisfied that it represents NMDHB‟s intentions and commitments to improve the health and independence of the Nelson Marlborough population with our ToSHA partners KHW MPHO and NBPH, and our South Island Alliance partners, for the period 01 July 2014 to 30 June 2015.

Together, working in partnership through consensus, we will continue to demonstrate real gains in health and independence outcomes for the Nelson, Tasman, Marlborough population, and do so within the funds provided to us by Government for this purpose.

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1.2

CONTEXT

1.2.1

BACKGROUND AND OPERATING ENVIRONMENT

Our Vision is „Leading the way to Healthy Families‟, through our Mission of working with the people of our community to promote, encourage, and enable their health, wellbeing, and independence.

Letter of Expectations The Minister of Health‟s letter for DHBs and subsidiary entities, received January 2014, sets the requirements for the road map of this Annual Plan, and is addressed in this Plan.

Te Tiriti o Waitangi Nelson Marlborough DHB recognises that the Treaty of Waitangi is a founding document of New Zealand. As an agent of the Crown, NMDHB is committed to fulfilling its role as a Treaty partner and we continue to maintain our investment in Maori Provider services and in mainstream services provided for Maori. We recognise the important role the health sector plays in recognising supporting the rights of Maori to achieve equitable outcomes in health and social wellbeing. Nationally, Maori continue to have poorer access to, and health outcomes from, the New Zealand health sector, including higher rates of cancer, diabetes, and cardiovascular disease1, resulting in lower life expectancy and higher infant mortality 2. We understand that health is a 'taonga' and that the Nelson Marlborough health system and Maori have a shared role in implementing health strategies for Maori. Addressing amenable mortality rates for local Maori is a key area for our Te Piki Oranga, Maori health provider coalition.

Our Geography and Population Profile The Nelson Marlborough health system covers a wide geographic area of 22,715 km2: Marlborough District Total Population# 136,995 12,484 km2, Tasman District 9,786 km2, and Nelson City 445 km2. The population is dispersed over large Maori rural topographic and geographic boundaries from European 118,935 12,384 Golden Bay across to Ward and inland down to Murchison, creating challenges around trauma Mid Eastn-Latn Pacific 2,250 Asian 4,020 response and access to services for our rural Am- Africn 597 population. These boundaries take in the townships of Nelson, Blenheim, Motueka, Murchison, Picton, and Nelson Marlborough Tasman Takaka. Eight Iwi are located within the district: 46,437 43,416 47,157 Rangitane, Ngati Koata, Ngati Rarua, Te Ati Awa, Ngati Tama, Ngati Kuia, Ngati Toa Rangatira, and Ngati Apa; the resident Maori population (including Maataa Waka3) at 2013 was 10.4% of the total population. The total population of the district has increased by almost 7,000 people in the past six years.

More people are living with a long-term condition, accounting for a significant portion of the health spend, and the number of people with co-morbidities (multiple complex conditions) is expected to continue to rise over the next ten years, including those linked to lifestyle choice4. Mental health problems continue to affect many in the adult population, with severe mental health problems affecting one in a hundred – inequitably dispersed through our population they all fall more heavily on the lower socio economic group in our society. Our population is structurally the oldest in New Zealand5; 18.6% are aged 65 and over (25,479 people). We are focusing on helping this group remain in their homes as long as is possible to improve their health and Tatau Kura Tangata: Health of Older Maori Chart Book (2011). Wellington: Ministry of Health.

Tatau Kahukura: Maori Health Chart Book (2010). 2nd Edition. Wellington: Ministry of Health. # 2013 Census statistics (Statistics NZ). Note: the ethnic group is a group a person identifies with or has a sense of belonging to; It is a measure of cultural affiliation (in contrast to race, ancestry, nationality, or citizenship); Ethnicity is self-perceived and a person can belong to more than one ethnic group therefore the total population number is less than the ethnic group numbers combined.

3 Non-local Iwi Maori 4 Health Loss in NZ: A report from the NZ Burden of Diseases, Injuries and Risk Factors Study 2006-2016. (2013). Wellington: Ministry of Health.

5 National Institute of Demographic and Economic Analysis & University of Waikato (2012). Marlborough, Nelson, and Tasman Regions – A socio-demographic profile.

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independence and ensure cost effective delivery of services for older people. NMDHB is an official resettlement zone for former refugees; over the last four years this population has grown significantly here; it is considered to be the fourth largest in the country. This group also has higher and unique health needs and we are focussing resources on addressing this through collaborative actions with the Top of the South/Te Tau Ihu o Te Waka a Maui Health Alliance (ToSHA) [see Appendix 8.2 – „Alliance‟], and the Maori Health Coalition – Te Piki Oranga.

Our healthcare system Our system operates as an interconnected and interdependent group of organisations. In addition to our District Health Board providers, this publicly-funded group includes: two Primary Health Organisations (PHOs) who support a primary care provider network of 36 general practices and, Nelson Bays Primary Health also operate the Integrated Family Health Centre in Golden Bay. There are also 28 community pharmacies two of which are crucial in servicing our rural population (Golden Bay and Wakefield based); 27 age-related residential care providers; five home-based support service providers; 29 contracted oral health providers (dentists); two hospices; two maternity services; hospital and private community radiology/imaging services, Southern Community Laboratories, who operate hospital and community laboratory services; and, 12 mental health providers including one Maori health provider. All of these healthcare and support care providers are dispersed geographically across Nelson, Tasman and Marlborough to provide care „closer to home‟.

Effective Governance Clinical integration requires effective clinical governance across the whole health system NMDHB has established a clinical governance group supported by a GM Clinical Governance which has close input from both PHO clinical governance groups. These clinically-led bodies inform a clinically-led, whole of health system approach to enable the implementation of high quality, integrated6, patient-centred health services across Nelson Marlborough. These clinical governance structures support an environment where clinical excellence flourishes, with clear accountabilities to patients, consumers, and the local health system.

Top of the South / Te Tau Ihu o Te Waka a Maui Health Alliance (ToSHA) This Alliance was formalised in July 2013 through the signing of the Alliance Agreement under the PHO Services Agreement. The ToSHA has developed an action plan and established Work Streams and Service Level Alliance Teams to address areas of transformational change across primary, community, and hospital settings of care that enable effective integration. One of the key enablers, ToSHA‟s Health Pathways work enables integrated patient-centered pathways of care that supports patients across the whole of their health and care journey. This work also ensures improvement and transformation in service delivery within and across care settings. NMDHB has budgeted more than $1.3 million to implement Alliance activities for 2014/15 as well as organising an Alliance Support Team that ensures the action plan is delivered. The ToSHA action plan initiatives for 2014/15, to support achievement of primary care impacts and outcomes, are detailed in Module 2.

Implementing Top of the South Review In early 2014 NMDHB consulted with our clinical and support staff and communities on the external Review Panel Report, the Top of the South Review. The agreed recommendations are being implemented with oversight from the clinical governance group over the next three years. These recommendations include improving how we sustainably, safely, and equitably deliver across the district our radiology, cardiology, orthopaedic, general medical and surgical services under the principle of „one-service/two-sites‟.

Iwi Health Board Our relationship with the tangata whenua of our district is expressed through the partnership with the Iwi Health Board and joint agreement titled „He Kawenata.‟ We ensure Maori participation and partnership in health planning, service design, development and delivery through engaging proactively with the Iwi Health Board and the Maori Health Coalition - Te Piki Oranga. Our Maori Health Plan has been developed alongside our NMDHB Annual Plan, and includes national and local priorities. We are strategically advised on the planning and delivery of Maori health services, by our Iwi Health Board.

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Joined up, coordinated clinical and service health care and social care that is planned and organised around the needs and preferences of the individual, their carer, and family/whanau. This may also involve integration with other services/sectors, for example housing.

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1.2.2

NATURE AND SCOPE OF FUNCTIONS, AND OPERATIONS of NMDHB

As a „District Health Board‟ operating under the NZ Health and Disability Act 2000, the Health Act 1956, and the Crown Entities Act 2004, we are required to plan, commission, deliver, monitor, and report on wide range of personal, population, and public health and disability services. At NMDHB we execute this responsibility through the following functions: 1. Plan the strategic direction of our health system in collaboration with our ToSHA partners, clinical leaders, key stakeholders, Te Piki Oranga, non-government organisation providers, and most importantly our communities. Delivery is planned with DHBs regionally through the South Island Alliance (SIA) with support from the South Island Alliance Programme Office, other DHBs nationally through the District Health Board Shared Services Agency, and with the National Health Board and Ministry of Health as well as National Entities.

2. Commission and fund the majority of the health and support care service provided for the population of Nelson Marlborough through our partnerships, alliances, and relationships with service providers including Maori health services through the Te Piki Oranga. A range of home based support services are commissioned through Support Works, our Needs Assessment and Service Coordination (NASC) agency. We commission a number of referred, personal, mental, Maori, and maternity health services. We fund our populations‟ access to services across their life course and across the continuum of care locally. We also support our community to access tertiary services, mainly provided in Christchurch, Wellington, and Auckland. With other DHBs we collectively fund the national agreements for Age-Related Residential Care (ARRC), Community Pharmacy Services (CPS), the National Dental Services (NDS), and PHARMAC. In addition we work alongside Ministry of Health funded services, such as public health services, primary maternity services, long-term disability support services.

3. Provide hospital specialist and community services. We also provide a disability support service (residential, support, and day services), a Public Health Service, and a needs assessment and service coordination team. This service provision spans two urban hospitals, one rural hospital, mobile health services, mental health and addictions services, psychogeriatric services, and a range of community homes.

1.3

OUR STRATEGIC PRIORITIES

1.3.1

NMDHB STRATEGIC VISION

NMDHB‟s HEALTH 20307 strategy provides a direction for future planning and implementation of health and support services for the Nelson, Tasman and Marlborough resident population. HEALTH 2030 places patients, their families/whanau, and the local population at the very centre of our health and support delivery system. This strategy seeks to improve system efficiency through an approach that recognises the patient and their family/whanau as a co-producer of health outcomes, promoting service accountability, and promoting literacy - low health literacy results in poorer disease management, less preventive services use, higher hospitalisation rates, increased risk of mortality; and report poorer overall health status8. The key strategic outcomes our health system is working towards are as follows (page references refer to actions towards these outcomes as described in NMDHB Annual Plan Module 2): Best use of resources targeted at improving health outcomes for our population and building prevention into our system.

Our Strategy: our Top of the South Review of services across the district is creating a one-service/two-sites approach to improving access to hospital services (page 38) – „two-sites‟ are Nelson and Blenheim, „one-service‟ is a district-wide, single approach to health care ensuring consistency of service delivery regardless of treatment location; eliminating inappropriate inter-district flows - IDFs; implementing consistent standardised intervention rates - SIRs; embedding a responsive primary and community nursing model (page 30); and, driving processes to ensure financial sustainability (page 59).

Openness and transparency across our health system to deliver better planning and health outcomes.

HEALTH 2030 Strategy: http://www.nmdhb.govt.nz/filesGallery/New%20Website/09Board%20Documents/HEALTH2030September2012.pdf Parnell, T., McCulloch, E., Mieres, J., Edwards, F. (2014) Health Literacy as an Essential Component to Achieving Excellent Patient Outcomes. National Academy of Sciences.

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Our Strategy: we are improving our performance in this area through practicing ToSHA Alliance Charter principles, including enabling access to appropriate and timely knowledge (page 30); collectively leading the health system and jointly working with the primary and community environment and Te Piki Oranga (page 35); and, our HealthPathways work across the system is enabling open access to knowledge around services, interventions, and best-practice, which in turn supports clinical integration.

Knowledgeable Consumers by addressing patients/consumers experience of care and health literacy with appropriate and accessible tools to support staff to improve the ability of patients and our population to manage their own health and wellbeing.

Our Strategy: our work towards diabetes care improvement package development and primary care responsiveness (page 21); and, embedding shared patients records and patient portal (page 30, 37, 39).

Incentivised Integrated Care through implementing mechanisms that reward positive outcomes.

Our Strategy: embedding „Results Based Accountability‟ to improve planning and reporting (page 35); promoting System-wide Care Coordination work to support integration of services e.g. our Coordinated Access Response Electronic Service – „CARES‟ (page 30) and enabling clinicians to work in multi-disciplinary teams; piloting the Maternal and Child Health Integration Project (page 34); and, introducing the Integrated Performance Incentive Framework (IPIF) into our accountability framework (page 30).

Embedded ‘Wrap around services’ that are patient-centred for the patient/health needs groups most likely to benefit.

Services that „wrap around‟ are services that work together seamlessly and communicate effectively, to ensure removal of both gaps and duplication in health service care and delivery.

Our Strategy: delivering on health of older people initiatives and the dementia care pathway with our South Island Alliance (page 31); developing a high and complex needs process for children and youth (page 29); and, growing our needs assessment and coordination services - NASC (pages 31, 32).

The NMDHB Jumbo Framework (Figure 1) demonstrates the spectrum with respect to population and personal health needs and our health system activity. For each of these groups there is a requirement to help people to recover from episodes of ill health or following injury (acute conditions). People move from one group to another and ensuring flexibility and ease of movement requires a whole of system approach and is influenced by our partnerships and alliances.

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

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

Figure 1: NMDHB „Jumbo‟ – continuum of health care delivery and health needs 13 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Health & Support Resources

Clinical Governance and Quality In late 2013 we implemented a management structure to demonstrate the support for the implementation of a robust Clinical Governance Framework. This is enabling us to focus on providing high quality and safe health service delivery, with the underpinning philosophy of one-service, two-sites, to ensure equitable and timely access to services and support. Over the next two years our focus is on six key development areas: 1. Establishing an effective Clinical Governance Framework, and supporting processes 2. Ensuring NMDHB has a robust serious and sentinel event process which integrates investigations and analyses across the system of care, including implementing effective feedback and supporting change processes in partnership across the system 3. Adequately capturing relevant system data and effective reporting progress against indictors 4. Providing effective monitoring and mitigation of Clinical risks across the health system in partnership with key stakeholders 5. Efficiently managing all complaints through to resolution that meets the expectation of consumers and NMDHB acknowledging our duty under Open Disclosure 6. Evolving clinical governance processes, clinical quality, to ensure a system of continuous improvement.

A quality audit is planned across the organisation, which will include clinical audit to link the outputs of the Morbidity and Mortality Review, Drug and Therapeutics, and Clinical Standards‟ Committees, and learnings from Grand Rounds. Clinical risk analysis and process is an area that significant effort will be given to; updating and developing procedures for identifying risks and developing mitigation strategies for our services.

Capital, Infrastructure, and IT Infrastructure/Capital Careful planning to stabilise NMDHB‟s financial position has enabled us to initiate the Nelson Marlborough Health Services Plan incorporating the Census 2013 demographic results and aligned facility requirements for the next ten years. This project is intended to lead to an approved Master Plan along with the associated business case. Our immediate infrastructure plans are primarily focused on strengthening earthquake prone buildings and structures, replacing core infrastructure that has reached the end of its useful life and, refining the mix of properties in our district to better meet current and future requirements.

Information Technology IT planning is primarily focused on the implementation of regional software solutions and on systematically upgrading our desktop and server infrastructure. Our planning for desktop upgrades and replacement is focused on systematically implementing a „zero client virtual desktop‟ environment in place of our traditional Personal Computers (PCs). This technology provides us with improved desktop management capability and the opportunity to systematically standardise our desktop environment.

A number of core clinical applications have been identified by the South Island Alliance for replacement or upgrade and our participation in these regional initiatives is crucial to our district and, other participating districts, gaining the benefits of being able to access patient information at a regional level. A critical regional initiative is the replacement of DHB Patient Administration Systems across the South Island with an approved regional solution. Our participation in and the local implementation of this regional solution is a primary area of focus.

Short-Term (2014/15) 1. In 2014/15 we intend to implement an initiative to stabilise our current Patient Administration System (PAS) whilst also planning for our future Patient Information Care System (PICS) implementation.

Stabilisation involves addressing the full range of application dependencies on the existing OraCare patient administration system now, allowing a smoother transition to the PICS regional solution.

2. Our clinicians currently use a product called Concerto to access a range of clinical information relevant to their patients. The Health Connect South initiative is a regional upgrade of the Concerto product that should allow clinicians to see patient information at a regional level. The upgrade also enables future initiatives that have been developed around the region to be implemented locally at NMDHB. For example, „electronic shared care record view‟ (eSCRV). The „eSCRV‟ is a key initiative that has been developed in Canterbury and its implementation at NMDHB should deliver our clinicians, GP‟s and Pharmacists the ability to have a single view across these disciplines for the patient.

3. Implementing a new regional Radiology Information System/Picture Archiving and Communication System implementation (RIS/PACS) should enable our Radiologists and Clinicians to gain better access to regional patient images and information and allow our Radiologists and Clinicians to use a solution that is widely used across the South Island.

14 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4. Collaborative Care Management System (CCMS) is a nationally supported tool that enables patients requiring complex care plans to have a plan that is coordinated across a number of providers. We intend to make a case for the implementation of this capability at NMDHB. Medium-Term (to 2017) 1. Following implementation of the regional PICS solution, the next phase should deliver additional capabilities to the DHB‟s that enable us to integrate disparate information needs from a range of clinical service providers.

2. Health Connect South (HCS) enables participation in regional initiatives that are dependent on this core capability; Electronic Shared Care Record View is a well regarded solution for GP‟s, Pharmacists and Hospital staff to have a single view of the patient and is enabled by the HCS implementation.

3. eMedicine Programme implementation enables the jointly sponsored programme (by the National Health Board/National Health IT Board, and the Health Quality & Safety Commission). NMDHB, through the SIA, is intending to implement the ePharmacy component using a single Regional instance (incorporating NZULM & NZ Formulary when sources are available) to enable the management of medications from a shared SI perspective.

Long-Term (2017-2019) 1. Datacentres are being planned for at a national level through the National Infrastructure Project (NIP) initiative. NMDHB intends to undertake longer term planning to retire servers and storage, and plan to consume „Infrastructure as a Service‟ from the national datacentres.

Disability Support Services (Residential, Support, and Day Services) The NMDHB DSS will be concentrating on these key areas in the following two years: 1. Redeveloping its culture in line with recommendations contained in a recent review of the service.

2. Reviewing the future service provision opportunities for the service in line with the Ministry of Health proposed service model changes for residential and day services.

3. Exploring ways to manage the declining numbers (through natural attrition) of service users who have an Intellectual disability.

4. Deciding whether NMDHB will exit the provision of Disability Support, Residential, and Day services by setting up a Trust to take ownership of the service. For the 2014/15 financial year no financial allowance has been made for a transfer of the service to a trust; if the decision is made to exit then provision will be made within the 2015/16 Annual Plan.

Maori Health and Wellbeing Maori Health Plans, introduced as part of the DHB annual planning cycle in 2011/12, provide a framework for Maori health improvement across care settings in Nelson Marlborough. NMDHB is continuing service transition changes initiated under the Maori Health Provider Coalition (Te Piki Oranga). This assists changes required to achieve the national policy direction in terms of Whanau Ora outcomes. These are described in our Maori Health Plan 2014/159, developed collaboratively with the DHB, the Coalition, and PHOs. Culturally appropriate Whanau Ora centred services to improve access, ensure services are appropriate, good quality management systems and best practice are in place. To improve equity of health outcomes for Maori, in 2014/15 Nelson Marlborough intends a focused effort on improving integration of services across the whole of system including hospital services, general practice, Maori health providers and other community services. Te Piki Oranga objectives include developing clinical leadership to enable the required integration. The priority health areas targeted for 2014/15 are people with cancer; CVD, diabetes, and other long-term conditions; immunisation; maternal and child health; mental health; oral health; smoking prevalence; and, nutrition and physical activity. This work is supported by our Whanau Ora activities and outcomes (page 35).

Public and Population Health Wellbeing The Nelson Marlborough District Health Board Public Health Service (PHS) provides a range of health promotion, health protection, public health nursing, Smokefree activities, and Medical Officer of Health services, across the district. The PHS Annual Plan for 2014 - 201510, describes the services that the Ministry of Health has agreed to purchase from NMDHB‟s PHS. A key area is regional collaboration across the Public 9

Maori Health Plan: http://www.nmdhb.govt.nz/filesGallery/New%20Website/09Board%20Documents/MaoriHealthActionPlan20142015.pdf Health Service Plan: http://www.nmdhb.govt.nz/filesGallery/New%20Website/09Board%20Documents/PublicHealthUnitAnnualPlan20142015.pdf

10Public

15 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Health Services in the South Island. The South Island Public Health Partnership is a specific workstream under the South Island Alliance with the purpose of „supporting population health approaches and planning and coordinating public health services for the South Island population‟. Areas within this work stream include workforce development and capacity building, population health information, communicable disease response, immunisation, and alcohol-related public health work. By working together in this way the South Island Public Health Services are being more effective in improving population health outcomes. At a local level, the PHS is collaborating with our two Primary Health Organisations (PHO), through physically colocating the PHS and PHO teams (both Nelson and Blenheim sites), and developing a joint Health Promotion plan under the Top of the South Health Alliance (ToSHA).

Mental Health and Addictions The vision for the Mental Health and Addiction Directorate is to promote, protect, and improve the mental health and wellbeing of the Nelson Marlborough community11. The Directorate is consolidating the gains and experience of the last three years in extending the collaborative integrated approach across the sector – health promotion, NGO, primary care and specialist services working closely and collegially – and continuing to include direct service user and family/whanau input. This aims to ensure better access to quality mental health and addiction services, which support people to recover from mental illness or addiction. The strategic direction set in the National Service Plan „Rising to the Challenge‟ and other Government directives, as well as the South Island Alliance planning, inform the service development and service provision across Nelson Marlborough. Our challenge is balancing the high acuity needs of those most severely affected by mental illness with provision of services across the continuum/spectrum of need and in that enlisting engagement with other various relevant government departments for example, Disability Support Services and Housing NZ, to address service gaps which are affecting the health of clients.

Regional Engagement The Government has clear expectations for increased regional collaboration between DHBs. In delivering our commitment to the „better, sooner, more convenient health services‟ policy, NMDHB is a partner in the South Island Alliance (SIA), which enables the five District Health Boards in the South Island region to work effectively together, utilising our combined resources to jointly solve problems, develop innovative solutions to health sector challenges and achieve outcomes for the people of the South Island Region. Four collective outcomes have been confirmed that require individual DHB performance to contribute to regional success along with a core set of associated outcomes indicators, which will demonstrate whether we are making a positive change in the health of our populations. These are long-term outcome indicators (5-10 years) and as such, the aim is for a measurable change in health status over time rather than a fixed target: 1. Outcome 1: People are healthier and take greater responsibility for their own health = Reduction in smoking rates; reduction in obesity rates.

2. Outcome 2: People stay well in their own homes and communities = A reduction in acute medical admission rates.

3. Outcome 3: People with complex illnesses have improved health outcomes = Reduction in acute readmission rate within 28 days of discharge; reduction in all cause mortality rates - people under 65.

4. Outcome 4: People experience optimal functional independence and quality of life = An increase in the proportion of the population over 75 living in their own homes.

The NMDHB intervention logic flow diagram (page 15) links South Island outcomes with our outcomes as a result of our Output Class measures in Module 3. The SIA also has a number of Service Level Alliance (SLA) programme areas of activity and enabler workstreams, which are detailed in the „2014/15 South Island Alliance Health Services Plan‟12. Our contribution to these SLAs is described in Module 2 (see also Table „Regional Priorities, page 17). A number of our regional projects also support the delivery of actions towards our National Entities commitments (page 41).

System Performance Performance expectations The DHB monitoring framework consists of up to 40 performance measures that aim to provide the Minister of Health with a rounded view of performance using a range of performance markers. NMDHB reports against these measures each quarter to the Ministry of Health. Four dimensions are identified that reflect DHBs functions as owners, funders and providers of health and disability services.

11 12

NMDHB Mental Health and Addictions Plan: www.nmdhb.govt.nz South Island Health Services Plan 2014/15: http://www.sialliance.health.nz/

16 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

The four identified dimensions of DHB performance cover: 1. Achieving Government‟s priority goals/objectives and targets or „Policy priorities‟ 2. Meeting service coverage requirements and supporting sector inter-connectedness 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‟.

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, but with the balance of measures focused on government priorities.

Integrated Performance and Incentive Framework (IPIF) In addition to our local quality priorities, the IPIF is a national performance improvement initiative being introduced in 2014/15. The framework will provide a line of sight which makes explicit the contribution of organisations to key system level performance measures across the dimensions of: improved quality, safety and experience of care; improvement health and equity for all populations; and best value for public health system resources. Initially it will be applied to general practice, the local Primary Health Organisations, and the DHB, but over time will encompass a wider range of services. The framework will incorporate the use of the Health Targets and Better Public Service Goals across the health sector and promote the goal of improved system integration. It will provide incentives to organisation to improve performance over time, with excellent performance ultimately becoming common across the health and disability system. Our ToSHA Alliance will be responsible for overseeing its implementation, monitoring, and evaluation of its application and effectiveness.

1.3.3

KEY CHALLENGES AND OPPORTUNITIES 2014 to 2017

Our Issues The health and disability system faces considerable challenges over the next decade13. These national challenges are our challenges: 1. Living within our means The rate of growth in health spending has been reduced as its long-term growth pathway was unsustainable.

2. IT and Infrastructure New models of care are demanding new technologies, and advances in technology are driving opportunities for new models of care; however, we have a legacy information system and limited funding for investment in this area. There is significant strengthening of earthquake prone buildings and structures required, and the need to replace core hospital infrastructure that has reached the end of its useful life.

3. Fragmentation and differences in service performance With responsibility split across the devolved health and disability system, coordination of service planning and delivery has proven difficult to achieve.

Despite recent changes, variation in practice and performance remains.

4. Workforce challenges An ageing workforce, international demand, a rapidly changing professional scope of practice (and few nurse-led models), and the need to work more in multidisciplinary teams delivering coordinated care across the continuum of settings, are all significant challenges facing our staff and our service development and improvement. Also, growing advanced practice (including nursing) in a fiscally constrained environment is hampering innovation and quality care.

5. Population ageing This issue will substantially increase the demands on the health and disability system, and at the same time there will be a decline in the proportion of the population that is of working age.

6. Increasing numbers of people with chronic conditions Heart disease, cancer, diabetes, and tobaccorelated disorders, and multiple conditions, accounting for 80% of early deaths, are a continuing concern and unnecessary burden to our health system and population.

Our Response 1. Living Within our Means We need to invest significant financial resource in our services, skilled staff, facility safety and upgrade, and IT infrastructure to ensure more effective and efficient service delivery.

Opportunities to enable this include NMDHB achieving a planned surplus over the next 3-4 years. (p. 63).

2. Supporting investment in IT/IS regionally and locally, and infrastructure Opportunities for IT are around working with the South Island Alliance Information System strategic direction, towards an integrated system that supports clinical integration and patient portal access. Our IT, facility, and Performance Improvement Framework Formal Review: of the Ministry of Health (2012) State Services Commission, the Treasury, and the Department of the Prime Minister and Cabinet: Wellington.

13

17 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

3.

4.

5.

6.

7.

infrastructure will be made fit for purpose with careful planning around stabilising NMDHBâ€&#x;s financial position to provide appropriate resource. We are updating our Health Services Needs Assessment, determining gaps due to demographic shifts and changing models of care, and updating our HEALTH 2030 Strategy and employing this knowledge towards developing our Health Services Plan and Master Site Development Plan to ensure we are sustainable and fit for purpose. (p. 43).

Integrating Care Delivery and Settings of Care for Services Our current model of service delivery does not fully provide a wrap around service for the patient, or a whole of system approach to people with chronic conditions which results in gaps in their care over a lifetime. Opportunities will be better management of people with chronic conditions, preventing and reversing deterioration, and resultant future costs. We are investigating and mining these opportunities with our PHOs through ToSHA. In addition, appropriate settings of care are required to improve access to services. We currently have too many services still sitting in the hospital setting. Opportunities are around moving specialist services from the hospital to the community, and improving integration, which should improve access and timeliness for patients. (pp. 34, 35, 38, 42).

Workforce Planning Opportunities include reconfiguration of the system that ensures the right health professional, at the right time, for the right consumers, to future proof services towards meeting projected population health needs and workforce capacity. (p. 44).

Determining Thresholds for Access to Home Based Support Services versus Age-Related Residential Care Our current restorative policy for support care does not consider the fiscal challenges associated with this. While ensuring the health and wellbeing of the older person, we need to review the prudent use of relevant public funds allocated. In order to ensure safety in staying in place. Opportunities are around ensuring our policies and systems are making the best use of government revenue in this area. (p. 35) Long-term multiple chronic conditions Our actions around community prevention programmes, analysis of current population needs, coordination of care and services, and through improved use of IT resource will support people to gain independence and control over their health. (p. 36) We also will be determining the future of NMDHB Disability Support Services (DSS) We are one of only a few DHBs still providing a disability support service for people with physical and intellectual disabilities. The population coming into this service is only from this district, and these numbers are gradually and sustainably declining and reflect the size of this district; the sustainability of this service is not clear. There are opportunities to work more effectively with the parents of clients to ensure a continuing quality service that supports them.

1.3.4 NMDHB BALANCED SCORECARD CONTEXT Figure 2 closes the loop on linking our strategy to our operational planning, delivery of services through to monitoring the performance of the services through our Balanced Scorecard, and aligning this to improvement of our planning and measuring our performance. The detail of what we deliver on our priority initiatives at an operational level is outlined in Module 2; how we will reach the objectives of each initiative is located in service level Action Plans available on our website at www.nmdhb.govt.nz.

Figure 2: NMDHB Annual Plan Key Initiatives in context of tactical and operational planning, and monitoring 18 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Nelson Marlborough DHB Intervention Logic Model The following intervention logic flow diagram shows the link between South Island outcomes, our outcomes as described in Module 2 priority area initiatives, and SOI Module 3 (Statement of Performance Expectations).

Ministry of Health Sector Goals All New Zealanders to liver longer, healthier, and more independent lives.

SECTOR OUTCOMES

A more unified and improved health and disability system

Good health and independence are protected and promoted

People receive better health and disability services

Health and disability services are trusted and used with confidence

South Island Alliance Regional Goals A sustainable South Island health and disability system, focused on keeping people well and providing equitable and timely access to safe, effective, and high quality services, that are as close to peoples homes as possible.

REGIONAL OUTCOMES 5-10 years

Population Health Improved, health & equity for all populations  

Measures of success

A reduction in smoking rates A reduction in obesity rates

Experience of Care Improved quality, safety, and experience of health care  A reduction in amenable mortality rates  A reduction in acute readmission rates

Sustainability Best value for public health system resource  An increase in the proportion of older people living in their own homes  Cost effective SI Alliance elective services

Nelson Marlborough DHB Goals Developing supportive and sustainable infrastructure and patient-centred service delivery across settings of integrated care.

Population Goals Improving health, independence, participation, equity - reduction in youth smoking rates

LOCAL IMPACTS 3-5 years

- increase in newborns enrolled with General Practice

Measures of success

- fewer people >75 years having falls

OUTPUTS

Prevention Services

INPUTS

Organisation Goals Whole-of-system; whole-of-person

- lower numbers of children with poor oral score (‘DMFT’); increase in number of children caries free - better diabetes management; more heart and diabetes checks

Influence to reinvest

Optimised Workforce – all health workers - ARRC rates decrease

- people have appropriate and timely access to diagnostic imaging services

- people have appropriate and timely access to mental health and addiction services

- people have access to appropriate Home Based Support Services - reduction in unplanned/acute readmissions at 28 days

Health Workforce

Top of the South Review

Early Detection and Management Services

Referred System-wide Financial Services systems & care Review coordination resources

19 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Intensive Assessment and Treatment Services

Clinical Intell, health knowledge & systems

Rehabilitation and Support Services

Quality systems & processes

Assets, infrastructure, & technology

MODULE 2: DELIVERING ON PRIORITIES AND TARGETS 2.1

HEALTH PRIORITIES AND TARGETS

This Module describes the actions that NMDHB is taking to effectively and efficiently deliver on the overarching goal of „Better, Sooner, More Convenient Health Services for all New Zealanders‟. It includes what will be delivered through our work in partnership with the South Island Alliance on our Regional Health Services Plan. It also describes actions under the responsibility of ToSHA, around integrating clinical services and delivering a range of hospital services in community/primary settings; actions that are designed to make better use of available resources; and indicates points of interaction with other planning activities, e.g. Maori Health Plan, Mental Health and Addictions Plan, and Public Health Service Plan. Priorities in health service delivery have been grouped into the six high level National Health Targets, the Government Priorities, regional (South Island) priorities, and last but not least – our local health system priorities.

The full detail on how the Annual Plan initiatives for each area will be executed have been developed into individual operational Action Plans, which are owned by the relevant service leader/manager and clinician; these contain the detail around the individuals responsible, tasks, timing, and resources required; our annual budgeting and expenditure process has been aligned with these plans.

2.1.1

PRIORITIES FOR A BETTER SOONER MORE CONVENIENT HEALTH SYSTEM

We will maintain our momentum on those Health Targets where we have shown consistent achievement; we will continue to build on the gains we are making in the other areas to ensure sustainable progress towards achievement. NMDHB and ToSHA are working to achieve outcomes against the Minister‟s Letter of Expectation, dated 30th January, 2014.

NATIONAL HEALTH TARGETS INCREASED IMMUNISATION (Better Public Service priority area)

WHAT WE’RE DOING p. 24

MORE HEART AND DIABETES CHECKS (System Integration priority area)

p. 25

BETTER HELP FOR SMOKERS TO QUIT (System Integration priority area)

p. 26

SHORTER STAYS IN EMERGENCY DEPARTMENT (System Integration priority area)

p. 27

SHORTER WAITS FOR CANCER TREATMENT (System Integration priority area)

p. 28

IMPROVED ACCESS TO ELECTIVE SURGERY (System Integration priority area)

p. 29

Better care through integration of our systems and services The World Health Organisation describes integration as „the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money‟.

The Minister of Health in particular requires demonstration of integration of services to provide the right care, resulting in the patient journey through the health system being seamless and as simple as possible.

Better public services It is acknowledged that there are cross-government priorities that can only be delivered upon with government agencies working together, particularly through Whanau Ora. However, the result areas in which health has a key role to play are the Immunisation Target, the Children‟s Action Plan (CAP), including reducing assaults on children, reducing incidence of Rheumatic Fever through actions aligned across the South Island (developing, embedding, and monitoring a localised process for delivery of prophylaxis by Public Health Nurses, general practice, and District Nursing; working with Canterbury clinical leads to develop similar roles locally; process for maintaining the local register), and delivering the Prime Minister‟s Youth Mental Health Project. Specific work in preparation for national implementation of the CAP includes preparing for future implementation of Children‟s Teams governance and leadership in collaboration with Strengthening Families, redesigning MAPRA (maternity, antenatal, postnatal risk assessment) into SAFER Teams care coordination, and enabling professionals to attend training on shaken baby syndrome, child protection alerts, and the Violence Intervention Programme.

20 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Maintaining our financial sustainability programme NMDHB is planning on investing in new services and new infrastructure, and is therefore planning agreed surpluses of $1.5 million for 2014/15, $3.0 million for 2015/16, and $4.5 million for 2016/17.

WHAT WE’RE DOING p. 25 p. 30 p. 31 p. 31 p. 32 p. 33 p. 34 p. 35 p. 36 p. 37 p. 38 p. 38 p. 39 p. 41 pp. 24-45 p. 45 (see table below)

GOVERNMENT PRIORITY AREAS SYSTEM INTEGRATION SYSTEM INTEGRATION SYSTEM INTEGRATION SYSTEM INTEGRATION SYSTEM INTEGRATION BETTER PUBLIC SERVICES SYSTEM INTEGRATION SYSTEM INTEGRATION SYSTEM INTEGRATION SYSTEM INTEGRATION SYSTEM INTEGRATION BETTER PUBLIC SERVICES BETTER PUBLIC SERVICES IMPROVING QUALITY LIVING WITHIN OUR MEANS NATIONAL ENTITY PRIORITIES REGIONAL PRIORITIES

2.1.2

Diabetes Care Improvement Packages Improved Access to Diagnostics/waiting times Cardiac – Secondary Services (network agreed) Acute Coronary Syndrome Mental Health Service Development Plan Prime Minister‟s Youth Mental Health Project Primary Care Health of Older People Multiple Long-Term Conditions Stroke Maternal and Child Health Children‟s Action Plan Whanau Ora Clinical Governance and Quality Improvement (All areas operating sustainability) South Island Health Alliance partnership

NATIONAL ENTITIES

In addition to these national priority targets, our Plan also states our responsibilities towards supporting delivery of initiatives with our National Entities (pp. 41, 43, 44, 45).

2.1.3

REGIONAL ACTIONS THROUGH THE SOUTH ISLAND ALLIANCE

The South Island Alliance Health Services Plan (SIHSP) is a framework for the collaborative activities of the South Island Alliance, comprising the five South Island District Health Boards. The SIHSP draws from national strategies and key priorities and is interwoven into each of our South Island DHB Annual Plans. This Alliance approach helps to use our resources to maximum effect across a large physical area with a small, dispersed population, to address the challenges we face in the South Island. In addition to the nationally driven priorities, we have also identified regional priorities to deliver improved public health services, child health services, quality and safety. In addition to these, there are a number of other smaller, but significant, regional initiatives that are continuing to develop (neurosurgery, bariatric surgery, and fertility services).

REGIONAL PRIORITIES Nationally directed: CANCER SERVICES ELECTIVES CARDIAC SERVICES MENTAL HEALTH AND ADDICTIONS HEALTH OF OLDER PEOPLE – DEMENTIA CARE PATHWAYS STROKE WORKFORCE IT/IS MAJOR TRAUMA Specific to the South Island: CHILD HEALTH QUALITY & SAFETY PUBLIC HEALTH – HPA related (see also NMDHB PHS Annual Plan for details)

21 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

WHAT WE’RE DOING p. 28 p. 29 p. 31 pp. 32, 33 p. 35 p. 37 p. 44 p. 43 p.40 p. 38 p. 41 p. 45 and www.nmdhb.govt.nz

2.1.4

NMDHB STRATEGIC PRIORITIES

NMDHB will plan and deliver services whilst living within our means, and operate within agreed financial plans and fund capital investment from internal sources. Specific themes underpinning this will ensure our financial and service sustainability: 1. Implementing recommendations from the Top of the South Service Clinical Services Development.

A formal Review Panel, comprising clinicians external to our DHB, reviewed secondary service delivery across our district at the end of 2013. The review focussed on General Medicine, Orthopaedics, and General Surgery as these services underpin 24/7 acute services, noting services such as ED, Radiology, Laboratory, and Theatre are all critical elements that are needed to support these core acute services. We are supporting a significant culture shift in both Nelson and Wairau patients‟ expectations around travelling to optimise service access and sustainability; improving workforce support and development, enabling flexibility in location; and analysing new and impending models of care. Review recommendations have been prioritised for delivery over the next 5–10 years. By ensuring balance between community confidence, workforce commitment, and our investment pathway we will succeed in creating high quality and safe services for patients and staff, one-service on two-sites, and internal prioritisation of the level of care delivery to match the level of service line need with available resources.

2. In developing our clinical services across Te Tau Ihu/Top of the South, we will also ensure better use of available resources in our diagnostic and referred services. We are implementing a new model for diagnostic imaging services that will improve productivity and appropriateness of imaging referrals, and optimise use of all resources; we are enhancing direct access for GPs to general imaging services, and reducing the waiting times for specialist imaging (e.g. MRI and CT).

3. Our Clinical Governance and Quality Improvement processes require significant effort to align with new models of practice, existing best practice, and expectations around clinical leadership and new quality improvement and performance incentive frameworks. We have a new leadership and governance structure that is targeting a number of ambitious programmes to enable this work.

4. System-wide care coordination14. We are further developing our single point of entry to services for all referrals, which may include referral to mental health, personal health, disability support, and palliative care. This will include referrals from all DHB services; hospital, community, and transitional care and support.

NMDHB PRIORITY AREAS TOP OF THE SOUTH CLINICAL SERVICES DEVELOPMENT (System Integration) REFERRED SERVICES (System Integration) CLINICAL QUALITY AND SAFETY SYSTEM-WIDE CARE COORDINATION (All areas coordinating and collaborating) WORKFORCE DEVELOPMENT

WHAT WE’RE DOING p. 42 p. 42 p. 38 pp. 24-45 p. 44

In July 2013 we initiated a formal DHB-PHO collaborative partnership with Nelson Bays Primary Health and Kimi Hauora Wairau Marlborough PHO. The ToSHA is supporting the integration of services across community and hospital settings, and is ensuring that any service reconfiguration focuses on what is best for patient and best for system. The development of all the following initiatives and subsequent actions are underpinned by the principle of partnership, as described in the ToSHA Alliance Charter 15.

14 15

System-wide care coordination is an approach to service design that underpins and guides every initiative across our local health system.

See NMDHB website for the ToSHA Alliance Charter: www.nmdhb.govt.nz.

22 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

2.1.5

PRIORITIES ALIGNED

The following sections pull the previous national, regional, and local priorities together. Each area was developed with logic flow using DoView outcomes framework software (P. Duignan, www.doview.com). Each map sets out the key actions needed to achieve higher-level results that NMDHB expects to achieve, and identifies accountability measures that provide evidence of progress towards achievement. Figure 3 below describes the logic flow between our overarching key initiatives, coloured coded in line with our organisational and population goals from our strategic vision HEALTH 2030, categorised according the Ministerâ€&#x;s system drivers (living within our means; clinical and service integration), underpinned by South Island and National Entity enablers, and aligned with our overarching Action Plans.

Figure 3: Nelson Marlborough District Health Board Annual Plan, logic planning map 23 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT Immunisation can prevent a number of diseases. It not only provides individual protection but also population-wide protection by reducing the incidence of infectious diseases and preventing spread to vulnerable people. Some of these population-wide benefits only arise with high immunisation rates, depending on the infectiousness of the disease and the effectiveness of the vaccine. Although New Zealandâ€&#x;s two-year-old immunisation rates have been increasing, immunisation rates prior to this time enabled the breakthrough of diseases such as measles and whooping cough. We are now focusing on increasing coverage for eight-month olds – NMDHB predominantly reaches our targets for this group. Our district-wide Immunisation Facilitation Plan has four key strategic areas for action to improve immunisation coverage: collaborative leadership; community engagement; access and equity; engagement of health professionals, and early enrolment with a GP and Well Child services. We will also work on targeted communication strategies promoting the normality of child immunisations, mobilising services, and improving access. NMDHB also measures coverage at other milestone ages as this provides more information about the immunisation system as a whole and population health outcomes related to immunisation.

24 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT Cardiovascular disease (CVD) includes heart attacks, strokes, poor leg circulation/amputation, and kidney failure – which are substantially preventable with lifestyle advice and treatment for those at moderate or higher risk. The indicator monitors the proportion of the eligible population who have had the blood tests for CVD risk assessment (including the blood tests to screen for diabetes) in the preceding five year period. Diabetes is important as a major and increasing cause of disability and premature death, and it is also a good indicator of the responsiveness of our health service. The number of people with diagnosed diabetes across our district is estimated at around 5,800; there are an estimated 46,000 people who are considered eligible for a Cardiovascular Risk Assessment. NMDHB has underperformed recently in reaching the national target for „More Heart and Diabetes checks‟, although we have been steadily increasing. Our Top of the South Health Alliance (ToSHA) Cardiovascular Disease and Diabetes Working Group has developed a framework enabling more coordinated care for people with CVD and Diabetes; this includes a significant quality improvement process to enable more coordinated care for people with CVD and diabetes, improving assessment and detection through engagement with enrolled and un-enrolled population, reducing inequalities in service provision, and improving communication between services to ensure timely flow of clinical information to support patient care. .

25 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT Smoking kills an estimated 5,000 people in New Zealand every year, and smoking-related diseases are a significant cost to the health sector. Most smokers want to quit, and there are simple effective interventions that can be routinely provided in both primary and secondary care. This target is designed to prompt providers to routinely ask about smoking status as a clinical „vital sign‟ and then to provide brief advice and offer quit support to current smokers. There is strong evidence that brief advice is effective at prompting quit attempts and long-term quit success, improved further by the provision of effective cessation therapies, in particular nicotine replacement therapy (NRT), and telephone or face-to-face support. Smoking rates in the NMDHB district are continuing to decline; however, it is still a major public health problem and is inequitably higher in Maori and Pacific people. We generally reach our target for Hospital ABC screening, but are continuing to work towards our primary care ABC target. Our ToSHA Smoking Cessation Alliance Working Group is working to reduce the prevalence of smoking in the district, to reduce the harm to health caused by smoking and aspire towards a „smoke free Nelson Marlborough‟. We are working to integrate cessation into clinical health pathways, and creating a Quality framework, develop a Tobacco Control/Quit Smoking Plan.

26 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT The ED target is a measure of the efficiency of flow of acute (urgent) patients through public hospitals and home again. It is an important measure of the quality of emergency and urgent care in our public hospitals because: minimum time spent waiting in ED is important for patients; long stays in emergency departments are linked to overcrowding of the ED; long stays can lead to negative clinical outcomes for patients, such as increased mortality and longer inpatient lengths of stay; and compromised standards of privacy and dignity for patients. NMDHB has consistently reached the national target for wait times in our emergency departments.

27 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT This target is organised around those patients who are ready to be treated; it excludes patients who require other initial treatments. Specialist cancer treatment and symptom control is essential in reducing the impact of cancer. Faster Cancer Treatment Indicators will be used to measure the timeliness of cancer treatment across the whole patient journey. As radiotherapy and chemotherapy are of proven effectiveness in reducing the impact of a range of cancers, and delay to radiotherapy and chemotherapy is likely to lead to poorer outcomes of treatment and we have historically had waiting time issues for patients, we use the waiting times for these treatments as representative indicators of specialist treatment efficiency and patient health outcomes. NMDHB has reached previous targets for the „Shorter waits for cancer treatment‟ Health Target, through the work of our local cancer coordinators, oncology service, and our tertiary cancer referral centres. We are embarking on a new „faster cancer treatment‟ target for the 2014-15/16 year, as above, of 85% of patients waiting 62 days or less for their first treatment.

28 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT Elective surgery operations improve quality of life for patients suffering from those significant medical conditions that can be delayed by effective surgical interventions, for example: a hip replacement can reduce pain and increase function; a cataract operation may ensure someone can drive their car; or a grommet operation might restore hearing to a young person. We generally reach the national target for elective surgery; we have planning processes in place for ensuring we improve in this area and maintain the target. Our NMDHB target also takes into account the particular health needs of our community. The rate of growth of elective surgery needs to increase to keep up with population growth; therefore we will enable patientsâ€&#x; access to this service, and reduce waiting times for surgery. Our electives system maintains elective discharges, ensures appropriate access to first specialist assessments, reduces waiting times for people requiring elective surgery, improves prioritisation and selection of patients, supports service innovation, and reduces the need for follow-up visits. NMDHB achieves above or at the standardised discharge ratios for elective services, and meets the national elective services targets.

29 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT Good quality and timely diagnostics – primarily imaging and diagnostic laboratory testing, but also hearing and vision assessments – with best practice reporting and clinical analysis, enable better diagnoses and faster identification of disease or injury impact, which ultimately lead to better health outcomes/prognoses for consumers. In 2014-15 we are reviewing our district wide diagnostic services and focusing on screening wait times, training and development for appropriate and cost-efficient use of our imaging services, defining access criteria, and developing referral pathways for more equitable and sustainable use of services. Our diagnostic services improvement work is being clinically overseen by DHB orthopaedic surgery, radiology, and ED clinicians, by primary care GPs, and by consumer representatives.

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CONTEXT The acute coronary syndromes („heart attackâ€&#x;) represent a spectrum of presentations of a sudden reduction in blood supply to the heart, usually caused by a blood clot within a coronary artery at the site of rupture of a plaque. Coronary heart disease and ACS are important causes of health loss and death in New Zealand, and health inequity; much of this burden is avoidable through a combination of prevention and treatment interventions including those around key risk factors of poor physical activity, diabetes, substance abuse, smoking, and hypertension. In terms of treatment, one of the best opportunities for improving survival for an ACS is reducing the delay from symptom onset to first medical contact, and then the initiation of targeted treatment.

31 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT One in five New Zealanders experiences a significant mental health or addiction issue in any one year, however often these issues go unrecognised. Especially significant are depression and alcohol misuse. NMDHB works alongside individuals, families, whanau and communities and providers of services, to ensure that: young people have a healthy beginning and can subsequently flourish; all people can learn and draw strength from the challenges they face; people with mental health or addiction issues can rapidly recover when they are unwell; and, social isolation or exclusion as a result of adverse experiences and illness become a thing of the past. We ensure continuous improvement in the integration between primary care and specialist mental health and addiction services, and support improving responsiveness and accessibility of all related services.

32 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT We understand the important relationship between healthy social and emotional development in the first three years of life, and later health and wellbeing. We know that mental health problems and substance misuse often first appear in adolescence - hidden mental health and AOD problems at a young age can have long-term detrimental effects on physical and mental health. NMDHB works to increase resilience and improved outcomes for young people with high-prevalence conditions through expanded access to integrated mental health and alcohol and other drug (AOD) responses, and decreased waiting times for these services. This work focuses on intervening earlier in the lives of young people in order to strengthen their resilience and avert future adverse outcomes.

33 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT Primary care is the first point of contact for access to the health system; it is also the gateway to hospital-based care and is integral to the success of the health system both in enabling care to be provided close to home, and in managing health service costs. The Nelson Marlborough Top of the South Health Alliance (ToSHA) is contributing collective effort and resource to support the integration (fragmentation reduction) of our health system services, and improving equity of outcomes for our population. This involves developing coordination of patient care across service providers and professions, in primary and community services, and in the patients‟ own home. Services currently offered within the hospital (e.g. cardiopulmonary rehabilitation, diabetes management) will be delivered from a community care setting. Our „Primary Care‟ initiatives are designed, implemented, and evaluated by the Leadership Team and clinical leaders of the independently-Chaired ToSHA. Clinically-led, task-focused groups bring together representatives from the whole-of-system (clinicians, managers, stakeholders, and consumers) to deliver on health system transformation projects. ToSHA was reformed in mid 2013 and is now actively delivering on its range of projects for improving integration between primary, community, and hospital services. The 2014 projects were evaluated against resource use and impact; the outcome of which informed the workstreams and service level alliances planning and budgeting for 2014/15. As a result of ToSHA work, our districts‟ population will enjoy more timely and efficient person-focused services, and our system will enjoy more cost-effective delivery, and no inappropriate duplication or gaps.

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CONTEXT Around 26,800 people aged over 65 years live in the Nelson Marlborough district; this number is expected to increase by 33% to approximately 40,000 people in 2026. The majority of these older people live independently at home (only 4% of older people reside in Aged-Related Residential Facilities „ARRCâ€&#x;). For the past six years NMDHB has worked to support and encourage older people to remain in their homes and communities where safe, practical, and affordable, as this ultimately has numerous health and social benefits for them and their whanau. Around 10% of those in their own home require, and are given, support by Home Based Support Services (HBSS) to enable them to remain there. NMDHB is developing and providing services that wrap around the older person, to enable them to live independently for as long as possible, with timely accurate health and social care assessments and rapid response teams, which are all enabled by care coordination amongst the different services that support them.

35 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT The National Health Committee defines a long-term condition as any ongoing or recurring condition that can have a significant impact on peopleâ€&#x;s lives. Long-term conditions include diabetes, cardiovascular disease (including stroke and heart failure), cancer, asthma, chronic obstructive pulmonary disease, arthritis and musculoskeletal disease, dementia and mental health problems and disorders. This group represent a major health burden on New Zealand currently, and into the foreseeable future, because as the population ages and lifestyles change, these conditions are likely to increase significantly.

Currently they are the leading cause of hospitalisations, account for most preventable deaths, are a barrier to independence and participation in the workforce and in society, and use a significant amount of our health care funds. This group of conditions disproportionately affects Maori, Pacific, and South Asian peoples. There is strong evidence that integrated care improves patient experience and health outcomes for people with multiple health needs and complex conditions. NMDHB is focusing on providing patient-focused, integrated services to people with multiple long-term conditions by working across the entire health spectrum, concentrating on prevention, identification, management, and incorporating technology systems that will enable better care and monitoring of outcomes, which in turn supports continuous improvement of our services. We continue to develop our co-ordinated access processes to triaging of this population, and are working more closely with primary health care sector to identify people „at riskâ€&#x; of developing long term conditions and intervene earlier.

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CONTEXT Stroke results in the blood supply from the brain being cut off, which can lead to damage and permanent disability – the degree of which depends on the length of the stroke, therefore an immediate and appropriate response is essential. Stoke prevention includes interventions around key risk factors of diabetes, smoking, and hypertension. NMDHB continues to focus on improving our response to stroke, thrombolysis, and transient ischaemic attack, by active involvement with both national and South Island Stroke Steering Groups. The 2014/2015 focus is on developing organised Stroke Services in both Nelson and Wairau/Marlborough Hospitals; these services require expert and dedicated Stroke Nursing resource, community rehabilitation across the district, and inpatient rehabilitation resources.

37 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT In order to have healthy adults we need to ensure we have healthy children; healthy children also need healthy caregivers and whanau. NMDHB is working to ensure that we provide the best coverage of high quality maternity and child health services to all families and whanau; including improving access and support to vulnerable families to make sure they can easily engage with services when they need to. This involves timely access to specialist and referred services when needed. As children and families access many health and social services for many reasons, we are working across sectors (such as education, social welfare, and justice) to establish functional effective linkages to better support families as they transition through them, and to ensure that there are no gaps in service provision; this requires better communications, staff training, procedures and policies, and appropriate use of information and technology. ToSHAâ€&#x;s integrated Maternal and Child Health Integration Project is crucial to ensuring the level of collaboration required into the future. Our maternity and child health work also links with child protection work within the hospital, across the health system, and into other sector; the national Childrenâ€&#x;s Action Plan and Drivers of Crime work, and the Youth Mental Health Initiative.

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CONTEXT The Nelson Marlborough Whanau Ora model is unique to this district and designed by six of the seven Maori health provider managers. In 2014-15, existing Maori health services will be disestablished across the district; the approved Whanau Ora framework will then be established by the new provider and employ Maori community health nurses, community health workers (navigators), and health social workers across the district who will work as a multi-disciplinary team. Our model is based on the Waka and introduces six hoe – Culturally Secure, Nurtures, Economically Secure, Knowledgeable, Healthy, and Leaders. The tikanga which support these hoe are Tapu, Mana, Aroha, Tika and Pono. The proposed changes will see the introduction of the following revised positions: Whanau Ora Maori Community Nurses, Whanau Ora Health Social Workers, and Whanau Ora Community Health Workers (Navigators). Health priorities for the new entity have been defined by the local community: diabetes, heart disease, cancers, and respiratory illness. In addition, there is a focus on Maori mental health and public health (e.g. oral health, nutrition, and physical activity). These domains cover the Maori population (Pepe, Tamariki, Pakeke, and Kaumatua) with a focus on prevention (breaking the intergenerational challenge) and intervention (managing pre- and diagnosed conditions). NMDHB will form strategic relationships with the Whanau Ora Commissioning Agency, Te Putahitanga, to ensure the aspirations of Whanau Ora locally and based on Te Tau Ihu O Te Waka a Maui are aligned to future regional developments. We expect, through local Iwi who are partners to Te Putahitanga, that our own Iwi Health Board will be advised about strategic priorities. For NMDHB this will, in part, be achieved through Te Herenga Hauora. Three Nelson Marlborough providers are part of the Te Waipounamu Whanau Ora Network (Te Amo Health, Te Korowai Trust, and Mata Waka ki Te Tau Ihu Trust); we are working with the Network – including these three providers – to support national implementation of Whanau Ora. 39 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT ‘Major traumaâ€&#x; generally refers to a subset of injuries which encompasses the patient with, or at risk for, the most severe or critical types of injury requiring a systems approach in order to save life and limb, resulting in admission to intensive care or urgent surgery; it is a time-critical condition where rapid transport to a site of care, or transport to where care is delivered, is essential. In New Zealand injury is the leading cause of lost years of life in those aged under 45; the main causes being motor vehicle crashes and falls; locally this is contributed to by our large workforce involved in primary industries (forestry and fishing). Injured patients stand the best chance of making an optimal recovery if the trauma care system performs well. Whilst NMDHB has a history of responding rapidly and appropriately to incidences involving major trauma for individuals or groups, we are taking the opportunity to work with the South Island Alliance DHBs to develop a nationally consistent data set over the next three years. Data will help to tell us on a national level how well our major trauma services are serving the population and offer further quality improvement opportunities.

40 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT Over the past year NMDHB has significantly refocused intent and effort on creating robust and transparent quality governance of our health system. We are guided by the work of the Health Quality and Safety Commission, and are embedding its recommendations through our Clinical Directors and the guidance of our Clinical Governance Group, which includes our Primary Health Organisation partners, and is informed by patients and consumers, and developed with our South Island Alliance partners. We intend our services to provide continuously improving quality, safety, and experience of care to the patient and consumer, to improve the health and equity of all populations served by us, and to provide better value for our public health system resources.

41 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT We are constantly reviewing our health and wellbeing services to ensure they are high quality, fit for purpose, and sustainable. In 2013 we commenced a review of our service delivery in key areas across the district. In 2014/15 we are starting improvement initiatives based on this Review, and will be continuing to roll this out over 2016/17. Our goals in looking at and improving our currently delivery approach include: ensuring sustainability of our services for the population of the district; improving quality and safety of services and putting a continuous improvement process in place; ensuring that the districts population benefit from equity of access to services; optimising our 24/7 acute and elective coverage; and ultimately improving care for patients and consumers (reducing serious and sentinel events). We will be concentrating in the initial phase on: district-wide consistent access to services through a redefined „one service-two sitesâ€&#x; approach; cost effective, timely, and productive South Island Alliance Elective Services; improved integration across settings of care (including primary and community); improved regional collaboration; workforce planning (competencies, recruitment/retention, MDTs); and, the elimination of inappropriate interdistrict flow. This work is supported by our IT and infrastructure developments and Facilities Plan, and Health Services Plan.

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CONTEXT Having the right information technology that is fully integrated is essential for clinicians to provide seamless care to patients. We are therefore working closely in 2014/15 with the South Island Alliance, and National IT Board to deliver locally some key IT systems and tools that will enable the beginning of integrated processes and communications between hospitals, GPs, pharmacies, and community settings.

These solutions will enable timely sharing of information and knowledge within and across the health system, effective multi-disciplinary team work, ultimately improving diagnoses, increasing patient safety, reducing unneeded assessment, treatment, or testing, reducing stress on patients and consumers, potentially saving lives, and contributing to savings through reducing unnecessary admission and readmissions.

Our infrastructure and capital investment work will focus on safe buildings and developing a facilities master plan that will provide the appropriate setting for our health service provision for the next five to ten years.

43 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

CONTEXT An appropriately trained, motivated, supported, and flexible workforce is essential for NMDHB to provide high quality, safe, and sustainable health services to our population. However, in this district as across the country, we are facing significant challenges with our health and wellbeing workforce: as the population ages so does our workforce meaning that maintaining current numbers of staff is difficult, compounded by growing demand for staff in the areas of aged care, mental health, and rehabilitation services; there are skills shortages nationally in medical physics, radiation, and sonography; we also need to ensure that we increase our Maori and Pacific workforce. Closer links between health and education and community providers is key to addressing these challenges, as is moving appropriate services and roles into the community, developing integrated multidisciplinary teams, and developing a health system that enables staff to reach their full potential to ensure the capacity, capability, and flexibility that will be demanded of our health system in the near future.

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CONTEXT NMDHB emphasis on integration, and system efficiency and effectiveness, will be enabled through working in an intentional and collaborative way with our national health entities and regional Alliance partners across the South Island. We are working with the national entities to ensure a holistic approach to managing and delivering a solid, sustainable health system, which will result in improved quality of care, reduction in service vulnerability and cost, will support better, sooner, and more convenient outcomes, and will ensure clinical and financial sustainability of our districtsâ€&#x; health services. The group comprises seven independent Crown Entities/Agencies which focus on supporting DHBs; on this page our actions contributing to work programmes of four of the entities are described; the initiatives we are involved in with the remaining entities (including our local and regional actions) is described on pages: p. 40 for Health Workforce NZ; p.39 for IT Health Board; and, p.37 for Health Quality & Safety Commission.

45 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

MODULE 3: STATEMENT OF PERFORMANCE EXPECTATIONS 3.1

MEASURING OUR PERFORMANCE BY OUTPUT CLASS

One of the functions of this Annual Plan is to show how we 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 2014/15, and use performance measures and targets that reflect quantity, quality, timeliness, and service coverage. Our performance against these outputs is described our end-of-year Annual Report.16 Module 4 (pp. 71-72) details the revenue and expenses by each Output Class.

Our four Output Classes and their related services as defined in Module 3 are: 3.1.1

3.1.2

3.1.3

3.1.4

Prevention Services i. Health Promotion and Educations Services ii. Statutory Regulation Services iii. Population-based Screening Services iv. Immunisation Services v. Well Child/Tamariki Ora Services vi. Mental Health Promotion Services Early Detection and Management Services i. Primary Health Care (GP) Services ii. Oral Health Services iii. Primary and Community Programmes of Care iv. Community Pharmacy Services v. Infection Control vi. Primary Mental Health vii. Community Referred Testing and Diagnostics Intensive Treatment and Assessment Services i. Inpatient Planned and Unplanned Services ii. Patient Safety; Scheduled Services; Unscheduled Services, Mental Health iii. Maternity Services iv. Assessment, Treatment and Rehabilitation Rehabilitation and Support Services i. Palliative Care Services ii. Needs Assessment and Support Services (NASC), Age-related Residential Care (ARRC), Carer Support, Day Programmes, Home-Based Support Services (HBSS) iii. Community Mental Health Older Persons iv. Geriatric Assessment, Treatment, Rehabilitation

Our measures for these outputs focus on four elements of performance: Volume (V) Quality (Q) Timeliness (T) Coverage (C)

- to demonstrate volumes of services delivered - to demonstrate safety, effectiveness and acceptability - to demonstrate responsive access to services - to demonstrate the scope and scale of services provided

DHB performance is also measured by the Ministry of Health through quarterly reporting against the Performance Monitoring Framework. A copy of previous years‟ Annual Reports on Output Class delivery and achievement can be found on our website: www.nmdhb.govt.nz 16

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The logic flow between our four service „output classes‟ and the specific stages of the NMDHB JUMBO continuum of care (p. 13), is depicted below in Figure 4.

Aggregated Health and Disability needs locally

Our Objectives

Our Activities

Well Population

At Risk Population

Population with Managed Early Conditions

Population with Long Term Complex Conditions

Population with End Stage Conditions

Living Well.

Health Literate.

Appropriate care accessed.

Healthy choices made.

Self-management.

Guidance and support accessed.

Avoidable deterioration prevented.

Progression management support.

Dignity in death.

Whanau supported.

Health Promotion. Health Protection.

Injury & Illness Prevention.

Population Screening.

At Risk Screening. Education.

Early Detection.

System-wide care coordination Diagnosis. Curative.

Care Co-ordination.

Case Management.

Top of the South Review Recovery. Rehabilitation. Respite.

Home Support Care.

Palliative Care.

Patient/Whanau Support.

Our Service Outputs

OUTPUT CLASS 1: ‘PREVENTION SERVICES’

‘JUMBO’

OUTPUT CLASS 2: ‘EARLY DETECTION & MANAGEMENT SERVICES’

OUTPUT CLASS 3: ‘INTENSIVE ASSESSMENT & TREATMENT SERVICES’

OUTPUT CLASS 4: ‘REHABILITATION & SUPPORT SERVICES’

Figure 4: NMDHB Output Classes logic flow from Jumbo continuum of health care service delivery and health needs

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Referred Services Review

OUTPUT CLASSES

3.1.1 OUTPUT CLASS 1:

PREVENTION SERVICES

Description „Preventativeâ€&#x; 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.

Significance 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. It has been estimated that 70% of health funding is spent on long-term conditions17. Two in every three New Zealand adults have been diagnosed with at least one long-term condition and long-term conditions are the leading driver of health inequalities 18. A majority of chronic conditions are preventable or could be better managed19. 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.

These prevention services also support people to address any risk factors that contribute to both acute events (e.g. alcohol-related injury) long-term conditions development (e.g. obesity, diabetes). High health need and at-risk population groups (low socio-economic, Maori, and Pacific) who are more likely to be exposed to environments less conducive to making healthier choices are a focus. 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 also ensure that threats to the health of the community such as communicable disease, water quality, imported disease-carrying pests, are detected early and prevented, and ensure our ability to respond to emergency events such as pandemics or earthquakes.

Success A. Outcome Measures Long-term (5-10 years) 1. A reduction in smoking rates - particularly for youth (ASH Survey) [we want to see a decrease] 2. A reduction in obesity rates in 4 year olds (B4 School Checks) [we want to see a decrease] B. Impact Measures medium term (3 to 5 years) 1. An increase in the proportion of children who are fully breast-fed [we want to see an increase] 2. An increase in the percentage of babies enrolled with a General Practitioner (GP) at 3 months of age [we want to see an increase] New Zealand Guidelines Group (2001) Chronic Care Management: Policy and Planning Guide. Compiled by the Disease Management Working Group Ministry of Health (2008) A Portrait of Health. Key Results of the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health 19 National Health Committee (2007) Meeting the Needs of People with Chronic Conditions 17 18

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Outputs Prevention Health Services Figure 5

1. Health Promotion Services: enable people to increase control over their health and its determinants, Newborns enrolled with general practice by and thereby improve their health through developing healthy public policy that addresses the prerequisites 3 months of age (by PHO) of health, such as income, housing, food security, employment, and quality working conditions. Health promotion activity is enacted through a range of platforms, as described by the Ottawa Charter 20: public 100% policy, reorienting the health system, environments, community action, and supporting individual personal Target 98% 90% skills. While health has a significant role here, some outcomes such as obesity require a whole of sector 80% approach; NMDHB works with other sectors (housing, justice, education) to enable this.

2. Health Education Services: inform people about health matters, risks, and support them to be healthy. 70% Success begins with awareness and engagement, reinforced by community health programmes that 60% support people to maintain wellness or assist them to make healthier choice.

3. Statutory and Regulatory Services: sustainably manage environmental elements and risks in a way that 50% 87% supports people and communities to maintain their health and safety; includes effective quarantine and 40% 76% bio-security procedures, proper management of hazardous substances, assurance of safe drinking water, 30% and compliance monitoring with liquor licensing and smoke environment legislation.

20% 4. Population Based Screening Services: encourage uptake of services predominately funded and provided through the National Screening Unit that help early identification of breast and cervical cancer, 10% 0% and carry out newborn hearing testing, and antenatal HIV screening.

2013 5. Immunisation Services: work to prevent the outbreak of vaccine-preventable diseases and unnecessary hospitalisations. The work spans primary and community care and allied health services to optimise provision of immunisations across all age groups, both routinely and in response to specific risk. A high Figure 6 Smoking by 14 & 15 Year Olds, NMDHB coverage rate is indicative of a well�coordinated, successful service.

6. Well Child Tamariki Ora Services: are screening, surveillance, education, and support services offered 80% to children and their family/whanau from birth to five year; provided by Plunket, Maori Health Providers, 70% and the NMDHB Public Health Service; includes B4 School Checks to all children in their fourth year of age.

60% 7. Mental Health Promotion: promote social and physical environments that enhance mental health and 50% resiliency, 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 40% illness. The Public Health Service promotes this work through Te Tau Ihu Mental Health Promotion 30% Network.

20% 10%

0% 20

Ottawa Charter http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

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Nelson Bays Primary Health Kimi Hauora Wairau Marlborough PHO

Daily % Regular % Never %

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3.1.2 OUTPUT CLASS 2:

EARLY DETECTION AND MANAGEMENT SERVICES

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 and more effective management and coordination of people with long-term conditions. These services are by nature more generalist, usually accessible from multiple providers, and at a number of different locations. Providers that deliver these services across our district include: 1. general practice services 2. primary and community services 3. personal and mental health services 4. Maori and Pacific health services 5. pharmacy services 6. diagnostic imaging and laboratory services 7. children and youth oral health and dental services.

Significance 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 in our population. 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, and reduce the burden of long-term conditions through supported self- management (avoidance of complications, acute illness and crises). These services deliver coordination of care, ultimately supporting people to maintain good health.

Success A. Impact Measures medium-term (3 to 5 years) 1. An increase in the proportion of children who have good oral health; measured as „DMFT‟ decayed, missing, filled teeth [we want to see a decrease] 2. An increase in the proportion of eligible people receiving Vascular Risk Assessments (heart and diabetes checks) [we want to see an increase]

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Outputs Early Detection and Management Services 1. Primary Health Care Services: are offered in local community settings by teams of general Figure 7 practitioners (GPs), registered nurses, nurse practitioners, and other primary health care 100% professionals; aimed at improving, maintaining, or restoring health. High numbers of enrolment with general practice are indicative of engagement, accessibility, and responsiveness of primary care 80% services (approximately 96% in this district). These services keep people well by: a) intervening early to detect, manage, and treat health conditions (e.g. health checks ) 60% b) providing education and advice so people can manage their own health c) reaching those at risk of developing long-term or acute conditions.

40% 2. Oral Health Services: are provided by registered oral health professionals to assist people in maintaining healthy teeth and gums. A reduction in the number of young children requiring invasive complex oral 20% health treatment (under general anaesthetic) is indicative of the quality of early intervention and of public health education and messages regarding the importance of good oral health. High enrolment indicates 0% engagement, while timely examination and treatment indicates a well�functioning, efficient service. We are influencing the oral health status of young children through: a) implementation of the new model of care for primary school and pre-school children through the Community Oral Health Hubs b) targeting children and adolescents living in disadvantaged areas with oral health promotion c) working with Well Child Tamariki Ora providers to increase the enrolment of preschool children Figure 8 with the Community Oral Health Service We maintain utilisation of dental service for adolescents through promoting access to services and ensuring dental service providers operate effective recall systems. We are also improving access to 75% dental services for low income adults.

70% 3. Primary and Community Programmes of Integrated Care: are targeted at people with high health need 65% due to long-term conditions; these aim to reduce deterioration, crises, and complications. Success is demonstrated through identification of need, regular monitoring, and successful management of 60% conditions. Early intervention strategies and additional services available in the community reduce the 55% 50% need for hospital interventions. The services provide: a) community programmes that support keeping people well and address inequalities 45% b) targeted interventions for people to support areas of key inequality such as clinical interventions 40% for people with asthma and other respiratory conditions, and podiatry services.

35% Delivery components of programmes of integrated care21 include: a) Self-management support and patient education: helping patients and families acquire the skills 30% and knowledge to manage their own illness, providing self-management tools, and routinely assessing problems and accomplishments.

21

Integrated Care Programmes for Chronically Ill patients: a review of systematic reviews. M. Ouwens, et.al. (2005). Int. J. Qual. Health Care. 17(2), 141-146.

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NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Health Target - More Heart and Diabetes Checks 90%

75%

69% 60% 50%

57%

59% NMDH B MoH Target

Oral Health, Caries Free 5 Year Old Children

NMDHB Maori NMDHB Other National Maori National All

2010

2011

2012

b) c)

4.

5.

6.

7.

Clinical follow-up: monitoring the patient during and after treatment; often done by a Nurse case manager who uses phone, post, or visits; part of self-management support.

Case management: 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; case manager or team takes responsibility for guiding the patient through the complex care process in the most efficient, effective, and acceptable way. d) Multidisciplinary patient care team: a group of professionals who communicate with each about the care of a defined group of patients and participate in that care. e) Multidisciplinary clinical pathway: structured multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem and describe the patientâ€&#x;s expected clinical course; should be derived from evidence-based guidelines translated into practice. f) Feedback and education for professionals: to provide health care providers with information regarding appropriate care for patients; from clinical pathways, medical records, computerised databases, patients, or audits by colleagues; education is given before consultation; feedback is given after the consultation; reminders are given before or during consultation.

Community Pharmacy 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 are introducing 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).

Community Referred Testing and Diagnostics: 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.

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

Primary Mental Health 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.

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3.1.3 OUTPUT CLASS 3:

INTENSIVE ASSESSMENT AND TREATMENT SERVICES

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 often 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.

Significance Equitable and timely access to intensive assessment and treatment can significantly improve peopleâ€&#x;s quality of life, either through early intervention (i.e. removal of an obstructed gallbladder to prevent 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 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. 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. There are expectations for the delivery of increased elective surgical volumes, a reduction in waiting times for treatments, and increased clinical leadership around improving service delivery and safety to improve the quality and efficiency of care being delivered.

The changes being made to meet expectations are providing opportunities to introduce innovative clinically led service delivery models and improve productivity within our hospital services.

Success A: Outcomes Measures long-term (5 to 10 years) 1. Reduction in unplanned (acute) readmissions to hospital and specialist services [we want to see a decrease] 2. Reduction in mortality (deaths) rates within 30 days of discharge from hospital and specialist services [we want to see a decrease] B: Impact Measures medium-term (3 to 5 years) 1. Meeting the planned (elective) surgical needs through phased production planning and delivery [we want to meet the target] 2. Deliver NMDHB share of national increase in access to planned (elective) surgical services [we want to meet the target] 3. A reduction in wait times for Urgent Care [we want to see a decrease] 4. Mental Health Measure: Service Access Rates by Age and Year - All Mental Health & Addictions Services [we want to see an increase] 5. Mental Health Measure: Percent of long-term clients with up-to-date relapse plans [we want to see an increase] 56

NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Outputs Intensive Assessment and Treatment Services Figure 9 1. Inpatient Planned; Unplanned; Mental Health Service Access Rates by Age and Year a) Planned Services (Elective surgery) are services for people who do not need immediate hospital All NMDHB Mental Health & Addictions Services treatment and are „booked‟ services. This also includes non-medical interventions (coronary angioplasty) 10% and specialist assessments (first assessments, follow-ups, or preadmission assessments). National Maori 019 years Elective Services Patient Flow Indicators (ESPIs) are indicative of a successful and responsive service; 8% addressing increasing needs and matching commitments to capacity.

Other - 019 years b) Unplanned Services (Acute services) are for illnesses that have an abrupt onset and are often of short 6% duration and rapidly progressive, creating an urgent need of care. Hospital-based acute services include Maori 2064 years emergency departments, short-stay acute assessments and intensive care services. Performance against 4% clinical triage guidelines is used to demonstrate the capacity and responsiveness of the system.

Other 2064 years Productivity measures such as length of stay rates are balanced with outcome measures such as 2% readmission rates to indicate the quality of service provision.

Maori over 65 c) Specialist Mental Health Services are services for people who are most severely affected by mental illness 0% years 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 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.

2. Maternity Services Figure 10 These demand-driven services are provided to women and their families through pre-conception, pregnancy, NMDHB 28 Day Readmissions 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 12% specialist obstetric, lactation, anaesthetic, paediatric and radiology services. We will monitor volumes in this 10% area to determine access and responsiveness of services.

8% 3. Assessment Treatment and Rehabilitation Maori 6% 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.

Other 4% Specialist geriatric and allied health expertise and advice is also provided to general practitioners, home and 2% community care providers, residential care facilities and voluntary groups. An increase in the rate of people 0% discharged home with support, rather than to residential care or hospital environments (where appropriate), is 2009/2010 2011/2012 2013/2014 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 persons‟ client base. The SHSOP service has inpatient as well as community teams.

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3.1.4. OUTPUT CLASS 4:

REHABILITATION AND SUPPORT SERVICES

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.

Significance 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.

Success A: Outcome Measures Long Term (5-10 years) [we want to see an increase] 1. We want to see an increase in the proportion of the population who are supported to better manage their long-term conditions, and see a resultant reduction in acute hospital discharges. a) 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. b) 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.

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NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

Figure 11 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 1400 acute care.

2. We want to see an increase in the proportion of the population aged over 65 who need 1200 support are supported to live well, in their own homes, with a decrease in rest home clients 1000 a) We have been monitoring the trend following the introduction of restorative Home Based Support Services (HBSS) „packaged interventions‟ for people with complex and non-complex 800 needs. High needs complex clients are at risk of requiring age residential care but are being 600 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.

400 b) The trend of the number of people in Age-Related Residential Care (ARRC), in NMDHB and demonstrates that overall there has been a reduction over the last two years.

200 3. We want to maintain people aged over 65 years healthily in the community 0 a) 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; trends of HBSS use over the last two years are generally increasing, indicating more older people are being supported at home.

c)

4. We want an increase in the proportion of people aged over 75 who are supported to Figure 12 maintain their functional independence measured through seeing a reduction in admissions from falls in the number of people aged over 75.

800 a) 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 700 prolonged hospital stay, loss of confidence, restriction of social activities, loss of in 600 independence and an increased risk of institutional care.

500 b) 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 400 falls by 1% would mean 550 fewer hospitalisations among people aged 75 and over across the 300 country. The incidence of falls in the community in this district for those aged 75 years and over is decreasing.

200 c) Achievement against this measure will also indicate improved health service provision for older 100 people, as the initiatives used to reduce falls will address various health issues and risk factors 0 associated with falls including: osteoporosis, lack of physical activity, poor nutrition, medications, impaired vision, and environmental hazards.

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NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

NMDHB Home Based Support Services Clients (HBSS) Strenthening independence Complex Low Complex Moderate Complex High Complex Very High Preventative Maintenance

NMDHB Clients in Age-Related Residential Care (ARRC)

Rest Home Care Dementia Care Hospital Care Psychogeriatric Care

Outputs Rehabilitation and Support Services 1. Palliative Care Services Figure 13 a) improve the quality of life of patients and their families facing the problems associated with NMDHB Falls Admissions from Community Dwelling life-threatening illness, through the prevention and relief of suffering by means of early Population Aged 75+ intervention, assessment, treatment of pain and other support services 9.00% b) ensure people have timely access to quality, culturally appropriate palliative care services 8.50% c) co-ordinate care across hospital, community, and support services NMDHB 8.00% d) utilise the „Liverpool Care Pathway‟ for palliative care services 7.50% e) deliver a responsive system that supports a person‟s choice to die at home.

7.00% Total NZ 6.50% Palliative Care is provided by both Primary/Generalist and Specialist Palliative Care: 6.00% a) Primary/Generalist is Palliative Care provided by any health care professional to those with a 5.50% terminal illness; District Nursing, Hospitals (e.g. Oncology departments), Maori Health providers, Total NZ 5.00% Allied health teams, and General Practice.

(08/09 4.50% Standardised) b) Specialist Palliative Care is provided by staff who have speciality training/accreditation in Palliative 4.00% Care/Medicine who work with clients who meet Hospice NZ referral criteria. NMDHB partly funds two Hospices: Nelson/Tasman Regional Hospice (368 referrals 2013/14); Salvation Army Marlborough Hospice (224 referrals 2013/14).

We are working on increasing the number of educated Primary Care staff who have Hospice NZ qualifications and will target increasing Palliative Care patients with an Advanced Care Plan (ACP) in place.

2. Needs Assessment & Support Services/NASC, Age-Related Residential Care (ARRC), Respite, Carer Support, Day Programmes, and Home Based Support Services (HBSS) The InterRAI tool ensures that older people, who have an assessed need, receive support services in their homes whenever possible. An increase in the number of people being supported is indicative of increased capacity in the system, and success is measured against decreased or delayed entry into residential or hospital services. NMDHB uses: a) regionally agreed service specifications for HBSS b) regionally agreed eligibility criteria and standardised approach to access c) locally agreed and expanded options for respite and day programmes for older people and their family-whanau/carers.

3. Community Support Services – Mental Health a) These services are targeted to improve service user recovery; accessing specialist mental health and addiction services early prevents deterioration in mental health.

4. 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) a holistic inter-professional team approach to the health and disability support needs of older people b) integrated specialist geriatric and psychiatry of old age assessment, treatment and rehabilitation, incorporating a palliative approach when necessary c) a consultation and liaison service for other health and disability support services d) a setting for the training and education of health practitioners, and evaluation of innovation.

5. Geriatric Assessment, Treatment, and Rehabilitation Specialist health of older (HOP) people services plans for HOP specialists to consult with health professionals in primary care and ARRC. An increase in the rate of people discharged home with support, rather than to residential care or hospital environments (where appropriate) reflects the responsiveness of services. Success of rehabilitation services is measured through increased referral of the right people to these services.

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MODULE 4: FINANCIAL PERFORMANCE 4.1

FISCAL SUSTAINABILITY

Over the past ten years an increasing share of national expenditure has been allocated into the health budget. Whilst health continues to receive a significant share of the national funding, the Government has given clear signals that the health sector needs to rethink how it will meet the needs of the constituent populations with a more moderate growth platform now and into the future. In setting the expectations for 2012/13, the Minister expects DHBs to operate within existing resources and approved financial budgets and to work collaboratively to meet fiscal challenges and ensure services and service delivery models are clinically and financially sustainable. The following section provides a summary of the Nelson Marlborough DHBâ€&#x;s financial assumptions and projections over the next three years, in order to achieve the objectives and goals outlined in this Annual Plan.

4.2

MEETING OUR FINANCIAL CHALLENGES

The Nelson Marlborough DHB faces the same fiscal pressures as other DHBs: demographically and technologically driven demand, increasing expectations, increasing cost growth and wage and salary expectations. The DHB acknowledges however that it must ensure that it operates within a constrained financial environment.

The Nelson Marlborough DHB reported deficits in the 2011/12 and 2012/13 financial years but is forecasting a surplus in 2013/14 and surpluses for the three years covered under this plan. Critically to ensure the health system is financially sustainable, we are focussed on making the whole of system work properly and achieving the best possible outcomes for our investment. This is work that Nelson Marlborough DHB has been focussing on, and investing in, over the last two years to meet the challenges faced across the health system.

4.2.1 FORECAST FINANCIAL PERFORMANCE For the 2014/15 year we are forecasting a surplus of $1.5M. The following two years project surpluses of $3.0M in 2015/16 and $4.5M in 2016/17. Surpluses of this level are vital in ensuring that the DHB positions itself for significant future capital investment, particularly an expected redevelopment of the Nelson hospital site within the next 10 years.

4.2.2 CONSTRAINING OUR COST GROWTH Constraining cost growth is critical to our success in delivering surpluses in the 2013/14 year and the projected surpluses in the years covered by this Plan. If an increasing share of our funding continues to be directed into meeting the growing cost of providing services, our ability to maintain current levels of service delivery will be at risk whilst placing restrictions in our ability to invest in new equipment, technology and new initiatives that allow us to meet future demand levels.

It is also critical that we continue to reorient and rebalance our health system. By being more effective and improving the quality of the care we provide, we reduce rework and duplication, avoid unnecessary costs and expenditure and do more with our current resources. We are also able to improve the management of the pressure of acute demand growth, maintain the resilience and viability of services and build on productivity gains already achieved through increasing the integration of services across the system.

The Nelson Marlborough DHB has already committed to a number of mechanisms and strategies to constrain cost growth and rebalance our health system. We will continue to focus on these initiatives, which have contributed to our considerable past success and given us a level of resilience that will be vital in the coming year: 1. Reducing variation, duplication and waste from the system; 2. Doing the basics well and understanding our core business; 3. Investing in clinical leadership and clinical input into operational processes and decision�making; 4. Developing workforce capacity and supporting less traditional and integrated workforce models; 5. Realigning service expenditure to better manage the pressure of demand growth; and 6. Supporting unified systems to shared resources and systems.

63 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.3

ASSUMPTIONS

In preparing our forecasts the following key assumptions have been made: 1. The DHB‟s funding allocations will increase as per funding advice from the Ministry of Health.

2. Revenue and expenditure have been budgeted on current Government policy settings and known health service initiatives.

3. Early payment arrangements will be retained by the DHB. 4. No additional compliance costs have been budgeted, as it is assumed these will be cost neutral or fully funded. It is also assumed that the impact of any legislative changes, sector reorganisation or service devolvement (during the term of this Plan) will be cost neutral or fully funded.

5. Any revaluation of land and buildings will not materially impact the carrying value or the associated depreciation costs.

6. IDF volumes and prices are at the levels identified by the MOH advised within the Funding Envelope.

7. Employee cost increases are based on terms agreed in current wage agreements. Expired wage agreements are assumed to be settled on affordable and sustainable terms. Efficiencies will be generated under the partnership programmes and tripartite agreements.

8. Staff vacancies (existing and as they occur in future) will be reassessed to ensure the positions are still required, affordable and alternatives explored before vacancies are filled. Improved employee management can be achieved with emphasis in areas such as sick leave, discretionary leave, staff training and staff recruitment/turnover.

9. External provider increases will be made within available funding levels, after allowance for committed and demand-driven funding.

10. Price increases agreed collaboratively by DHBs for national contracts and any regional collaborative initiatives will be within available funding levels and will be sustainable.

11. Any increase in treatment related expenditure and supplies is maintained at affordable and sustainable levels and the introduction of new drugs or technology will be funded by efficiencies within the service.

12. All other expense increases including volume growth will be managed within uncommitted funds available or deferred.

13. The DHB will meet the mental health ring fence expectations.

4.4

ASSET PLANNING AND SUSTAINABLE INVESTMENT

4.4.1 ASSET MANAGEMENT PLANNING The Nelson Marlborough DHB is committed to asset management planning with a view to a more strategic approach to asset maintenance, replacement and investment. A revised Asset Management Plan (AMP) is due for completion in June 2014. This revision of the AMP includes a detailed review of the asset management practices and will provide a robust platform on which to base capital investment decisions in the future. The AMP reflects the joint approach taken by all DHBs and current best practice.

4.4.2 CAPITAL EXPENDITURE The Nelson Marlborough DHB has significant capital expenditure committed in the next four financial years.

Based on the DHB‟s fiscal position, we estimate that we will fund a total of $10M of general capital expenditure in 2014/15. In addition a total of $14m has been allowed in 2014/15 for major or strategic projects which includes the investment into Health Benefits Ltd programmes and the regional information systems projects. With this level of capital investment, the remaining capital expenditure funding available will be very tight. To manage this level of capital expenditure will require discipline and focus on the DHB‟s key priorities. The following table summarises the capital expenditure plan.

64 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.4.2. (cont.) PROSPECTIVE CAPITAL EXPENDITURE 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

338 2,424 1,873 280 897 2,431 316

0 2,020 2,836 94 2,324 499 346

0 2,000 3,500 200 1,000 500 800

0 2,000 3,500 200 1,000 500 800

0 2,000 3,500 200 1,000 500 800

0 2,000 3,500 200 1,000 500 800

8,559

8,119

8,000

8,000

8,000

8,000

Major & strategic capital expenditure Buildings & plant Clinical equipment Clinical information systems HBL - Finance, procurement & supply chain programme

1,135 0 0 0

1,855 1,000 400 546

8,200 1,000 4,900 803

11,000 0 3,500 0

0 0 617 0

5,000 0 536 0

Total major & strategic capital expenditure

1,135

3,255

14,100

14,500

617

5,536

Total capital expenditure

9,694

11,374

22,100

22,500

8,617

13,536

2014 Forecast

2015 Projection

2016 Projection

2017 Projection

2018 Projection

$000

$000

$000

$000

$000

5,000

3,000

1,000 2,000 200

5,000

Baseline capital expenditure Land Buildings & plant Clinical equipment Other equipment Information technology Intangible assets (software) Motor vehicles Total baseline capital expenditure

Details of major/strategic capital planning

Facilities related Seismic work Alexandra hospital refurbishment Wairau remediation Arthur Wicks refurbishment Learning & development centre Murchison Boiler replacement Nelson hospital redevelopment preliminary phase Total facilties Clinical information systems related PICS BUS PICS HCS ePharmacy eSCRV Total clinical information systems

1,100 755

3,000 5,000 1,855

8,200

11,000

0

5,000

3,000 1,600 300

3,000

617

536

4,900

3,500

617

536

400

500 400

4.4.3 BUSINESS CASES The Nelson Marlborough DHB is aware of several business case initiatives in varying stages of development at the time of writing. These include:  Facilities: o Learning & Development Centre o Alexandra Hospital development o Master Site Plan: Chemotherapy Facility; ICU; Acute Admitting Unit; Earthquake strengthening; Medical wards  IT o PICS (Patient Information Care System) o HCS (Health Connect South) 65 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.4.4 ASSET VALUATION The Nelson Marlborough DHB completed a full revaluation of its property and building assets at 30 June 2012 in line with generally accepted accounting practice requirements. The next revaluation is due to be completed at 30 June 2015. This Plan assumes that there will be no material difference between the carrying value and the revaluation occurring at that time.

4.5

DEBT AND EQUITY

4.5.1 CORE DEBT The Nelson Marlborough DHB has a long-term debt facility of $55.5M with the National Health Board through the NZ Debt Management Office which has been fully drawn down. No repayments of this debt have been assumed to occur over the period covered by this Plan. The core debt is secured by a negative pledge. Without the NHB‟s prior written consent the DHB cannot perform the following actions:  Create any security over its assets, except in certain circumstances;  Lend money to another person or entity (except in the ordinary course of business and then only on commercial terms) or give a guarantee;  Make a substantial change in the nature or scope of its business as presently conducted, or undertake any business or activity unrelated to health; or  Dispose of any of its assets except disposals at full value in the ordinary course of business.

At the time of writing, $8M of this core debt is due for refinancing within 2014/15. It is assumed that this will be refinanced to longer term arrangements. This amount is reflected in current liabilities as at 30 June 2014 in the projected statement of financial position (refer section 4.8) in accordance with generally accepted accounting practice.

4.5.2 OTHER DEBT FACILITIES In addition to the core debt facilities the Nelson Marlborough DHB has a number of finance lease facilities covering a range of clinical equipment and information technology assets. The DHB does not have the option to purchase the asset at the end of the leased term and no restrictions are placed on the DHB by any of the financing lease arrangements.

The Nelson Marlborough DHB has a finance lease arrangement relating to the Golden Bay Community Health Centre (GBCHC). This relates to the 35 year lease arrangement entered into by the DHB to lease the GBCHC from the Golden Bay Community Health Trust. The DHB has in turn sub-leased the GBCHC to the Nelson Bays Primary Health Trust. Further disclosures on this arrangement will be made in the 2013/14 Annual Report of the DHB.

4.6

ADDITIONAL INFORMATION AND EXPLANATIONS

4.6.1 DISPOSAL OF LAND AND OTHER ASSETS The Nelson Marlborough DHB actively reviews assets to ensure that it has no surplus assets. No significant assets are scheduled for disposal during the period covered by this Plan as a result of being declared surplus except land declared surplus adjacent to the Wairau hospital site. At the time of writing the DHB was progressing with the requirements to commence formal consultation on the proposed disposal and the required notifications for the disposal of surplus Crown land. The approval of the Minister of Health is required prior to the DHB disposing of land.

The disposal process is a protective mechanism governed by various legislative and policy requirements.

4.6.2 ACTIVITIES FOR WHICH COMPENSATION IS SOUGHT No compensation is sought for activities sought by the Crown in accordance with Section 41(D) of the Public Finance Act.

66 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.6.3 ACQUISITION OF SHARES Before the Nelson Marlborough DHB or any associate or subsidiary subscribes for, purchases, or otherwise acquires shares in any company or other organisation, the Board will consult the responsible Minister/s and obtain their approval. The investment in the Finance, Procurement and Supply Chain (FPSC) programme lead by Health Benefits Ltd (HBL) includes the acquisition of “B” Class shares in HBL. HBL is owned by the Crown with the shareholding ministers being the Minister of Health and the Minister of Finance. The :”B” Class shares have received the approval from the shareholding ministers and have been allocated to the DHBs on a proportionate share based on the FPSC Business Case split of costs associated with each DHB. The shares carry a right to one vote per DHB on specific activities allowed for within the Deed of Shares as approved by the shareholding ministers

4.7

ACCOUNTING POLICIES

The accounting policies adopted are consistent with those in the prior year. For a full statement of accounting policies refer to the 2012/13 Annual Report.

4.8

PROSPECTIVE FINANCIAL STATEMENTS

The projected financial statements for the parent and group comprising Nelson Marlborough District Health Board are shown on the following pages. The actual results achieved for the period covered by the financial projections are likely to vary from the information presented, and the variations may be material. The financial projections comply with section 142(1) of the Crown Entities Act 2004 and the information may not be appropriate for any other purpose.

4.8.1 STATEMENT OF PROSPECTIVE FINANCIAL PERFORMANCE 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Income

420,436

433,068

439,604

448,264

456,389

464,511

Operating Expenditure Workforce costs Other operating costs External providers Inter-district flows Interest Depreciation & amortisation Capital charge

153,206 69,087 139,077 40,236 2,926 11,404 7,430

156,269 68,995 143,808 38,555 3,160 11,753 7,028

161,422 69,804 143,500 41,399 3,048 11,742 7,189

163,843 70,301 146,493 42,240 3,050 11,742 7,595

166,301 71,064 148,816 43,079 3,052 11,742 7,835

168,795 72,314 151,134 43,920 3,111 11,742 8,995

Total expenditure

423,366

429,568

438,104

445,264

451,889

460,011

Net surplus / (deficit)

(2,930)

3,500

1,500

3,000

4,500

4,500

67 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.8.2 STATEMENT OF PROSPECTIVE COMPREHENSIVE INCOME 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Net surplus / (deficit)

(2,930)

3,500

1,500

3,000

4,500

4,500

Other comprehensive income (Impairment)/revaluation of property, plant & equipment

(3,565)

0

0

0

0

0

Total comprehensive income

(6,495)

3,500

1,500

3,000

4,500

4,500

4.8.3 STATEMENT OF PROSPECTIVE MOVEMENTS IN EQUITY 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Equity at beginning of the year

93,888

86,846

89,799

90,752

93,205

97,158

Comprehensive income Net surplus/(deficit) Other comprehensive income

(2,930) (3,565)

3,500 0

1,500 0

3,000 0

4,500 0

4,500 0

Total comprehensive income

(6,495)

3,500

1,500

3,000

4,500

4,500

Owner transactions Equity injections Equity repayments

(547)

(547)

(547)

(547)

(547)

(547)

Total owner transactions

(547)

(547)

(547)

(547)

(547)

(547)

Equity at end of the year

86,846

89,799

90,752

93,205

97,158

101,111

68 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.8.4 STATEMENT OF PROSPECTIVE FINANCIAL POSITION 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Non current assets Property, plant & equipment Intangible assets Prepayments Other financial assets

157,272 3,602 130 3

164,796 7,073 130 3

178,113 7,278 130 3

172,396 15,253 130 3

171,257 23,425 130 3

170,117 26,323 130 3

Total non current assets

161,007

172,002

185,524

187,782

194,815

196,573

Current assets Cash & cash equivalents Debtors & other receivables Inventories Prepayments Assets held for sale

30,445 10,970 2,048 411 4,131

29,258 10,970 2,048 411 2,479

16,742 10,970 2,048 411 2,182

18,619 10,970 2,048 411 0

15,249 10,970 2,048 411 0

17,177 10,970 2,048 411 0

48,005

45,166

32,353

32,048

28,678

30,606

209,012

217,168

217,877

219,830

223,493

227,179

29,134 47,423 10,289

28,587 47,423 13,789

28,040 47,423 15,289

27,493 47,423 18,289

26,946 47,423 22,789

26,399 47,423 27,289

86,846

89,799

90,752

93,205

97,158

101,111

45,252 11,461

54,983 11,461

56,713 11,461

47,449 11,461

56,185 11,461

47,421 11,461

56,713

66,444

68,174

58,910

67,646

58,882

23,175 29,707 11,141 1,430

24,480 26,534 8,481 1,430

24,481 26,534 6,506 1,430

24,481 26,534 15,270 1,430

24,482 26,534 6,243 1,430

24,482 26,534 14,740 1,430

65,453

60,925

58,951

67,715

58,689

67,186

Total liabilities

122,166

127,369

127,125

126,625

126,335

126,068

Total equity & liabilities

209,012

217,168

217,877

219,830

223,493

227,179

Total current assets Total assets Equity Crown equity Revaluation reserve Retained earnings Total equity Non current liabilities Interest bearing loans & borrowings Employee entitlements Total non current liabilities Current liabilities Creditors & other payables Employee benefits Interest bearing loans & borrowings Provisions Total current liabilities

69 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.8.5 STATEMENT OF PROSPECTIVE CASH FLOWS 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

421,138 1,767 (152,944) (250,672) (7,430) (2,926) 2,649 11,582

431,003 2,062 (154,717) (255,888) (7,028) (3,161) 0 12,271

438,385 1,500 (159,611) (257,399) (7,475) (3,048) 0 12,352

446,760 1,500 (162,076) (260,797) (7,595) (3,050) 0 14,742

454,884 1,500 (164,685) (264,571) (7,835) (3,051) 0 16,242

463,006 1,500 (167,335) (268,823) (8,995) (3,111) 0 16,242

Cash flows from investing activities Sale of property, plant & equipment Cash inflow on maturity of investments Acquisition of property, plant & equipment Acquisition of intangible assets Acquisition of investments Net cash inflow / (outflow) from investing activities

40 25,285 (6,219) (2,431) 0 16,675

3,574 0 (11,399) (4,270) 0 (12,095)

301 0 (18,800) (5,577) 0 (24,076)

2,182 0 (10,000) (4,000) 0 (11,818)

0 0 (10,000) (8,774) 0 (18,774)

0 0 (10,000) (3,500) 0 (13,500)

Cash flows from financing activities Loans raised Finance leases raised Equity injections Equity repaid Repayment of borrowings Repayment of finance lease liabilities Net cash outflow from financing activities

0 0 0 (547) (1,020) (1,045) (2,612)

0 0 0 (547) 0 (816) (1,363)

0 0 0 (547) 0 (245) (792)

0 0 0 (547) 0 (500) (1,047)

0 0 0 (547) 0 (291) (838)

0 0 0 (547) 0 (267) (814)

Net increase/(decrease) in cash & cash equivalents

25,645

(1,187)

(12,516)

1,877

(3,370)

1,928

4,800

30,445

29,258

16,742

18,619

15,249

30,445

29,258

16,742

18,619

15,249

17,177

Cash flows from operating activities Receipts from Ministry of Health & patients Interest received Payments to employees Payments to suppliers Capital charge paid Interest paid Net GST paid Net cash inflow from operating activities

Cash & cash equivalents at 1 July Cash & cash equivalents at 30 June

...

4.8.6 SUMMARY OF PROSPECTIVE REVENUE AND EXPENSES BY DIMENSION 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Revenue Funds Governance & funding administration Provider Eliminations Total revenue

383,495 6,430 237,596 (207,085) 420,436

393,093 7,382 240,718 (208,125) 433,068

400,712 7,382 244,435 (212,640) 439,889

408,540 7,382 249,150 (216,808) 448,264

416,370 7,382 253,613 (220,976) 456,389

424,196 7,382 258,075 (225,142) 464,511

Expenses Funds Governance & funding administration Provider Eliminations Total expenses

386,397 6,430 237,624 (207,085) 423,366

390,488 7,038 240,167 (208,125) 429,568

400,712 7,382 242,935 (212,640) 438,389

408,540 7,382 246,150 (216,808) 445,264

416,370 7,382 249,113 (220,976) 451,889

424,196 7,382 252,075 (225,142) 458,511

Net contribution Funds Governance & funding administration Provider

(2,902) 0 (28)

2,605 344 551

0 0 1,500

0 0 3,000

0 0 4,500

0 0 6,000

Net surplus / (deficit)

(2,930)

3,500

1,500

3,000

4,500

6,000

70 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.8.7 STATEMENT OF PROSPECTIVE REVENUE AND EXPENSES BY OUTPUT CLASS 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Revenue Prevention services Early detection & management services Intensive assessment & treatment services Support services Total revenue

7,563 112,258 213,903 86,711 420,435

7,786 111,625 222,302 91,355 433,068

7,548 114,505 226,890 90,661 439,604

7,697 116,761 231,359 92,447 448,264

7,837 118,877 235,552 94,123 456,389

7,976 120,993 239,744 95,798 464,511

Expenses Prevention services Early detection & management services Intensive assessment & treatment services Support services Total expenses

6,370 108,799 219,176 89,020 423,365

6,524 110,762 222,020 90,262 429,568

6,858 113,003 226,955 91,288 438,104

6,977 115,144 230,696 92,857 445,674

7,095 116,997 233,674 94,284 452,050

7,214 118,858 236,641 95,683 458,396

Net contribution Prevention services Early detection & management services Intensive assessment & treatment services Support services

1,193 3,459 (5,273) (2,309)

1,262 863 282 1,093

690 1,502 (65) (627)

720 1,617 663 (410)

742 1,880 1,878 (161)

762 2,135 3,103 115

Net surplus / (deficit)

(2,930)

3,500

1,500

3,000

4,500

6,000

4.8.8 STATEMENT OF PROSPECTIVE FINANCIAL PEFORMANCE – PREVENTION SERVICES 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Income

7,563

7,786

7,548

7,697

7,837

7,976

Operating Expenditure Workforce costs Other operating costs External providers & inter district flows

3,733 621 2,016

3,567 847 2,110

4,036 962 1,860

4,097 981 1,899

4,158 1,007 1,930

4,220 1,032 1,962

Total expenditure

6,370

6,524

6,858

6,977

7,095

7,214

Net surplus / (deficit)

1,193

1,262

690

720

742

762

71 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.8.9 STATEMENT OF PROSPECTIVE FINANCIAL PEFORMANCE – EARLY DETECTION AND MANAGEMENT SERVICES 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

112,258

111,625

114,505

116,761

118,877

120,993

19,477 8,893 80,429

20,022 9,720 81,020

21,084 9,027 82,892

21,400 9,133 84,611

21,721 9,247 86,029

22,047 9,366 87,445

Total expenditure

108,799

110,762

113,003

115,144

116,997

118,858

Net surplus / (deficit)

3,459

863

1,502

1,617

1,880

2,135

Income Operating Expenditure Workforce costs Other operating costs External providers & inter district flows

4.8.10 STATEMENT OF PROSPECTIVE FINANCIAL PEFORMANCE – INTENSIVE ASSESSMENT AND REHABILITATION SERVICES 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Income

213,903

222,302

226,890

231,359

235,552

239,744

Operating Expenditure Workforce costs Other operating costs External providers & inter district flows

108,548 71,686 38,942

111,649 72,451 37,920

115,312 71,116 40,527

117,041 72,288 41,367

118,797 72,817 42,060

120,579 73,309 42,753

Total expenditure

219,176

222,020

226,955

230,696

233,674

236,641

Net surplus / (deficit)

(5,273)

282

(65)

663

1,878

3,103

4.8.11 STATEMENT OF PROSPECTIVE FINANCIAL PEFORMANCE – SUPPORT SERVICES 2013 Actual $000

2014 Forecast $000

2015 Projection $000

2016 Projection $000

2017 Projection $000

2018 Projection $000

Income

86,711

91,355

90,661

92,447

94,123

95,798

Operating Expenditure Workforce costs Other operating costs External providers & inter district flows

21,447 9,648 57,925

20,958 10,736 58,568

20,989 10,679 59,620

21,304 10,697 60,856

21,624 10,784 61,876

21,948 10,841 62,894

Total expenditure

89,020

90,262

91,288

92,857

94,284

95,683

Net surplus / (deficit)

(2,309)

1,093

(627)

(410)

(161)

115

72 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

MODULE 5: STEWARDSHIP 5.1

INFORMATION TECHNOLOGY

A modernisation of our desktop fleet is planned for implementation. We will be implementing a „zero client, virtual desktop infrastructure‟ solution at NMDHB. The solution involves replacing traditional desktop computers with a small client t the desktop and the computing capability is delivered at the back-end on the server infrastructure. „Zero client‟ will enable us to progressively migrate all users onto a standard set of hardware and will enable us to manage our desktop users‟ computing requirements centrally. Further investment will be made to upgrade and modernise our server and back-up capabilities. This work will be delivered through NMDHB IT/Capital Plan. A significant amount of time will be focused on supporting regional work: the South Island Alliance is embarking on a number of important supporting IT/IS projects over 2014-15, NMDHB is committed to supporting these, and our actions are described in Module 2 IT/Infrastructure page, including our commitment to National Entity projects.

5.2

INFRASTRUCTURE/CAPITAL 1.

2.

3.

4.

5.3

Building configuration Work will begin in 2014/15 to develop a Facilities Master Plan that considers a range of requirements including the need to upgrade existing facilities, and the future facility needs given our preferred models of care and changes to the population demographics in the Nelson region. The Plan will build on the information derived from the Health Services Plan assessing service development and configuration needs for the district‟s population over the next five to ten years.

Energy generation infrastructure (boiler) at the Nelson Hospital site is nearing the end of its useful life and a number of options, including different ownership scenarios, are being considered with the intention of selecting an option that will lower the cost associated with this infrastructure whilst ensuring continued, reliable operation.

Vehicle fleet In order to make efficiencies with our vehicles, we will work to systematically reduce the average age of our fleet, with the systematic investment in retiring older vehicles over the next 3-4 years.

HBL Laundry A national initiative to lower the costs and improve the efficiency of laundry delivery has resulted in a short list of propositions for consideration. The preferred solution will be implemented in the current year and may result in changes to the laundry facilities at Nelson and Wairau Hospitals. This work will be delivered through NMDHB IT/Capital Plan.

QUALITY ASSURANCE AND IMPROVEMENT

Nelson Marlborough District health Board has a management structure that demonstrates the organisations commitment of support for the implementation of a robust Clinical Governance Framework. Clinical Governance for this organisation is a framework through which NMDHB will strive to provide an environment where clinical excellence will flourish. This will be achieved through a culture that strives to continuously improve the quality of the services provided to the patient community. Imperative to the success of this framework is Clinical leadership, engagement at all levels of the organisation, and a no-blame culture where incidents are viewed as an opportunity to learn from and therefore improve systems and processes. NMDHB views the framework as currently being in its development phase, whilst there has been an initial implementation of systems, the goal in 2014/15 will be to refine and streamline these systems to ensure seamless and integrated approach to enable further development of key initiatives.

NMDHB has a 2014/15 Clinical Governance Plan, and a Clinical Governance Group overseeing implementation of quality actions. Specifically, quality system development will focus on updating and improving processes and procedures around: 1. Serious and sentinel events 2. Complaints 3. Organisational Systems for a. Creating Champions b. Embedding quality culture c. Enabling and supporting Leadership.

73 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

From an organisational development perspective, we will focus on core practices that require strengthening: 1. Research and development capacity 2. Innovation support 3. Project work capability 4. Promoting and maintain clinical professional development.

This work will support effective introduction and uptake of the HQ&SC IPIF indicators, and the Picker Inpatient Survey.

With respect to embedding the Quality Safety Markers (QSMs) and the Open for Better Care Campaign we will: 1. Act to reduce falls by improving quality and accessibility of recording and reporting systems, establish an ilearning module, review nursing care plan and pre-admission/surgical pathways to ensure coordination; 90% of older people are given a falls assessment, 20% reduction in acute hospital falls.

2. Act to improve hand hygiene through a system of peer review to provide short feedback loops at a clinical level to champion hand washing as a clinical quality initiative; review policy and procedures to ensure they are relevant, up-to-date, and fit for purpose. 80% compliance with good practice.

3. Act to promote the surgical safety checklist by promoting Surgical Safety during the reducing peri-operative harm campaign; actions on teamwork and communication. 3 parts of the checklist are used 90% of the time 4. Act to appropriately use of antibiotics for hip and knee replacement through communications with all anaesthetists; placing guidelines on all anaesthetic machines. 90% patients receive Cephazolin.

5. Act to ensure appropriate skin preparation for hip and knee replacements by clipping instead of shaving patients. 100% patients are clipped.

6. Act to reduce surgical site infections by following through on actions 4 and 5 above. 80 % reduction.

7. Act to reduce perioptive harm through promoting Perioptive Harm Avoidance during the reducing perioperative harm campaign, focusing on surgical safety checklist and reducing the risk of VTE. 80% reduction.

8. Act to improve medication safety by recording allergy status on inpatient medication charts (90% of charts); ensure prescriptions are signed by a doctor before administration of a medicine (90% are signed); review supplementary medication charts (90% are reviewed) and introduce pre-printed prescriptions for routine prescribing processes (100%).

We have also established a strong clinical leadership team spanning our local health system, comprising: Chief Medical Officer, Associate Chief Medical Officer, and Chief Medical Advisor Primary, and dedicated Clinical Directors for Child Youth and Maternity, Information Systems, Public Health, Surgical Systems, Mental Health, Mental Health Primary, Medicine and Surgery Primary, and Medical Systems, and Directors of Nursing/Midwifery and Allied Health.

To enable comprehensive quality improvement across our entire health system, the Clinical Leadership team has created the following set of guiding „Core Elements to Create an Environment Where Clinical Excellence Flourishes‟: 1. Patients are at the absolute centre of our considerations – consumers engaged at every level, learning from patient stories, learning about our cultural practices to Maori patients, services are developed for people not for services, and “never” events never happen.

2. All Clinical Staff have a focus on caring for the wider health system as well as the patient in front of them – all staff.

3. Partnerships between clinicians (nursing, medical, and allied health) and management are embedded at every level of the organisation a. brings leadership and management together to create effective efficient systems and services; including the Board, ALT, ELT, Services, Departments, Multi disciplinary teams, etc., b. leadership and management together own cultural (Maori) practices to build effective, efficient systems and services; including the Board, ALT, ELT, Services, Departments, , Multi disciplinary teams, etc.

4. Robust employment, orientation, training, supervision, mentoring, performance appraisal, maintenance of skills, and processes are in place; we make sure we have the right staff and right skills – Credentialing Committee and credentialing new employees.

5. Patient care and system function enabled by clinically-focused Information Systems.

6. Use learning from adverse events and complaints to improve systems of care – an „intelligent system‟ that learns from experience - Serious Event process, complaints, no-blame systems approach.

7. Information about Clinical Performance and Quality is collected, analysed, shared, and used to improve the system: 74 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

a. A Board that focuses more on clinical performance than financial performance b. He Taura Tieke (Maori service review tool), becomes part of NMDHB Quality Framework, it is measured, and the focus is on improved performance and learning.

8. Financial and Clinical Systems are linked – we know where we spend our money, what we get for the money and what clinical outcomes change because of what we spend.

9. Communication across whole health system so the right people know the right things – two way information flow avoiding over and under communication.

5.4

OUR WORKFORCE

A more tangible, flexible relationship is being developed between clinical workforce and workload so that the system will become more responsive and self regulating. All of our health care workers should be working at the top of their scope to provide high quality care as close to home as possible, only involving more specialised when needed. In this district consideration is being given to the context that exists in specific clinical areas where throughput is insufficient to maintain particular medical/surgical skills; systems will be deliberately developed with this in mind through the Top of the South Review; overall, our strategy is looking at the best balance of access, quality, and sustainability. We will develop innovative solutions that share workforce with other providers to ensure critical mass for sustainable, safe, and quality services is maintained. We are also focusing on the challenge presented to us by our ageing workforce, in particular in regard to our largest workforce - Nursing; some actions towards how we will manage this issue over the next five years are described below.

5.4.1 MANAGING OUR WORKFORCE WITHIN FINANCIAL CONSTRAINTS NMDHB has identified a range of workforce issues that we must address over the next three years to ensure a sustainable and fit-for-purpose health and support workforce, including: 1. Retention/ recruitment 2. Vulnerability of the workforce 3. Supply and demand 4. Monitoring workload to adapt workforce to meet needs 5. Capacity building of existing workforce 6. Limitation in geographical region of access to tertiary education centre 7. Non-regulated workforce 8. Aging workforce (all groups and ethnicities) 9. Inconsistency in the way workforce data is collected 10. Changes in professional standards 11. Strategic partnership opportunities (e.g. NMIT/ Massey etc) 12. Recruitment of (future) workforce a. Relationships with secondary schools b. Career expo‟s c. Incubators – secondary to first year enrolled students

5.4.2 STRENGTHENING OUR WORKFORCE To address these issues, NMDHB is developing an integrated workforce plan across this district and the South Island; providing increased capability, productivity, and capacity within our health workforce. Over the next three years we will focus on the following areas: 1. Workforce integration focused on patient needs, reducing barriers between services and enhance professional cross-disciplinary relationships, communication, and outcomes 2. Partnerships with clinical leaders, across professional groups, and a manager becoming the norm 3. Development of systems identify anticipated or planned need and then to match workforce to current, and future, workload 4. Priority health workforce areas identified and plans developed, in alignment with national and South Island Regional Training hub activity 5. Nurture RMO, nursing, and allied health workforce to grow staff who will want to stay in the region and have opportunities to remain 6. Identify gaps, supply, and pipeline issues, and opportunities including models of service delivery and interdisciplinary practice aiming to support practice at top of scope 7. Create opportunities for training by creating career paths locally to support „grow our own‟ workforce model 75 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

8. Work at regional and national level to support training programmes that develop the generalist work force required to meet the needs of NMDHB 9. Review our polices to support return-to-work programmes 10. Work with partners to develop the plan for the multi-disciplinary training and development centre, identifying the location and potential funding sources 11. Increase the Maori and Pacific Workforce by collating available workforce data and initiatives in place and develop a regional action plan for both Maori workforce and Pacific workforce Our actions towards supporting these approaches include: 1. Identify most critical potential workforce gaps and mitigations developed in advance of critical situations 2. Ongoing capacity for the 12% community based training at PGY 1 and 2 created providing broader based training and growing workforce for the future 3. New medical registrar training programme established in NMDHB which meets college requirements and provides potential applicants for future specialist roles 4. Increased RMO co-ordinator FTE to match MCNZ recommendations Supervision of PGY 2 and 3 recognised as a defined role 5. Creation of 12 more specialised roles within primary and secondary care supporting medical, nursing, and allied health staff 6. Campaign management and targeted marketing in place for critical workforce groups 7. Clinical pathways become less professionally siloed and instead chart an integrated patient journey which smoothly navigates across professional groups 8. Top of the South Plan implementation commences operationalising the concept of one-service, two-sites 9. Staff who train in NMDHB stay in NMDHB - filling or returning to fill critical workforce roles 10. Plan for Multidisciplinary Training centre developed and funding identified 11. Inventory of staff training and planned training needs embedded within performance appraisal system 12. Scope options for development of an acute medical/nursing workflow management system 13. Continue to strengthen Maori and Pacific health workforce development by focusing on recruitment/ retention policies and targets and pathways linked to training and professional development plans.

14. Supporting participation in health as a career for Maori and Pacific, and increasing their number studying 15. Create two permanent new nurse graduate positions for Maori health.

16. Maori and Pacific health workforce career planning is directly linked to succession planning.

17. We will work with local and regional education providers to ensure supply of trained regulated and nonregulated workforce. Future workforces will be encouraged through strong relationships with local education providers, i.e. schools, to foster health career aspirations through career expos and working with school/higher education providers career advisors across the sector. Emphasis on identifying and encouraging careers across health.

18. Roles are identified for nurse practitioners to enhance the health system and increase the numbers of new graduates being employed on a pathway of development as nurse practitioners.

19. Non-regulated allied health assistants have increased access to allied health systems training.

20. Develop regulated allied health clinical networks; in audiology, sonography, and speech language therapy 21. Succession planning for vulnerable workforces – focus on generalist specific models 22. Developing return to work programmes for vulnerable workforce employees 23. Increase the number of midwives across the district and , improve access to education and develop a midwife network across the South Island to allow access to standardised use of a scarce workforce 24. Provide robust career advice, guidance and support to all HWNZ funded trainees enabling their career development 25. Develop specific strategies for working with schools to fostering and nurture young Maori to be introduced to the sciences to provide a pathway for future careers.

5.4.3 SAFE AND COMPETENT WORKFORCE We will be developing a new human resource policy to ensure higher levels of compliance through: 1. Police checks are completed prior to employment commencing 2. Develop an employment passport – an education and training passport for all staff. The passport will be transferable across DHBs and will cover generic organisational orientation, with links to identify key training is delivered that is applicable to all DHB settings - VIP training, CPR, fire safety etc 3. Introduce incubator programmes for: a. Return to work b. Career expos 76 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

4.

c. Work place training – a means for introducing future workforce to opportunity to learn about a particular discipline, particular allied health e.g. speech therapy, audiology Roll out e-learning training packages that: a. Supports the implementation of the Kaiakatanga, the NMDHB Cultural Competency Framework; and b. Strengthen programmes based on the Treaty of Waitangi and Hei Oranga Maori/ Maori Health Best Practice.

5.4.4 CHILD PROTECTION POLICIES NMDHB has a range of policies designed to protect children which are reviewed three-yearly. We are continually updating and implementing changes around these in response to our environment and in keeping with the directions of the Children‟s Action Plan. We will include implementation status of our key policies in our 2014/15 Annual Report.

Policies specify that every contract, or funding arrangement, the NMDHB enters into with an independent person requires the person as soon as practicable to adopt a child protection policy. Contractors also receive a copy of relevant DHB child protection policies and/or provide evidence of their own organisations child protection policies; new DHB staff are given training on child protection policy application, and staff are given FVIP training. Particular attention is being given to issues around the responsibility of sharing information to help better protect children.

5.4.5 CHILDREN’S WORKER SAFETY CHECKING The Vulnerable Children Bill is expected to be enacted June 2014. Nationally District Health Boards will work together to get a consistent approach around the guidelines and implementation of the proposed bill within the DHBs. Requirements for standard safety checks within NMDHB provide for consistent and rigorous vetting and screening of employees within the NMDHB. The Vulnerable Children Bill is designed to protect children from the threats posed by a small number of high-risk individuals with the need to ensure that safe and competent individuals are not discouraged from entering the workforce. Every safety check of a person will comply with the requirements for safety checks for core workers or for non-core workers (as appropriate) prescribed in the Act. We will: 1. Carry out safety checks on all employees; those in core children‟s‟ will be prioritised first 2. Ensure that every safety check on these employees includes: a. Confirmation of the identity of the person, and b. Consideration of specific information prescribed by regulations made under the proposed Act; and c. A risk assessment, carried out as prescribed by regulations made under the proposed Act, which assesses the risk the person would pose to the safety of children if employed or engaged as a children's worker.

3. Complete safety checks for all current staff within NMDHB that have not had been police checked within the last 3 years; starting initially with staff in core children‟s services 4. Ensure that ongoing regular police checks are completed for staff within NMDHB at intervals of no more than three years.

5.5

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; holds trust funds for the benefit of public hospitals  Marlborough Hospital Equipment Trust; provides equipment, other items from public donations raised by Trust  Churchill Private Hospital Trust; provides private medical and surgical services in Marlborough  Agreement with Nelson Radiology Ltd; joint MRI service from the Nelson Hospital site  Agreement with Top of the South Cardiology Ltd; covers private cardiology services from Nelson Hospital.  Golden Bay Health Alliance for an Integrated Family Health Centre with Nelson Bays Primary Health Trust and Golden Bay Community Health Trust – Te Hauora O Mohua Trust  Appointment of Trustee to the Board of the Golden Bay Community Health Trust – Te Hauora O Mohua Trust  South Island Alliance Project Office (SIAPO); supports the activities of the South Island DHBs by providing services (planning and funding audit, analysis and advice and contract management) NMDHB does not hold any controlling interests in a subsidiary company.

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5.6

STEWARDSHIP ROLE AS OWNER OF CROWN ASSETS

DESCRIPTION

PHYSICAL ASSETS

NMDHB is a Crown Entity with ownership of

Buildings and Equipment

Nelson Hospital delivering the full range of New Zealand Role Delineation Model level 4 secondary services: emergency, surgical and medical specialist (acute and elective), primary and secondary maternity, neonatal, paediatric, specialist health services for older people and support services, diagnostic imaging.

Wairau Hospital delivering the full range of New Zealand Role Delineation Model level 3 secondary services: 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.

Murchison Hospital and Health Centre delivering the full range of primary care services: „Primary Response for Medical Emergencies [PRIME], district nursing service, aged residential care rest home, and hospital services for Murchison residents.

District Nursing Services located in Motueka.

Disability Support Services (DSS) – Nelson community based residential and day activities for people with intellectual and physical disabilities.

Needs Assessment and Coordination Services (Support Works) for people with life-long, longterm conditions and age-related disabilities.

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 some members of Executive Leadership Team: GM Strategy and Planning, GM Finance and Performance, GM Clinical Governance, GM IT and Infrastructure; GM Human Resources, GM Disability Support Services, Director of Maori Health and Whanau Ora; Chief Medical Officer; Director of Nursing and Midwifery.

South Island DHB Alliance Project Office (SIAPO) – ownership shared with Canterbury DHB, South Canterbury DHB, Otago DHB, Southland DHB and West Coast DHB. 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.

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Waimea Rd, Nelson

Hospital Rd, Blenheim

Tipahi St & Braemar Campus Nelson; Hospital Rd Blenheim Gilbert St, Richmond Fairfax St Murchison Courtney St, Motueka Tahunanui Drive, Nelson, plus 65 individual community homes Harley St, Nelson and Blenheim Hospital Campus Richmond (Tasman) and Blenheim (Marlborough) Various locations Braemar Campus, Waimea Road, Nelson Christchurch TAS Building, L7, 186 Willis St, Wellington

MODULE 6: SERVICE CONFIGURATION 6.1

SERVICE COVERAGE

There are no identified significant service coverage exceptions identified for 2014/15.

6.2 SERVICE Fertility Services RFP

Laboratory Services Review

SERVICE CHANGE SPAN

Regional

Regional

Local (districtTop of the wide); South Medicine, Clinical General Services Surgery, and Development Orthopaedic Services.

6.3

FUNDING PATH

APPROVAL PROCESS

Maintenance of current funding

Regional approach with regional RFP, noting existing provider contract is due for renewal December 2014

Equitable and consistent access to publically funded, high quality fertility services across the South Island

Explore a sub-regional approach to contracting laboratory services (community and hospital). The first stage of this activity is to produce a laboratory strategy which will aim to identify the best use of available resources, to strengthen clinical and financial sustainability, and to increase and improve patient access to services.

Following endorsements from participating DHB Boards in early 2015, the DHBs will follow up with an EOI and RFP for a new service by 01/07/16

Affordable, sustainable, laboratory diagnostic service that meets the needs of the South Island population consistently and equitably

Constraining growth in funding

Ensuring sustainable growth in funding

Steering Group appointed to oversee the recommendations coming from the workstreams followed by a change management approach, consultation, and reconfiguration

SERVICE ISSUES

There are no identified significant service issues identified for 2014/15.

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BENEFIT

Implementable recommendations to enable NMDHB to significantly progress the delivery of a safe and sustainable one-service/two-site model of secondary care service delivery.

Recommendations will reflect both wise judgment and be evidenced based; will be in keeping with the values of the organisation and consistent with the aims of improving quality, ensuring equity, providing value for money, and retaining the confidence of the organisation and community.

MODULE 7: PERFORMANCE MEASURES 7.1

MONITORING FRAMEWORK PERFORMANCE MEASURES

The DHB monitoring framework aims to provide a rounded view of performance using a range of performance markers. Four dimensions are identified reflecting DHB functions as owners, funders, and providers of health and disability services.

DIMENSIONS OF DHB PERFORMANCE „Policy priorities‟ „System Integration‟ „Outputs‟ „Ownership‟ „Developmental‟

DESCRIPTION

CODE

Achieving Government‟s priority goals/objectives and targets Meeting service coverage requirements and supporting sector interconnectedness Purchasing the right mix and level of services within acceptable financial performance Providing quality services efficiently Establishment of baseline (no target/performance expectation set)

PP SI OP OS DV

2014/15 PERFORMANCE EXPECTATION/TARGET

PERFORMANCE MEASURE Age 0-19

PP6: Improving the health status of people with severe mental illness through improved access

Age 20-64 Age 65+ Long term clients

PP7: Improving mental health services using transition (discharge) planning and employment

Child and Youth with a Transition (discharge) plan Mental Health Provider Arm Age <= 3 weeks 0-19 80% Addictions (Provider Arm and NGO) Age <= 3 weeks 0-19 80% Ratio year 1 Ratio year 2 Ratio year 1

PP8: Shorter waits for non-urgent mental health and addiction services for 0-19 year olds

PP10: Oral Health- Mean DMFT score at Year 8 PP11: Children caries-free at five years of age

Ratio year 2 % year 1 % year 2 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

PP12: Utilisation of DHB-funded dental services by adolescents (School Year 9 up to and including 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

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Maori 4.2% Total 4.2% Maori 6.5% Total 4.6% Total 0.9% Provide report as specified At least 95% of clients discharged will have a transition (discharge) plan. <=8 weeks 95% <=8 weeks 95% 1.00 1.00 60% 65% 85% 85% 80% 85% 10% 10% 100%

PP20: improved management for long term conditions (CVD, diabetes and Stroke) Focus area 1:Long term conditions

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

Focus area 2: Diabetes Management (HbA1c) Improve or, where high, maintain the proportion of patients with good or acceptable glycaemic control

Improve or, where high, maintain the proportion of patients with good or acceptable glycaemic control

Improve or, where high, maintain the proportion of patients with good or acceptable glycaemic control

Focus area 3: Acute coronary syndrome services

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

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

Over 95 percent of patients presenting with ACS who undergo coronary angiography have completion of ANZACS QI ACS and Cath/PCI registry data collection within 30 days.

Focus area 4: Stroke Services

6 percent of potentially eligible stroke patients thrombolysed 80 percent of stroke patients admitted to a stroke unit or organised stroke service with demonstrated stroke pathway

Over 95 percent of patients presenting with ACS who undergo coronary angiography have completion of ANZACS QI ACS and Cath/PCI registry data collection within 30 days.

6% 80%

PP21: Immunisation coverage (previous health target)

Percentage of two year olds fully immunised

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.

95%

PP26: The Mental Health & Addiction Service Development Plan

Provide quarterly narrative progress reports against the local alliance Service Level Agreement plan to implement named initiatives/actions to improve primary care responsiveness to youth. Include progress on named actions, milestones and measures.

Report on the status of quarterly milestones for a minimum of eight actions to be completed in 2014/15 and for any actions which are in progress/ongoing in 2014/15.

PP27: Delivery of the children‟s action plan

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

PP25: Prime Minister‟s youth mental health project

Provide a „progress report‟ against DHBs‟ Rheumatic Fever prevention plan; including quarterly reporting of the Case Review (actions taken and lessons learned) of each new case of Rheumatic Fever.

PP28: Reducing Rheumatic fever

Hospitalisation rates (per 100,000 DHB total population) for acute Rheumatic Fever are 40% lower than the average over the last 3 years

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0.3 per 100,000

1.

Coronary angiography – 90% of accepted referrals for elective coronary angiography will receive their procedure within 3 months (90 days) 2. CT and MRI – 90% of accepted referrals for CT scans, and 80% of accepted referrals for MRI scans will receive their scan within than 6 weeks (42 days) 3. Diagnostic colonoscopy – a. 75% of people accepted for an urgent diagnostic colonoscopy will receive their procedure within two weeks (14 days) and b. 60% of people accepted for a diagnostic colonoscopy will receive their procedure within six weeks (42 days)

PP29: Improving waiting times for diagnostic services

c.

a. 62-day indicator This indicator will be included within PP30 for quarter one 2014/15 only. From quarter two 2014/15 this indicator will become a health target. b. 31-day indicator This indicator will be included within PP30 for all quarters of 2014/15. c. Radiotherapy and chemotherapy This indicator will be included within PP30 from quarter two 2014/15 (transitioning from Health Target).

Age 0-4 Age 45-64 Age 0-74

PP30: Faster cancer treatment

SI1: Ambulatory sensitive (avoidable) hospital admissions SI2: Delivery of Regional Service Plans SI3: Ensuring delivery of Service Coverage

a. 75% of people accepted for an urgent diagnostic colonoscopy will receive their procedure within two weeks (14 days) and b. 60% of people accepted for a diagnostic colonoscopy will receive their procedure within six weeks (42 days) c. 60% of people waiting for a surveillance colonoscopy will wait no longer than twelve weeks (84 days) beyond the planned date 85 % of patients referred with a high suspicion of cancer wait 62 days or less to receive their first treatment (or other management); by July 2016. < 10 percent of the records submitted by the DHB are declined.

All patients ready-for-treatment receive treatment within four weeks from decision-to-treat. <95% <95% <95%

Provision of a single progress report on behalf of the region agreed by all DHBs within that region ( the report includes local DHB actions that support delivery of regional objectives 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 Intervention Rates (SIRs)

SI5: Delivery Whānau Ora

Surveillance colonoscopy 60% of people waiting for a surveillance colonoscopy will wait no longer than twelve weeks (84 days) beyond the planned date

Coronary angiography – 90% of accepted referrals for elective coronary angiography will receive their procedure within 3 months (90 days) CT and MRI – 90% of accepted referrals for CT scans, and 80% of accepted referrals for MRI scans will receive their scan within than 6 weeks (42 days)

of

major joint replacement

an intervention rate of 21.0 per 10,000 of population

cataract procedures cardiac surgery

an intervention rate of 27.0 per 10,000

percutaneous revascularization

a target rate of at least 12.5 per 10,000 of population

coronary angiography services

a target rate of at least 34.7 per 10,000 of population

a target intervention rate of 6.5 per 10,000 of population

Report progress on planned activities with providers to improve service delivery and develop mature providers.

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OS3: Inpatient Length of Stay OS8: Reducing Acute Readmissions to Hospital

OS10: Improving the quality of identity data within the National Health Index (NHI) and data submitted to National Collections Focus area 1:Improving the quality of identity data

Focus area 2:Improving the quality of data submitted to National Collections

Focus area 3:Improving the quality of the programme for Integration of mental health data (PRIMHD)

Output 1: Mental health output Delivery Against Plan

Developmental measure DV4: Improving patient experience

Elective LOS

3.10 days, 75th centile of national performance

Acute LOS Total population

3.47 days â&#x2030;¤7.0%

75 plus New NHI registration in error B. Greater than 1% and less than or equal to 3% Recording of non-specific ethnicity Greater than 0.5% and less than or equal to 2% Update of specific ethnicity value in existing NHI record with a nonspecific value Greater than 0.5% and less than or equal to 2%

â&#x2030;¤10.3% New NHI registration in error B. Greater than 1% and less than or equal to 3%

Validated addresses unknown Greater than 76% and less than or equal to 85% Invalid NHI data updates causing identity confusion %tbc NBRS links to NNPAC and NMDS Greater than or equal to 97% and less than 99.5%

Validated addresses unknown Greater than 76% and less than or equal to 85% Invalid NHI data updates causing identity confusion %tbc

National collections file load success Greater than or equal to 98% and less than 99.5% Standard vs edited descriptors Greater than or equal to 75% and less than 90%

Recording of non-specific ethnicity Greater than 0.5% and less than or equal to 2% Update of specific ethnicity value in existing NHI record with a non-specific value Greater than 0.5% and less than or equal to 2%

NBRS links to NNPAC and NMDS Greater than or equal to 97% and less than 99.5% National collections file load success Greater than or equal to 98% and less than 99.5% Standard vs edited descriptors Greater than or equal to 75% and less than 90%

NNPAC timeliness Greater than or equal to 95% and less than 98%

NNPAC timeliness Greater than or equal to 95% and less than 98%

PRIMHD File Success RateGreater than 95%

PRIMHD File Success Rate- Greater than 95%

PRIMHD data quality

Routine audits undertaken with appropriate actions where required

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 No performance target set

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APPENDIX 8.1 GLOSSARY OF ACRONYMS ABC ACS ACPP ARRC ASH AT&R B4SC C CARES CAMHS CCMS CGF CMO CNSD/SCN Concerto COPD CPAC CPAMs CPSA CVD DHB DMFT DoView DSS ERMS ECC/ECE ED EDaaG eSCRV ESPI EQI FASD FSA FTE FVIP GM GP HBSS HEeADSSS HOP HQ&SC HR IANZ IDF IPIF IS IT KHW MPHO LMC LOS MDM

Ask about and document every person‟s smoking status, give Brief advice to stop to every person who smokes, and strongly encourage every person who smokes to use Cessation support (a combination of behavioural support and stop-smoking medicine works best) and offer to help them access it.

Acute Coronary Syndrome Accelerated Chest Pain Pathway Aged Related Residential Care Ambulatory Sensitive Hospitalisation Assessment, Treatment, & Rehabilitation Before School Checks Coverage Coordinated Access Response Electronic Service Child and Adolescent Mental Health Services Collaborative Care Management System Clinical Governance Framework Chief Medical Officer Clinical Nurse Specialist Diabetes/Specialist Clinical Nurse IT system which provides clinician‟s interface to systems Chronic Obstructive Pulmonary Disease Clinical Priority Assessment Criteria Community Pharmacy Anticoagulation Services Community Pharmacy Services Agreement Cardiovascular Disease District Health Board Decayed, Missing, Filled Teeth Visual map using outcomes software; sets out main actions needed to achieve higher-level impacts and outcomes Disability Support Services Electronic Referral Management System Early Childhood Centre/Early Childhood Education Emergency Department ED at a Glance Electronic shared care record view Elective Services Patient Flow Indicators Endoscopy Quality Improvement Fetal Alcohol Spectrum Disorder First Specialist Assessment Full Time Equivalent Family Violence Intervention Programme General Manager General Practitioner Home Based Support Services Psychosocial tool – Home, Education, eating, Activities, Drugs and Alcohol, Sexuality, Suicidality (mood), Safety Health of Older People Health Quality & Safety Commission Human Resources International Accreditation New Zealand Inter District Flow Integrated Performance Incentive Framework Information Systems Information Technology Kimi Hauora Wairau Marlborough PHO Lead Maternity Carer Length of Stay Multi Disciplinary Meeting

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MDT MECA MLTC MoH MOH MOSAIQ MRI NASC NBPH NCSP NGO NHI NHC NMDHB NMDS NPF OIS PACS PAS PBF(F) PGY PHS PHO PICS PMHI POAC POETIC PPE PP PRIMHD Q RFP SHSOP SI SICHA SIA SIAPO SIMHSLA SIR SIRTH SMO SOI SPOE SP&AS SPE SSE SSIP T Te Piki Oranga ToSHA V

Multi Disciplinary Team Multi Employer Collective Agreement Multiple Long Term Condition Ministry of Health Medical Officer of Health Oncology Patient Information System Magnetic Resonance Imaging Needs Assessment Service Coordination Nelson Bays Primary Health National Cervical Screening Programme Non Government Organisation National Health Index National Health Committee Nelson Marlborough District Health Board National Minimum Dataset National Patient Flow Outreach Immunisation Services Picture Archiving Computer System Patient Administration System Population Based Funding (Formula) Post Grad Year Public Health Service Primary Health Organisation Patient Information Care System Primary Mental Health Initiative Primary Options for Acute Care Primary Options for Extended Therapy Interventions in the Community Pregnancy and Parenting Education Policy Priority Project for the Integration of Mental Health Data Quality Request for Proposal Specialist Health Services for Older People South Island South Island Child Health Alliance South Island Alliance South Island Alliance Programme Office South Island Mental Health Service Level Alliance Standardised Intervention Rate South Island Regional Training Hub Senior Medical Officer Statement of Intent Single Point of Entry Strategy, Planning, and Alliance Support Statement of Performance Expectations Serious and Sentinel Events Surgical Site Infection Programme Timeliness The Nelson Marlborough Maori Health Coalition Top of the South/ Te Tau Ihu o Te Waka a Maui Health Alliance Volume (quantity)

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APPENDIX 8.2 DEFINITIONS Term

Definition

Activity

What an agency does to convert inputs to outputs.

Alliance

An agreement between two or more participants made in order to advance common goals and secure common interests; it is not an entity as individual participants retain their separate identify and accountabilities; the Alliance approach entails a collaborative, incentive-driven method of contracting where all participants work co-operatively to the same end, sharing the risk and reward, whilst respecting the principles of good faith and trust. Our local Top of the South Alliance „ToSHA‟ comprises the partners Kimi Hauora Wairau Marlborough PHO, Nelson Bays PHO, and NMDHB. 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 complex intervention for the mutual decision making and organisation of care processes for a well defined group of patients during a well defined period: an explicit statement of the goals and key elements of care based on evidence, best practice, and patients‟ expectations and their characteristics; the facilitation of the communication among the team members and with patients and families; the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; the documentation, monitoring, and evaluation of variances and outcomes; and, the identification of the appropriate resources. The aim is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimising the use of resources.

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

Capability Care Pathway

Crown agent Crown entity

Cost containment Efficiency Effectiveness

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 nearterm 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.

The resources such as labour, materials, money, people, information technology used by departments to produce outputs, that will achieve the Government's stated outcomes.

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: 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.

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 Management systems

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.

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

Impact

Impact measures Input Integrated care

Intervention Intervention logic model

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Measure

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

Objectives

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 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. 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. 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 non-financial measures are also reflected in your financial measures (s 142 (2) (b) Crown Entities Act 2004).

Prevention 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.

Preventative services address individual behaviours by targeting population wide physical and social environments to influence health and wellbeing.

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.

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 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.

They include: - Ambulatory services (including outpatient, district nursing and day services) across the range of secondary preventive, diagnostic, therapeutic, and rehabilitative services - Inpatient services (acute and elective streams) including diagnostic, therapeutic and rehabilitative services - Emergency Department services including triage, diagnostic, therapeutic and disposition services 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.

Outcome

Output agreement

Output classes

Output class definitions

Outputs Ownership

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,

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Performance measures

Priorities Productivity Purchase agreement

Regional collaboration

Results Standards of Service Measures Statement of Performance Expectations Strategy Sub regional collaboration

Targets

Te Piki Oranga Values

Value for Money Wrap around services

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.

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.

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.

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. 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.

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.

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. They form the basis of the Annual Report.

See Ownership.

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 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 Nelson Marlborough Maori Health Coalition 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. NMDHB Values: Respect, Innovation, Trust, Integrity.

The assessment of benefits relative to cost, in determining whether specific current or future investments/expenditures are the best use of available resource.

Services that „wrap around‟ are services that work together seamlessly, communicating effectively, to ensure removal of both gaps and duplication in health service care and delivery. It places the patient/consumer at the centre of our service design, planning, delivery, and monitoring, in order to ensure that what is best for the patient is not subsumed by what is best for the health professional or the health system; resulting in the patient/consumer having a seamless journey throughout their involvement with all services/professionals, with gaps in health care delivery and professional/consumer communications removed. It is supported by incorporating consumers in continuous quality improvement activities.

88 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18

‘NMDHB Annual Plan 2014-15 & Statement of Intent 2014-2018’

Pursuant to Section 38 of the New Zealand Public Health and Disability Act 2000; Section 139 of the Crown Entities Act 2004; Section 49 of the Crown Entities Amendment Act 2013; New CE Act s149C. Nelson Marlborough District Health Board, Private Bag 18, NELSON

89 NMDHB ANNUAL PLAN 2014-15 & SOI 2014-18