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Counties Manukau District Health Board Agenda

Counties Manukau District Health Board Board Meeting Agenda Wednesday, 6 May 2015 at 1.30 – 4.30pm, Innovation Lab, Ko Awatea, Middlemore Hospital, Hospital Road, Otahuhu, Auckland Time Item

1.00 – 1.30pm Board Only Session

1. Welcome

1.30 – 1.35pm 2. Governance

2.1. Attendance & Apologies 2.2. Conflicts of Interest/Specific Interests 2.3. Confirmation of Public Minutes – 25 March 2015 2.4. Action Items Register

1.35 – 1.45pm 1.45 – 1.55pm

3. Strategy

3.1. Chair’s Report (Verbal Update) 3.2. Chief Executive’s Report

4. Presentation

5. General Business

1.55 – 2.00pm 6. Resolution to Exclude the Public

2.00 – 2.05pm 2.05 – 2.10pm 2.10 – 2.20pm 2.20 – 2.35pm 2.35 – 2.50pm 2.50 – 3.00pm

7. Confidential

7.1. Confirmation of Confidential Minutes – 25 March 2015 7.2. Action Items Register 7.3. HBL Transition (Lee Mathias) 7.4. Annual Plan & Budget Presentation (Geraint Martin/Ron Pearson) 7.5. 2015/16 Draft Annual & Maaori Health Plans (Dawn Kelly & Riki Nia Nia) 7.6. Draft Northern Region Health Plan (Geraint Martin)

Afternoon Tea Break

3.10 – 3.20pm 3.20 – 3.30pm 3.30 – 3.40pm 3.40 – 3.55pm 3.55 – 4.05pm 4.05 – 4.20pm 4.20 – 4.30pm

7.7. Strategy Refresh (Marianne Scott) 7.8. Health Targets - 2014/15 Quarter 1 Progress Report (Pauline Hanna) 7.9. Integrated Community Service Hubs Planning Update (Benedict Hefford) 7.10. FPSC Business Change Case (Margaret White) 7.11. Government Rules of Sourcing (Ron Pearson) 7.12. Project SWIFT Update (Sarah Thirlwall) 7.13. IS Strategic Projects Update (Sarah Thirlwall)

Next Meeting: 17 June 2015 Innovation Lab, Ko Awatea, Middlemore Hospital, Otahuhu

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Agenda for Counties Manukau District Health Board

Board Member Attendance Schedule 2015

Name

Jan 11 Feb 25 Mar 6 May 17 June 29 July 9 Sept 21 Oct 2 Dec

Lee Mathias (Chair)

No

Mee

ting

Wendy Lai (Deputy Chair)

Arthur Anae

Colleen Brown

Sandra Alofivae

Lyn Murphy

David Collings

Kathy Maxwell

George Ngatai

Dianne Glenn

Reece Autagavaia

* Attended part meeting only

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BOARD MEMBERS’ DISCLOSURE OF INTERESTS

April 2015 Member Disclosure of Interest

Dr Lee Mathias, Chair • Chair Health Promotion Agency

• Deputy Chair Auckland District Health Board • Director, Pictor Limited • Director, iAC Limited • Advisory Chair, Company of Women Limited • Director, John Seabrook Holdings Limited • Chairman, Unitec • External Advisor, National Health Committee • Director, Health Innovation Hub • Director, healthAlliance Ltd • Director, healthAlliance (FPSC) Ltd • Member, HBL Transition Governance Group • MD Lee Mathias Limited • Trustee, Lee Mathias Family Trust • Trustee, Awamoana Family Trust • Trustee, Mathias Martin Family Trust

Wendy Lai, Deputy Chair • Board Member and Partner at Deloitte • Board Member Te Papa Tongarewa, the Museum of

New Zealand • Chair, Ziera Shoes • Board Member, Avanti Finance

Arthur Anae

• Councillor, Auckland Council • Member The John Walker ‘Find Your Field of

Dreams’ • Chairman, NZ Good Samaritan Heart Mission to

Samoa Trust Colleen Brown • Chair, Disability Connect (Auckland Metropolitan

Area) • Member of Advisory Committee for Disability

Programme Manukau Institute of Technology • Member NZ Down Syndrome Association • Husband, Determination Referee for Department of

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

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Dr Lyn Murphy • Member, International Society for Pharma-coeconomics and Outcomes Research (ISPOR).

• Member of the New Zealand Association of Clinical Research (NZACRes)

• Senior lecturer in management and leadership at Manukau Institute of Technology

• Member, ACT NZ • Director, Bizness Synergy Training Ltd • Director, Synergex Holdings Ltd • Associate Editor NZ Journal of Applied Business

Research • Member Franklin Local Board

Sandra Alofivae

• Member, Fonua Ola Board • Board Member, Pasefika Futures

David Collings

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

Kathy Maxwell • Director, Kathy the Chemist Ltd

• Regional Pharmacy Advisory Group, Propharma (Pharmacy Retailing (NZ) Ltd)

• Editorial Advisory Board, New Zealand Formulary • Member Pharmaceutical Society of NZ • Trustee, Maxwell Family Trust • Member Manukau Locality Leadership Group,

CMDHB • Board Member, Pharmacy Guild of New Zealand

Dianne Glenn • Member – NZ Institute of Directors

• Member – District Licensing Committee of Auckland Council

• Life Member – Business and Professional Women Franklin

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

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

Therapy Inc. • CMDHB Representative - Franklin Health

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

Zealand

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

Network • Director Transitioning Out Aotearoa • Director BDO Marketing • Board Member, Manurewa Marae

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• Conservation Volunteers New Zealand • Maori Gout Action Group • Nga Ngaru Rautahi o Aotearoa Board

Reece Autagavaia • Member, Pacific Lawyers’ Association

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

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

Amata Preschool

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BOARD MEMBERS’ REGISTER OF DISCLOSURE OF SPECIFIC INTERESTS

Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 25 March 2015 Director having interest

Interest in Particulars of interest Disclosure date Board Action

David Collings

Potential Botany Land Development

Mr Collings declared a specific interest in relation to the Potential Botany Land Development, being a member of the Howick Local Board.

4 September 2013 That Mr Collings’ specific interest be noted and that the Board agree that he may remain in the room and participate in any deliberations or decisions.

David Collings Innovation Hub Mr David Collings has a conflict of interest in regard to ATEED (being a member of the Local Community Board, which is part of the Auckland Council) and will be involved in the Innovation Hub.

5 October 2011 The Board notes that Mr Collings has a conflict of interest in regard to the Innovation Hub. He may participate in the deliberations of the Board in relation to this matter because he is able to assist the Board with relevant information, but is not permitted to participate in decision making.

Wendy Lai

HBL – Food & Laundry & FPSC Programme

Ms Lai declared a specific interest in regard to Deloitte providing support to HBL in the food and laundry and FPSC Programme. Deloitte has mainly been providing Oracle implementation resources to FPSC. Ms Lai is not directly involved with this work.

12 February 2014 That Ms Lai’s specific interest be noted and that the Board agree that she may remain in the room and participate in any deliberations, but be excluded from any voting.

George Ngatai Community Services Pharmacy Funding Policy

Mr Ngatai declared a specific interest in terms of their GP Service being like to use a local Pharmacy.

13 August 2014 That Mr Ngatai’s specific interest be noted and that the Board agree that he may remain in the room and participate in any deliberations, but be excluded from any voting.

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Wendy Lai HBL Business Cases Ms Lai declared a specific interest

in regard to Deloitte’s involvement with HBL on this work.

13 August 2014 That Ms Lai’s specific interest be noted and that she may not participate in either the deliberations or determination of the Board in relation to this matter and is asked to leave the room.

Wendy Lai Ko Awatea Panel Advisory Services

Ms Lai advised that Deloitte have been shortlisted to provide Panel Advisory Services to Ko Awatea. This work does not have any involvement with the APAC Business Case

5 November 2014 Noted. Ms Lai advised on the 3 December 2014 that Deloitte have now been selected to work with the Ko Awatea team to improve commercial awareness and increase income levels.

Lee Mathias Otahuhu Boundary Change The Chair noted her Specific Conflict of Interest, being Deputy Chair at ADHB.

25 March 2015

That Dr Mathias’ specific interest be noted and that the Board agree that she may remain in the room and participate in any deliberations, but be excluded from any voting.

Lee Mathias Northern Region Electronic Health Record (NEHR) Project & Regional Information Strategy (RIS 10-20) Refresh

The Chair declared her specific interest as a Director of HealthAlliance.

25 March 2015 That Dr Mathias’ specific interest be noted and that the Board agree that she may remain in the room and participate in any deliberations, but be excluded from any voting.

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Minutes of Counties Manukau District Health Board Held on Wednesday, 25 March 2015 at 1.30 – 4.30pm, Innovation Lab, Ko Awatea, Middlemore Hospital, Hospital Road, Otahuhu, Auckland Present: Dr Lee Mathias (Chair), Ms Wendy Lai, Mrs Dianne Glenn, Mrs Kathy Maxwell, Mr Reece Autagavaia, Dr Lyn Murphy, Mrs Colleen Brown, Mrs Sandra Alofivae In attendance: Mr Geraint Martin (Chief Executive), Mr Ron Pearson (Deputy Chief Executive), Mrs Lyn Butler (Board Secretary) Apologies: Anae Arthur Anae, Mr George Ngatai The Board met on its own for 25 minutes prior to the Board meeting. The Chairman gave feedback on the Board appraisal process which had recently been undertaken. 1. Welcome

The Chair welcomed everyone to the meeting. Ms Samantha Smith, Reporter from the Manukau Courier, was also present at the meeting.

2. Governance 2.1. Attendance & Apologies

Noted.

2.2. Conflicts of Interest/Specific Interests Noted. The Chair advised that she is a Director of hA, and is a Member of the HBL Transition Governance Group.

2.3. Confirmation of Public Minutes – 11 February 2015

Resolution That the public Minutes of the Board Meeting held on Wednesday, 11 February 2015, were taken as read and confirmed as a true and correct record. Moved: Dianne Glenn Seconded: Colleen Brown Carried: Unanimously

2.4. Action Items Register

Noted.

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3. Strategy 3.1. Chair’s Report (verbal update) (Lee Mathias)

The Chair gave a brief update on regional activities and the desire to have more services located nearer to where our people live but that this was in the context of ensuring that all services across the region could maintain their viability. Further discussion will take place at RGG meetings.

3.2. Chief Executive’s Report The report was taken as read. Mr Martin expressed his concern at the recent inaccurate reporting by the Manukau Courier, following their attendance at the February Meeting. A corrective CEO’s Blog has been published, to address the high level of staff concern that resulted from the article. The position going forward is a challenge, and work is continuing prioritizing and focusing on improvements to improve delivery of service, as well as reviewing the strategic vision. Management and staff are well engaged. Staff are continuing to work on getting good healthcare into homes through family education, including; throat swabbing, insulating homes, oral health, etc. 3.2.1. Values Refresh Presentation (Beth Bundy)

Mrs Bundy advised that this work has been underway since January when it was discussed with ELT, who agreed that it was timely to review the organization’s values and strategy. All complaints and compliments have been reviewed, to see what consistent messages are coming through. This has shown that there is no consistent delivery of care. An online staff survey is available, with hard copies also available at Middlemore, Lambie Drive and Manukau Super Clinic. Over 1,000 staff have completed this so far. Patients are being provided with patient surveys, which are also being handed out with all patient meals this week. The survey closes on the 8 May 2015. A Values Week is being held across the organization from the 28 April to the 4 May 2015. 100 staff will attend each session. The structure has been based on that used at the NHS, WDHB, ADHB and US organisations. There are three Sessions: • In Our Shoes – for all staff to attend and provide feedback. • In Your Shoes – for patients to attend and share their experiences. • Leading with Values – for staff with leadership roles to build skills to role model

and manage values, attitude and behaviours. All ELT are expected to attend at least one session. Clinicians will also attend. Ms Lai asked how many frontline staff would be able to attend ‘In our Shoes’. Mrs Bundy advised that having the sessions running throughout the week at different locations offered the best opportunities for staff to attend.

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3.2.2. Annual Plan 2014/15 Q2 Report (Marianne Scott)

The paper was taken as read. Ms Lai noted that not all targets are being met. Mr Martin advised that Mrs Pauline Hanna is focused on ensuring that any status ‘orange’ would become ‘green’. All significant targets are being met, and an update will be provided as at the next quarter and will come to the May meeting. Mr Benedict Hefford is focusing on CVD and Diabetes targets. The Chair referred to the Northern Region Health Plan and queried whether the Well Child Checks are being met. Mr Martin is to follow up and advise.

3.2.3. Patient Information Strategy & Plan 2015 & Presentation (Phillip Balmer/Margie

Apa/Denise Kivell) Mr Balmer provided an update and presentation to the Board on the above. Health literacy in the Counties Manukau area is below the rest of the country, and numeracy is low. The Chair noted that the Institute of Medicine had found that the issue is very much from the provider’s perspective. Mr Martin added the importance of knowing that health literacy has nothing to do with a patient’s intelligence. Mrs Apa agreed, adding that it is CMDHB that needs to do work in this area. Ko Awatea is leading some collaborative work helping to provide support for people leading chronic care management. This work needs to be done collectively and with primary care. A lot more is expected of patients that previously. The Chair recommended that the term ‘patient’ is not used, as it has a passive implication. In addition, the references to Primary, Second and Tertiary needs to be addressed. Ms Lai acknowledged this work is a good start, but found the language used confusing, again noting that health literacy is not connected to literacy. Mrs Apa re-iterated that this work is about CMDHB’s systems, not patients. This will assist Clinicians in standing back and looking at themselves to enable them to make future interactions more meaningful. Mr Martin recommended that the term ‘Health Literacy’ should be revised. Mr Autagavaia noted the importance of communal knowledge, as it is just as important for family members to know relevant information, as patients often ask them. Agreed. The Blue Zones slide is to be sent to the Board.

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Resolution That the Chief Executive’s Report be received. Moved: Lee Mathias Seconded: Kathy Maxwell Carried: Unanimously

4. Presentations

None.

5. General Business None.

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

The meeting was re-opened to the public. The meeting closed at 4.40pm. The next Meeting of the Board will be Wednesday, 6 May 2015 at Ko Awatea, Middlemore Hospital. The Minutes of the Meeting of the Counties Manukau District Health Board of Wednesday, 25 March 2015 are approved. Signed as a true and correct record on Wednesday, 6 May 2015. Chair ______________________________ Dr Lee Mathias (Chair) Recommendation (moved / seconded )

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Counties Manukau District Health Board Action Items Register (Public)

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

25 March Patient Information

Strategy & Plan 2015

The Chair recommended that the term ‘patient’ is not used, as it has a passive implication. In addition, the references to Primary, Second and Tertiary needs to be addressed. Mr Martin recommended that the term ‘Health Literacy’ should be revised. The Blue Zones slide is to be sent to the Board.

April April April

P Balmer P Balmer L Butler

Noted. Noted. Done.

25 March Annual Plan 2014/15 Q2 Report

All significant targets are being met, and an update will be provided as at the next quarter and will come to the May meeting. The Chair referred to the Northern Region Health Plan and queried whether the Well Child Checks are being met. Mr Martin is to follow up and advise.

May May

G Martin/ P Hanna G Martin

Updated provided in May meeting papers. Verbal update to be provided at the meeting.

1 October CE Strategic Discussion

Mr David Moore of Sapere Group, one of the leading research agencies, has been engaged to look at economic models, datasets, etc. A report will be provided to the Board when the work has been completed. A new Health Services Plan will be worked on over the next few months, with the Plan coming to the Board in June.

June G Martin/ B Hefford

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Counties Manukau District Health Board Chief Executive’s Report

Recommendation It is recommended that the Board receive the Chief Executive’s Report. Prepared and submitted by Geraint Martin, Chief Executive 1.0 Introduction

1.1 As routine, my report is set out in three sections:

- Strategic – with a special focus on planning for 2015/16.

- Operational – including the reports from the Director of Strategic

Development, Director of Corporate & Business Services and Director of Ko Awatea.

- Compliance – no new items to report, but there is an update on health &

safety.

2.0 Strategy 2.1 The values refresh work has enabled us to focus upon some key questions for the

organisation. The Lancet recently published a lead article where it identified that culture and how values are expressed have a strong correlation with mortality rates and patient safety standards. Far from being a ‘soft’ subject, we have approached the Refresh by engaging with staff and patients by effectively holding a mirror up to the organisation and celebrating where we do well, but being clear where we need to improve. If we are to be serious about ‘Passing the Granny Test’, and being an organisation of excellence and compassion, then a sense of honesty and positive challenge is vital. I shall update the Board on progress verbally at the meeting.

2.2 Closely related to this work is our ‘Healthy Together’ Strategic Review. We are planning to bring to the Board June Meeting the Strategic Framework for 2015-2020 for debate, revision and approval. A key element of this will be achieving the objective of a health system which is characterised by operational excellence, but engineered into improving Population Health – becoming a health system as much as an illness system. Once the Framework has been agreed, this will then guide the development of our implementation plan through a revised Clinical Services Plan, which will be completed by Spring 2015. However, a key component of this is the development of localities, and within them, health hubs and clusters. Included on the Agenda is a paper prepared by Benedict Hefford outlining our current thinking and approach. Included also is a paper entitled ‘Turning the Oil Tanker’, which clearly identifies how our strategy of re-design in the localities is beginning to change the

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pattern of demand, and meet the needs of chronic disease more effectively. It remains early days and accelerating change and building momentum is becoming high priority.

2.3 We are now at an advanced stage with the preparation of the Annual Plan for 2015-16, having: - Reviewed detailed feedback from the Ministry (mainly positive and

technical).

- Through an organisational wide (one team approach) commitment, we are at breakeven, with a clear delivery plan which maintains and improve services.

Key points for the Annual Plan Financial Planning Status are: - In achieving breakeven, we have, however, retained our strategic shape and

ensured investment continues in key agreed strategic direction areas, i.e. Localities, SWIFT, Quality & Safety. The focus has been on meeting Ministerial expectations and improving services – working more smartly to deliver better care.

- We have Clinical/Management ownership of the challenge across the

organisation.

- Efficiencies/savings and provisions have been released without any deterioration in Clinical services overall. In line with strategic thinking, they may be provided in a different way or location. However, our focus has been on providing the same, if not better, in the future.

- This has been a huge financial challenge and the response from the

organisation has been first class, focussed and professional. An important point to be mindful of is that we have greatly reduced the number of one off savings this year, replacing them with ongoing sustainable savings.

- We will ensure that the implementation of the plan will be detailed and

closely monitored. Progress will be formally reported each month to ELT by Pauline Hanna and from there to the Board.

Whilst this has been a challenging process, the: - Maintenance of a strategic approach based on improvement and Triple Aim.

- Full commitment of the organisation as a whole.

- Senior Team leadership.

has been very impressive. Ron Pearson and I will update the Board in more detail at the meeting itself.

3.0 Operational 3.1 The DHB remains on target to deliver its third surplus in a row at the end of this

financial year. All focus is being brought to bear on ensuring we achieve this during the last eight weeks of the year.

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In addition, our patient care performance remains very strong and we are confident of maintaining our meeting of the six headline targets for the third year in succession. Along with that, we are also improving on our performance in key second tier target, such as cervical screening and diagnostic testing. We aim to be compliant by year end. In the case of Faster Cancer Services, although the target is not ‘due’ until June 2016, we have committed to achieve the target several months in advance; currently we are aiming for the second quarter of 2015-16. Achieving this means better patient care. In addition, significant improvement in the Quality Safety Marker reports, especially in Theatres, means better care for patients and I would like to acknowledge Dr David Hughes’ leadership in this area. Finally, our 5th Patient Experience Report has been our best yet, with 93% of patients rating us good to excellent:- improvements continue to be needed, but this reflects the impact of the Patient and Whanau Council and the executive walkarounds.

3.2 I wish to inform the Board of some changes to ELT responsibilities. This is to enable us to ensure focus and delivery in key and critical areas over the next few months: - Ron Pearson will focus on leading SWIFT and the Finance portfolio, with

other responsibilities re-allocated. This will be in place for the next six months to allow us to co-ordinate delivery of the SWIFT Business Case by September, and to allow the recruitment of a Project Manager to be completed.

- To strengthen the HR role in the organisation, Beth Bundy, GM HR, will join ELT.

3.3 In the same vein, I have agreed with the Chair that it is appropriate we refresh

the support and expectations for Board and its Sub-Committees. As CEO, providing the highest level of support for the Governance of the organisation is vital and a foundation of good performance and accountability. Consequently, always seeking to improve our support is an important task. Anna-Maree Harris, Project Management Office, and former Board Secretary, is leading the review of: - Expectations - Support - Timetable - Standards for papers This will be presented to the Board for agreement in June. She will be meeting with each Sub-Committee Chair and Senior Director to complete this process.

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4.0 Compliance 4.1 There are three major issues:

- Risk Management Framework: the recommended approach will be presented to ARF at its May Meeting for approval.

- Delegations: This will be review taking into account DHB, Regional and National business changes. Ron Pearson is leading this review.

- Government Procurement: We are currently reviewing and implementing the required changes in our procurement process. John Hanson and Karli Menary are leading this.

4.2 At the next Board Meeting, I will update the Board on progress regarding Health

& Safety legislation.

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Strategic Development

There are seven teams that provide “corporate services” and two direct patient support services (Maaori and Pacific cultural support) in the Strategic Development Directorate. The table below highlights progress on key business as usual or initiatives as at end March. The table also highlights risks that are of organisation concern.

Team Highlights Risks Strategic Planning

15/16 Annual Planning - preliminary feedback has been received from the Ministry of Health for the first draft Annual and Maaori Health Plans submitted 13 March 2015. Most of the Ministry’s planning guidance is completed with the exception of the national agency expectations (e.g. HSQC, National Health IT Board etc) that typically have budget impacts. There is no confirmed date for guidance communication at this time. We continue to work regionally on matters that span all DHBs. 14/15 Annual Plan Non-Financial Reporting - Ministry of Health Quarterly Reporting - Q3 report is in progress. Strategy Refresh – reported in separate paper to Board.

15/16 Annual Plan is able to be implemented within current resources.

Population Health

• Meeting with Human Rights Commissioner about indicators related to health as a human right.

• Ongoing participation in PBFF review and MoH Health Tracker support

• Population health leadership in the development of Children’s Team for South Auckland – preparing paper on how to define and identify ‘vulnerable children’ for next meeting

Census 2013 sociodemographic profile for CM population still waiting revision.

Maaori Health Development

Integrated Service Agreement with NHC: A solution has been agreed to manage the poor performance of the NHC ISA agreement. The result is likely to be a scaling back of the current ISA agreement to return contracting functions to the DHB and progress the outcomes frmaework using more of an Alliancing approach with NHC. Maaori Health Plan - The first draft plan was tabled with ELT at the 24 Feb 2015 meeting prior to submission to MoH 13 March. The attached working second draft plan has a small number of changes to date. Provisional feedback has recently been received from Ministry/NHB and is currently being circulated to indicator champions. Formal feedback is expected within the next few weeks. Key feedback areas are focused around the Acute Coronary Syndrome, Cervical Screening and SUDI indicators. Te Rapunga Paeora – The review of Whaanau ora services with CM Health (currently known as Te Kaahui Ora who provide inpatient cultural support) has been completed and a decision made on the way forward. We are now entering the implementation phase. Over the next wo months we will be working with staff to develop necessary tools, capability and enablers to implement the new model of care from the 1st of July 2015.

Delays to the roll out of year two deliverables of the ISA Potential legal intervention if a mutual way forward cannot be found Loss in confidence and productivity by our Maori provider network Potential for staffing changes. Will ensure that if any changes are required they are guided by HR capability and policy.

Pacific Health Development

Integrated Service Agreement: Alliance Health Plus – Progress is on track for a 1 July implementation of the ISA agreement changes. This will move $1.5million of Pacific funding from purchasing individual services to packages of care, co-ordination and intervention for high risk or vulnerable Pacific Fanau. This will result in a change to the way providers are currently funded from “inputs” based to ‘Fanau Ola’ central services. An outcomes and results framework is also being finalized with Alliance Health Plus as part of this model.

Providers may not be able to manage the transition from input based purchasing to Fanau ola centred care co-ordination and interventions.

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Regional Pacific Samoa - MFAT is to extend the current Institutional Linkage Programme to 31 March 2016. The current ILP finishes on 30 September 2015. The reason for this is to provide Samoa NHS to reassess their areas of priority and capability development. Samoa NHS now has a new Emergency and General Outpatients Department and some services have been relocated to the new complex. Planning to the end of the next financial year will allow the NHS to also think beyond this financial year and have a three year ILP Plan in place. Cook Islands - Emergency Ambulance Contract – St John, the external contract holder for this Activity, are now on the final stages of the new ambulance refit and delivery of the ambulance to Cook Islands MOH. The ambulance will be delivered in late May, early June and will be launched during the Cook Islands Health Conference in July 2015. MOU between CMDHB and Cook Islands MOH is under review.

Communications

CEO Blog - total hits for March reached 3,908. This is the 3rd highest performing month since the blog started late 2011. Most popular blog: Middlemore Hospital Emergency Care leads the way. New CM Health Website – the new CM Health website launched on Thursday 9 April with 80% of content complete. Positive response to look and feel. New content is being uploaded daily based on priority, aiming to have website completed by June. Total number of visitors to the corporate website for March 39,337. The following table compares to previous months.

No. of Visitors Mar -14 Feb -15 Mar-15 New Visitors 21538 10489 13105 Returning Visitors 9071 24272 26232 TOTALS 30609 34761 39337

SouthNET (internal intranet)

Month Mar 14 Feb 15 Mar -15 SouthNET 243427 207397 246 695 Daily Dose 4566 5242 6150

Social Media - Stong growth continues across social media channels with increased regular activity and posts. Facebook: 1221 likes, 58 new likes, and post reach 6096. Twitter: 1320 followers, top tweet 145 impressions

Human Resources

Organisation Health Priority Indicators: The Organisation Health Priority indicators for sick leave and annual leave remain within acceptable limits. Interventions to reduce the annual leave liability over the last year indicate that plans to manage leave at a sustainable operating level has been achieved. Values: The ‘Listening Week’ part of the Values review begins week beginning 28th April. The frame for this programme of work will then be expanded to include activities to embed the values and the way we work across CMH. From a human resources perspective this will inform the short, medium and long term HR plan including the intervention to improve the performance management system. The human resources department are will continue the consideration of the “why, what and how” of performance management in an integrated system context will be progressed over the coming months to determine a new structure for 15/16. Risk: Regional discussion is required regarding the progress of SMO

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Job Sizing and sustaining regional compliance to the agreed principles established under the original project. Changes in HR leadership at all three DHBs and the cessation of the RIG Meeting increases the potential for inconcistencies in approach to occur going forward. In addition the infrastructure to support the generation of job sizes remains a fragile system that warrants review in the coming months.

1. Deep Dive –Te Hikoi Rangahau: Study Tour Findings This section will take a “deep dive” or focus indepth on activities in the work programme. This month we focus on Te Hikoi Rangahau Study Tour Findings. Background Tumu Whakarae (National GM, Maaori Health group) implemented an international study tour of the USA & Canada (15/3 – 31/3/15). The main objectives were: • Develop leadership capability through exposure to international indigenous health

leadership and excellence • Gain exposure to initiatives/strategies that accelerate indigenous health gain in across a

range of settings • Gain exposure to excellence occurring in integration, systems measures, cultural

competence, leadership and service delivery • Gain exposure to initiatives/strategies to accelerate indigenous workforce development. • Test the commitment for ongoing meaningful engagement and sharing of learning and

expertise to accelerate indigenous health gains. Overview of findings The findings from the stour can be summarized as follows: • We should be further ahead in our endeavours to accelerate Māori health gain then we

are given the history of Treaty settlement and relations compared to observed indigenous populations

• There were many excellent examples of tribal leadership at all levels of health systems from ownership, service planning, funding to delivery

• Transparent leadership was a standard way of working that appears to generate success – in some organisations leadership KPIs were visibly displayed and progress measured publicly from Chief Executive and Board down to practicing clinicians. This reflects a desire to be accountable to indigenous communities about how the health system and leadership roles within the system were performing

• The existence of indigenous health Epidemiological centres was an importing finding for us. These were centralised teams of clinical, research and development expertise that informed frontline service delivery directly. This enabled high quality and evidence based advice and ensured research investment was solution focused not about describing the problem in different ways

• Some interesting work being progressed with indigenous communities to define and implement ‘wellness indicators’ for their population

• Workforce development is a shared priority and seen as an essential ingredient to success • Strong and shared desire for ongoing collaboration and learning • Excellent example of why having a strong vision, robust values and transparent leadership

in place is critical to achieving success. • The importance of culture was reinforced. • Indigenous leadership is valued and see as critical. Numerous examples of success. • Policy is extremely powerful. Actions: The following table describe the actions that will be actioned by Tumu Whakarae as a consequence of the learnings from the study tour. One of those actions is an international symposium to be hosted by CM Health on behalf of Tumu Whakarae on the 22nd and 23rd of September, 2015 to progress a shared Indigenous health gains agenda. “Hui Kaiookiri Iwi Taketake” lead into APAC. The main objectives are to share solutions and intelligence about key enablers for the aceleration of indigenous health gains. The symposium will also be an opportunity for us to progress meaningful relationships established during the Te Hikoi Rangahau

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Study Tour. It is our aspiration that these relationships result in ongoing and sustanable engagement that will lead to a greater sharing of intelligence, capability and shared learning.

Action Local Regional National Leadership Advocate for and role

model transparent leadership

Advice paper to CEOs entitled Te Ara Whakawaiora Tuarua

Advice paper to CEOs entitled Te Ara Whakawaiora Tuarua

Direction Provide greater clarity on expectations actions required for the acceleration of Maori health gain

Align regional priorities framework for Maori health to refreshed Tumu Whakarae priorities Framework

Refresh Tumu Whakarae Priorities Framework

Influence Strengthen the Maori health gains teams capability to provide high quality and robust advice and direction

Work collaboratively to progress a shared epidemiological Maori health agenda

Establish a Maori health Epidemiological centre or joint agenda with one or more of the tertiary institutions to achieve a focus on solution focused research.

Enablers Implement gold standard enablers locally, starting with tools for real time A MHP reporting by PHO

Build on the A MHP performance culture we have developed

Build on the MHP performance culture we have developed

Exposure

Create more opportunities to expose our local workforce to indigenous health excellence

Create more opportunities to expose our system to indigenous health excellence

Create more opportunities to expose our system to indigenous health excellence

Relationships

Work with Mana Whenua to develop the capability of the local health workforce

Establish a working relationship with the Iwi Chairs Group aimed at accelerating Maori health gains

Establish a working relationship with the Iwi Chairs Group aimed at accelerating Maori health gains

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FINANCIAL POSITION at March 2015 Summary: The month produced a slight positive variance of $7, with only a slender favourable variance of $117k year to date. The outlook for the remaining three months will be challenging. While only a very minor favourable variance in the month it makes it hard to absorb any cost fluctuations with the organisation. At this point in time the organisation is still on target to come in on budget (subject to the anticipated gain on sale of land at Botany ($3.0m)). The last three months have a budget loss of $2,445k, offset by the sale of land $3,007 (current position $2,555 less budgeted loss $2,445 plus sale of land $3,007 equals $3,117 against a budget of $3,000). Month / Year to date The consolidated result for the month as stated above was a slight favourable variance $7k, with the actual result being a deficit of $(968)k v’s budget $(975)k. The year to date result is a favourable variance of $117k, with actual $2,555k v’s budget $2,438k surplus.

The Funder Arm was $469k favourable to budget and year to date $2,323k favourable. Community pharmacy continues to produce an unfavourable variance to budget. As per previous months the trend is for Aged Residential Care (over 65s) demand to continue to be below budget which is the main driver for the months and year to dates favourable result. This trend is contrary to previous history and forecast projections with no specific driver apparent but can reverse just as quickly

The Provider Arm consolidated, produced a result that was favourable to budget by $3k, year to date is favourable $122k. The Hospital side of the provider arm was favourable for the month by $223k and year to date $346k favourable. HBL saving for linen and laundry have not been achieved and are likely to be delay until the start of the New Financial Year, costing the organisation over $1m in lost savings. Governance was unfavourable for the month by $(465)k and year to date $(2,328)k unfavourable, primarily driven by continuing costs related to Project SWIFT $(187)k which at this point in time are unable to be capitalised, Planning and Funding $(112)k DHB management $(118)k personnel and consultancy. Statement of Performance by Operating Arm

Month March 15

Net Result YTD March 15

Full year

Act $000 Var. $000 Act Bud Var. Last year

Bud Forecast

527 304 223 Hospital Provider 14,887 14,541 346 11,354 16,713 17,931

(796) (805) 9 Integrated Care (6,549) (7,245) 696 (1,661) (9,590) (9,626)

(1,136) (1,143) 7 Ko Awatea (9,648) (10,130) 482 (10,900) (13,413) (13,490)

(149) 87 (236) HBL (1,378) 24 (1,402) (1,369) (714) (1,738)

(1,554) (1,557) 3 Provider (2,688) (2,810) 122 (2,576) (7,004) (6,923)

1,050 581 469 Funder 7,571 5,248 2,323 7,333 6,996 7,644

(464) 1 (465) Governance (2,328) - (2,328) (347) 1 (724)

- - - Gain on Sale - - - - 3,007 3,007

(968) (975) 7 Surplus (deficit) 2,555 2,438 117 4,410 3,000 3,004

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Volume Summary (March 2015)

Total WIES Month Year to date Act Bud Var. % Last.

Yr. Act Bud Var. % Last. Yr.

5,605 5,498 107 1.95% 5,692 Acute 51,497 49,961 1,536 3.07% 50,249

1,482 1,581 (99) (6.3)% 1,595 Elective 13,135 13,341 (206) (1.5)% 13,179

7,087 7,079 8 0.11% 7,287 Total 64,632 63,302 1,330 2.10% 63,428

The elective WIES have been affected by the delay in the refurbishment project of four Manukau theatres. This project was due to finish on 28 February. Instead it finished at the end of March – the theatres were handed over on 31 March and Surgery spent the two days before Easter getting cleaning and inventory completed. The four theatres were open for business on Tuesday 7 April. During the closure period we brought as many cases as we could from the four theatres back to Middlemore theatres. We had a small increase in subcontracting where the budget permitted. However, March also saw a large jump in acute Surgical volumes which had first preference over theatre capacity, thus limiting the elective work. Discharges Month Year to date

Act Last Yr. Var. % Act Last Yr. Var. %

7,566 7,330 236 3.2% Acute 65,306 63,797 1,509 2.37%

1,604 1,287 317 24.6% Elective 12,503 12,713 (210) (1.7)%

9,170 8,617 553 6.4% Total 77,809 76,510 1299 1.70%

0.77 0.85 0.07 8.6% Ratio WIES to discharges 0.83 0.83 - (0.4)%

Volumes Other Month Year to date

Act Last Yr. Var. % Act Last Yr. Var. %

630 570 60 10.53% Birth Numbers 5,465 5,462 3 0.05%

9,312 8,776 536 6.11% ED Volumes 82,248 75,457 6,791 9.00%

4,273 4,013 260 6.48% Renal Dialysis

36,521 34,380 2,141 6.23%

50,146 49,254 892 1.81% Outpatient Summary

428,801 422,040 6,761 1.60%

2.3 2.2 0.1 4.55% ALOS

2.3 2.4 (0.1) (4.2)%

Statement of Performance (March 2015)

22


Month

Year to Date

Full Year

Act Bud Var. $000 Act Bud Var. Last year Bud Forecast

Revenue

121,295 121,277 18 Crown 1,086,836 1,091,973 (5,137) 1,171,997 1,456,397 1,455,400

3,457 2,761 696 Other 28,169 24,979 3,190 31,208 32,246 32,597

124,752 124,038 714 Total Revenue 1,115,005 1,116,952 (1,947) 1,203,205 1,488,643 1,487,996

Expenses

45,959 46,408 449 Personnel 403,549 408,660 5,111 437,506 556,961 541,174

6,198 4,646 (1,552) Outsourced 49,659 42,365 (7,294) 53,979 46,607 59,503

52,890 54,855 1,965 Funder

Provider payments

483,476 493,685 10,209 529,141 657,917 653,550

9,435 8,337 (1,098) Clinical Sup. 78,667 72,084 (6,583) 81,043 97,038 104,019

6,280 5,546 (734) Infrastructure 51,828 50,729 (1,099) 54,062 67,471 67,307

120,762 119,792 (970) Operating Exp 1,067,179 1,067,523 344 1,155,731 1,425,994 1,425,553

3,990 4,246 (256) Surplus after

operating Exp.

47,826 49,429 (1,603) 47,474 62,649 62,443

2,717 2,846 129 Depn. 24,714 25,616 902 25,106 34,156 34,157

1,083 1,280 197 Interest 9,570 11,520 1,950 6,691 15,360 14,539

1,158 1,095 (63) Capital Chg. 10,987 9,855 (1,132) 11,267 13,140 13,751

- - - Gain on Sale - - - 3,007 3,007

(968) (975) 7 Net Surplus 2,555 2,438 117 4,410 3,000 3,004

Better than 5%

Worse than 5%

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Revenue

Month YTD Full Yr.

Act Bud Var. $000 Act Bud Var. Bud

69,770 67,568 2,202 Provider 614,614 608,712 5,902 778,434 116,464 117,286 (822) Funder 1,050,452 1,055,585 (5,133) 1,363,247 (62,524) (61,850) (674) Elimination (559,405) (556,652) (2,753) (715,366)

1,042

1,034 8 Governance 9,344

9,307 37 15,085

124,752 124,038 714 Total 1,115,005 1,116,952 (1,947) 1,441,400 Provider: favourable for the month of March. The main drivers for the current month’s variance are: • Government Revenue; CTA Nursing timing of revenue to budget, ACC revenue phasing reflects a

positive variance for the month; Integrated care additional revenue for initiatives (offset by cost); Acute spines revenue; Breast screening revenue below budget.

• Patient/Consumer Sourced; Minor Tahitian burns; Non-resident additional billings for the month (offset by bad debts).

• Other Income; Interest Received above budget for the month; donation revenue to be reviewed; Bad debt recovery; kA 20k days funding offset against costs; Pacific revenue offset against costs; Youth forensics revenue Mental Health.

• Funder Payments; Variation in revenue phasing from Funder for contracts outside base funding i.e. 20k days, localities, IDF inflow revenue

Funder: Revenue is directly related to demand driven expenses. Staff Costs

Month

YTD Full Yr.

Act Bud Var. $000 Act Bud Var. Bud 45,156 45,733 577 Provider 396,863 402,591 5,728 519,227

803 675 (128) Governance 6,686 6,069 (617) 9,898 45,959 46,408 449 Total 403,549 408,660 5,111 529,125

14,740 15,137 397 Medical 127,153 130,756 3,603 169,096

17,098 16,981 (117) Nursing 151,988 150,074 (1,914) 197,975

6,345 6,694 349 Allied Health 57,853 60,114 2,261 77,878

2,054 2,018 (36) Support Personnel 18,257 18,062 (195) 21,966

5,722 5,578 (144) Management Admin 48,298 49,654 1,356 62,210

45,959 46,408 449 403,549 408,660 5,111 529,125 Provider: Favourable personnel costs reflects a deliberate strategy to balance overall 2014/15 budget expectations. Key variances include delayed realisation of Practicing Sustainable Health Care procurement savings for the month. A measure of these costs, have been offset by planned management of vacancies and annual leave. Outsourcing to cover key vacancies (e.g. Mental Health) and clinical services where we are short on specialist capacity, for the month.

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Medical Personnel costs for the month, reflects existing vacancies, offset by outsourced services. Nursing personnel costs for the month reflects the level of clinical demand within the hospital Note that the Personnel cost variance above includes costs incurred in delivering additional unbudgeted revenue.

Outsourced Services

Month YTD Full Yr.


794 465 (329) Medical 5,975 4,165 (1,810) 4,860 278 37 (241) Nursing 1,369 338 (1,031) 549

40 70 30 Allied Health 480 633 153 768 57 37 (20) Support 386 339 (47) 444

256 162 (94) Management/Administration 2,599 1,431 (1,168) 1,486

1,425 771 (654) Total Personnel 10,809 6,906 (3,903) 8,107 2,670 2,540 (130) Corporate & Funder Services 23,991 22,920 (1,071) 28,296 2,103 1,335 (768) Clinical Service 14,859 12,539 (2,320) 18,864 6,198 4,646 (1,552) Total 49,659 42,365 (7,294) 55,267 • Provider: unfavourable for March (includes personnel, clinical and other).

Medicine. Renal, gastro and sleep studies that are partly funded. Surgical. Outsourced surgical procedures continue to maintain MoH ESPI 120 day targets. Mental Health. Vacancies covered by locums. Non-Clinical Outsourcing. Unbudgeted inventory management costs and Pharmac Device contract, Pacific Health additional contracts (funded). HBL. National Procurement, FPSC, Regional Food services unbudgeted costs. Integrated Care. Additional outsourcing costs offset by revenue. Kidz and Woman’s Health. UoA additional cost and external bureau usage.

Independent Service Provider (Demand driven expenditure) Month Major Categories YTD Full Yr.


Personal Health

19,702 20,858 1,156 IDF Personal Health 185,874 187,711 1,837 245,784

8,482 8,350 (132) Pharmaceuticals 76,421 75,146 (1,275) 99,096

6,911 6,976 65 Primary Practice Services – Capitated

63,684 62,782 (902) 81,144

576 576 - Child and Youth 5,248 5,180 (68) 5,767

470 465 (5) Adolescent Dental Benefit 4,194 4,186 (8) 5,664

93 247 154 Chronic Disease Management and Education

1,922 2,222 300 5,772

374 361 (13) Palliative Care 3,369 3,250 (119) 4,332

343 427 84 General Medical Subsidy 3,087 3,838 751 4,176

1,682 1,992 310 Other 14,061 17,934 3,873 16,603

38,633 40,252 1,619 Total Personal Health 357,860 362,249 4,389 468,338

Other: change in coding in budgeting between Personal Health and Mental health other.

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Mental Health

1,226 1,225 (1) IDF Mental Health 11,032 11,031 (1) 13,824

856 917 61 Community Residential Beds & Services

7,657 8,248 591 11,232

701 688 (13) Other Home Based Residential Support

6,306 6,197 (109) 8,280

316 320 4 Dual Diagnosis – Alcohol & Other Drugs

2,856 2,884 28 3,636

272 271 (1) Crisis Respite 2,442 2,446 4 3,267

357 327 (30) Child & Youth Mental Health Services

3,199 2,944 (255) 3,561

176 164 (12)

Kaupapa Maori Mental Health Services - Community

1,573 1,476 (97) 1,975

161 185 24 Mental Health Community Service

1,405 1,666 261 1,785

368 740 372 Other 3,373 6,665 3,292 13,086

4,433 4,837 404 Total Mental Health 39,843 43,557 3,714 60,646

Disability Support Services

4,368 4,342 (26) Residential Care: Hospitals 38,003 39,068 1,065 49,707

2,050 2,035 (15) Residential Care: Rest Homes 17,342 18,315 973 23,076

1,693 1,731 38 Home Support 15,432 15,577 145 20,116 1,435 1,420 (15) Other 12,795 12,787 (8) 15,808

9,546 9,528 (18) Total Disability Support Services 83,572 85,747 2,175 108,707

165 115 (50) Total Public Health 1,128 1,033 (95) 852

113 123 10 Total Maori Health 1,073 1,099 26 1,308

52,890 54,855 1,965 Funder 483,476 493,685 10,209 639,851 Note: this cost area has a Revenue/Cost match methodology i.e. as costs are incurred; Revenue is allocated, with a year end wash-up. Revenue currently is similarly down under Revenue: Funder.

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Clinical Supplies

Month YTD Full Yr. Act Bud Var. $000 Act Bud Var. Bud

3,944 3,518 (426) Treatment Disposables 32,559 30,030 (2,529) 40,569

758 584 (174) Diagnostic Supplies & Other Clinical Supplies

6,453 5,553 (900) 7,345

1,090 1,012 (78) Instruments & Equipment 9,486 8,749 (737) 11,786

339 278 (61) Patient Appliances 2,683 2,383 (300) 3,217

1,612 1,425 (187) Implants & Prostheses 12,638 11,727 (911) 15,983

1,422 1,225 (197) Pharmaceuticals 12,306 10,973 (1,333) 14,582

270 295 25 Other Clinical Supplies 2,542 2,669 127 3,558

9,435 8,337 (1,098) Total 78,667 72,084 (6,583) 97,040 • Provider: unfavourable for the month.

Delayed target procurement savings across the services are partially offset in other cost and revenue areas. Clinical Support. Volume increase in Labs, Pharms and radiology based on surgical services volumes. Surgical Services. Increase in Acute patients, part offset by a reduction in elective volumes. ARHOP. Community continence, ostomy and bandages & dressing overspends. Facilities. Clinical equipment R&M reduction. .

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Non-Clinical / Infrastructure (excluding Interest and Capital Charge)


5,649 5,252 (397) Provider 47,539 48,080 541 89,056 631 294 (337) Governance 4,289 2,649 (1,640) 4,053

6,280 5,546 (734) Total 51,828 50,729 (1,099) 93,109 • Provider: unfavourable for March explained by delayed target laundry procurement savings across the

services; training underspend; Utilities underspend; Bad Debts offset by revenue; R&M Overspend; electricity saving; additional rent.

•

Interest and Capital Charge


267 100 167 Interest - Received 267 100 167 1,200

1,083 1,280 197 Interest Paid - Debt 1,083 1,280 197 13,450

816 1,180 364 Net Interest Paid 816 1,180 364 12,250 1,158 1,095 (63) Capital Charge 1,158 1,095 (63) 12,996

- Interest cost: CMDHB level of borrowings is lower than budgeted delivering a favourable interest cost variance for the month.

- Capital Charge: Timing of top up payments expected but not confirmed until March.

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Ratios Provider Arm (only) Costs to Revenue (%) last six months

Mar 15

Feb 15

Jan 15

Dec 14

Nov 14

Oct 14

Sep 14

Medical 21.08 20.29 20.85 20.81 20.05 21.03 20.61 Nursing 24.47 23.62 25.68 24.89 24.66 25.32 24.43 Allied 9.09 9.29 9.23 9.61 9.33 9.59 9.56 Support 2.94 2.86 3.11 3.13 2.96 3.03 2.88 Management 7.13 6.56 6.52 7.18 6.60 6.95 7.04 Personnel 64.72 62.62 65.39 65.62 63.60 65.92 64.52 Outsourced Pers. 2.18 1.83 1.85 2.10 2.01 1.73 2.01 Total Personnel 66.90 64.45 67.23 67.72 65.61 67.65 66.53 Outsourced Clinical Services 3.01 2.17 2.97 2.15 2.21 2.70 2.11

Outsourced Corp (hA) 3.59 3.69 3.70 3.61 3.72 3.60 3.71

Clinical Supplies 14.81 13.18 12.99 14.38 13.95 14.51 14.34 Infrastructure 13.91 13.31 13.77 13.21 13.74 14.42 14.06 Total 102.23 96.81 100.66 101.09 99.23 102.88 100.75

Provider cost as a percentage of revenue over the last four years and year to date

2015 YTD 2014 2013 2012 2011 Medical 20.6 20.7 21.2 20.5 20 Nursing 24.7 25.1 25.5 24.7 24.3 Allied Health 9.4 9.7 9.7 9.5 9.2 Support 3.0 2.9 2.7 2.7 2.6 Man/Admin 6.9 6.8 7.2 7.8 7.7 Personnel 64.6 65.2 66.3 65.2 64.0 Outsourced Personnel 1.9 1.8 1.8 1.7 1.9 Total Personnel 66.5 67.0 68.1 66.9 65.9 Outsourced Clinical Supplies 2.4 2.7 2.9 2.8 3.4 Outsourced Corporate 3.7 3.7 3.4 3.3 2.4 Clinical supplies 14.1 14.0 14.4 14.7 14.6 Infrastructure 13.8 13.0 12.4 13.2 13.8 Total 100.4 100.4 101.2 100.9 100.0 Depn 4.0 3.8 3.1 2.8 3.6 Interest 1.6 1.1 1.5 1.3 1.4 Capital Charge 1.8 1.7 1.7 1.7 1.7

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Balance Sheet Actual Budget Variance Opening

1st July 14 YTD

Movement Current Assets Petty Cash 10 10 - 10 - Bank 1 42,266 8,703 33,563 20,705 21,561 Trust 879 860 19 865 14 Prepayments 412 500 (88) 1,196 (784) Debtors 35,261 42,000 (6,739) 32,887 2,374 Inventory 2,064 4,490 (2,426) 1,434 630 Assets Held for Sale 12,503 12,503 - 12,503 - Total current Assets 93,395 69,066 24,329 69,600 23,795 Fixed Assets Land 110,020 62,430 47,590 110,020 - Buildings & Plant 616,244 735,155 (118,911) 710,607 (94,363) Investment Property 1,360 1,360 - 1,360 - Information Technology 2,745 2,975 (230) 4,145 (1,400) Information Software 323 880 (557) 4,391 (4,068) Motor Vehicles 3,932 4,548 (616) 4,292 (360) Total Cost 734,624 807,348 (72,724) 834,815 (100,191) Accum. Depreciation (144,482) (223,055) 78,573 (195,671) 51,189 Net Cost 590,142 584,293 5,849 639,144 (49,002) Work In-progress 3,662 10,000 (6,338) 1,851 1,811 Total Fixed Assets 593,804 594,293 (489) 640,995 (47,191) Investments (hA IT / HBL) 29,349 28,250 1,099 27,127 2,222 Total Assets 716,548 691,609 24,939 737,722 (21,174) Current Liabilities Creditors 88,889 95,606 (6,717) 91,817 (2,928) Income in Advance 1 15,474 1,300 14,174 3,192 12,282 GST and PAYE 8,159 5,000 3,159 6,761 1,398

Loans (Crown and HBL shared banking) 40,000 40,000 - 40,000 -

Payroll Accrual & Clearing 40,777 29,049 11,728 32,452 8,325 Employee Provisions 78,608 82,800 (4,192) 81,249 (2,641) Total Current Liabilities 271,907 253,755 18,152 255,471 16,436 Working Capital (178,512) (184,689) 6,177 (185,871) 7,359 Net Funds Employed $444,641 $437,854 $6,787 $482,251 $(37,610) Non-Current Liabilities Term Loans 227,600 227,600 - 227,600 -

Employee Provisions (non-current)

17,466 15,300 2,166 16,984 482

Trust and Special Funds 875 860 15 864 11 Insurance Liability-Non Current 1,337 1,300 37 1,337 - Total Non-Current Liabilities 247,278 245,060 2,218 246,785 493 Crown Equity Crown Equity 124,497 124,498 (1) 124,497 - Revaluation Reserve 134,373 127,443 6,930 175,031 (40,658) Retained Earnings – Provider (77,199) (76,553) (646) (74,511) (2,688)

Retained Earnings – Govern. (20,479) (16,644) (3,835) (18,151) (2,328)

Retained Earnings - Funder 36,171 34,050 2,121 28,600 7,571 Total Crown Equity 197,363 192,794 4,569 235,466 (38,103) Net Funds Employed $444,641 $437,854 $6,787 $482,251 $(37,610)

30


Commentary

Net borrowings: Long and short term debt less bank balance is $33.5m lower than budget. Stronger closing cash position, opening position $20.7m higher than budgeted and not drawing down on the final $30m facility for CSB.

Debtors: $6.7m lower than budget, $2.3m higher than June 14 due to timing of payments mainly by Crown organisations (MOH ACC and other DHB’s).

MOH Debtors $000

Total Current 30 day +

Invoiced 5,421 4,223 1,198

Accrued 345

Total 5,766

Accounts payable: $6.7m lower than budget and $2.9m lower than June 2014. Net Fixed Assets: Are $5.8m higher than budget. Due to the revaluation on Buildings there is movement between accumulated depreciation and Buildings Plant and Equipment of $72m. Also buildings were devalued by $40m in June 2014. Investments in Associates: Health Benefits Ltd, $ 7.7m for the FPSC project. Note: we will need to continue to ensure that these investments have underlying value through the future success of HBL or its successors. healthAlliance, $21.6m for ICT capital investment.

Payroll Accrual & Clearing: due to timing of payroll cut offs. Income in Advance There are no other significant issues regarding the Balance Sheet

31


Cash flow

Month YTD Actual Budget Variance Actual Budget Variance Cash flows from operating activities: Crown Revenue 125,406 121,058 4,348 1,097,054 1,088,567 8,487 Other 3,190 2,442 748 25,716 21,996 3,720 Interest rec. 267 100 167 2,453 900 1,553 Expenses Suppliers 62,704 77,612 14,908 676,303 661,748 (14,555) Employees 41,434 41,194 (240) 397,383 401,640 4,257 Interest paid 1,083 1,280 197 9,570 11,523 1,953 Capital charge Net cash from Operations 23,642 3,514 20,128 41,967 36,552 5,415

Fixed Assets (1,166) (1,968) 802 (18,181) (19,756) 1,575 Investments (hA & HBL) - (499) 499 (2,222) (3,766) 1,544

Restricted & Trust Funds 3 (1) 4 11 1 10

Net cash from Investing (1,163) (2,468) 1,305 (20,392) (23,521) 3,129

Debt - - - - - - Other non-current liability - - - - - -

Net cash from Financing - - - - - -

Net increase / (decrease) 22,479 1,046 21,433 21,575 13,031 8,544

Opening cash 2,205 8,527 (6,322) 21,580 (3,458) 25,038 Closing cash 24,684 9,573 15,111 43,155 9,573 33,582

Summary Month YTD Actual Budget Variance Actual Budget Variance Opening cash 20,676 8,527 12,149 21,580 (3,458) 25,038 Operating 23,642 3,514 20,128 41,967 36,552 5,415 Investing (1,163) (2,468) 1,305 (20,392) (23,521) 3,129 Financing - - - - - - Closing cash 43,155 9,573 33,582 43,155 9,573 33,582 Commentary:

Cash from Operations GST refund received YTD now ahead of budget by $5.4m Employee cost under budget but offset by $4.0m in outsourced personnel recorded for cash purposes as suppliers. Suppliers Outsourced Services $7.3m (includes personnel) Clinical Supplies $6.5m Non Clinical Supplies $1.1m

32


Treasury All term debt facilities are now through the MOH, with interest rates “locked in” at fixed rates. Working capital facilities remain with Westpac via Health Benefits Ltd ($64.4m). Both ASB/Commonwealth Bank ($10.0m) and Westpac ($10.0m) lease facilities are allowable by the Crown. Crown Debt

Drawn ($ millions)

Date of Advance

Maturity Interest rate Rate

5.0 16-Jul-12 15-Apr-17 3.32% Fixed, Semi-Annual 15.0 15-Jul-08 15-Dec-17 6.36% Fixed, Semi-Annual 10.0 28-Jan-09 15-Dec-17 4.41% Fixed, Semi-Annual

5.0 03-Feb-09 15-Dec-17 4.41% Fixed, Semi-Annual 5.0 20-May-09 15-Dec-17 5.65% Fixed, Semi-Annual

10.0 30-Apr-10 15-Dec-18 5.88% Fixed, Semi-Annual 20.0 20-Mar-13 15-Dec-18 3.30% Fixed, Semi-Annual

5.0 15-Nov-11 15-Mar-19 5.13% Fixed, Semi-Annual 13.0 27-Oct-09 15-Dec-19 6.10% Fixed, Semi-Annual

7.0 27-Oct-09 15-Dec-19 6.10% Fixed, Semi-Annual 5.0 20-Jun-12 15-May-21 3.45% Fixed, Semi-Annual

42.6 29-Jun-12 15-May-21 4.22% Fixed, Semi-Annual 20.0 18-Dec-12 15-May-21 3.56% Fixed, Semi-Annual 30.0 15-Apr-13 15-Apr-22 3.45% Fixed, Semi-Annual 30.0 20-Dec-13 15-Apr-23 4.91% Fixed, Semi-Annual

5.0 20-May-09 15-Apr-23 4.74% Fixed, Semi-Annual 40.0* 15-Apr-15 15-Apr-25 3.40% Fixed, Semi-Annual

$267.6 4.33% Weighted Average

* $40m of loans were rolled over for ten years at a rate of 3.40% on 15 April 2015.

33


Capital Report (Quarterly)

Greater than 200k

Project March 2015 Budget Spend to date Variance CCU / SDU Telemetry Monitoring System 1,638 3 1,635 MSC Theatre Upgrade 976 594 382 Refurb. Emergency Dept. for CT Scanner 759 67 692 Work Area Modifications Blood Bank / Haematology 515 544 (29) Wards 23 & 24 Ensuite Development 422 283 139 Digital Radiography Equip for Rm. 2 MSC 403 402 1 Equipment & LHI for MRI 350 157 193 Install 1MVA step up / step down 340 - 340 Kidz First Data Centre Ext – Yr. 3 Funding 311 - 311 Cardiac Ultrasound 282 205 77 Building 31 Refurbishment 280 262 18 Pharmacy Dispensing Records 263 - 263 Digital radiography Equipment for Room 1 MSC 260 259 1 Manukau Theatre Air Handler Unit Replacement 250 243 7 Replace Kidz First Roof 250 169 81 Tiaho Mai Cladding Sealing 250 32 218 ALBU Medical Air 250 140 110 Endoscopes x 9 250 250 - Galbraith Diesel Tank Replacement 240 13 227 Electronic Laboratory Orders 235 - 235 Power supply Upgrade phase 3, Galbraith 230 - 230 Steriliser Pre VAC for SSU at MSC 220 168 52 Computer replacement Program (Laptops) 204 - 204 Road Repairs 200 - 200 Replace Manukau Electric Reheat System in Air Con 200 167 33 Diesel Fuel Tank - Support Building 200 41 159 National Shared Care Plan 200 - 200

Total 9,978 3,999 5,979

34


FTE Reporting Provider Arm

Actual Budget Variance Comparative Actual Budget Variance

FTE FTE FTEVariance to Prev Mnth FTE FTE FTE

Medical Personnel 780 785 5 F 772 789 17 F

Nursing Personnel 2,602 2,529 (73) U 2,595 2,542 (53) U

Allied Health Personnel 1,107 1,122 15 F 1,084 1,125 41 F

Support Personnel 478 470 (8) U 478 474 (4) U

Management/Administration Personnel 807 828 21 F 777 828 52 F

Total (before Outsourced Personnel) 5,773 5,733 (40) U 5,706 5,758 52 F

Outsourced Medical 29 16 (13) U 24 16 (8) U

Outsourced Nursing 25 3 (21) U 14 3 (10) U

Outsourced Allied Health 3 5 2 F 4 5 1 F

Outsourced Support 11 7 (4) U 8 7 (1) U

Outsourced Mangement/Admin 43 37 (6) U 46 36 (10) U

Total Outsourced Personnel 110 69 (42) U 96 68 (28) U

Total Personnel 5,884 5,802 (82) U 5,802 5,826 24 F

FTE By Professional GroupMarch 2015

Month Year to Date

Total FTE (including outsourced) for March is 5,884 which is (82) FTE unfavourable to budget and 107 FTE lower than last month. The March FTE variance reflects high levels of vacancies (221 FTE) within the services due to the absence of available skilled workforce within some specialities. Cover has been provided in overtime 54FTE, bureau 55FTE, casuals 61FTE and external outsourcing 42FTE. Annual leave 65FTE, sick leave 37FTE and study leave 17FTE are partly offset by current year’s favourable budget phasing of 81FTE. CMH have employed an additional unbudgeted 45FTE which has been funded externally. Personnel Costs per FTE (Rolling average)

Mar 15

Feb 15

Jan 15

Dec 14

Nov 14

Oct 14

Sep 14

Aug 14

Medical 168,840 167,474 166,122 166,148 166,418 166,387 165,785 165,500

Nursing 77,494 77,248 76,784 76,853 77,041 77,028 76,879 76,537

Allied Health 70,724 70,823 70,776 70,790 70,538 70,320 70,283 70,062

Mgmt/Admin/Clerical 73,657 73,403 73,223 73,120 72,714 72,318 72,394 72,020

Support 50,366 50,444 50,351 50,570 50,259 50,206 50,369 50,207

The table below shows the Management Admin cap return to the MoH each month. Counties Manukau Only Mar 15 Feb 15 Jan 15 Dec 14 Nov 14 Oct 14 Accrued FTE (as per MOH template) 865.5 865.1 760.7 818.8 854.5 817.0 Annual Leave loading (76.3) (76.0) (75.9) (75.8) (75.6) (75.7) FTE’s on holiday 59.0 55.6 158.6 98.8 61.0 99.5 Payroll FTE’s 848.2 844.7 843.4 841.8 839.9 840.8 Contractors / Consultants (FTE equivalent) 11.0 11.0 11.0 11.0 11.0 11.0 Vacancy 8.3 11.8 13.1 14.7 16.6 15.7 Total 867.5 867.5 867.5 867.5 867.5 867.5 Number submitted Jan 09 for 31 Dec 08 867.5 867.5 867.5 867.5 867.5 867.5 Variance - - - - - -

35


Ko Awatea Ko Awatea delivers a comprehensive portfolio of organisational support functions including data analysis and support, Learning and Development, Workforce, Libraries, Quality Improvement, Research Office and research support, Digital services, clinical simulation, evaluation and knowledge management. Ko Awatea has created a very significant change capability, locally, regionally and nationally. Over 750 frontline staff have trained in the model for improvement and had experience in a change project. We have also delivered core leadership training to 80 emerging clinical and non-clinical leaders in our staff and in depth leadership training for 16 Counties emerging leaders. We are in discussions with the Leadership Institute led by Dr Lester Levy to develop a joint program for leadership for Doctors. Regionally and nationally we have led training of Improvement advisors in every DHB, and engaged them in an active network. Additionally we have built capability and capacity for change and improvement through regional and national campaigns (see below). Ko Awatea acts as an engine for transformation primarily locally, but also regionally and nationally, with a strategy of building ‘will’, harvesting and generating ‘ideas’, and efficiently “executing change”. The vision for Ko Awatea is “Learning globally, impacting locally” and our mission is to “improve together to ensure Counties has the best healthcare system in Australasia by December 2015.” Key themes of this transformation work currently include:

• Education and capacity/capability building • Collaborative improvement • Networking resources • Spreading organising skills and practice to support our community • Reshaping knowledge, data and decision support infrastructure to be fit for 21st century • Building rapid improvement skills and discipline into frontline • Building leadership • Community organising • Creating an education centre that provides a space conducive to learning • Building a workplace that reflects our community

In addition to these functions Ko Awatea is also charged with generating revenue for the District Health Board. We will highlight one key area of our activity in each report: This month we would like to focus on the work in our Development and Delivery team. Activity for the Development and Delivery team has ramped up this month with numerous abstracts for the Middle Eastern poster presentations have been submitted by the Beyond 20,000 Days collaborative teams for later in May. Notification of acceptance will be by mid April 2015. The Handle the Jandal campaign leadership team successfully recruited 43 new Pacific youth at the ASB Polyfest Pacific secondary school’s competition on 20 March to attend next month’s Handle the Jandal community organising training as part of the campaign strategy kick off tactic. The successful launch of all three Handle the Jandal sub-campaign leadership teams brings our existing snowflake team structure to 24 active Pacific youth leaders, meeting weekly across the three sub-campaigns of Brown Touch Down, The Big D and Reach Out. Safety in Practice hosted learning session 3 on Tuesday 17 March 2015 with 77 attendees. The evening’s agenda was positively received with the shared discussion sessions again proving very

36


popular for shared learning across the practice climate surveys, the primary care trigger tool and the three care bundle audits. On Wednesday 25 March, the Early Learning collaborative saw a successful third Learning Session for cohort 2 (and selected cohort 1). Good progress was shown by the teams involved and all centres have completed a storyboard to share across the collaborative. A new contract for the Whanganui Early Learning has been agreed to and planning for an engagement session is underway for Thursday 16 April 2015, with a view to gaining a full support contract to that provided for south Auckland. Negotiations continue for a Hawkes Bay collaborative. A meeting is planned for April to talk with the Ministry of Education Auckland Task Force Leader regarding a national approach. Speaker invitations have been received from Apex 2015 (Early Childhood Conference) and APAC 2015 conference to share the learning from our improvement work in Early Childhood Education. The ERAS data summary has been received from the Ministry of Health and an analysis has commenced with other DHBs on completing their sustainability plans. Planning for the final Learning Session is planned for May to celebrate their success. The School-based Health Services contract work has begun on the seven written case studies and one video case study on improvement work as selected by the Ministry of Health within the school based health services sector. The Wanganui Rise to the Challenge framework for the Older Adult work stream is progressing well and started using the Model for Improvement to test changes and are considering incorporating an underpinning co-design methodology. Although it has taken a lot longer than anticipated the Child and Youth work stream have got a project team and ‘buy in’ and believe that they will be able to progress the work. The current contract needs to be reviewed to include co-design and a possible increase in the number of on-site visits and ongoing support with the BTS methodology and measurement. The Faster Cancer Treatment Executive Leadership team were briefed on the progress (observations, maps and opportunities for improvement) and favourable comments about the mapping process was positive with how quickly the Development & Delivery team have got organised around this piece of work within a short timeframe. APAC FORUM UPDATE: The APAC Forum is progressing extremely well, in terms of programme, target and budget wise. The intensive and general programmes are fully set. The programme includes expert faculty leading longer intensive workshop type sessions, with an additional 45 general sessions led by a mix of expert faculty, invited and speaker abstract presentations. This year the programme includes a variety of presentations from health systems across Asia Pacific including Israel, Canada, the United States and United Kingdom, and complimented by New Zealand’s own home grown talent presenting on an array of innovative improvement work showing a better way for our delegates.

37


The APAC statistics are healthy and climbing at a steady pace daily with group bookings also received weekly APAC Registrations = 179 Intensive = 112 Dinner = 83 Represents 17% of Breakeven target

Represents 17% of Intensive Target

Represents 27% of Target no. for the Dinner

Marketing analysis indicates that the APAC Forum is attracting delegates who have not previously attended the forum via word of mouth and direct electronic mail. This has been a favourable outcome of previous Forums and also from the increased effort which has been placed on boosting the CRM (Customer Relationship Management database), the database has approximately 12,000 individuals from across Asia Pacific subscribed (an increase of 50% since the last APAC forum in Melbourne). To coincide with APAC, the Ko Awatea International Excellence in Health Improvement Awards 2015 have also been launched and is now available on both the APAC and Ko Awatea website entry submissions (http://apacforum.com/excellence-in-health-improvement-award/). Judging panels will be appointed within the next four-six weeks.

38

http://apacforum.com/excellence-in-health-improvement-award/


CM HEALTH INTEGRATION INITIATIVES: TURNING THE OIL TANKER SUMMARY

• CM Health has a number of initiatives underway that seek to reduce acute demand while improving patient experience and offering opportunity for more patients to be well at home.

• We perform well in primary and secondary prevention and long term condition management, resulting in lower acute medical bed day growth and reduced aged residential care admissions

• There is recognition that there is complexity both within the system and also within the various initiatives currently underway within CM Health.

• The focus now needs to be on consolidation and further development of initiatives to deliver a comprehensive and systematic response that is transparent across the healthcare continuum.

Good progress in prevention and long term conditions management There have been concerted efforts over the last five years to improve performance in target areas focused on prevention through primary and community services. CM Health consistently performs well on national health targets and performance against all five prevention indicators is trending upward. We also achieve above target on some secondary prevention measures, particularly CVD triple therapy (85% compared to 60% target).

Counties Manukau Health continues to focus on wider determinants which impact on health status and, together with our partners, has insulated 4,750 homes since July 2011 through the Warm up Counties programme. The DHB continues to receive high numbers of referrals for this intervention. A 2011 evaluation of a similar programme in Counties found an 11-32% reduction in hospital admissions for occupants of 3,400 homes insulated through the programme.

CM Health consistently

performs well in health targets

0

10

20

30

40

50

60

70

80

90

100

Jan-11 Jan-12 Jan-13 Jan-14 Jan-15

Popu

latio

n pe

rcen

tage

Imms 8

Imms 24

More heart anddiabetes checks

Smoking brief advice

Smoking cessation

39


The Mana Kidz programme has made excellent progress in providing access to primary health care for children in school years one to eight who do not currently access healthcare adequately given their level of need. The programme seeks to reduce the incidence of rheumatic fever in South Auckland as well as the hospital admission rate for skin infection. The increased presence of registered nurses and school health teams, with delegated prescribing for antibiotic treatments as required, has demonstrably increased access to primary care services for RF and skin infections. There are approximately 24,000 children across 61 schools, consented to be part of the Mana Kidz programme at any one point in time. Early indications from an ongoing cross-sectional study showed a marked statistically significant reduction using multivariable analysis in pharyngeal GAS burden in a population sample of Year 1-8 students in three Mana Kidz schools between May 2013 (before the commencement of the programme in those schools) and May 2014. Cross-sectional studies of pharyngeal GAS are ongoing through the University of Auckland in CMDHB and other DHBs. An analysis of changes from May 2013 (n=1,299) to May 2014 (n=1,751) in Counties Manukau has been performed. Raw positive pharyngeal GAS rates were 25% in 2013 and 14% in 2014. This was consistent within the three schools surveyed, with changes in rates for individual schools being 23% to 12%, 24% to 14%, and 32% to 15%. Analysis was performed to account for school clustering, and for age and gender differences. There was evidence of a difference in the rates of pharyngeal GAS between 2013 and 2014 (p=0.01) with the adjusted estimates of rates of 26% (95%CI 20-34%) and 14% (11-18%) for 2013 and 2014 respectively. The relative risk (95%CI) of being pharyngeal GAS positive in 2013 compared to 2014 was 1.8 (1.3-2.3). Interpretation of this data should be cautious as this change has only been measured at two time points, so a year with particularly low rates of circulating Strep A cannot be ruled out.

GAS+ swabs, Feb 2013 – Sep 2014

4,750 houses insulated

through Warm Up Counties

191,423 throat swabs through

Mana Kidz

40


Health literacy of children and parents/whaanau is improving in Mana Kidz schools with increased knowledge in relation to sore throats, rheumatic fever and its prevention, the importance of adhering to medication, as well as skin infections and their treatment. Mana Kidz teams have treated 17,593 skin infections (note “treatment” includes cleaning and covering not solely antibiotic treatment). District level hospitalisation data for 2013/14indicates a reduction in admission rates for skin infections in children across all ethnicity groups and although it is not possible to directly attribute to the Mana Kidz programme the reduction is temporally related to the introduction of the school based programme. The overall acute rheumatic fever rate has dropped from 14/100,000 population to 10/100,000 since the Mana Kidz programme was started in 2012.

Admissions/1,000 for skin infection 5-12 years, by ethnicity

Secondary prevention and long term condition management Gains made through the Beyond 20,000 Days Campaign have resulted in savings and achievements for several hospital and community based collaborative teams.

• Safer Medical Admission Review Team – prevention of medication errors - making 2,200 contributions to patient care and preventing patient harm in 900 cases, of which 206 errors had potential to cause moderate to severe harm

• Kia Kaha – 25% reduction in hospital and GP utilisation for patients enrolled on the programme through introduction of primary care peer support specialist role to engage hard to reach patients

• Supporting Life after Stroke – average reduction of length of stay of 14.9 days; 99.5% patient and carer satisfaction

• Feet for Life – reduction in amputations by 30%, reduced DNA from 275 to 6, reduced hospitalisations and waiting time for diabetic patients on dialysis to see a podiatrist. Increase in patient satisfaction, quality of life and self-management skills.

Through these initiatives, patients are enabled to manage their own health and feel in control of their condition.

The Very High Intensive User programme (VHIU) is a nurse led but multi-disciplinary service which link the hospital to GP/community care and are part of the

Reduction in hospitalisations

for skin infections for all ethnicity groups within 5-12yrs

Acute rheumatic

fever rate dropped from 14/100,000 to

10/100,000 since Mana Kidz

41


locality/integration initiatives. These teams enhance and co-ordinate discharge from hospital returning care to GP/Community services, and have been shown to reduce length of stay and reduce readmissions. Effective long term condition management requires activated clinicians and activated patients working collaboratively. In order to make significant gains in terms of demand management for patients with long term conditions the DHB needs to both activate clinicians (via the ARI programme) and also activate patients – to embed behavioural changes that see patients feel more in control of their condition. Ko Awatea is currently supporting this through the Manaaki Hauora – Supporting Wellness campaign. The aim of this campaign is to provide self management support for 50,000 people living with long term conditions across Counties Manukau by 1 December 2016. This campaign will test and implement the changes through the Breakthrough Series Collaborative methodology which builds on previous improvements implemented in the Beyond 20,000 Days and 20,000 Days campaigns. Over 100 people attended each of the two learning sessions held to date and over the last three months 22 collaborative teams have been established from across CM Health which include health professionals and community people from across the mental health, primary care, community and hospital continuum. The teams are establishing their aims that will contribute to the Campaign aim, collecting baseline data and forming their teams. The At Risk Individuals Programme (ARI) provides a flexible, patient centred model of care to support planned, proactive care for complex patients with long term conditions. To date 92 practices within Counties Manukau have adopted the ARI model of care with over 7,000 patients enrolled within the programme. Implementation of ARI has seen a shift in the way primary care teams are able to support their more complex patients, with increased nursing time dedicated to the co-ordination of care, goal based care planning and increased sharing of information between care team members across the sector. The introduction of multi-disciplinary team case conferencing (MDTs) within each of the localities has provided the opportunity for input from across primary, community, specialist services and social services to support care for complex patients with long term conditions and psycho-social factors impacting on their health status (see appendix B). Clusters of general practices are working more closely with their home healthcare teams as ‘enhanced general practice teams’ to provide more holistic and efficient pathways of care for patients. The uptake of ARI from practices is increasing rapidly – and the way in which practices have adopted the philosophy of care (rather than simply accessing a funding source) indicates that practices are ready to adopt new models of care in line with the SWIFT programme of work.

Prevention of 206 medication

errors 30% reduction in amputations

through Feet for Life

VHIU reduces hospital use by

up to 30% Whaanau will be

inspired, enabled, resourced to be

in control of their health

Self management

support for 50,000 people living with long term conditions across Counties Manukau by 1

December 2016

42


Early evaluation of the ARI model of care amongst five early adopter practices shows a statistically and quantifiably significant impact on early readmissions as a result of identification and alternative General Practice-based responses to patients that were identified as being of moderate to high risk of readmission utilising hospital based data. This independent evaluation from Sapere Research Group suggests conservative estimates of 500 inpatient admissions avoided per annum, and indicates that the much wider and large scale implementation now underway will likely produce additional benefits. Efficiencies and improved patient journeys are also likely to be seen more broadly, as feedback from patients and practice nurses indicates that ARI interventions, particularly care co-ordination and care planning, are demonstrating significant benefit. The ARI programme is based on international evidence suggesting that proactive care planning and self-management support reduces acute hospital bed days by between 15-35%.

Over 7,000 patients

enrolled in ARI

MDTs are underway within all 4 localities

43


We are utilising pathways to support the consistent implementation of evidence based care… In December 2014 the Northern region purchased the HealthPathways Platform for the publishing of regional agreed pathways. This gives access to the clinical content of over 500 pathways (of which 54 have been regionally agreed by primary and secondary clinicians). Utilisation enables a consistent approach which will identify those patients at high risk who can be best managed within secondary care and those who would be best treated in primary care. This means the patient gets the right treatment option at the right time, improving patient wellness and increasing system efficiencies. The Dynamic Pathways tool now has 9 pathways (iron deficiency, Diabetes and Atrial Fibrillation added) available to the 86 already trained General Practitioners. This has seen 466 patients across the Northern region being managed through these pathways with some patients on more than one pathway. Historically, patients coming through the general medical, Acute Care for the Elderly and/or rehab pathway have longer lengths of stay than others in the hospital. The Acute Care for the Elderly pathway (ACE) provides an efficient and clinically effective pathway for the >85 year old age group moving through hospital, showing a reduced length of stay from 25 to 20 days, a decrease in readmission from 6% to 4%, and a decrease in step down of care from 14% to 8%. There are, however, still opportunities to improve the community transition and handover for this cohort of patients. Patients under 85 years would benefit from input from an ACE type model which will be realised through the introduction of the reablement model for community services. There is work underway to integrate community health teams… All four locality teams have redesigned the way they work to strengthen relationships with primary care – supporting the development of enhanced primary care teams and reviewing their processes, tasks and relationships with a view to re-engineering these to support equity of service access, improved patient outcomes and to create team capacity. Common themes emerged around the patient journey (intake, assessment, care planning, intervention and transition); workforce development (capability and capacity and integration); and health information technology. The Papakura Home Health Care Team was the first to undertake this process and have made the following progress:

• Intake process – Patients no longer put on multiple waiting lists - the first best responder sees the patient and co-ordinates other input as needed.

• Changing the culture of declines – referrals indicate a need so who can help with that? Patients are no longer declined without an alternative option.

• Review and consolidation of assessment processes and an electronic form developed so patients do not have multiple assessments.

The development of this interdisciplinary way of working introduces a structured process to develop trust between disciplines to share roles and tasks. All team members are trained in the use of eShared care and how to interpret and access interRAI assessments – improving the ability to share information between care team members.

466 patients managed through dynamic

pathways Patients on the ACE pathway have a 20%

reduction in LOS

44


Patients from the Manukau locality are overrepresented in EC presentations (44% of presentations compared to 39% of the population) and dedicated initiatives are underway to address this. Locality care coordinators for both Manukau and Mangere/Otara localities have been implemented to work closely with the APAC and VHIU teams. These roles identify those patients who would benefit from an ARI enrolment, and liaise with the general practice to facilitate timely enrolment, or where this is not possible; identify existing DHB teams to provide short term case management for the patient until they can be transitioned to the general practice teams. The NASC teams have been integrated with home health care teams and are working to develop a more interdisciplinary-based approach to meeting patient’s support needs. NASC team members are encouraged to use their discipline skills when working with patients, for example occupational therapists employed as NASC complete the OT intervention as well as the NASC function. It is of note that from Sept/Oct 2013 there has been a significant reduction in rest home admissions.

Localities as an incubator of integration Many of the programmes and initiatives outlined above began as small scale initiatives/pilot in a locality, including ARI (Mangere/Otara) and Community Health Integration (Manukau and Franklin). The most prolific locality for innovative pilots which can be scaled up is Eastern where a range of initiatives are underway, including:

• Musculoskeletal - Falls prevention; Osteoarthritis early intervention; Joint replacement alternative pathway; fracture liaison.

• Respiratory – spirometry; post discharge contact; COPD self-management and blue cards;

• Integrated community health – admission avoidance/rapid response co-ordinator; supported discharge; frailty; youth health; clinical advisory pharmacists

• Alternative (technology enabled) care – dynamic pathways; virtual; consults; telemonitoring; online self-management programmes; social marketing campaign

Redesign of HHC teams will result

in less cars in the driveway

45


1 MacLeod et al (2014). People identified with selected long term conditions in CM Health in 2013.

Although patient numbers are small, many of these initiatives can potentially be scaled as an alternative to increased hospital volumes e.g. musculoskeletal

Acute Medical Bed Days have been lower than expected since 2011. Further breakdown and commentary can be found within appendix A. Next steps and areas for accelerated development Expansion of the At Risk Model of Care Work is underway to develop the At Risk model of care to provide a greater focus on complex families and households and facilitate the improved alignment of community-based staff to enhanced general practice teams. There is also great opportunity to work more holistically with other sectors to provide more planned, proactive care for these families and a more co-ordinated response to support wellness within whaanau. In order to achieve this we need to better understand the motivations for our communities, look more broadly at the workforce able to support this and remove barriers to engaging with primary healthcare. In conjunction with our alliance partners an action plan has been developed – outlining specific gains that can be made within mental health and addictions, children and youth, and palliative care. This will be implemented within the next 12 months. To support the broadening of the programme, and the focus on quality care planning, a quality and training plan is being developed. Improved care for diabetics There are over 38,000 people with diabetes in Counties Manukau1, representing the highest population of diabetics in New Zealand. Performance in many measured outcomes is favourable when compared nationally (HBA1c monitoring, renal screening, prescribing of metformin) however there are areas where there is room for improvement – namely retinal screening rates and insulin prescribing.

46


In order to improve these outcomes work is underway to redesign the community approach to diabetes, specifically including how the ARI programme can be expanded to incorporate the current DCIP programme – particularly poorly controlled diabetics with an HBA1c >100 and ensuring newly diagnosed diabetics receive early support and education in order to delay the need for medication. As the ARI programme matures into year two there will be greater emphasis on the outcome indicators and the opportunity to attribute funding to achievement of diabetes indicators as funded outcome measures. The Manukau Locality clinical team have developed an initiative to work with PHO’s to proactively identify patients with HBA1C higher than 100 and support them to transition onto ARI and work with the practice teams to review their diabetes management. Mainstream Mana Kidz into an efficient school/primary based model of care The Mana Kidz programme is currently being delivered in a third of Primary and Intermediate schools in Counties Manukau. Kidz First Community is the largest provider of the school based service with almost half of the schools being serviced by Kidz First Community Public Health Nurses. Approximately 24,000 children (>95% of whom are Maaori and Pacific) aged 5-12 years have access to the Mana Kidz programme or throat swabbing service meaning that about 64% of Maaori and Pacific children, in this age group living in Counties Manukau, have access to a school based health service. One of the major issues with the current programme is the lack of service within the remaining two thirds of schools who do not qualify for the Mana Kidz programme. These schools are currently being provided with a very limited service which is restricted to Immunisations, Child Protection and general health referrals. Determining whether this is a school based health service model or an ARF prevention model is also an important consideration regarding configuration of services. Over the next nine months we will review the school based health service model of care across Primary, Intermediate and Secondary schools. The new model of care will provide a platform for the integration of programmes being lead through Primary Care, leverage off collaborative intersectorial partnerships, and avoid duplication in service delivery. Community Health Service Integration A programme of work has been established to progress the integration of community-based services. 1. Reablement Workstream

The scope of this workstream focuses on the development of locality community teams to assist people to be as well as they can be at home (“reablement”), particularly during and after an acute deterioration. This includes continuation of work commenced to refocus district nursing, allied health and NASC teams to work effectively within the locality model. We will develop ‘ReaCH’ services within the locality community teams that include early supported discharge, admission avoidance and the reablement approach across the continuum. In order to create capacity for rapid response within existing community teams work is underway to identify services such as the wound care component of the current district nursing role and scoping opportunities for these

We are

expanding to ARI model of care to more specifically

support complex families

Half of all Indian and Pacific aged 65-74yrs people

in CM Health have diabetes

We will mainstream Mana Kidz

47


services to be delivered differently. We are currently investigating aspects of this work programme which can be accelerated to support winter demand and have reached agreement to utilise the capability of POAC to co-ordinate short term supports for people being discharged from hospital – utilising DHB short term personal health contracts.

2. Restorative Workstream - Re-design and procurement of contracted long term home and community support services under a restorative services model. A review and procurement of currently contracted home and community support services is required to align care delivery with the future integration and service delivery approach.

3. Community Central Community Central will be one point of contact and referral for all, enabled by a technology solution that supports a ‘first response’ request for services, triaging, allocating resources, capacity planning and telehealth capability. This is centrally organised, but locality driven. An initial workshop has been held with project SWIFT team members and key stakeholders to develop the concept and scope of community central. A phased introduction of this functionality will be required – starting with the merging of the intake function for needs assessment for older people and all home health care referrals which will enable efficiencies within the process for patients, release capacity within the team and will move to an approach of one discipline or service response assigned and then a feedback process via MDT’s to plan and co-ordinate from there. This stops patients going onto multiple waitlists. Work is underway to scope possibilities for a winter rapid response approach that can be used to test systems and processes to inform the Reablement Workstream and also seeks to utilise a different approach to co-ordination which in turn tests processes for community central.

There are a number of initiatives underway to support the ‘front door’ of the hospital… There are currently a number of initiatives underway to provide timely community response to EC and Medical Assessment Unit. Eastern and Franklin localities have established rapid response services in place, which facilitates early supported discharge of patients and also contributes to admission avoidance. In addition, work is underway to improve the identification of patients at risk or readmission. The combined predictive risk algorithm has been developed to analyse primary and secondary data to quantify the risk of readmission for patients. ProCare are currently rolling this tool out to their member practices to aid in the identification of patients for enrolment within the ARI programme. This score will also be made available on the patient summary page within Concerto and the daily handover reports, enabling secondary clinicians to also identify those patients who may benefit from a more co-ordinated primary and community response.

Development of

reablement focus within

locality community

teams

48


Community Hubs To better support the Healthcare Home model and enable delivery of intermediate care services in each Locality, the plan is to work with private sector parties to establish Community Health Hubs. These hubs will enable the shifting of services ‘closer to home’, and provide primary and community care with a ‘centre of gravity’ within each locality. CM Health will contract with Community Hubs to deliver a suite of services that are beyond the typical scope of general practice and require specialised facilities and/or equipment and/or volume to be viable. The work currently being undertaken by Sapere will inform the scope of services for Community Health Hubs. Likely services include:

• Extended accident and medical services, including observation and short stay • Rehabilitation and diagnostic services • Minor procedures & SMO/GP with a special interest consultation clinics

These services will interface with the Locality Reablement Teams, to provide specialised nursing and allied health expertise and care planning. The aim of the Community Health Hub is to prevent unnecessary ED visits and hospital admissions and enable communities to access services close to home. The Integrated Infrastructure Planning Group will be shortly considering Community Health Hub development and associated investment requirements, within the context of CM Health’s overall investment plan. Subject to Ministerial approval, the Botany Community Health Hub is expected to be operational from 2017. A procurement process for Community Health Hubs in other Localities is likely to commence in early 2016. It is expected that the private sector will require long term service contracts to underpin their investment in facilities/services. A balanced scorecard to track progress It is proposed that selected indicators from this report such as:

• ARI enrolments, • HbA1C • Resthome admissions • Acute medical bed days • Readmission rates • Acute rheumatic fever rates.

This will provide a sense of progress at a service delivery level, closing the gap between specific project measures such as those captured through 20,000 bed days and the very high level indicators such as those reported through the system level measures.

Community hubs will enable communities to

access care closer to home

A balanced scorecard should be developed

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Appendix A: Current indications of system demand, success and challenges Across the system there is various monitoring happening at a project level in relation to activities that are working to provide care closer to home and impact hospital demand. At a higher level, the System Level Measures seek to evaluate the overall quality of our health system and progress toward and achievement of the Triple Aim. The following graphs try to give a picture in between those levels, using data that is accessible, of the demand for hospital services which can reflect actions across the system. In this context, system supply is being used as a proxy for demand (which is also different from ‘need’ and this paper does not seek to quantify need and unmet need). In considering system demand, it is important to accept that this is an ‘imperfect science’ in which attribution is very challenging. Hence this paper does not attempt attribution but tries to contribute to understanding of demand across the system and to consider where there might be opportunities to further impact demand, and ultimately health outcomes. There are limitations with the data, both in what is not collected but also what is collected but doesn’t necessarily count what people think it does (e.g. a medical discharge is a discharge from a medical team not a medical bed in a ward; a bed day means the person was in the hospital facility at the time of the midnight Census, not that they spent 24 hours or more in hospital). Also improved data capture over time can distort trend patterns (e.g. this is why supply of allied health and community services is not shown). It is also important to try to understand growth in the context of the growing and changing population CM Health serves. The analyses shown below draw on previous work, projecting ‘expected’ growth by

• using calendar years 2010-2011 utilisation as base, stratified by ethnicity (Maaori, Pacific, Asian, NZ E/O) and age (0-14, 15-44, 45-74, 75 years & over).

• Projecting this to the current time and a further 5 years using Stats NZ estimated and projected population growth for the respective age/ethnicity cohorts.

This assumes people continue to be admitted at the same rate as in 2010-2011 with the same length of stay, and same complexity for each age and ethnic group, and assumes no capacity constraints. The graphs show the picture for children and adults, and medicine and surgery separately. In addition to health system actions and demographic growth, there are many other factors that influence demand growth. Capacity constraint in the hospital is already reducing supply and as a result demand is truncated. Historical analysis has documented growth in excess of demographic growth (in parallel with facility growth). Future non-demographic growth drivers include:

• advancing technology, • change in disease prevalence, • people’s expectations (via clinicians / advocacy groups/ internet)

Potential mitigators of growth include:

• fall in risk factors (e.g. smoking), • specific interventions (e.g. immunisation), • well defined alternative care pathways

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Other factors that may influence demand from year to year include: • Infectious disease outbreaks • Weather patterns • Migration patterns not accounted for by Stats NZ

The graphs below demonstrate the ‘front door pressure’ being experienced, with the number of ED presentations growing in excess of what might be expected from demographic growth and change. The picture for children and adults is similar for both age groups, both being 6% above ‘expected’ totals in 2014 (an extra 3,850 presentations for adults and 1,200 extra for children). People have tended to think of ‘front door’ demand across the system operating as a ‘see-saw’ -if busy in one area, probably quiet in another. However anecdote says all parts of the system tend to be busy at the same time (primary care, A&M centres, ED) but at present we don’t have access to the data to present that picture.

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Adult acute medical discharges have grown slightly in excess of demographic growth while growth in corresponding bed days had slowed but from 2013 appears to have resumed a trajectory parallel to but lower that ‘expected’ growth based on demographic growth and change, this may be a result of better discharge processes.

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Medical acute discharges for children aged 0-14 are growing in excess of what might be ‘expected’ based on projecting historic utilisation while apart from 2012, bed days are tracking at about what might be ‘expected’. Population growth was estimated to be just 1.1% between 2010 and 2014 for 0-14 year olds, yet acute medical discharges for this aged group grew by 11%.

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Adult acute surgical discharges and bed days are tracking fairly much as projected based on historical patterns and population growth and change.

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Acute surgical discharges and bed days for children have decreased in the last two years and are tracking lower that what might be ‘expected’, although numbers are relataively small. Just under 40% of discharges for this group are from ADHB; the decrease applies to discharges from both ADHB and MMH.

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There has been a particular focus on COPD, with significant work carried out within the Eastern locality. A recent paper published in the NZMJ2 shows that Counties Manukau Health has the lowest ALOS and second lowest 30 day readmission rate for COPD when compared to all other DHBs nationally. The paper draws conclusions regarding the effectiveness of community interventions that are targeted to high risk individuals in improving outcomes and economic burden of COPD.

Admissions, admission rates, 30 day readmissions, average length of stay and budget impact by DHB in FY2012/13.

2 Milne, R.J. & Beasley, R. (2015). Hospital admissions for chronic obstructive pulmonary disease in New Zealand. NZMJ 30 january 2015, Vol 128 No 1408.

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Appendix B: MDT structure for Otara/Mangere

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Counties Manukau Health Board Meeting Resolution to Exclude the Public

Resolution:

That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000:

The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

1. Minutes of 25 March 2015 That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)]

Confirmation of Minutes For reasons given in the previous meeting.

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

For reasons given in the previous meeting.

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

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

4. Annual Plan & Budget Presentation

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


5. 2015/16 Draft Annual & Maaori Health Plans

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section

Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities.

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9(3)(g)(i))of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)]

[Official Information Act 1982 S9(2)(i)]

6. Draft Northern Region Health Plan



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


8. Health Targets 2014/15 Quarter 1 Progress Report



9. Integrated Community Service Hubs Planning Update



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


11. Government Rules of Sourcing

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which

Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to

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good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)]

carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S9(2)(i)]

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


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


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