Board Meeting. Wednesday, 18 February :30pm. A+ Trust Room Clinical Education Centre Level 5 Auckland City Hospital Grafton

Transcription

1 Board Meeting Wednesday, 18 February :30pm A+ Trust Room Clinical Education Centre Level 5 Auckland City Hospital Grafton Published 12 February

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3 Agenda Meeting of the Board 18 February 2015 Venue: A+ Trust Room, Clinical Education Centre Level 5, Auckland City Hospital, Grafton Time: 2:30pm Board Members Dr Lester Levy (Chair) Jo Agnew Peter Aitken Doug Armstrong Judith Bassett Dr Chris Chambers Dr Lee Mathias (Deputy Chair) Robyn Northey Morris Pita Gwen Tepania-Palmer Ian Ward ADHB Executive Leadership Ailsa Claire Chief Executive Officer Simon Bowen Director of Health Outcomes AHB/WDHB Margaret Dotchin Chief Nursing Officer Christine Etherington Director of Strategic Human Resources Naida Glavish Chief Advisor Tikanga and General Manager Māori Health ADHB/WDHB Dr Debbie Holdsworth Director of Funding ADHB/WDHB Dr Andrew Old Chief of Strategy, Participation and Improvement Rosalie Percival Chief Financial Officer Linda Wakeling Chief of Intelligence and Informatics Sue Waters Chief Health Professions Officer Dr Margaret Wilsher Chief Medical Officer ADHB Senior Staff Andrew Davies Mark Fenwick Bruce Levi Auxilia Nyangoni Marlene Skelton Gilbert Wong Performance Director Adult Health Communications Manager General Manager Pacific Health Deputy Chief Financial Officer Corporate Business Manager Director Communications (Other staff members who attend for a particular item are named at the start of the respective minute) Apologies Members: Apologies Staff: Morris Pita Margaret Wilsher Register of Interests Does any member have an interest they have not previously disclosed? Does any member have an interest that may give rise to a conflict of interest with a matter on the agenda? Karakia Agenda Please note that agenda times are estimates only ATTENDANCE AND APOLOGIES 2. CONFLICTS OF INTEREST CONFIRMATION OF MINUTES 10 DECEMBER 2014 Auckland District Health Board Board Meeting 18 February

4 4. ACTION POINTS 10 DECEMBER CHAIRMAN S REPORT - VERBAL CHIEF EXECUTIVE S REPORT 7. LIFT THE HEALTH OF PEOPLE IN AUCKLAND CITY Health Needs Assessment 7.2 CPHAC Recommendations - Nil 8 LIVE WITHIN OUR MEANS Funder Report 9 GENERAL BUSINESS Strategy and Values for ADHB Waitemata DHB and Auckland DHB Maori Workforce Strategy Crown Directive April 2014 Rules of Sourcing RESOLUTION TO EXCLUDE THE PUBLIC Next Meeting: Wednesday, 01 April 2015 at 2:30pm A+ Trust Room, Clinical Education Centre, Level 5, Auckland City Hospital, Grafton Hei Oranga Tika Mo Te Iti Me Te Rahi Healthy Communities, Quality Healthcare Auckland District Health Board Board Meeting 18 February

5 1 Attendance at Auckland District Health Board Meetings Attendees 11 December February March April May June August September October December 2014 Dr Lester Levy (Chair) Jo Agnew Peter Aitken Doug Armstrong Judith Bassett 1 1 x 1 1 x Dr Chris Chambers Dr Lee Mathias (Deputy Chair) x 1 1 Robyn Northey x Morris Pita x Gwen Tepania-Palmer 1 1 x Ian Ward x x absent # leave of absence Auckland District Health Board Meeting of the Board 17 September

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7 2 Conflicts of Interest Quick Reference Guide Under the NZ Public Health and Disability Act Board members must disclose all interests, and the full nature of the interest, as soon as practicable after the relevant facts come to his or her knowledge. An interest can include, but is not limited to: Being a party to, or deriving a financial benefit from, a transaction Having a financial interest in another party to a transaction Being a director, member, official, partner or trustee of another party to a transaction or a person who will or may derive a financial benefit from it Being the parent, child, spouse or partner of another person or party who will or may derive a financial benefit from the transaction Being otherwise directly or indirectly interested in the transaction If the interest is so remote or insignificant that it cannot reasonably be regarded as likely to influence the Board member in carrying out duties under the Act then he or she may not be interested in the transaction. The Board should generally make this decision, not the individual concerned. Gifts and offers of hospitality or sponsorship could be perceived as influencing your activities as a Board member and are unlikely to be appropriate in any circumstances. When a disclosure is made the Board member concerned must not take part in any deliberation or decision of the Board relating to the transaction, or be included in any quorum or decision, or sign any documents related to the transaction. The disclosure must be recorded in the minutes of the next meeting and entered into the interests register. The member can take part in deliberations (but not any decision) of the Board in relation to the transaction if the majority of other members of the Board permit the member to do so. If this occurs, the minutes of the meeting must record the permission given and the majority s reasons for doing so, along with what the member said during any deliberation of the Board relating to the transaction concerned. IMPORTANT If in doubt declare. Ensure the full nature of the interest is disclosed, not just the existence of the interest. This sheet provides summary information only - refer to clause 36, schedule 3 of the New Zealand Public Health and Disability Act 2000 and the Crown Entities Act 2004 for further information (available at and Managing Conflicts of Interest Guidance for Public Entities ( ). Auckland District Health Board Board Meeting 18 February

8 Register of Interests Board Member Interest Latest Disclosure Lester LEVY (Chair) Jo AGNEW Peter AITKEN Doug ARMSTRONG Judith BASSETT Chris CHAMBERS Lee MATHIAS Chairman - Waitemata District Health Board (includes Trustee Well Foundation - ex-officio member as Waitemata DHB Chairman) Chairman - Auckland Transport Independent Chairman - Tonkin and Taylor Ltd (non-shareholder) Director - Orion Health (includes Director Orion Health Corporate Trustee Ltd) Professor (Adjunct) of Leadership - University of Auckland Business School Head of the New Zealand Leadership Institute University of Auckland Director and sole shareholder Brilliant Solutions Ltd (private company) Director and shareholder Mentum Ltd (private company, inactive, nontrading, holds no investments. Sole director, family trust as a shareholder) Director and shareholder LLC Ltd (private company, inactive, non-trading, holds no investments. Sole director, family trust as shareholder) Trustee Levy Family Trust Trustee Brilliant Street Trust Professional Teaching Fellow - School of Nursing, Auckland University Appointed trustee Starship Foundation Casual Staff Nurse - ADHB Pharmacy Locum - Pharmacist Shareholder/ Director, Consultant - Pharmacy Care Systems Ltd Shareholder/ Director - Pharmacy New Lynn Medical Centre Fisher and Paykel Healthcare Ryman Healthcare Daughter is a partner Russell McVeagh Lawyers Fisher and Paykel Healthcare Westpac Banking Corporation Employee - ADHB Wife is an employee - Starship Trauma Service Clinical Senior Lecturer in Anaesthesia - Auckland Clinical School Member Association of Salaried Medical Specialists Associate - Epsom Anaesthetic Group Shareholder - Ormiston Surgical Chair - Counties Manukau Health Deputy Chair - Auckland District Health Board Chair - Health Promotion Agency Chair - Unitec. Director - Health Innovation Hub Director - Health Alliance Limited Director - Health Alliance (FPSC) Limited Chair - IAC IP Limited Director/shareholder - Pictor Limited Director - Lee Mathias Limited Director - John Seabrook Holdings Limited Advisory Chair - Company of Women Limited Trustee - Lee Mathias Family Trust Trustee - Awamoana Family Trust Trustee - Mathias Martin Family Trust Auckland District Health Board Board Meeting 18 February

9 2 Robyn NORTHEY Morris PITA Gwen TEPANIA- PALMER Ian WARD Self-employed Contractor - Project management, service review, planning etc. Board Member - Hope Foundation Trustee - A+ Charitable Trust Member Waitemata District Health Board Shareholder Turuki Pharmacy, South Auckland Owner and operator with wife - Shea Pita & Associates Ltd Wife is member of Northland District Health Board Wife provides advice to Maori health organisations Board Member - Waitemata District Health Board Board Member - Manaia PHO Chair - Ngati Hine Health Trust Committee Member - Te Taitokerau Whanau Ora Committee Member - Lottery Northland Community Committee Member - Health Quality and Safety commission Board Member - NZ Blood Service Director and Shareholder C4 Consulting Ltd CEO Auckland Energy Consumer Trust Shareholder Vector Group Auckland District Health Board Board Meeting 18 February

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11 Minutes Meeting of the Board 10 December Minutes of the Auckland District Health Board meeting held on Wednesday, 10 December 2014 in the A+ Trust Room, Clinical Education Centre, Level 5, Auckland City Hospital, Grafton commencing at 2:30pm Board Members Present Dr Lester Levy (Chair) Jo Agnew Peter Aitken Doug Armstrong Judith Bassett Dr Chris Chambers Dr Lee Mathias (Deputy Chair) Robyn Northey Morris Pita Gwen Tepania-Palmer Ian Ward (Present from Item 10.1) ADHB Executive Leadership Team Present Ailsa Claire Chief Executive Officer Simon Bowen Director of Health Outcomes AHB/WDHB Margaret Dotchin Chief Nursing Officer Dr Debbie Holdsworth Director of Funding ADHB/WDHB Dr Andrew Old Chief of Strategy, Participation and Improvement Rosalie Percival Chief Financial Officer Linda Wakeling Chief of Intelligence and Informatics Sue Waters Chief Health Professions Officer Dr Margaret Wilsher Chief Medical Officer ADHB Senior Staff Present Bruce Levi General Manager Pacific Health Marlene Skelton Corporate Business Manager Gilbert Wong Director Communications (Other staff members who attend for a particular item are named at the start of the minute for that item) 1. APOLOGIES That the apologies of Fionnagh Dougan, Director Provider Services, Margaret Dotchin, Chief Nursing Officer, Naida Glavish, Chief Advisor Tikanga and General Manager Māori Health Auckland DHB/Waitemata DHB and Auxilia Nyangoni, Deputy Chief Financial Officer be received. 2. CONFLICTS OF INTEREST There were no declarations of conflicts of interest for any items on the open agenda. Lester Levy advised that from the end of December 2014 he would no longer be a Director of Health Benefits Ltd and at that time he would advise an amendment to the interests register. There was discussion in regard to the position that some Board Members and staff might find themselves in with regard to directorships held on the Board of healthalliance. As staff received no stipend for the role it was agreed that legally they had no conflict of interest. It was agreed that in the case of Board Members the following action would be taken: That in accordance with the New Zealand Public Health and Disability Act 2000, Board Members would declare an interest in an item and formally seek the approval of the Board to take part in discussion and to vote on that item. 3. CONFIRMATION OF MINUTES 29 October 2014 (Pages 8-16) Auckland District Health Board Board Meeting 10 December 2014 Page 1 of 10 8

12 Resolution: Moved Jo Agnew / Seconded Peter Aitken That the minutes of the Board meeting held on 29 October 2014 be confirmed as a true and accurate record. Carried 4. ACTION POINTS 29 OCTOBER 2014 NIL There were no action points from the meeting of 29 October PRESENTATION [Secretarial Note: This presentation was taken before item 1 on the agenda with the remainder of the agenda items being taken in sequence] 5.1 Services and Food Workers Union presenting their submission in relation to the future state of Food Services at Auckland DHB Jill Oven from the Service and Food Workers Union made a submission on behalf of Service and Food Workers at Auckland DHB. In support with her were Daniel Ngawaka (Food Supervisor), Mariana Uapere (Ward) and Alofa Lemalu (Kitchen worker) The submission is attached as item The submission was heard and received. [Secretarial Note: Item 1 was taken next and the agenda items then followed in sequence] 6 CHAIRMAN S REPORT There was no report. 7 CHIEF EXECUTIVES REPORT (Pages 17-26) The Chief Executive asked that her report be taken as read, highlighting that: The Health Excellence Annual Awards were celebrated on Wednesday, 3 December 2014 at the Auckland War Memorial Museum. This year there was an increased number of applications from primary and community care providers due to the inclusion of a category of Community Health and Wellbeing. Dr Andrew Old, Chief of Strategy, Participation and Improvement and his team had put in a lot of effort to make the evening a success and had set a new benchmark for the celebration. Celebration Week has been broadened to encompass more evenly spread events Auckland District Health Board Board Meeting 10 December 2014 Page 2 of 10 9

13 over December that include both staff and stakeholder engagement events throughout the month. This is dubbed Ka Pai Whānau to convey the core element of thank you to staff for their efforts in the calendar year. 3 Two Long Service Award ceremonies were held on 17 November to recognise staff who achieved 30 and 40 years service. About 150 staff attended with their family, friends and colleagues. The feedback from attendees was very positive. This experience and the learnings taken from it will help facilitate further long service events which will be held in the New Year. Auckland Transport and Auckland DHB hosted a bike-to-work breakfast to celebrate the opening of the new storage facilities for bicycles. This is one of many initiatives to address parking issues on campus. Organ Donation New Zealand ran an information booth at Auckland City Hospital in the week leading up to this awareness day. New Zealand does not have a high donor rate and ways to address this are being investigated. A number of staff had been recipients of a wide and varying range of awards. Christine Etherington has been appointed on a one year contract as the Director of Strategic Human Resources for Auckland District Health Board. Christine had most recently served as the General Manager, Human Resources for the Ministry of Social Development. A review of tertiary services, led by the joint funder is now underway. A systematic methodology has been agreed in addition to a prioritised list of services, starting with paediatric services. A proposal will be put to the Board around potential content for a regular routine funder report for the Board agenda. Auckland DHB has gone to market to seek proposals for a refreshed Auckland DHB website that is patient and visitor focussed. The District Health Board has signed an agreement with the Department of Internal Affairs and Silverstripe to use the public sector common web platform. This enables efficiencies of scale and sharing of experience and knowledge with a range of public sector organisations. The refreshed website will incorporate a dynamic, intelligent knowledge base. The first GP open day was held on Monday 10 August with over 60 GPs visiting the adult emergency department and APU. The GPs were able to meet informally with various members of the Senior Leadership Team and had an opportunity to discuss matters of concern. There was a high degree of engagement and much positive feedback. The Minister of Health, the Hon. Dr Jonathan Coleman visited Auckland City Hospital in October and met with senior clinical leaders. He indicated his interest in clinical leadership, children's health (including vulnerable children), obesity and mental health. The annual research week was held between November. This year it was in recognition of the Auckland Academic Health Alliance. Auckland District Health Board Board Meeting 10 December 2014 Page 3 of 10 10

14 Matters covered in discussion of the report and in response to questions included: Advice being given that in relation to affordability of parking on site that staff received a substantial parking discount and some key client groups received parking vouchers. At times the availability of parking was seen as a problem. Lester Levy advised that he had been in discussion with Auckland Council/Transport and that the Auckland DHB campus had now been accepted by them as a critical site in relation to future planning. That the December 2014 report of the Chief Executive be received. 8 LIFT THE HEALTH OF PEOPLE IN AUCKLAND CITY 8.1 The Auckland Plan Working with Auckland Council to Create the World s Most Liveable City (Pages 27-43) Simon Bowen, Director of Health Outcomes Auckland DHB/Waitemata DHB introduced the item advising that the document addresses the key determinants of a good plan. There was no discussion. Resolution: Moved Gwen Tepania-Palmer / Seconded Chris Chambers That the Board: (a) (b) Formally endorse the Auckland Plan as a sound foundation with the determinants of a good plan and encourages Auckland Council to go further. Provide support and encouragement to working very closely with the Auckland Council on issues going forward and developing relationships at all levels of the organisations from governance to the operational level. Carried /2016 Annual Plan Approach (Pages 44-50) Simon Bowen, Director of Health Outcomes Auckland DHB/Waitemata DHB introduced the item advising that a considerable amount of work was required to be undertaken between now and late January to provide a quality draft plan. With a new Minister it was anticipated that there could be required changes notified by Ministry staff. Simon Bowen encouraged Board members to participate in the planning day that was to be held on 22 January Ailsa Claire advised that the Minister had clearly stated his interests which centred around: Shifting resources from Primary to Community settings Auckland District Health Board Board Meeting 10 December 2014 Page 4 of 10 11

15 Mental health and in particular primary mental health A focus on clinical leadership Affordability across all systems The potential to move health funding directly to schools. 3 Ailsa Claire pointed out that there was a need to work more closely with other public sector agencies along with a requirement to communicate better what Auckland DHB was doing on a local basis. If structural change was to be avoided then collaboration was not just a necessity but a priority. Resolution: Moved Robyn Northey / Seconded Judith Bassett That the Board: (a) Approve the approach to annual planning for 2015/16, including the longer term direction and timetable. (b) Note the national planning guidance, including updates and changes. Carried 9 LIVE WITHIN OUR MEANS NIL There was no report. 10 GENERAL BUSINESS 10.1 Te Toka Tumai A Strategy for Auckland DHB to 2018 (Pages 51-66) Dr Andrew Old, Chief of Strategy, Participation and Improvement asked that the paper be taken as read. An additional paper on Values was tabled and is attachment Andrew Old advised that a considerable amount of effort had gone into developing a new set of values for Auckland DHB. This has taken longer than was imagined as it has been difficult to capture values which reflected Auckland DHB as a tertiary provider and also a provider of last resort. The next step was to take this version of the document to Auckland DHB community partners for their feedback and support. Work was also being done with the Chief Adviser Tikanga to make sure that the Māori language is used correctly and that there is appropriate use of Tikanga. A translation of the words Te Toku Tumai which sit at the foot of the Auckland DHB logo has revealed a general meaning of, a rock that stands firm. This fits particularly well with the Values Project. A Provider Strategy is being developed concurrently. This will provide more information around the complexity of providing services to a local population as well as services on Auckland District Health Board Board Meeting 10 December 2014 Page 5 of 10 12

16 contract to other District Health Boards. The issues around cost pressures and solutions will sit in the Provider Plan. It is critical to ensure a logical connection between this work, the annual plan and other various provider and directorate plans. Matters covered in discussion of the report and in response to questions included: Advice that a cross check to ensure connections existed with the Northern Regional Plan was being made. There was nothing that was in conflict with this and concentration was now being applied to ensure an internal alignment was in place. Lester Levy expressed concern around the lack of a value that reflected accountability. It is only lightly touched on and requires more work. Overall the document is sound. Ailsa Claire said that she believed a set of behaviours sitting along-side the values would address this point. Morris Pita felt that it should also relate to people s daily work challenging the way peoples work is shaped and that position descriptions should also reflect this. Action That the next iteration of the plan be circulated to Board members and that Andrew Old proceeds with the next stage of completion. Resolution: Moved Jo Agnew / Seconded Gwen Tepania-Palmer That the Board approve the final draft Strategy for Auckland DHB for stakeholder consultation. Carried 10.2 Establishment of Executive Committee of the Board (Pages 67) Lester Levy advised that this was a procedural requirement to cover the Board during the holiday recess. Resolution: Moved Doug Armstrong / Seconded Gwen Tepania-Palmer 1. That the Board approve the establishment of an Executive Committee (under schedule 3 clause 38 of the New Zealand Public Health and Disability Act 2000) to consider any matters that require the urgent attention of the Board during the Christmas/ New Year Board recess. 2. That membership of the Committee is to comprise the Board Chair (or Acting Board Chair), the Deputy Board Chair (Lee Mathias), Ian Ward, Jo Agnew, Chris Chambers and Gwen Tepania-Palmer, with a quorum of three members (the Chair or Acting Board Chair needs to be one of the three members). 3. That the Executive Committee be given delegated authority to make decisions on the Auckland District Health Board Board Meeting 10 December 2014 Page 6 of 10 13

17 Board s behalf relating to the urgent approval of business cases, leases and the awarding of contracts for facilities development, services and supplies and information services and on any other urgent recommendations from a Committee or the Chief Executive (same arrangements as last year). 4. That all decisions made by the Executive Committee be reported back to the Board at its meeting on 18 February That the Executive Committee be dissolved as at 18 February Carried 11 RESOLUTION TO EXCLUDE THE PUBLIC (Pages 68-70)) Resolution: Moved Chris Chambers / Seconded Robyn Northey That in accordance with the provisions of Clauses 32 and 33, Schedule 3, of the New Zealand Public Health and Disability Act 2000 ( Act ): 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 each item to be considered: 1 Confirmation of the Public Excluded Minutes of the Board Committee Meeting 29 October Confirmation of the Confidential Addendum Minute Meeting of the Board held on 29 October Health and Safety Report Reasons for passing this resolution in relation to each item: Confirmation of Minutes As per resolution(s) from the open section of the minutes of the above meeting, in terms of the NZPH&D Act Confirmation of Minutes As per resolution(s) from the open section of the minutes of the above meeting, in terms of the NZPH&D Act 2000 Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Obligations of Confidence The disclosure of information would not be in the public Ground(s) under Clause 32 for the passing of this resolution That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] Auckland District Health Board Board Meeting 10 December 2014 Page 7 of 10 14

18 4.1 Financial Report 6.1 Fluroscopy Replacement Machines 6.2 Cytology Service Fit-Out 6.3 Perioperative Service Fleet Instruments 6.4 Auckland DHB Authorised Banking Signatories 6.5 Food Services Business Case interest because of the greater need to protect information which is subject to an obligation of confidence [Official Information Act 1982 S.9(2)(ba)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Negotiations To enable the Board to carry on, without prejudice or That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] That the public conduct of the whole or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] That the public conduct of the whole or the relevant part of the meeting would be likely to result Auckland District Health Board Board Meeting 10 December 2014 Page 8 of 10 15

19 6.6 Upgrade of Access Control and CCTV Systems at Auckland DHB/dispensation 7.1 Human Resources Report 8.1 Women s Health Auckland DHB/Waitemata DHB Collaboration Options for Change 9.1 DHB Board Community Lab 9.2 Regional Wicked Project Status Update disadvantage, negotiations (including commercial and industrial negotiations) [Official Information Act 1982 S.9 (2) (j)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Negotiations To enable the Board to carry on, without prejudice or disadvantage, negotiations (including commercial and industrial negotiations) [Official Information Act 1982 S.9 (2) (j)] Negotiations To enable the Board to carry on, without prejudice or disadvantage, negotiations (including commercial and industrial negotiations) [Official Information Act 1982 S.9 (2) (j)] Obligations of Confidence The disclosure of information would not be in the public interest because of the greater need to protect information which is subject to an obligation of confidence [Official Information Act 1982 S.9(2)(ba)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] Commercial Activities To enable the Board to carry out, without prejudice or disadvantage, commercial activities [Official Information Act 1982 S.9 (2) (i)] in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official Information Act 1982 [NZPH&D Act 2000] or the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under any of sections 6, 7, or 9 (except section 9(2)(g)(i)) of the Official 3 Auckland District Health Board Board Meeting 10 December 2014 Page 9 of 10 16

20 Information Act 1982 [NZPH&D Act 2000] Carried The meeting closed at 5.15pm. Signed as a true and correct record of the Board meeting held on Wednesday, 10 December 2014 Chair: Lester Levy Date: Auckland District Health Board Board Meeting 10 December 2014 Page 10 of 10 17

21 OPEN 3 Te Toka Tumai - a Strategy for Auckland DHB to 2018 Recommendation That the Board: Approve the final draft Strategy for Auckland DHB for stakeholder consultation Prepared by: Approved/Endorsed by: Julie Helean, Assistant Director Strategy Dr Andrew Old, Chief of Strategy, Participation and Improvement Ailsa Claire, Chief Executive Attachments: The final draft of the Strategy for Auckland DHB 1. Executive Summary This paper updates the Board on the overall Strategy for Auckland DHB. Some of the early work done on the strategy has been revised. In early versions, a settings-based approach dominated and within this, the need for the DHB to be more active in work outside the hospital. This work was based on the self-directed model of care and adaptations of this. It proposed that the DHB expand activities that enable people to take greater responsibility for health and wellbeing. The expectation being that, a) empowering people, and, b) developing more services in the community, would help to reduce demand on the hospital. Feedback to date has suggested a need to not lose emphasis on the clinical expertise of the hospital and related services. This needs to be a point of focus and not simply assumed. We have also revised some of the language. It s important that the message conveys our belief that we are all experts about our own bodies and our health. The big shift we need for the future is the sense of health workers, a) recognising the sovereignty of the individual, and, b) working in ways that partner with patients, concentrating on what matters most for each patient. This version of the strategy has been modified on the basis of feedback from the senior team and others. The current version now concentrates more deliberately on the dual role that the DHB has as Commissioner/Funder and Provider. We have also brought the provider issues to the foreground and made them more explicit. Managing provider services in a sustainable way while expanding our clinical, teaching and research expertise is one of our greatest challenges for the future. While the strategy remains high level, it provides sufficient direction for both the Funder and Provider. The detail for each priority action and within each workstream will sit in in other plans. The Strategy will remain a live document and will iterate to ensure it meets the on-going needs of the organisation. The next steps are to take this version to our community partners for their feedback and support. We are also working with the Chief Adviser Tikanga to make sure that the Māori language is used correctly and that we have appropriate use of Tikanga. Auckland District Health Board Board Meeting 10 December 2014 Page 1 18

22 OPEN 2. The Provider Strategy A planning session was held with the Provider Group in early November. From this planning day, several themes were selected to drive future activity. These themes aligned well with the draft work streams in the Strategy and the Strategy now encompasses the majority of issues that are currently facing the Provider and the organisation as a whole. We are keen that every staff member has a clear line of sight from the work they are doing, to the high level direction of the organisation. A Provider Strategy is being developed concurrently. This will tease out more of the complexity of providing services to a local population as well as services on contract to other DHBs. The issues around cost pressures and solutions will sit in the Provider Plan. It is critical to ensure a logical connection between this work, our annual plan and our various provider and directorate plans. 3. Annual Plan for 2015/16 The first year actions to advance the Strategy will go into the Annual Plan for In order to inform the Annual Plan, our Strategy work needs to be completed by February 2015 and we are well on track to achieve this. We are working closely with the Planner for Auckland DHB to make sure that the various plans under development are done together and are designed with good and logical links between them. 4. Values work A considerable amount of effort has gone into developing a new set of values for Auckland DHB. Although this has taken longer than was imagined, the Strategy is considerably improved by being grounded in a set of values that set the organisational culture and behaviour. The Values Project will arrive at a set of organisational values by the end of December The results of Values Week have been analysed and various options for values developed and tested. We have been greatly assisted in this process by Tim Keogh of April Strategy. Many options and iterations of values have been tested with a variety of staff groups and especially with our executive. The preferred option under final discussion at the moment is: The words in bullet points are taken directly from language used by patients and staff through the process. Auckland District Health Board Board Meeting 10 December 2014 Page 2 19

23 OPEN Each value will have a corresponding translation in Māori. We are working with our Chief Adviser Tikanga and her team to make sure that we represent our relationship with Māori correctly, and that we have the appropriate use of te reo alongside the English words. 3 Throughout the process, there was a Maya Angelou quote that resonated well with people and it will sit as part of the material that supports the values. I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. Maya Angelou This quote has been translated into Māori by Matua Pita Pou. We are currently testing these final preferred values with some groups of staff and with our executive. Once we have completed this final feedback phase, we will return to the Board. This version of the Strategy includes the preferred set of values that are being consulted on. Once agreed, the final values will have a high profile across the Strategy and related material, and the organisation. In 2015 the values will be rolled out across the organisation as part of a coordinated organisation development plan. 5. Next Steps In December we will complete the final wave of feedback on the proposed values. They will be incorporated into the Strategy and the work to roll them out will be led by the new Director of Strategic Human Resources who joins us in the New Year. The Strategy will be circulated to our community partners, and in particular to Te Runanga o Ngati Whatua and our Primary Health Organisations, for their feedback and support. The Strategy will inform the Provider Strategy process which is underway and the Annual Plan for 2015/16. We will keep the Board updated on progress as the detailed work to progress the Strategy is developed. Auckland District Health Board Board Meeting 10 December 2014 Page 3 20

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25 Action Points from Previous Board Meetings 4 As at Wednesday, 10 December 2014 Meeting and Item Detail of Action Designated to Action by Dec 2014 Auckland DHB Strategy and Values That the next iteration of the plan be circulated to Board members and that Andrew Old proceeds with the next stage of completion. Andrew Old See item 9.1 in this agenda Auckland District Health Board Board Meeting 18 February

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27 Chief Executive s Report Recommendation That the report be received. 6 Prepared by: Ailsa Claire (Chief Executive) Glossary 1. Introduction This report covers the period from 21 November to 30 January. It includes an update on the management of the wider health system and is a summary of progress against the Board s priorities to confirm that matters are being appropriately addressed. The report on Maori and Pacific health outcomes will now be in the Funder report to the Board. 2. News and Events 2.1 External and internal communications 2.2 External Auckland DHB has made public statements about: The introduction of a Welcome Wall with multilingual greetings to reflect the diverse communities of Auckland. (The Welcome Wall is a supersized banner in the main entrance on Level 4, ACH and it will be supported by a series of posters around the main public areas.) Installation of triple bins for better recycling at Auckland City Hospital, Greenlane Clinical Centre and Starship Children s Hospital. (The triple bins have had good uptake by staff and patients and are a visible sign of the sustainability programme.) Kari Centre introduces renown Parent-Child interaction Therapy for families (Two clinical psychologists Dr Bev George and Dr Melanie Woodfield are leading the new therapy which has proved effective with children between 2 and seven with severe emotional and behavioural difficulties.) Seeking nominations from suitably qualified candidates from the Pacific communities for appointment to the Disability Advisory Committee, joint committee for Auckland and Waitemata DHBs. (The Committee has been seeking members with Pacific heritage and lived experience of disability issues to give Pacific disabled communities a better voice at health governance level.) Auckland District Health Board Meeting of the Board 18/02/15 22

28 We received 149 requests for information, interviews or for access from media organisations in the period from 21 November to 30 January. Media enquiries included interest in: Health Excellence Awards, Doco on couple seeking treatment at Fertility Plus Decision on Food service proposal Health and Disability Commissioner upholds complaint from patient of Epsom Day Unit Common holiday injuries Apart from those noted, 77 per cent of the enquiries over the period were routine enquiries about the status of patients hospitalised following crimes or accidents or who were of interest because of their public profile. We reviewed 22 Official Information Act requests and provided responses 2.3 Internal Four blog posts were published by the CE to celebrate excellence, a thank you for the year s work. Celebrating elective target results, local heroes. 25 news updates were published on the DHB intranet. Nine enova (weekly electronic newsletters) were published. The December/January edition of Nova magazine was published. 2.4 Social Media Our social media channels have the following audience size: Facebook 2,629 Twitter 1,383 Linkedin 2,966 Most popular items of content during this period were: Our People recognitions, Local Heroes, Starship nurse volunteering aboard Africa Mercy Education NIHI Healthy Food Choices study, #greentuesday tip, sun smart tip, Auckland DHB breastfeeding support survey Site information new maps for ACH and GCC Events Ka Pai Whānau, Christmas decorating Patient stories Starship patient getting visit from her dog Mental health story about role of caregiver and spouse from Mental Health NZ Weekly job postings 2.5 Events Health Excellence Awards Auckland District Health Board Meeting of the Board 18/02/15 23

29 The annual Health Excellence Awards took place in December at the Auckland Museum. Guest speaker Kevin Biggar entertained the audience of Auckland DHB staff, Primary and Community providers along with guests from our neighbouring DHBs and Universities. This year the winners of the Health Excellence Awards were: Excellence in Clinical Care: David Semple and team - Haemodialysis access work stream Excellence in Process and Systems Improvement: Janine Mortimer and team - Women's health physiotherapy waiting time 6 Excellence in the Workplace: Richard Doocey and team - New Northern region Haematology & Bone Marrow Transplant Unit - Motutapu Ward, Auckland City Hospital Excellence in Community Health and Wellbeing: ProCare Health - ProCare Mission Smokefree Excellence in Research: Dr Catherine Han and team - Calcium and Magnesium Infusions Effects on oxaliplatin Chief Executives Award: Leigh Manson and team - Conversations that Count Campaign Young Investigator of the Year Auckland District Health Board celebrated the achievements of early career researchers at the Young Investigator Awards 2014 held at the Grafton Campus of the Faculty of Medical and Health Sciences. The winners were selected from a highly competitive field of nominees across a variety of health professions. The winners received prizes donated by A+ Charitable Trust. First place winner was, Kylie Russell (Nutrition Services) she won the award for her presentation "Effect of Preoperative Immunonutrition on Outcome in Patients Undergoing Liver Resection: A Randomised Pilot Study. Nicholas Gow (LabPlus) received the second place award for his presentation "The role of echocardiography in Staphylococcus aureus bacteraemia at Auckland City Hospital." Design lab tours The Design for health and Wellbeing Lab is a hive of activity, where a team of students and staff are designing, prototyping and researching ideas that will help us improve our spaces and experience for patients, families and staff. In December staff had the opportunity to enter into this creative space and hear about some of the innovative projects taking place in partnership with AUT University. Creative healthcare Two 20x20 Creative Healthcare events were held in December, one at Greenlane and one at Grafton. Modelled on PechaKucha, the challenge was for presenters to follow a format that consists of 20 visual-based slides with 20 seconds to speak about each slide. Our first events featured a range of topics including: advance care planning, social media, the design lab, play specialists, patient experience, and mental health. We will be looking at organising further 20x20 Creative Healthcare events this year. Ka Pai Whanau Auckland District Health Board Meeting of the Board 18/02/15 24

30 During the month of December a range of events took place to entertain staff and patients, as we counted down to the holiday season. We called this Ka Pai Whānau (thank you family). Musicians came into the hospital and brought smiles to the faces of staff, patients and visitors. We are seeking feedback to build on the event this year. Ward decoration competition Staff on some of our wards got into the Christmas spirit and went to amazing lengths to make the wards festive for patients and visitors. The winners of the Ward competitions were: first place - ward 41, second place - ward 42 and third place - ward 73. Ward 97 took first place for Women s health ward decorations. City Mission Donations - Christmas is a time of giving and during December Auckland DHB staff did their bit to help the needy this Christmas. The number of gifts and tinned foods provided this year outnumbered previous years. Christmas day entertainment whilst others were enjoying Christmas day at home with family some of our staff took time out to entertain those people attending the City Mission Christmas day lunch. Auckland DHBs Dr Margaret Wilsher and Dr Sarah Parry became a spice girls and Mark Entwhistle, John Scott, James Beecroft and David Rowbotham formed the village people. The entertainment was organised by Lab Plus s Joe McDermott 2.6 People Local Heroes Forty seven people were nominated as Local Heroes during December and January. Local hero awards were presented to Ann Verbeemen and Lynley Frame. Their nominators told us: Ann, a booking administrator in level 8 theatres, was nominated by a colleague who described a situation in which a patient holidaying in New Zealand with his wife was admitted acutely in a critical condition. Both spoke very little English and being very late we were unable to get an interpreter in, says the colleague. Ann was asked to assist in interpretation, and went above and beyond the call of duty. She stayed late that night, organised the transportation of their belongings, showed the wife around hospital accommodation, and the next day sacrificed her breaks to check that the wife was OK. She had a massively positive impact on the wife s experience. Lynley is one of our volunteers and was nominated by the parent of a patient in Starship. She told us: Lynley has just been amazing and has been visiting and reading to my daughter, Grace, every Friday for the past 10 months. Grace is in a coma and it has made a huge difference to me to know that she is with Grace when I can t be there. She has got to know Grace who responds positively to Lynley when she is there. It has made this dramatic time in our lives easier to bear. Fionnagh Dougan Fionnagh Dougan, Director Provider Services for Auckland DHB was formally farewelled in January and has now taken up her position as the Chief Executive of Children s health Queensland Hospital and Health Services. Fionnagh has held a number of key roles at Auckland DHB since first joining us in 1997 and her leadership will be missed. Dr Steven Heap Auckland District Health Board Meeting of the Board 18/02/15 25

31 Paediatric Resident Medical Officer Dr Steven Heap has been awarded the inaugural Emma Ball Memorial Prize. The award was established in memory of former Starship Chief Resident Emma Ball. It is presented to a trainee who has contributed significantly to paediatrics at Auckland DHB. It acknowledges a doctor who stood out during their year in training by supporting other junior doctors and stressed parents, and making a busy paediatric team a more enjoyable place to work. Mario Pascual Mario Pascual was selected as the first winner of the Keith de Carteret Award for trained anaesthetic technicians who go above and beyond in their supervision of trainees. Mario has been described by colleagues as unparalleled and exceptional - a mentor who motivates trainees to persevere when they are struggling. He willingly assists them in their study with extra tuition and is appreciated for his wisdom, encouragement, positive attitude and honest communication Strategy, Participation and Improvement 3.1 Strategy and Values It was agreed at the December 2014 meeting of the Board that the strategy would be circulated to members before it went out for wider consultation. Since December the material has been further developed to make it clear how the five strategic priorities address the challenges we face. The strategy has also been updated to keep pace with the work on the Auckland DHB values. The values project has been greatly assisted by Naida Glavish, Chief Advisor Tikanga, who has helped with Māori translations and checks for proper use of Te Reo and Tikanga. We now have a final set of values that the steering group is happy with. A final draft of the strategy with updated values is included in the Board papers. We propose to take this version out for stakeholder feedback in late February. The work will be finalised in time to inform the Annual Plan. 3.2 Issues Waste water leak Auckland City Hospital was affected by a waste water leak on Auckland Anniversary Weekend that affected part of Level 5 and Level 6 of the Support Building. No clinical areas were affected. However a range of out-patient clinics had to be temporarily relocated. Access to the level 6 bridge way was restricted and the Muffin Break café was closed temporarily. The staff café has been opened to the public and chairs and tables set up for visitors and patients to use with the temporary closure of Muffin Break. Thanks to good organisation and goodwill, the inconvenience for patients has been kept to a minimum. I want to give a special thanks to staff, especially the cleaning staff, who worked long hours to keep services running smoothly for patients Cluster of Starship patients treated for circumcision complications In January Starship Children s Hospital admitted eight patients who had serious complications following traditional circumcision in the Pacific community. The boys who were near puberty, had been discharged by 30 January. Paediatricians, the Pacific Health team and Communications worked on appropriate community focussed health messaging. Before it was deployed, mainstream media outlets came across the story. Auckland DHB coordinated a media response with Counties Manukau DHB and the Ministry of Health. 4. Performance of the Wider Health System Auckland District Health Board Meeting of the Board 18/02/15 26

32 4.1 National Health Targets Performance Summary Status Comment Acute patient flow (ED 6 hr) Dec 90%, Target 95% Improved access to elective surgery Shorter waits for radiation therapy & chemotherapy 99% to plan for the year Dec 100%, Target 100%, Year to Date 100% Better help for smokers to quit Dec 96%, Target 95% Cardiac bypass surgery Dec 89 patients, Target < 104 More heart & diabetes checks Sep Qtr 90%, Target 90% Increased immunisation 8 months Sep Qtr 95%, Target 95% Key: Proceeding to plan Issues being addressed Target unlikely to be met Commentary Auckland DHB met the revised Ministry of Health target of providing patients with their First Specialist Assessment (FSA) or elective surgery within 120 days in December. The target is a challenge and only achieved by a team effort that involved people working right up to 31 December. The ongoing challenge will be to maintain Auckland DHB s performance in meeting this target. The Adult Surgical team have made a pledge to beat the target by aiming to give all patients a date for their FSA or surgery within 90 days of being added to the waiting list. Reducing waiting times is always difficult as we have to do more on top of our current activity to make the reduction. The Acute patient flow target has not been met due to unprecedented numbers of adult and child patients presenting to our emergency departments and others in the Auckland region. Work is underway to address the issues and to meet the target. 5. Performance of the Wider Health System (continued) 5.1 Clinical Governance Commentary Patient safety As part of a review of clinical governance, the CHPO, CNO and CMO have drafted a quality framework for the provider arm describing the quality systems that underpin our commitment to patient safety and demonstrating the structure for reporting clinical governance activities from directorate through to Clinical Board and then Hospital Advisory Committee. Auckland District Health Board Meeting of the Board 18/02/15 27

33 In concert with this activity the clinical partners have reviewed IT systems that can support Auckland DHB s quality activities allowing easier capture of data for assurance. One tool, CRAB Clinical Informatics Ltd, has been evaluated regionally. CRAB is able to generate a risk adjusted analysis of surgical care and avoidable harm in acute medicine. All four northern district DHBs have provided historical data for an audit in order for the tool to be evaluated more fully and initial results were presented to the Directors and CE in December. Whilst decisions regarding the nature and type of IT support for patient safety activities have not yet been made, there are several opportunities for improving the quantity and quality of data so that our clinicians can more fully engage in clinical audit and quality improvement activities. 6 The Chief Executive has congratulated Dr Sai Wong, the consultant psychiatrist for the Asian Mental Health team at Auckland DHB, on recognition for his service to mental health and the Chinese community with the Order of New Zealand Merit (ONZM) in the New Year s honours. Trained in Hong Kong and New Zealand, Dr Wong has worked in his field for 30 years, helping to found a number of community initiatives, including the Chinese Lifeline telephone counseling service and a day centre for elderly Chinese. 5.2 Tamaki Whānau Ora Centre Plans to develop a whānau ora centre in Tamaki are coming together with agreement reached with Ngati Whatua Orakei just prior to Christmas on an approach. Ngati Whatua Orakei will develop the centre with Auckland DHB partnering as the foundation leaseholder. The centre will house a new community renal dialysis centre and discussions are underway with the Women s Health, Community & Long Term Conditions and Mental Health directorates to develop new models of care for key services that could be delivered from such a centre. Project governance is being established and we will provide a detailed progress report to the next Board meeting. 6.0 Financial Performance 6.1 For December 2014, we recorded a year-to-date net surplus of $0.9m, which is $0.1m higher than budget. Year-to-date income is higher than budget due to the receipt of higher base income to cover the cost of an increased capital charge resulting from the revaluation of land at the end of the previous financial year. Expenditure is higher that budget as result of a higher Capital charge. In addition, there is a favorable variance in the funder provider payment line which offsets unfavorable variances predominantly in outsourced personnel. Our savings program is on track to achieve an overall target of $49.6m with YTD savings to November of $20.7m versus a budget of $19.8m, supporting our year-end breakeven target. 7. Primary care and community services The Alliance Leadership Team (ALT) meets again of 12 th February and is considering a diabetes CVD performance framework to measure how well diabetic care is delivered. The Auckland Regional Clinical Governance Group have reviewed and endorsed the framework. This framework is based on the Ministry of Health quality framework released last year. The ALT has agreed that all Service Level Alliance will report up to the Alliance to enable consistency of approach and alignment of outcomes and work programmes. After-Hours The After-Hours procurement plan has been finalised and was independently reviewed by an independent probity advisor, the McHale Group. The Expression of Interest documents will be released in February. Auckland District Health Board Meeting of the Board 18/02/15 28

34 The procurement of the GP Deputising service has been delayed until the completion of the national telephone advice line procurement. This is to ensure respondents to the Auckland service are not engaged in two processes simultaneously. Auckland District Health Board Meeting of the Board 18/02/15 29

35 OPEN Health and Health Needs of the People of the Auckland District 2015 Recommendation That the report be received Prepared by: Simon Bowen(Director of Health Outcomes) Approved/Endorsed by: Name (position title) 7.1 Glossary HNA: Health Needs Assessment 1. Executive Summary The Planning and Funding team have undertaken a summarised update of the Health Needs Assessment for the Auckland DHB population. 2. Introduction/Background We have prepared this document because DHBs are required to regularly investigate, assess and monitor the health status of their resident population, and their need for services. The purpose of needs assessment is to bring about change beneficial to the health of the population. The needs assessment forms an integral part of the overall planning cycle, informing both funding decisions and the strategic planning process. It is reflected in Te Toka Tumai : The Strategy for Auckland District Health Board to 2020 and in the major programmes of work currently being developed. It is envisioned that this needs assessment be a living document where its content is regularly updated as new statistics become available. 3. Risks/Issues None. 4. Progress/Achievements/Activity The key findings are summarised here. Our population is diverse and growing Auckland DHB serves the population resident on the Auckland isthmus and the islands of Waiheke and Great Barrier. It is an area of stunning natural beauty. Residents enjoy easy access to green spaces, parks and beaches and Auckland ranks highly among surveys of the world s most liveable cities. The Auckland DHB contains approximately 478,000 people, making it the fourth largest of New Zealand s DHBs. We have an ethnically diverse population with 8.3% Māori, 11% Pacific, 29% Asian and 52% European/Other. Over 40% of our population were born overseas. The age composition of Auckland residents is somewhat different from that observed nationally, with 35% in the age group, compared with 26% in this age group nationally. Auckland has 10% of its population in the 65+ age group, compared with 14% nationally. Auckland District Health Board 18 February 2015 Page 1 30

36 OPEN Many factors affect the health of individuals and communities. Whether people are healthy or not is determined for the most part by an individual s socio-economic circumstances and their environment. While Auckland s population enjoys a high median income, home ownership is increasingly unaffordable. Over-crowding is more common than in New Zealand overall, especially for Māori and Pacific families. Our Māori and Pacific populations have lower rates of educational achievement and high unemployment. Environmentally, air pollution from motor vehicles and domestic fires causes around 100 premature deaths per year. Improving the wider determinants of health requires a co-ordinated approach between many agencies and services. Significant population growth is expected in the future. The population is projected to increase by nearly a third, reaching 610,000 by It will also be an older population with the number of people aged 65 years and older expected to nearly double, increasing from the current 50,000 to approximately 96,000, and making up 16% of our population, compared with 11% at present. Our Māori and Asian populations will also grow, with our Māori population projected to grow by 14% and Asian population by nearly 60%. We need to plan and develop our services to meet the needs of this expanding and changing population. We also need to work with other public agencies and services to improve the wider determinants of health such as housing, education and the physical environment, as well as improving access to health services. Our population is healthy and health is improving We have similar health outcomes to New Zealand as a whole, with a life expectancy of almost 83 years. The self-reported health status of our population is excellent and we continue to see positive health outcomes overall. Our mortality rates from cardiovascular disease and cancer, the two biggest causes of avoidable deaths, have declined steadily over the last decade. The children in our region are experiencing a great start to life with a much lower rate of infant mortality than is observed nationally and our immunisation rates are very high, with nearly 95% of our 8 month old children and 96% of our two year old children, fully immunised. We are seeing positive improvements in many lifestyle risk factors, and identifying these risks earlier. Smoking, the largest cause of preventable ill health, declined substantially between 2006 and 2013, with rates falling from 16.5% to 11% of adults. We now have the lowest rate of smoking of any DHB in the country. This will support improvements in health for many years to come. Our population experiences more positive mental health than New Zealand as a whole, with our selfreported diagnosed rate of anxiety and depression lower than the national rate. Our older population also experience positive health outcomes. The majority of our older population are able to live unassisted in their own homes. Many older people continue to work after reaching the age of 65 which is reflective of an overall positive health status. Our key health challenges Although the majority of our people enjoy very good health, particular population groups in our district experience inequalities in health outcomes. With better prevention of ill health, we could improve mortality further and increase healthy years of life for our residents. In 2011, there were 620 potentially avoidable deaths of Auckland residents (26% of the total), 33% of which are amongst our Maori and Pacific populations. Of these deaths, half could have been avoided through primary prevention, for example through adopting healthier lifestyles; a quarter could have been prevented by identifying and managing problems like hypertension before they caused illness; and a quarter could have been avoided through prompt identification and treatment. We also need to plan and develop health services to respond to the significant growth and changes to the population in our district. Auckland District Health Board 18 February 2015 Page 2 31

37 OPEN Reduce inequalities in health Our Māori and Pacific population live on average six to seven years less and have hospitalisation and mortality rates from many chronic diseases two to three times higher than our European/Other population. Although overall life expectancy is rising for Māori and Pacific people, the increase is similar to that for Europeans/Others. As a result, there remains a gap between Māori and Pacific life expectancy and that of Europeans/Others. The main drivers of this equity gap are circulatory disease, cancer, diabetes and injuries. For Māori women, respiratory disease is also significant, reflecting high rates of smoking. Nearly 20% of our population live in areas ranked as highly deprived, concentrated in Rosebank/Avondale in the west, Mt Roskill and the CBD and the eastern and southern areas from Glen Innes to Mt Wellington and Otahuhu. These people experience poorer health outcomes than those in more affluent areas. 7.1 Support healthier lifestyles Although smoking rates are declining, 11% of our adult population are regular smokers of cigarettes, with higher rates in our Māori (26%) and Pacific (22%) populations. Progress has been made with over 90% of all smokers accessing health services receiving brief advice to quit, however more can be done to back this up with effective support. Data from the New Zealand Health Survey reports one in five of our adults are obese and over half are overweight with very little change within the past ten years. The rate of childhood obesity in our Māori and Pacific populations is high with 20% of Maori and 30% of Pacific 2-14 year olds considered obese. Only around half of our population are meeting daily exercise recommendations and more than 40% are not meeting daily fruit and vegetable consumption guidelines. Our district s rate of hazardous alcohol consumption when compared with the national rate is higher across all ethnicities except for Asian. Effective management of cardiovascular disease and diabetes Cardiovascular diseases are the largest cause of death and as much as 70% of cardiovascular disease is avoidable. Although our risk assessment rates are high (90% of eligible adults), only 56% of eligible cardiovascular disease patients are on triple therapy. Although the rate of triple therapy is increasing, many more patients could potentially benefit from pharmacological treatment than is currently the case. We need to ensure that those identified as being at high risk of disease, as well as those with existing disease, are well-managed and receive prompt treatment. In 2013, nearly 700 Auckland residents were admitted to hospital following a stroke. The mortality rate from stroke is 21.1 per 100,000 which is similar when compared to New Zealand as a whole. Prompt assessment together with effective targeted treatment and rehabilitation is essential in providing the best outcomes for these patients. The number of people with diabetes has more than doubled since 2003 and this is now estimated to affect 6% of our population. If the number with diabetes continued to rise at this rate, it would affect 20% of the population in 20 years time. In 2013, 10.3% of medical/surgical bed-days were for people with diabetes. There is room for improvement in supporting people with diabetes to manage their key risk factors, such as blood pressure and blood sugar levels, and to attend retinal screening. Of the estimated number of people with diabetes in Auckland, 72% had an annual health check. Around half (53%) people with diabetes aged years are known to be well-managed (defined as having an HbA1c of <64 mmol/mol). Within the last two years, only 72% of diabetics have had the recommended retinal screening in the public sector. In 2013, 10.3% of medical/surgical bed-days were for people with diabetes. For both cardiovascular disease and diabetes, Māori and Pacific carry a heavier burden than other ethnicities. Auckland District Health Board 18 February 2015 Page 3 32

38 OPEN Rapid identification and treatment of cancer There are 2,200 new cancer registrations in Auckland every year. Cancer causes 28% of all deaths with the most significant being breast (in women), lung and colorectal cancers, and prostate cancers in men. Around 30-35% of cancers are caused by modifiable risk factors and are avoidable. Early detection and prompt diagnosis and treatment can reduce mortality and morbidity from cancers. Our one year survival rate from all cancers is 78.6%, one of the highest in the country. However, if Auckland DHB had the same five-year survival rates as Australia, 25% of women who die of breast cancer within five years would survive for longer (7 per year). Similarly, 13% who die of bowel cancer within five years would survive for longer (8 per year). For melanoma the difference is 46% (11 per year) and for non-hodgkin lymphoma it is 25% (5 per year). Public screening programmes for breast and cervical cancer are well-established; despite this, one quarter of all eligible women do not participate. Screening rates are lowest in Māori with only 57% of eligible women participating in cervical screening and 69% in breast screening. To support continued improvement in services and waiting times for people with cancer, accessing faster cancer treatment is a key priority and forms an integral part of the national health targets. Currently 62% of cancer patients wait less than 62 days for treatment or other care to commence compared with the target of 85% (by June 2016). Access to Mental Health services Mental ill-health affects one in five people each year and the New Zealand health survey identified one in eight of our residents (equivalent to around 43,000 people) as suffering from common mental illnesses. Around 3.5% of our population (17,000 people) are accessing secondary mental health services with this rate increasing yearly. Māori are particularly affected by mental health conditions, being twice as likely as Europeans/Others to access services. Pacific people report anxiety and distress twice as often as Europeans/Others, but do not access mental health services proportionately. While our suicide rate is lower than the national rate, we still lost 41 people in 2011 to suicide. Mental illness is also associated with reduced life expectancy, with sufferers at increased risk of other illnesses particularly cancer and cardiovascular disease. Even when these disorders are recognised, rates of intervention are lower for this population compared with people without mental illness. Give children the best start in life The well-being of children is critical to the well-being of the population as a whole. Healthy children are more likely to become healthy adults. Our overall infant mortality rate is lower than the national rate, however rates in Māori and Pacific are nearly twice that of European/Others. One-third of our pregnant mothers are not enrolled with a lead maternity carer (LMC) at 12 weeks of pregnancy and addressing this would improve outcomes for mothers and babies. The percentage of children enrolled with a PHO by three months of age (56%) is lower than the national figure (63%), and further lower in Māori children (47%). The national target is 88%. We are close to achieving our immunisation target of 95% at 8 and 24 months, with 94% of children fully immunised at 8 months of age and 96% of children fully immunised at 24 months of age. However, immunisation rates are not as high for Māori as for non-māori. We are below target for completion of core Well Child/Tamariki Ora checks in the first year of life and the percentage of fouryear-olds receiving comprehensive health checks before school entry. Children are admitted to hospital most commonly for injuries, gastroenteritis, asthma and infections. In 2012/13, there were 21.5 admissions per 100,000 population aged 0-14 for injuries resulting from domestic assault, neglect or maltreatment of children. The incidence of rheumatic fever (3.5 per Auckland District Health Board 18 February 2015 Page 4 33

39 OPEN 100,000 population) is lower than the national average, however significant inequalities are present for Māori and Pacific populations. Older people The large majority of older people in Auckland DHB are able to live unassisted in their own homes. Over half (52%) of people who are 85 years or older receive no funded living assistance, while 26% are funded to live in a rest home or private hospital and 22% have some funded support at home. Older people have greater needs for health services and hospital care and occupy about 45% of our medical/surgical beds. With the projected increase in the population aged 65 and over, meeting the associated increase in demand for health care will be challenging. Meeting future health needs Between 2007 and 2013, acute admissions to hospital increased by 20% and ED attendances increased by almost 60% for Auckland residents, after allowing for population ageing and growth. Future population growth and constraints on funding will place pressure on hospital services. We therefore need to plan and develop hospital services to manage this demand. Fully integrated services with a focus on prevention and good access to primary care services will be essential to meet the future health needs of the population Conclusion The Health Needs Assessment forms part of a suite of resources which includes interactive presentation of demographic and health data using the Statplanet mapping tool, available on the internet. For key topic areas, we will undertake more detailed assessments and these will be published as separate documents. Auckland District Health Board 18 February 2015 Page 5 34

40 Population Health Profile 2015 Auckland DHB serves the Auckland isthmus and the islands of Waiheke and Great Barrier. Demographics Population: 478,320 in population: will increase from 11% in 2015 to 16% in 2034, almost doubling in number Ethnicities: 8% Māori,11% Pacific, 30% Asian, 51% European/Other Migrants: 42% born overseas, compared with 25% nationally; 4.8% of total population do not speak English well Deprivation 18% live in poorest two deciles (20% nationally) Income, Education, Employment Income: third highest amongst DHBs; 37% of adults have income under $20,000, similar to national percentage Education: 88% leave school with a qualification, compared with 79% nationally Employment: 7.9% unemployed, 7.1% nationally Housing Over-crowding: 15.5% live in household with a deficit of one or more bedrooms, compared with 10.1% nationally Affordability: Auckland region is the least affordable for house purchase in NZ Modifiable Risk Factors Smoking: 11% are regular smokers, down from 16% in 2006, lower than national average of 15%. Higher rates amongst Māori (26%), Pacific (22% ) Diet: 60% eat enough vegetables, 57% eat enough fruit, better than national average. Physical activity: 50% meet guidelines for physical activity, up from 42% in 2006 Obesity: 22% of adults are obese and a further 34% are overweight. In children, 9.8% are obese and 17% overweight Alcohol: 18% overall drink in a hazardous manner, but 25% of men. Health Status Life expectancy: 82.7 years overall, 0.6 years higher than NZ average, but Māori and Pacific lived 4 and 7 years less than European/Other in 2013 Mortality: top causes of avoidable mortality Women: breast cancer, lung cancer, IHD Men: IHD, lung cancer, unintentional injuries CVD: leading cause of death; mortality is decreasing; 56% with IHD are on triple therapy; Māori and Pacific have higher rates of mortality Diabetes: 28,000 people (6%) have diabetes; Māori, Pacific, Indian ethnicities are particularly affected; 53% well-managed (HbA1c level <64) Cancer: second highest cause of death; mortality is decreasing slowly. One-year survival rate is 79% Mental health: 41 suicides per year; 12% of the population have a common mental disorder, lower than the national average of 16% Community and Hospital Services GPs: 97 per 100,000 population, higher than the national average of 74; 77% of population have visited a GP in the past year; 20% report unmet need for GP services; 11% report cost as barrier Hospitals: acute demand is rising; access to elective surgery is below the national average 35

41 Section Indicator Auckland DHB Maori Pacific Asian European /Other Population ,320 39,450 (8%) 52,850 (11%) 139,680 (30%) 246,340 (51%) 4,579,530 Annual growth % 1.7% 1.4% Under 5 years -number and percent of ethnic group 28,990 (6%) 4,030 (10%) 5,230 (10%) 8,600 (6%) 11,130 (5%) 302,595 Our 65+ years 52,220 (11%) 2,160 (5%) 3,580 (7%) 9,240 (6%) 37,240 (15%) 675,445 Population 75+ years 21, ,350 3,370 16, ,085 Projected population in ,333 44,600 49, , ,600 Projected 65+ population in ,610 5,690 5,920 24,640 58,350 Deprivation % living in NZDep13 Quintile 5 (most deprived) areas 18% 27% 40% 21% 12% 20% Income, % leaving school with qualification 88% 76% 70% 90% 79% education, Unemployment rate 7.9% 14% 16% 10% 5% 7% employment % of adults with income < $20,000 37% 41% 47% 48% 30% 36% Housing House over-crowding (people needing 1+ bedrooms) 15.5% 25% 45% 19% 6% 10% Air pollution Annual deaths due to air pollution 2006 estimate 93 % of children living in single parent households 16% 33% 22% 10% 12% 20% Social factors Violent offences per 1,000 people Feel safe walking alone at night 58% Internet access 84% 77% Smoking - % of adults 11% 26% 22% 7% 10% 15% Obesity - % of adults 22% 46% 61% 12% 19% 29% Obesity - % of children 9.8% 20% 30% 4% 4% 11% Overweight - % of children 17% 28% 23% 17% 15% 21% Modifiable Healthy diet: eating recommended servings fruit/veges 59% 62% risk factors Physical activity: % active 30 minutes per day 50% 51% 47% 45% 54% 54% Active travel to school 48% Active travel to work - walk, jog, cycle 7% Breast feeding (Exclusive at 3 months) - % 60% 51% 44% 60% 66% 56% Hazardous drinking - % of adults 18% 38% 24% 4% 25% 17% Self-reported health good, v. good, excellent 91% 90% 86% 91% 92% 90% Life Expectancy Total population Overall LE Male health LE Female Avoidable deaths per year CVD mortality ASR per 100, Cardiovascular % of pop'n with IHD on triple therapy 56% 58% disease % of adults medicated for high cholesterol 8.3% 10.5% 9.9% 11.7% 6.9% 8% % of adults medicated for high blood pressure 10.1% 14.6% 14.7% 10.6% 8.7% 11.7% Stroke Stroke mortality ASR per 100, Estimated population with diabetes 28,000 Diabetes % of population with diabetes 6% 5% 12% Indian: 11.5% 5% 6% % of diabetics having annual check 72% % of diabetics well-managed (HbA1c <64 mmol/mol) 53% Cancer mortality rate ASR per 100, Cancer Breast screening uptake (% of eligible women) 71% 70% 89% 69% Cervical screening uptake (% of eligible women) 75% 56% 84% 59% 86% 77% Respiratory % of adults on asthma medication 8% 14% 11% 4% 10% 11% disease COPD hospitalisation ASR per 100,000 1,611 1, Suicide ASR per 100, Mental Annual suicides (average ) 41 Health Diagnosed w mental health conditions (NZ Health Survey) 11.8% 16% Injury Injury hospitalisation ASR per 100,000 5,600 5,500 1,800 4,100 Births Infant mortality rate per 1,000 live births Infants, Teenage pregnancy (births per 1,000 women aged 15-19) children and % children enrolled w PHO at 3 months 56% 47% 61% 63% young people Rheumatic fever incidence per 100, % fully immunised at 8 months Q1 2014/15 96% 95% 98% 97% 94% 92% % fully immunised at 24 months Q1 2014/15 96% 96% 99% 99% 93% 93% Disability Arthritis IHD MH disorder Diabetes Older People % a ged >65 with: 59% 43% 18% 11% 24% Planning and Health Intelligence Health Needs Assessment 2015 Population HEALTH DRIVERS HEALTH STATUS NZ

42 37 Health Needs Assessment 2015

43 Contents 1 Executive Summary Our population is diverse and growing Our population is healthy and health is improving Our key health challenges Reduce inequalities in health Support healthier lifestyles Effective management of cardiovascular disease and diabetes Rapid identification and treatment of cancer Access to Mental Health services Give children the best start in life Older people Meeting future health needs Introduction Needs assessment and Māori Our Population Migrants Population Health Drivers Deprivation Income, Education and Employment Housing Environmental factors Social factors Violence and crime Cultural factors Modifiable Risk Factors Smoking Diet and Physical Activity Alcohol and Drugs Health Status Overall health Life expectancy Total Mortality Avoidable causes of mortality Specific conditions Cardiovascular disease Stroke Diabetes Cancer Respiratory disease Mental Health Injury Disability Sexual Health Infants, Children and Young People Births Infants and Children Young people Older people Health services Community health care Oral health Hospital-based health care Emergency Departments Outpatient services Admitted patients Access to publicly-funded elective surgery Hospital quality and safety Avoidable causes of hospitalisation Data and information sources Major data sources References

44 1 Executive Summary DHBs are required to regularly investigate, assess and monitor the health status of their resident population, and their need for services. The health needs assessment forms an integral part of the overall planning cycle, informing both funding decisions and the strategic planning process. We have used data from a wide range of sources to provide a picture of the health status and needs of our population. With this information, the District Health Board (DHB) can plan future health services and health programmes to ensure the best health outcomes for all the people in our region. 1.1 Our population is diverse and growing Auckland DHB serves the population resident on the Auckland isthmus and the islands of Waiheke and Great Barrier. It is an area of stunning natural beauty. Residents enjoy the easy access to green spaces, parks and beaches and Auckland ranks highly among surveys of the world s most liveable cities. The Auckland DHB contains approximately 478,000 people, making it the fourth largest of New Zealand s DHBs. We have an ethnically diverse population with 8.3% Māori, 11% Pacific, 29% Asian and 52% European/Other. Over 40% of our population were born overseas. The age composition of Auckland residents is somewhat different from that observed nationally, with 35% in the age group, compared with 26% in this age group nationally. Auckland has 10% of its population in the 65+ age group, compared with 14% nationally. Many factors affect the health of individuals and communities. Whether people are healthy or not is determined for the most part by an individual s socioeconomic circumstances and their environment. While Auckland s population enjoys a high median income, home ownership is increasingly unaffordable. Overcrowding is more common than in New Zealand 1.2 Our population is healthy and health is improving We have similar health outcomes to New Zealand as a whole, with a life expectancy of almost 83 years. The self-reported health status of our population is excellent and we continue to see positive health outcomes overall. Our mortality rates from cardiovascular disease and cancer, the two biggest causes of avoidable deaths, have declined steadily over the last decade. The children in our region are experiencing a great start to life with a much lower rate of infant mortality than is observed nationally and our immunisation rates are very high, with nearly 95% of our 8 month old children and 96% of our two year old children, fully immunised. We are seeing positive improvements in many lifestyle risk factors, and identifying these risks earlier. Smoking, the largest cause of preventable ill health, overall, especially for Māori and Pacific families. Our Māori and Pacific populations have lower rates of educational achievement and high unemployment. Air pollution from motor vehicles and domestic fires causes around 100 premature deaths per year. Improving the wider determinants of health requires a co-ordinated approach between many agencies and services. Significant population growth is expected in the future. The population is projected to increase by nearly a third, reaching 610,000 by It will also be an older population with the number of people aged 65 years and older expected to nearly double, increasing from the current 50,000 to approximately 96,000, and making up 16% of our population, compared with 11% at present. Our Māori and Asian populations will also grow, with our Māori population projected to grow by 14% and Asian population by nearly 60%. We need to plan and develop our services to meet the needs of this expanding and changing population. We also need to work with other public agencies and services to improve the wider determinants of health such as housing, education and the physical environment, as well as improving access to health services. declined substantially between 2006 and 2013, with rates falling from 16.5% to 11% of adults. We now have the lowest rate of smoking of any DHB in the country. This will support improvements in health for many years to come. Our population experiences more positive mental health than New Zealand as a whole, with our selfreported diagnosed rate of anxiety and depression lower than the national rate. Our older population also experience positive health outcomes. The majority of our older population are able to live unassisted in their own homes. Many older people continue to work after reaching the age of 65 which is reflective of an overall positive health status. 3 Health Needs Assessment

45 1.3 Our key health challenges Although the majority of our people enjoy very good health, particular population groups in our district experience inequalities in health outcomes. With better prevention of ill health, we could improve mortality further and increase healthy years of life for our residents. In 2011, there were 620 potentially avoidable deaths of Auckland residents (26% of the total), 33% of which are amongst our Māori and Pacific populations. Of these deaths, half could have been avoided through primary prevention, for example through adopting healthier lifestyles; a quarter could have been prevented by identifying and managing problems like hypertension before they caused illness; and a quarter could have been avoided through prompt identification and treatment. We also need to plan and develop health services to respond to the significant growth and changes to the population in our district Reduce inequalities in health Our Māori and Pacific population live on average six to seven years less and have hospitalisation and mortality rates from many chronic diseases two to three times higher than our European/ Other population. Although overall life expectancy is rising for Māori and Pacific people, the increase is similar to that for Europeans/Others. As a result, there remains a gap between Māori and Pacific life expectancy and that of Europeans/Others. The main drivers of this equity gap are circulatory disease, cancer, diabetes and injuries. For Māori women, respiratory disease is also significant, reflecting high rates of smoking. Nearly 20% of our population lives in areas ranked as highly deprived, concentrated in Rosebank/ Avondale in the west, Mt Roskill and the CBD and the eastern and southern areas from Glen Innes to Mt Wellington and Otahuhu. These people experience poorer health outcomes than those in more affluent areas Support healthier lifestyles Although smoking rates are declining, 11% of our adult population are regular smokers of cigarettes, with higher rates in our Māori (26%) and Pacific (22%) populations. Progress has been made with over 90% of all smokers accessing health services receiving brief advice to quit, however more can be done to back this up with effective support. Data from the New Zealand Health Survey reports one in five of our adults are obese and over half are overweight with very little change within the past ten years. The rate of childhood obesity in our Māori and Pacific populations is high with 20% of Māori and 30% of Pacific 2-14 year olds considered obese. Approximately half of our population are meeting daily exercise recommendations and more than 40% are not meeting daily fruit and vegetable consumption guidelines. Our district s rate of hazardous alcohol consumption when compared with the national rate is higher across all ethnicities except for Asian Effective management of cardiovascular disease and diabetes Cardiovascular diseases are the largest cause of death and as much as 70% of cardiovascular disease is avoidable. Although our risk assessment rates are high (90% of eligible adults), only 56% of eligible cardiovascular disease patients are on triple therapy. Although the rate of triple therapy is increasing, many more patients could potentially benefit from pharmacological treatment than is currently the case. We need to ensure that those identified as being at high risk of disease, as well as those with existing disease, are well-managed and receive prompt treatment. In 2013, nearly 700 Auckland residents were admitted to hospital following a stroke. The mortality rate from stroke is 21.1 per 100,000 which is similar when compared to New Zealand as a whole. Prompt assessment together with effective targeted treatment and rehabilitation is essential in providing the best outcomes for these patients. The number of people with diabetes has more than doubled since 2003 and this is now estimated to affect 6% of our population. If the number with diabetes continued to rise at this rate, it would affect 20% of the population in 20 years time. In 2013, 10.3% of medical/surgical beddays were for people with diabetes. There is room for improvement in supporting people with diabetes to manage their key risk factors, such as blood pressure and blood sugar levels, and to attend retinal screening. Of the estimated number of people with diabetes in Auckland, 72% had an annual health check. Around half (53%) people with diabetes aged years are known to be well-managed (defined as having an HbA1c of <64 mmol/mol). Within the last two years, only 72% of 4 Health Needs Assessment

46 diabetics have had the recommended retinal screening in the public sector. In 2013, 10.3% of medical/surgical beddays were for people with diabetes. For both cardiovascular disease and diabetes, Māori and Pacific carry a heavier burden than other ethnicities Rapid identification and treatment of cancer There are 2,200 new cancer registrations in Auckland every year. Cancer causes 28% of all deaths with the most significant being breast (in women), lung and colorectal cancers, and prostate cancers in men. Around 30-35% of cancers are caused by modifiable risk factors and are avoidable. Early detection and prompt diagnosis and treatment can reduce mortality and morbidity from cancers. Our one year survival rate from all cancers is 78.6%, one of the highest in the country. However, if Auckland DHB had the same five-year survival rates as Australia, 25% of women who die of breast cancer within five years would survive for longer (7 per year). Similarly, 13% who die of bowel cancer within five years would survive for longer (8 per year). For melanoma the difference is 46% (11 per year) and for non-hodgkin lymphoma it is 25% (5 per year). Public screening programmes for breast and cervical cancer are well-established; despite this, one quarter of all eligible women do not participate. Screening rates are lowest in Māori with only 57% of eligible women participating in cervical screening and 69% in breast screening. To support continued improvement in services and waiting times for people with cancer, accessing faster cancer treatment is a key priority and forms an integral part of the national health targets. Currently 62% of cancer patients wait less than 62 days for treatment or other care to commence compared with the target of 85% (by June 2016) Access to Mental Health services Mental ill-health affects one in five people each year and the New Zealand health survey identified one in eight of our residents (equivalent to around 43,000 people) as suffering from common mental illnesses. Around 3.5% of our population (17,000 people) are accessing secondary mental health services with this rate increasing yearly. Māori are particularly affected by mental health conditions, being twice as likely as Europeans/Others to access services. Pacific people report anxiety and distress twice as often as Europeans/Others, but do not access mental health services proportionately. While our suicide rate is lower than the national rate, we still lost 41 people in 2011 to suicide. Mental illness is also associated with reduced life expectancy, with sufferers at increased risk of other illnesses particularly cancer and cardiovascular disease. Even when these disorders are recognised, rates of intervention are lower for this population compared with people without mental illness Give children the best start in life The well-being of children is critical to the well-being of the population as a whole. Healthy children are more likely to become healthy adults. Our overall infant mortality rate is lower than the national rate, however rates in Māori and Pacific are nearly twice that of European/Others. One-third of our pregnant mothers are We are close to achieving our immunisation target of 95% at 8 and 24 months, with 94% of children fully immunised at 8 months of age and 96% of children fully immunised at 24 months of age. However, immunisation rates are not as high for Māori as for non-māori. We are below target for completion of core Well Child/Tamariki Ora checks in the first year of life and the percentage of fouryear-olds receiving comprehensive health checks before school entry. not enrolled with a lead maternity carer (LMC) at 12 weeks of pregnancy and addressing this would improve outcomes for mothers and babies. The percentage of children enrolled with a PHO by three months of age (56%) is lower than the national figure (63%), and further lower in Māori children (47%). The national target is 88%. Children are admitted to hospital most commonly for injuries, gastroenteritis, asthma and infections. In 2012/13, there were 21.5 admissions per 100,000 population aged 0-14 for injuries resulting from domestic assault, neglect or maltreatment of children. The incidence of rheumatic fever (3.5 per 100,000 population) is lower than the national average, however significant inequalities are present for Māori and Pacific populations. 5 Health Needs Assessment

47 1.3.7 Older people The large majority of older people in Auckland DHB are able to live unassisted in their own homes. Over half (52%) of people who are 85 years or older receive no funded living assistance, while 26% are funded to live in a rest home or private hospital and 22% have some funded support at home. Older people have greater needs for Meeting future health needs Between 2007 and 2013, acute admissions to hospital increased by 20% and ED attendances increased by almost 60% for Auckland residents, after allowing for population ageing and growth. Future population growth and constraints on funding will place pressure on hospital services. We therefore need to plan and health services and hospital care and occupy about 45% of our medical/surgical beds. With the projected increase in the population aged 65 and over, meeting the associated increase in demand for health care will be challenging. develop hospital services to manage this demand. Fully integrated services with a focus on prevention and good access to primary care services will be essential to meet the future health needs of the population Health Needs Assessment

48 2 Introduction DHBs are required to regularly investigate, assess and monitor the health status of their resident population, and their need for services. The purpose of needs assessment is to bring about change beneficial to the health of the population. The needs assessment forms an integral part of the overall planning cycle, informing both funding decisions and the strategic planning process. Treaty of Waitangi New Zealand Health Strategy New Zealand Disability Strategy Health Needs Assessment Prioritise work and funding programme (statement of intent and annual plan) Monitor and report on outputs, impacts outcomes Agree annual plan/funding agreement with Minister of Health Manage provider relationships (includes payment) Implement plans Purchase Through assessing the health needs of our population we can both identify and reduce inequalities and produce better health outcomes for the population as a whole. In this assessment we have concentrated on describing the health of Auckland residents compared to that of New Zealand overall, and on highlighting inequalities within the district and between particular groups of the population. It is envisaged that this needs assessment will be a living document and its content regularly updated as new statistics become available. It forms part of a suite of resources which includes Locality Profiles and interactive presentation of demographic and health data using the Statplanet mapping tool, available on the internet. 1 For key topic areas, we will undertake more detailed assessments and these will be published as separate documents. 1 Planet.html 7 Health Needs Assessment

49 2.1 Needs assessment and Māori The New Zealand Health Strategy includes a set of principles to guide health sector development. These include acknowledging the special relationship between Māori and the Crown under the Treaty of Waitangi. In Auckland this is particularly recognised in the relationship between the DHB and Te Rūnanga o Ngāti Whātua. The three principles of the Treaty of Waitangi partnership, participation and active protection apply to health and health service provision. The Treaty of Waitangi in Article 3 provides for equal rights for Māori with non Māori. While many Māori within Auckland enjoy better health than Māori in other parts of New Zealand and Māori life expectancy in Auckland DHB is 77 years, 2 years above the national average for Māori across New Zealand (75 years) at birth (2012), inequalities in health outcomes for Māori are still apparent in this DHB when compared to non-māori. The New Zealand Health Strategy specifically provides that Māori health outcomes will be addressed and health inequalities eliminated. 7.1 In undertaking health needs assessments this has a number of implications: Wherever possible we provide information on Māori health needs as well as the health needs of the general population We need to ensure that collection of data about Māori is as accurate as possible. In particular this means we need to ensure that ethnicity recording is accurate. This is an area of on-going work and improvement for Auckland DHB We need to report information that describes health from a Māori world view as well as a mainstream world view. This is very challenging because nearly all of the information in this document is derived from routinely collected data sources. These data sources have limited information on a broad perspective of health (rather than disease) and even more limited information that describes some perspectives that are important to Māori. We recognise this limitation and the need to attempt to address this in on-going work We need to specifically address Māori health needs rather than simply doing so in the context of assessing the needs of the overall population We need to involve the Māori community in the development of health needs assessments. This has not been done in the development of this document but development of Māori Health Needs Assessment for Auckland DHB in the future would need to factor in the engagement and involvement of Māori in the community. 8 Health Needs Assessment

50 3 Our Population Auckland DHB serves the population resident on the Auckland isthmus and the islands of Waiheke and Great Barrier. It is an area of stunning natural beauty. Residents enjoy the easy access to green spaces, parks and beaches and Auckland ranks highly among surveys of the world s most liveable cities. The Auckland Council divides the area between a number of local boards. These are: Waitemata, stretching from Westmere in the west to Parnell in the east and including the central business district and the suburbs of Western Springs, Grey Lynn, Arch Hill, Newton, Herne Bay, Ponsonby, St Marys Bay, Freemans Bay, Eden Terrace, Grafton and Newmarket; Albert-Eden, covering from coastal Pt Chevalier in the west across to Greenlane and including Mt Albert, Mt Eden, Waterview, St Lukes, Balmoral, Sandringham, Morningside, Kingsland, and Epsom; Orakei, covering Remuera, Ellerslie, Meadowbank, St Johns, Ōrākei, Mission Bay, Kohimarama, Saint Heliers and Glendowie; Puketapapa, bordering the Manukau Harbour, including Three Kings, Mt Roskill, Hillsborough, Waikowhai, Lynfield and Wesley; Maungakiekie-Tāmaki which covers an area from the Tamaki estuary west across to the inner Manukau Harbour and includes Glen Innes, Point England, Tamaki, Panmure, Mount Wellington, Penrose, Onehunga, Te Papapa and Royal Oak; Whau (part) in the west of the isthmus, with the suburbs of Kelston, Rosebank, New Lynn, Avondale, New Windsor, Blockhouse Bay and Green Bay; Otahuhu, part of the Otahuhu-Mangere local board area; Waiheke; Great Barrier. There are 478,320 people living in the Auckland district in 2015, accounting for approximately 10.5% of the national population. The age composition of Auckland residents is somewhat different from the national picture, with 35% in the age group, compared with 26% in this age group nationally. Auckland has 10% of its population in the 65+ age group, compared with 14% nationally in By ethnicity, our population is 8.3% Māori, 11% Pacific, 29% Asian and 52% European/Other. Just over one-third of Māori and Pacific people live in the south-east of the district in Maungakiekie-Tamaki with two-thirds spread across the remainder of the district. Half of our Indian population lives in the south-west in Puketapapa and Whau, while our Chinese and other Asian population is fairly evenly spread but sparser in the south-west. Two-thirds of the European/Other population live in the north/central wards of Waitemata, Orakei and Albert/Eden. Our Pacific population is predominantly Samoan (44%), Tongan (31%) and Cook Island Māori (17%). Our Asian population is diverse but is predominantly Chinese (41%) and Indian (33%). Auckland s population is urban with only 0.2% of our population living in rural areas (Great Barrier Island). (Source: Statistics New Zealand, population projections based on 2013 census.) 9 Health Needs Assessment

51 Figure 3.1: Ethnicity of our population 2015 Figure 3.3: Age structure of Auckland DHB in 2014 and 2034 Māori Pacific Asian Other 52% 8% 11% 30% 90+ years Years Male Female Years Years Years Years Years Years Years Years 6% 4% 2% 0% 2% 4% 6% 7.1 By age group, our population is 17% children (under 15 years), 15% young people (15-24 years), and 10% older people (65 years or older). However our Māori, Pacific and Asian populations are considerably younger with 46% of Māori, 50% of Pacific and 34% of Asians under the age of 25, compared with 25% for European/Other people. These populations are also notable for the small proportion of older people they contain (6% or less of their total populations). Figure 3.2: Age structure by ethnic group Source: Statistics NZ Population projections based on 2013 census Figure 3.4: Projected change in Auckland DHB population aged > 65 years, , ,000 80,000 60, % 80% 60% 40% 40,000 20, % 0% Māori Pacific Asian Other Figure 3.5: Projected change in Auckland DHB population by ethnicity, , ,000 By 2034 Auckland s population is projected to increase by 142,000 people, making it 30% larger than it is now. The population will also be considerably older with the number of people aged 65 years and older expected to nearly double, increasing from the current 50,000 to approximately 96,000, and making up 16% of our population, compared with 11% at present. Our Māori and Asian populations will also grow, our Māori population by 14% and Asian by nearly 60%. The Pacific population is projected to decline slightly. We need to plan and develop our services to meet the needs of our changing population. 500, , , , , Māori Pacific Asian Other Source: Census Health Needs Assessment

52 3.1 Migrants Auckland has a large migrant population. Two out of five (42%) Auckland residents were born overseas (compared to 25% nationally). This includes 63,113 people of European/Other ethnicity, 23,486 Pacific people and 115,700 Asian people; as a percentage, 82% of Asian people, 45% of Pacific people and 27% of people of European/Other ethnicity. Of these migrants, 28% have lived in New Zealand less than 5 years. English language ability is important in order to participate in New Zealand society. Among Auckland s adults in 2013, it was estimated that 4.8% could not hold a conversation in English about everyday things. The Auckland DHB Interpreting Service provides face-toface and telephone conference call interpreting, appointment confirmation and document translation, in both primary and secondary health care settings, to assist this group to access health services. Figure 3.1.1: Number of migrants living in Auckland by duration of residence, 2013 Number 140, , ,000 80,000 60,000 40,000 20,000 0 Pacific Asian Other less than 5 years 5-9 Years 10 Years or More Source: Census 2013 Usually Resident population 11 Health Needs Assessment

53 4 Population Health Drivers Many factors affect the health of individuals and communities. Whether people are healthy or not, is determined, for the most part, by an individual s socio-economic circumstances and their environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level and our relationships with friends and family all have considerable impact on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. Most of the information in this section is taken from the 2013 census, NZ Health Survey pooled results for , and from the Quality of Life (QoL) Survey 2012 (note: QoL data includes all of Whau ward and all of Mangere-Otahuhu ward) Deprivation The index by which we measure the relative prosperity or deprivation of our population is calculated from census information. It is based on averaged information about the households and individuals in the area and incorporates factors such as income, employment, qualifications, internet access, home and car ownership, overcrowding and single parent households. The ranked categories are calculated so that as nearly as possible, one-tenth of the population of New Zealand falls into each. (University of Otago, NZDep13 deprivation index by census area unit based on 2013 census). On this basis, Auckland has a similar profile to New Zealand as a whole. Almost one in five (19%) of our total population, and 22% of children under five years, live in the poorest areas (NZDep13 decile 9 and 10, or Quintile 5), and 23% of our population live in areas of the wealthiest two deciles. Māori and Pacific people are much more likely to live in NZDep13 Quintile 4 and 5 areas. The most deprived areas are concentrated in Rosebank/Avondale in the west, Mt Roskill and the CBD, and the eastern and southern areas from Glen Innes to Mt Wellington and Otahuhu. The least deprived areas are Orakei, Glendowie, Remuera, Herne Bay and Mt Eden. Figure 4.1.1: Deprivation by ethnicity 100% 80% 60% 40% 20% 0% Māori Pacific Asian Other Total ADHB The chart of deprivation by ethnicity is approximate only and is calculated from Census Area Unit data. Figure 4.1.2: Proportion in each NZ deprivation quintile, by local board area 100% 80% 60% 40% 20% 0% NZ NZ Deprivation Quintiles; Q1 = least deprived Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 12 Health Needs Assessment

54 Figure 4.1.3: Geographic spread of deprived areas, Auckland DHB 13 Health Needs Assessment

55 4.2 Income, Education and Employment Economic factors such as income, occupation and education are powerful determinants of health. The median annual income for Auckland individuals aged 15 years and over in 2013 was $31,500, higher than the national figure of $28,500. When the high cost of housing in the Auckland region is taken into account, disposable income is lower than this figure suggests. While 29% of European/Other people have an income of under $20,000 per year, the percentage is much higher for Māori (41%), Pacific (47%) and Asian people (48%). Women are much more likely to be on low incomes than men. However, the figures should be treated with caution because many people did not respond to census questions about income. The Quality of Life survey in 2012 found that almost one in four people (24%) felt they did not have enough income to meet their everyday needs. Overall 12% of people in Auckland left school with no qualification, but this figure is much higher for Pacific people (30%) and Māori (24%). By contrast, 10% of Asians have no qualifications. At the high end of educational achievement, 38% of Asian people have tertiary or higher qualifications and 39% of European/ Other people, but only 20% of Māori and 10% of Pacific people. 4.3 Housing Poor quality housing, including poor physical living conditions, overcrowding and lack of heating constitutes a significant health risk particularly for the young and old. In Auckland region, crowding is much more common amongst Māori (25% living in overcrowded houses), Pacific (45%) and Asians (19%) than Europeans/Others (6%) (Census 2013). Within Auckland DHB, overcrowding is most common in Mangere-Otahuhu (43% of people living in overcrowded houses) and Maungakiekie-Tamaki (23%), but in every board except Waiheke Island and Orakei, the proportion of people living in crowded housing is higher than the national average. Across the region, 22% of children aged under 15 years live in crowded houses. Nationally 3% of households use no heating fuel, however in Auckland DHB the figure is 7.6%. A high proportion of households in Waitemata board area (15.8%) report using no fuel, possibly reflecting a large number of apartments. There are also high proportions using no fuel in Mangere-Otahuhu (12.3%), Great Barrier (7.6%), Maungakiekie-Tamaki (7.1%) and Whau (6.3%). The Auckland region has the least affordable housing for purchase in New Zealand, with an affordability index (the ratio of cost to income) of At the time of the 2013 census, Māori and Pacific people were more than twice as likely to be unemployed as other ethnicities, at 14% and 16% respectively, compared with 5% of Europeans/ Others and 10% of Asian people. Figure 4.2.1: Percentage of population aged 15+ years with income under $20,000 by ethnicity, % 50% 40% 30% 20% 10% 0% Source: Census , 36% higher than the New Zealand average of 21.8 (Massey affordability index report Nov 2013). Auckland region is also the least affordable region for renters, with households on average paying 35% of income on rent, compared with a national average of 31%. Renting is common in Auckland, with 40% of households living in rented housing, compared with 29% nationally. The 2013 census recorded 2,040 Auckland residents as homeless (living in mobile and improvised dwellings, roofless or rough sleepers, or living in boarding house, night shelter or welfare institution). Figure 4.3.1: Proportion of people living in a crowded house by local board, % 40% 30% 20% 10% 0% Māori Pacific Asian Other Total Auckland DHB Source: Statistics NZ. Overcrowding is defined as a deficit of one or more bedrooms on the Canadian National Occupancy Standard. NZ Health Needs Assessment

56 4.4 Environmental factors Auckland has relatively good air quality compared with other cities and towns in New Zealand. However, some parts experience quite high air pollution, which is primarily generated by motor vehicle emissions and by indoor heating fires. The Health and Air Pollution in New Zealand report 2012 estimated that in 2006, amongst adults aged over 30 years, Auckland DHB had 56 premature deaths per year due to motor vehicle pollution and 37 due to pollution from domestic fires. Māori made up 11% of these deaths (6 and 4 respectively). Air pollution also causes hospital admissions for cardiac and respiratory problems. In Auckland in 2006, motor vehicle pollution caused 9 cardiac admissions; it also caused 18 respiratory admissions, of which 6 were for children under 5 years old and 4 were for children aged 5-14 years. Indoor heating fires caused 7 cardiac admissions; they also caused 12 respiratory admissions, of which 4 were for children under 5 years old and 3 were for children aged 4.5 Social factors Social support and good social relations make an important contribution to health. Social support helps give people the emotional and practical resources they need. Belonging to a social network of communication and mutual obligation makes people feel cared for, loved, esteemed and valued. This has a powerful protective effect on health. Supportive relationships may also encourage healthier behaviour patterns. (WHO 2003) The Quality of Life survey reports that about half (48%) of people in Auckland feel that there is a sense of community where they live and 62% feel that people can usually be trusted. Over one-third (38%) of people feel isolated some of the time. Many older people, and older women in particular, live alone. Four out of five people (80%) are happy with their quality of life but only 58% with their work/life balance. Internet access, which is now a cornerstone measure of opportunity, information and communication, is available in 84% of Auckland DHB households compared with 77% of households nationally. A mobile phone is available in 86% of Auckland households. Single parenting is an issue that affects almost every part of the population. While singleparent homes exist in significant numbers across nearly all ethnicities (15%), some ethnicities have higher rates than others, for example 33% of Māori children live in single parent families. Single parent homes often have lower socio-economic status and children are at an increased risk of emotional and behavioural problems and more likely to have poor school performance years. The Quality of Life Survey 2012 found that 22% of Auckland residents considered air pollution to be a problem. Greater use of public transport would contribute to reducing air pollution. Car transport remains the dominant mode of travel to work in Auckland with 83% of employed people travelling to work by car. Bus or train is the mode for 8% of people (Census 2013). Means of travel to work has been relatively stable since 1996 although there has been a slight increase in use of public transport and slight decrease (three percentage points) in car use. Most people living in Auckland have access to safe reticulated sources of drinking water. However, 35% of Auckland residents felt that there was pollution of lakes, streams or the sea (Quality of Life Survey 2012). Figure 4.5.1: Proportion of people who feel isolated by ward, % 50% 40% 30% 20% 10% 0% Source: NZ Quality of Life Survey 2012 Figure 4.5.2: Proportion of children living in single parent families, % 30% 20% 10% 0% Always Most of the time Sometimes Māori Pacific Asian Other Total Source: Census 2013 Auckland DHB NZ 15 Health Needs Assessment

57 4.6 Violence and crime Crime affects not only the health of individual victims but also community life. Fear of crime can also influence the health and well-being of individuals and communities. People may make adjustments to their lifestyles and behaviour as a result of an experience of crime or fear of crime for example, not going out after dark, not using public transport and avoiding certain areas. The concentration of crime in particular neighbourhoods means that the adoption of avoidance measures can weaken social ties and undermine social cohesion. Three quarters of people (74%) think unsupervised children are safe in their area, but 42% do not feel safe walking alone at night in their neighbourhood. Police records of offences in general and of violent offences peaked in 2009 and have declined since, but have not dropped back to pre-recession levels. This is in line with national trends. There were 29 hospitalisations per 100,000 population for domestic violence in Auckland in The rates were very different between ethnic groups, with 135 per 100,000 population for Māori, 58 per 100,000 population for Pacific people and 14 per 100,000 population for Europeans/ Others. These figures are not age-standardised and the difference between ethnic groups partly reflects the age distribution of each population. Figure 4.6.1: Recorded rates of violent offences recorded rate per 1000 population Auckland Police Source: Statistics NZ, Offences recorded by NZ police authorities NZ Cultural factors Culture and cultural beliefs to explain ill health can have a profound effect on health, acceptance of treatment and use of services. For example, Māori views on health are framed by an holistic approach that encompasses four key elements, wairua (spiritual), hinengaro (psychological), tinana (physical) and whanau (extended family). Karakia (blessing or prayer) plays an essential part in protecting and maintaining these four key elements of health. Amongst Māori people in Auckland, 21% do not know their Iwi and approximately 82% cannot speak Te Reo Māori. Many people in Auckland are immigrants and may be dislocated from their culture. This is particularly the case for Asians, of whom 81% are immigrants, and Pacific people (43% are immigrants) but is also common amongst other ethnicities. 16 Health Needs Assessment

58 5 Modifiable Risk Factors Lifestyle factors have a significant impact on overall health and well-being and are key contributors to cancer, cardiovascular disease and diabetes, which are major causes of death and poor health in our population. The Ministry of Health has estimated the burden of disease across New Zealand. They use a measure called disability-adjusted life years (DALYs) that includes burden from early death and from lives led with disability. In terms of modifiable risk factors that drive this health loss, four lifestyle factors have a major impact: smoking (9.1% of health loss), obesity (7.9%), physical inactivity (4.2%) and poor diet (3.3%). Three further factors can be modified by lifestyle changes and by pharmaceuticals: high blood pressure (6.4% of health loss), high blood glucose (4.6%) and high cholesterol (3.2%) (Health Loss in New Zealand, 2013). Obesity may be reduced by surgery. These risk factors are present in the Auckland population at rates of 10.1% medicated for high blood pressure, 8.3% medicated for high cholesterol and 6% with diabetes (NZ Health Survey 11/13, VDR 2013). Figure 5.1: Attributable burden of disease (percentage of DALYs) for selected risk factors, % in However, rates are higher amongst some groups, notably Māori (26%), Pacific people (22%) and younger adults. The proportion of Year 10 students who smoke has declined dramatically over the last 10 years, from 16% in 2003 to 5.5% in 2013 (ASH Year 10 surveys). For all ethnicities except Māori, women have lower smoking rates than men. In the quarter July to September 2014, nearly all smokers who are admitted to hospital (96%) and all those who see their family doctor receive brief advice to quit smoking. Auckland DHB bans smoking on all of its premises. Figure 5.1.1: Proportion of people who are regular smokers of cigarettes by age group and ethnicity, Auckland DHB 40% 35% 30% 25% 20% 15% 10% 5% 0% Female Male Māori Pacific Asian Other Source: Census 2013 Figure 5.1.2: Proportion of adults aged 15+ years who were regular smokers of cigarettes 25% 20% 15% Notes: Attributable burdens are not additive across risk factors. Source: Health Loss in New Zealand, Smoking Smoking is the most significant cause of premature and preventable death in New Zealand. Eleven per cent of Auckland adults are regular smokers of cigarettes (one or more per day). This is considerably lower than for New Zealand as a whole (15%) and has reduced from 10% 5% 0% 2001 census 2006 census 2013 census Auckland DHB NZ Source: Census Health Needs Assessment

59 5.2 Diet and Physical Activity Over-consumption of fats and sugars leads to excess weight and high cholesterol levels, while too much salt can contribute to high blood pressure. These are risk factors for cardiovascular disease and diabetes. Nutrition is complex and we only have limited information at DHB level. In Auckland DHB, only 60% of adults eat the recommended daily intake of vegetables and only 57% eat the recommended daily intake of fruit, although women have a healthier diet than men. Māori, Pacific and Asian people are also less likely to have the recommended intake of vegetables. Children in Auckland tend to have healthier eating habits than their national peers, although still far from ideal, and they are more likely to eat fast food. At three months of age, 60% of babies seen by Plunket in Auckland are fully breastfed, compared with 56% nationally. European/ Other babies are more likely to be breastfed than Māori, Pacific and Asian babies, in Auckland DHB and New Zealand. Physical activity is protective against health conditions such heart disease, type 2 diabetes and certain cancers. It also helps to reduce the prevalence of overweight and obesity. Half of Auckland adults are regularly physically active and undertake at least 30 minutes of exercise five days a week. Pacific and Asian people are the least likely to be physically active (47% and 45% respectively). Active travel to work or school is a good source of physical activity. Just under half of New Zealand school children walk, cycle or otherwise travel actively to school. Māori (53%) and Pacific (56%) are a more likely to travel actively to school than Asian (48%) and European/Other children (45%; NZ Health Survey 2011). Amongst employed adults, 6.5% in Auckland Region biked, walked or jogged to work (Census 2013). Obesity is associated with a wide range of health conditions including cardiovascular disease, various types of cancer, type 2 diabetes, kidney disease, osteoarthritis, gout, gallstones, complications of pregnancy and mental health issues. For adults, obesity is defined here as a body mass index (BMI) of 30 or above, and for children obesity is defined as a BMI above Cole cut-offs (international standard reference points for BMI by age and gender). Half (51%) of women and 61% of men in Auckland are overweight or obese. One in five of our adult population is obese (similar to the rate in 2003), compared to 30% of the national population. However, obesity is much more common in our Māori (46%) and Pacific (61%) populations and much less common in our Asian population (12%). Amongst children aged 2-14 years, 4% of European/Other and Asian are obese, but 20% of Māori children and 30% of Pacific children are obese. Overall, 9.9% of Auckland children are obese and 26.8% are overweight or obese. Figure 5.2.1: Proportion of Plunket babies fully breastfed at 6wks/3mths or partially breastfed at 6mths, % 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Plunket NZ Figure 5.2.2: Obesity (age-standardised) by age group and ethnicity, % 60% 50% 40% 30% 20% 10% 0% Māori Pacific Asian Other Total Māori Pacific Source: NZ Health Survey ; obesity defined as body-mass index >= 30 (adults) or above Cole cut-offs (children) Asian Other Total Māori Pacific Asian 6 weeks 3 months 6 months Auckland DHB NZ Other Total Māori Pacific Asian Other Total Māori Pacific Asian Other Total Adults 18+ yrs Auckland DHB Children 2-14 yrs NZ Health Needs Assessment

60 5.3 Alcohol and Drugs As well as its acute and potentially lethal sedative effect at high doses, alcohol has effects on every organ in the body (Health Promotion Agency). Alcohol use accounts for 5.6% of health loss (Health Loss in New Zealand 2013). Four out of five (80%) adults and young people in New Zealand drink alcohol. In Auckland, 18% of adults drink alcohol in a way that is classified as hazardous. Men are far more likely to be hazardous drinkers (25%) than women (10%). The rate for Māori (38%) is much higher than for Pacific (24%), Asian (4%) and European/Other (25%) ethnicities. Illicit drugs account for 1.2% of health loss from all causes (Health Loss in New Zealand 2013). The 2007/08 survey of drug use in New Zealand found that marijuana was the most commonly used illegal drug in Auckland and New Zealand with about 15% of people having used it in the last year. Māori were particularly likely to have used it (39%), whilst its use was very rare amongst Asians. Figure 5.3.1: Proportion of adults who are hazardous drinkers (age-standardised), % 35% 30% 25% 20% 15% 10% 5% 0% Māori Pacific Asian Other Total Auckland DHB Source: NZ Health Survey NZ Nationally other drugs most commonly used are nitrous oxide, Kava, Ecstasy and amphetamines; but each of these was tried by less than 4% of people in the last year. Party pills were commonly used in 2006, however since this survey party pills have been made illegal. Police offences records show that possession of marijuana constituted 68% of recorded illicit drug possession offences in Auckland in 2013, and amphetamine/meth-amphetamine constituted 22%. In the 2013 New Zealand Arrestee Drug Use Monitoring System (NZADUM) survey, 50% of the police detainees had tried methamphetamine in their lifetimes, 30% had used it in the past year and 19% had used it in the past month. Detainees in Auckland Central were more likely to have recently used methamphetamine than those in Christchurch Central and Whangarei. 19 Health Needs Assessment

61 6 Health Status 6.1 Overall health Overall, the self-reported health status of Auckland residents is excellent. More than 91% of adults in Auckland report that their overall health is excellent, very good or good. (New Zealand Health Survey ) The following sections look at how long we are living and at the key diseases which shorten our lives through avoidable deaths, and those causing avoidable hospital admissions. The most significant diseases causing health loss, measured in DALYs, are cancers (17.5% of the total burden), vascular and blood disorders including coronary heart disease and stroke (17.5%), mental disorders (11.1%), musculoskeletal disorders especially back disorders (9.1%) and injury (8%). Together these account for almost two thirds of the burden of all disease. Other important conditions are chronic obstructive pulmonary disease (COPD, 3.7%) and diabetes (3%). (Health Loss in New Zealand 2013) Figure 6.1.1: Percentage of DALYs by condition group, New Zealand, 2006 Vascular and blood disorders Cancers and other neoplasms Mental disorders Musculoskeletal disorders Source: Health Loss in NZ 2013 Injury Neurological conditions Respiratory disorders Infant conditions and birth defects Diabetes and other endocrine disorders Reproductive and gestational disorders Gastrointestinal disorders Infections Genitourinary disorders Skin disorders Sense organ disorders Dental disorders 0% 10% 20% Life expectancy In 2013 life expectancy at birth in the Auckland DHB area was 82.7 years, a little higher than the national figure of 82.1 years. For New Zealand as a whole, the trend has been an increase in life expectancy of 2.8 years per decade over the last 15 years. For Auckland, the increase has averaged 2.6 years per decade. Life expectancy varies across ethnic groups with Māori living 79.3 years on average and Pacific people 77.0 years, while Europeans/Others live 83.6 years. Women live 2.7 years longer than men. While total life expectancy for Māori and Pacific has increased, it has done so at the same rate as life expectancy of European/Other people and the long-term trend in the gap has remained at around seven years. Circulatory disease, cancer and diabetes accounted for over half the difference in life expectancy between Māori and Pacific people when compared to European/Other ethnicities in Auckland. Accidents were also a large contributor to the gap for Māori men and respiratory diseases were important for Māori women. Figure : Life expectancy at birth LEB (Years) Auckland DHB Source: Ministry of Health mortality data collection NZ 20 Health Needs Assessment

62 6.1.2 Life expectancy (continued) Figure : Average life expectancy at birth in Auckland DHB (years) by ethnicity; male and female combined LEB (years) Māori Pacific Others Source: Ministry of Health mortality collection; Statistics NZ population estimates based on census 2006 Figure : Causes of life expectancy gap between Māori/Pacific and European/ Other men in Auckland DHB, Figure : Causes of life expectancy gap between Māori/Pacific and European/Other women in Auckland DHB, Difference in life expectancy (years) Māori Male Pacific Others Respiratory Accidents Endocrine Cancer Circulatory Difference in life expectancy (years) Māori Pacific Female Others Infectious disease Digestive Accidents Endocrine Respiratory Cancer Circulatory 21 Health Needs Assessment

63 6.1.3 Total Mortality About 2,500 people die each year in Auckland and 80% of these are aged over 65 years. The most common causes of death are cardiovascular disease (29%), cancers (28%), respiratory diseases (8%) and nervous system diseases (5%). The age-standardised mortality rate in 2013 was 348 deaths per 100,000 population, compared with 370 for New Zealand as a whole. Mortality rates are highest in Mangere-Otahuhu (agestandardised 850 per 100,000 population, standardised to Auckland Region ) and Mangakiekie-Tamaki (790 per 100,000 population). As well as looking at mortality rates, it is helpful to measure how many years of life are lost for each person who dies before the age of 65. This calculation gives more weight to the deaths of younger people. The age-standardised rate of potential years of life lost (PYLL) per 1,000 people was 18 for Auckland, compared with 25 for New Zealand as a whole. This suggests that Auckland is doing better than average at avoiding mortality amongst younger people. Māori and Pacific lose three times as many years of life as European/Others per 1,000 population. Figure : All deaths, age standardised mortality rate per 100,000 population, Per 100,000 population Figure : All deaths, age-standardised mortality rate per 100,000 population by local board, 2011 Rate per 100, Source: StatPlanet, standardised to Auckland Region population Figure : ASR of Potential Years of Life Lost per 1,000 population, 2013 PYLL rate per 1,000 population Auckland DHB NZ Auckland DHB NZ Figure : ASR of Potential Years of Life Lost per 1,000 population, by ethnicity and gender, Auckland DHB residents, Source: Ministry of Health Mortality Collection, standardised to WHO population PYLL per 1,000 population Māori Pacific Asian Others Female Male 22 Health Needs Assessment

64 6.1.4 Avoidable causes of mortality Avoidable mortality includes deaths occurring in those aged 0-75 years (excluding stillbirths) that could potentially have been avoided through population-based interventions or through preventive and curative interventions at an individual level. Prevention includes successful public health promotion (including lifestyle changes) and injury prevention. In 2011, 620 deaths (26% of the total) were considered potentially avoidable. The leading causes of avoidable mortality in Auckland are ischaemic heart disease (IHD), lung cancer, injury, colorectal cancer, stroke and chronic obstructive pulmonary disease (COPD). For women breast cancer is also important and for men unintentional injuries are important. The mortality rate for COPD is largely due to high rates for Māori and Pacific. The very marked differences between groups highlight the opportunity for reduction in health inequalities. Men have a 36% higher avoidable mortality rate than women. Māori and Pacific avoidable mortality rates are more than double that of European/Other ethnicities. The chart below shows the rates that could be avoided through primary prevention (avoiding occurrence of disease eg through immunisation or lifestyle related interventions), secondary prevention (detecting and addressing disease before the appearance of symptoms eg by treating hypertension) and tertiary prevention (treatment and rehabilitation eg by surgery). Figure : Most common causes of avoidable mortality, combined Female Figure : Avoidable mortality by ethnic group (age-standardised per 100,000 population), Rate per 100,000 Male Cause Mortality prevented by avoiding occurrence of disease Mortality prevented by early detection of disease Age-standardised rate per 100,000 population Breast Cancer 13.9 Lung Cancer 12.0 Ischaemic heart disease 8.8 Colorectal cancer 7.3 Cerebrovascular disease 7.2 COPD 6.3 Ischaemic heart disease 34.9 Lung Cancer 17.4 Unintentional injuries 12.9 Intentional injuries 11.7 Cerebrovascular disease 11.4 Diabetes 9.4 Colorectal cancer 9.3 COPD 7.0 Mortality prevented by treatment Total Māori Pacific Asian Other 23 Health Needs Assessment

65 6.2 Specific conditions Cardiovascular disease Cardiovascular diseases (CVD) are diseases affecting the heart and circulatory system. They include ischaemic heart disease, rheumatic heart disease, cerebrovascular disease and other forms of vascular and heart disease. Cardiovascular disease is the leading cause of death in Auckland DHB. It is also the leading cause of years lost to premature mortality. The main risk factors for cardiovascular disease including stroke are high blood pressure, high body mass index, high cholesterol, tobacco use and low physical activity (Health Loss in New Zealand 2013). These risk factors interact with each other, for example low physical activity contributes to high body mass index, high blood pressure and high cholesterol. Cardiovascular disease is exacerbated and compounded by diabetes. Overall, around 70% of the burden of cardiovascular disease is attributed to modifiable risk factors and is preventable through adopting a healthy lifestyle, and manageable with lifestyle change, early intervention and effective management. The age-standardised mortality rate (ASR) from CVD of the Auckland DHB population was slightly lower than the New Zealand rate (102 per 100,000 population vs 106 per 100,000 population). The rate for men (122 per 100,000 population) was much higher than for women (83 per 100,000 population). Amongst men, it was more common in Māori (178 per 100,000 population) and Pacific (223 per 100,000 population) than Asian (85 per 100,000 population) and European/Other ethnicities (95 per 100,000 population). The rate for Māori women was also high at 153 per 100,000 population. For both Auckland and the country as a whole, the mortality rate for CVD has reduced from over 140 per 100,000 popultaion since Figure : Age standardised mortality rate per 100,000 population for cardiovascular disease by year, male and female, all ages Rate per 100,000 population Auckland DHB New Zealand Figure : Cardiovascular disease mortality by ethnic group (ASR per 100,000 population), combined Rate per 100, Māori Pacific Asian Other Auckland DHB NZ 7.1 Source: Ministry of Health Mortality data collection 24 Health Needs Assessment

66 Within Auckland DHB, 90% of eligible adults have been assessed within the past five years for their risk of cardiovascular disease and diabetes. One in nine Auckland adults takes medication for high blood pressure, and one in 11 takes medication for high cholesterol (NZ Health Survey ). A higher proportion of Māori and Pacific people are on these medications than European/Other and Asian people, reflecting higher rates of cardiovascular disease (CVD) within these populations. Current New Zealand guidelines recommend that people who have had a heart attack or stroke should be treated with a combination of medications also known as triple therapy. These medications include aspirin, a cholesterol-lowering drug and a blood pressure lowering drug. Of Auckland residents who have been admitted to hospital with CVD in the previous 10 years, 56% are on triple therapy, just below the national average of 58%. This rises to 65% amongst people who also have diabetes. Men (57%) are more likely than women (48%) to be on triple therapy. (Atlas of Healthcare Variation, 2011) Rates of cardiac investigation and surgery carried out in public hospitals for Auckland residents are similar to the national average. Figure : Heart and Diabetes Checks 100% 90% 80% 70% 60% 50% 40% Jan- Apr - Jul - Oct - Jan- Apr - Jul - Oct - Jan- Apr - Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun 2011/ / /14 Auckland DHB Target Source: Ministry of Health quarterly non-financial indicators Stroke Stroke is a sudden interruption of blood flow to a part of the brain, causing damage to the brain cells. The impact of stroke and transient ischemic attack (TIA) can be catastrophic for the individual and family/whanau and is resource intensive for health services. Management of high blood pressure through medication reduces the risk of stroke as well as of cardiac disease (see rates above). The mortality rate from stroke is 21.1 per 100,000 which is similar when compared to New Zealand as a whole. There were 695 strokes leading to hospital admission in Auckland DHB residents in the year to March Approximately 18% of these patients died within 30 days of admission. For patients admitted acutely, the risk of dying is higher if the admission takes place at the weekend, resulting in five excess stroke deaths per year for Auckland DHB. Managing these events according to the New Zealand Stroke Management Guidelines (2012) is essential for improving and maximising health outcomes for people after a stroke, or who are at risk of stroke. It is also important to commence rehabilitation promptly as delays in acute wards may inhibit the crucial motor recovery process taking place shortly after a stroke. 7.9% of eligible stroke patients received thrombolysis (breaking down blood clots using medication), above the national target of 6%. This has ranged between 5% and 14% over the past two years. Four out of five patients (80%) were cared for on a dedicated stroke unit, achieving the national target. Around one in four stroke patients is transferred from acute care to rehabilitation, and of these, between a half and twothirds are transferred within 10 days of having a stroke which is a similar rate to the Regional average. 25 Health Needs Assessment

67 6.2.3 Diabetes Diabetes is a disease which affects the body's ability to control blood glucose. Type 1 diabetes is primarily an inherited condition generally diagnosed in childhood/adolescence. Type 2 diabetes is usually thought of as an adult disease, but is increasingly being diagnosed in children. We estimate that over 28,000 people in Auckland have some form of diabetes, 6% of the population. The number has doubled since 2003 and if it continued to rise at this rate, it would affect 20% of the population in 20 years time. Diabetes prevalence increases dramatically with age reaching 20% of the population for European/ Other/ Asian people by the time people are in their 60s. From the age of 40, prevalence in Māori is increasingly higher than in European/Other/Asian and is even higher for Pacific people and Indians. The presence of diabetes can lead to cardiovascular disease, blindness, dementia, kidney disease and foot problems which may lead to amputations. Early detection and good management can delay or avoid the onset of these problems. Risk assessment for CVD and diabetes has been mentioned above. We need to provide more support to people with diabetes to manage their risk factors such as high blood pressure and blood sugar levels, and to encourage them to attend retinal screening. Of the estimated number of people with diabetes in Auckland, 72% had an annual health check. Just over half (53%) of people with diabetes aged years are known to be wellmanaged (defined as having HbA1c of <64 mmol/mol). Within the last two years, 60% of diabetics have had the recommended retinal screening in the public sector. Type II diabetes, which makes up 90% of diabetes, can be managed by diet alone or by oral medication or insulin. Prescribing rates given here are therefore only a partial indication of the quality of management. Auckland s rate of dispensing regular insulin or metformin in people with diabetes aged 25 and over was 51.7%, the same as the national rate. 18% filled at least one insulin prescription, 58% filled a metformin prescription and 29% filled a sulfonylurea prescription. Auckland has average rates of admission for diabetic ketoacidosis (70 admissions, 0.2% of people with diabetes) and hypoglycaemia (118 admissions, 0.4% of people with diabetes) (Atlas of Healthcare Variation 2014). Admission rates may be an indicator of the quality of management in primary care and/or Emergency departments. In total, people with diabetes used 41,558 medical/surgical bed days in 2013, which was 10.3% of all medical/surgical bed days. Between 2006 and 2013, Auckland has seen the rate of lower limb amputations rise from 9 per 100,000 population to 11 per 100,000 population. This increase reflects the growing number of diabetics in the population, and increasing time with diabetes at patient level. Rates of amputation per medicated diabetic person are relatively stable between 0.20% and 0.25%. In 2013 the actual number of amputations was 33. Figure : Diabetes prevalence in Auckland DHB, % 70% 60% 50% 40% 30% 20% 10% 0% Source: Ministry of Health Virtual Diabetes Register, 2013 Figure : Diabetes related non-traumatic lower limbs amputation age standardised rate, Auckland region District Health Boards and New Zealand, Rate per 100, Māori Pacific Indian Other Total Waitemata DHB Counties DHB Auckland DHB New Zealand Health Needs Assessment

68 6.2.4 Cancer Cancer is an abnormal growth of cells that can result in the invasion of normal tissues and which may spread to other parts of the body (metastasis). The main risk factors for cancer are tobacco use, high body mass index, physical inactivity, alcohol use, low fruit and vegetable intake and unsafe sex. For melanoma, sun exposure is also important. (Health Loss in New Zealand 2013). Overall, around 30-35% of the burden of cancer is attributed to modifiable risk factors and is preventable through adopting a healthy lifestyle, and manageable with lifestyle change, early intervention and effective management. Cancer is the second highest cause of death in Auckland, accounting for 28% of deaths. Amongst our residents, the age-standardised mortality rate (ASR) from cancer was 118 per 100,000. This is lower than the national ASR of 126 per 100,000 population. The Māori mortality rate (196 per 100,000 population) and Pacific mortality rate (195 per 100,000 population) are substantially higher than that of European/Other ethnicities (116 per 100,000 population), whilst Asian people have the lowest rate at 73 per 100,000 population. Over the three years from 2009 to 2011, the national cancer mortality rate fell slightly, while the Auckland rate fell slightly in The table to the right shows the ten most common cancers causing death in the Auckland DHB for the 3 year period Sixty-eight per cent of all cancer deaths in Auckland are covered in the top 10 and close to 40% are due to lung, colorectal and breast cancer. The vast majority of deaths occur in the adult population (1,990) compared with only 6 deaths in those aged under 15 years in the same period. The most significant causes of cancer mortality in adults are lung cancer (36 per 100,000 population aged 25 years and over), colorectal cancer (26 per 100,000 population aged 25 years and over) and breast cancer (26 per 100,000 women aged 25 years and over). The lung cancer mortality rates for Māori men (123 per 100,000 population aged 25 years and over) and women (114 per 100,000 population aged 25 years and over) and Pacific men (88 per 100,000 population aged 25 years and over) are more than double the rates for European/Other men (46 per 100,000 population aged 25 years and over). Source: Ministry of Health mortality data collection Figure : Age standardised mortality rate for all cancers by year, Rate per 100, Auckland DHB Source: Ministry of Health Mortality data collection Figure : Top 10 causes of cancer mortality by major site in Auckland DHB for ( )* NZ * Data represent the number of deaths for a 3 year period Cancer type (ICD 10 code) Lung cancer Colorectal and anal cancer Female breast cancer (C33- C34) (C18- C21) Age (years) Total (C50) Prostate cancer (C61) Malignant melanoma of skin Pancreatic cancer Leukaemia Non-Hodgkin lymphoma (C43) (C25) (C91- C95) (C82- C85, C96) Liver cancer (C22) Stomach cancer (C16) All other cancer Total Health Needs Assessment

69 On average, 1,800 people are diagnosed with cancer per year in Auckland DHB, some of whom have more than one cancer. The age-standardised rate of cancers registered in the period was 418 per 100,000 population, lower than the national figure of 443 per 100,000 population. The most commonly registered cancers were breast, prostate, colorectal, melanoma and lung. Within these total figures, Māori and Pacific have higher rates of lung and breast cancer but very low rates of melanoma, compared with European/Others. Asian people have generally low rates of cancer registration, except for lung cancer where Asian men have higher rates than European/Other men. Cancer hospitalisation rates tend to mirror the pattern for mortality, but skin cancer is the top cancer for hospitalisations. The one-year relative survival rate for cancer in Auckland DHB is 79%, which is the fourth-highest in New Zealand. However, Australia performs better than New Zealand in treating cancers. If Auckland DHB had the same five-year survival rates as Australia, 25% of women who die of breast cancer within five years would survive for longer (7 per year). Similarly, 13% who die of bowel cancer within five years would survive for longer (8 per year). For melanoma the difference is 46% (11 per year) and for non-hodgkin lymphoma it is 25% (5 per year). Rapid diagnosis and treatment of cancer increases the options for treatment and the chances of survival. In Auckland DHB we undertake routine screening for cervical and breast cancers. Cervical screening is offered every three years and 75% of eligible women (25-69 year olds) have taken this up, but this varies from 57% for Māori, and 60% for Asian women to 84% for Pacific women and 86% for European/Other women. Breast screening is offered every two years and 71% of eligible women (45-69 year olds) have taken this up, although Pacific women have a higher rate at 89%. To support continued improvement in services and waiting times for people with cancer, accessing faster cancer treatment is a key priority and forms an integral part of the national health targets. Currently 62% of cancer patients wait less than 62 days for treatment or other care to commence, compared with the target of 85% by June : Cancer mortality by ethnic group (ASR per 100,000 aged 25+ years) combined Rate per 100,000 Source: Ministry of Health mortality data collection Figure : Most common causes of cancer registrations for Auckland DHB residents, combined Type Source: NZ Cancer Registry, NZ Mortality data collection Figure : Percentage of women up to date with cervical and breast screening June 2014, Auckland DHB 100% 80% 60% 40% 20% Māori Pacific Asian Other Māori Pacific Asian Other Māori Pacific Asian Lung Colorectal Breast Auckland DHB Registration s NZ One-year relative survival rate Other Deaths Female breast cancer % 154 Prostate cancer % 112 Colorectal cancer % 250 Melanoma % 87 Lung cancer % 383 Other 3,390 1,010 Total 6,584 79% 1, % Māori Pacific Asian* Other Total Cervical smear Mammogram *BSA figure for Other ethnicities includes Asian women Source: National Screening Unit 28 Health Needs Assessment

70 6.2.5 Respiratory disease Respiratory diseases are those conditions that impact the lungs and the airways. They range from acute infections, such as pneumonia and bronchitis to chronic conditions such as asthma and chronic obstructive pulmonary disease (COPD). Respiratory disease accounts for about 190 deaths per year, or 8% of the total in Auckland DHB. Whilst the prevalence of asthma for Māori (14%) and Pacific (11%) is slightly higher than that of European/Other ethnicities (8%) found by the NZ Health Survey 11/13, Māori and Pacific hospitalisation rates are more than four times that of Asians and Europeans/Others, at 240 and 283 admissions, compared with 51 admissions per 100,000 population aged 15 years and over for European/Other and Asian people. Women have more than double the hospitalisation rate of men. Asian people had both a low asthma prevalence (4%) and low hospitalisation rates (51 admissions per 100,000 population aged 15 years and over). Around 10% of non-asian Auckland residents are taking medication for asthma. Amongst people admitted to hospital with a primary diagnosis of asthma (or wheeze in children aged 0-14 years), Auckland had significantly lower rates than average for dispensing one or more asthma inhalers in the year following their admission (63 compared with the New Zealand average of 81 per 1,000 population). Figure : COPD hospitalisation (ASR per 100,000 aged 35+), 2013 Rate per 100,000 1,800 1,600 1,400 1,200 1, Auckland DHB NZ Māori Pacific Asian Other COPD is a particular burden for Māori and Pacific people. Age-standardised hospitalisation rates (ASR) per 100,000 for these groups are 1,611 (Māori) and 1,419 (Pacific), more than three times as high as those of European/Other ethnicity (394 per 100,000 population), and higher than for Māori and Pacific in New Zealand as a whole. One of the main risk factors for COPD is smoking Mental Health Mental ill-health is one of the leading causes of disability and overall health loss. Mental health encompasses an array of disorders including but not limited to: depression, schizophrenia, dementia, intellectual disabilities and developmental disorders including autism. Nationally one in five people have suffered some kind of mental illness in the last year and 3% have suffered from a serious mental illness. Mental illness is also associated with reduced life expectancy of ten or more years resulting from other illnesses, particularly cancer and cardiovascular disease. Even when these disorders are recognised, rates of intervention are lower for this population compared with people without mental illness. There were on average 41 suicides per year in Auckland DHB over the five years to 2011, a disproportionate number of whom were young and Māori. Auckland s age-standardised suicide rate of 8.5 per 100,000 population is slightly lower than the national rate of 10.6 per 100,000 population. People who make an unsuccessful suicide attempt are at high risk of making further attempts and an estimated 9% die within five 29 Health Needs Assessment

71 years. The New Zealand Mental Health survey (2006) found that 0.4% of adults had attempted suicide in the previous year. Twelve per cent of adults in Auckland DHB report that they have depression, anxiety or bipolar disorder (equivalent to around 43,000 people), compared with 16% in New Zealand as a whole (NZ Health Survey ). Women reported these conditions almost twice as often as men. In the Auckland DHB population, 3.6% (approximately 17,000 people) used secondary mental health services in Utilisation rates were higher amongst young people (15-24 years) although rates remained high in later adulthood (25-49 years) for Māori and Pacific. Māori have double the utilisation rates of Pacific and European/Other ethnicities in all age groups except children aged 0-9 years and people aged over 65 years. Asian people have very low utilisation rates. There are wide differences in the rates at which people of different ethnicities are diagnosed and access secondary services for the various types of mental illness. In particular, the prevalence of schizophrenia is more than double in Māori (1,996 per 100,000 population) compared with European/Other ethnicities (733 per 100,000 population). Conversely, European/Other people have a higher prevalence of depression (1,117 per 100,000 population) than do Māori (800 per 100,000 population), Pacific (345 per 100,000 population) and Asian (252 per 100,000 population). Given the higher prevalence of psychological distress for Pacific people, of whom 10% experience distress compared with 5% of European/Other people, the low treatment rate for Pacific people may indicate poor access to services. Almost nine out of ten (89%) adults accessing non-urgent mental health services were seen within 3 weeks and 96% accessed services within 8 weeks. For those aged 0-19 years, a smaller proportion (70%) accessed non-urgent services within 3 weeks and 96% accessed services within 8 weeks. Amongst older adults, 70% accessed non-urgent services within 3 weeks and 94% accessed services within 8 weeks. Two-thirds (66%) of Auckland DHB residents who are admitted acutely to hospital have had pre-admission care (compared to 56% for NZ as a whole) and 78% receive post-discharge care (compared to 62% for NZ as a whole). Auckland DHB also has lower readmission rates than the national average, although rates have been steadily increasing between 2009/ /13, from 6% to 12%. Auckland DHB has the longest mean length of stay in the country at 30 days but this has reduced from 46 days in 2009/10 and continues to decrease. It remains substantially longer than the national average of 18 days. Figure : Rate per 100,000 population seen by secondary Mental Health services by age and ethnicity, 2013 Rate per 100,000 15,000 10,000 5, Source: Programme for the Integration of Mental Health Data (PRIMHD) Māori Pacific Asian Injury Injuries have a substantial impact on the health of the population, both as a leading cause of premature death and through disability following an injury. The age-standardised mortality rate from unintentional injury is 13 per 100,000 population, compared with 18 per 100,000 population for New Zealand as a whole. The rate for men is higher than for women (17 vs 9 per 100,000) and the rates for Māori and Pacific men are particularly high at 58 and 27 per 100,000 population respectively. For older people, falls are the largest cause of injury-related deaths, while for adults aged years, suicide is the largest cause. For younger adults, road traffic accidents and suicide dominate. Injury is also an important cause of hospitalisation. The agestandardised rates for Māori (5,600) and Pacific (5,500) people per 100,000 population are considerably higher than for Asians (1,800 per 100,000) and Europeans/Others (4,100 per 100,000 population). Injury is the leading cause of 30 Health Needs Assessment

72 mortality and hospitalisation for children and young people aged between 1 and 24 years. In 2013/14, Auckland residents made 184,000 claims to the Accident Compensation Corporation (ACC) for injury, an average of five claims for every ten people. The highest rates of claim occur amongst youths and young adults. European/Other people have higher rates than Pacific people and Māori and Asian people have the lowest rates of claim. Soft tissue injuries make up 64% of claims, and 19% are for lacerations and puncture wounds. Fractures and dislocations account for 7% of claims. Most injuries occur at home (45%) or during sport or recreation (27%). Figure : ACC claims for injury per 100 population 2013/14 financial year 100 Rate per 100 population Age group Māori Pacific Asian Other Source: Accident Compensation Corporation Figure : Mortality from injury by cause and age group, Auckland DHB, 2011 Source: Ministry of Health mortality data collection Type Figure : Hospitalisations for all injuries per 100,000 population, Auckland DHB residents, 2012/13 Rate per 100,000 population 6,000 5,000 4,000 3,000 2,000 1,000 Under Total Other accident Accidental poisonings Burns Drownings Falls Intentional self-harm Road traffic injuries Violence Total Māori Pacific Asian Other Source: Ministry of Health national data collection 31 Health Needs Assessment

73 6.2.8 Disability Disability is a broad term and covers a range of conditions. These are broadly grouped into sensory (hearing and vision impairment), physical (mobility and agility), intellectual, psychiatric/psychological, and other disabilities (impaired speaking, learning and developmental delay in children aged 0-14 years, and impaired speaking, learning and remembering for adults). Only regional and national data is available from the 2013 New Zealand Disability Survey. One in five (19%) of the Auckland population had a disability, which was lower than the New Zealand average (24%). Nationally, amongst adults the percentage with a disability increases from 16% amongst young adults (15-44 years) to 59% in older people (65 years and older). Māori and Europeans have higher rates of disability and Asians low rates (26% and 25% vs. 13%). Mobility, agility, hearing, sight and remembering are the most common disabilities in adults while learning, speaking and psychological/psychiatric disabilities are the most common in children. Multiple disabilities are common and over half of those with disabilities report more than one problem. In children disabilities present at birth are the commonest type In middle ages, disease and illness and accidents are important and aging processes impact disabilities in older people. Figure : Prevalence of disability by type of impairment (National) Total Mobility Hearing Agility Learning Psychiatric/psychological Remembering Sight Speaking Intellectual Developmental delay Note: any individual may appear in more than one disability type Source: NZ Disability Survey, 2013 Figure : Prevalence of disability 2013 (National) 80% 60% 40% 20% 0% 0% 5% 10% 15% 20% 25% 30% Māori Pacific Asian Other European 7.1 Source: NZ Disability Survey Sexual Health Information on sexually transmitted diseases is limited in New Zealand. Sexually transmitted infections (STIs) with the exception of AIDs are not notifiable. Surveillance efforts are based on the voluntary provision of data from sexual health clinics (SHCs), family planning clinics (FPCs) and laboratories. Sexual health services in the Auckland region are provided through primary health care, including Family Planning and regional sexual health clinics and youth clinics. In 2013, the national chlamydia rate was 633 cases per 100,000 population, a decrease from 744 cases per 100,000 population in The Auckland region rate was the same as the national rate. More than twothirds of laboratory-diagnosed cases of chlamydia in 2013 were females. Chlamydia is most commonly diagnosed in females in the years age group and in males in the years age group in both the laboratory and clinic settings. Nationally, there has been a steady decline in the chlamydia rate for females in the years age group since (ESR, Sexually transmitted infections in New Zealand 2013) 32 Health Needs Assessment

74 6.3 Infants, Children and Young People Births There has been a gradual increase in the number of births in Auckland, from 6,000 in 2003 to more than 6,500 per year (Statistics NZ Registered Births 2012). The increase has not been steady, with the year-onyear change in live births ranging from a drop of 340 to an increase of 460. The general fertility rate is 40 per 1,000 population of European/Other women aged years. It is much higher for Māori (86 per 1,000 women aged 15-49) and Pacific (88 per 1,000 women aged 15-49) than for Asian (42 per 1,000 women aged 15-49). In 2012, 208 babies were born to young women aged 15-19, an overall rate of 14.5 per 1,000 women in this age group, compared with a national rate of 25 per 1,000 women aged years. Again the rate was higher for Māori (62 per 1,000 women aged 15-19) and Pacific (38 per 1,000 women aged 15-19). The rate for European/Other and Asians was less than 3 per 1,000 women aged There were 16 terminations of pregnancy per 1000 women aged in 2013 in the Auckland Region, compared with 15 per 1,000 for New Zealand as a whole (Statistics NZ). If these follow national patterns, just over half of women having a termination would have used no contraception. Nationally, looking at all age groups, 19% of pregnancies (excluding miscarriages) are terminated. Poor outcomes for pregnant women and their babies are associated with later engagement with health professionals, smoking during pregnancy and obesity, amongst other factors. Earlier access to a range of health advice, information and interventions can improve health outcomes. Two-thirds (64%) of women were enrolled with a LMC at 12 weeks of pregnancy Again this varied with higher smoking rates amongst mothers under 26 years old, mothers living in areas of high socioeconomic deprivation, and Māori and Pacific mothers. Gestational diabetes also varies across ethnic groups with the highest rates found in Indian mothers (19%), Asian mothers (14%), Pacific mothers (10%) and Māori mothers (8%), compared with 4% in NZ European mothers. (National Women s annual clinical report 2013) In 2013, 6.1% of babies born had low birth weight in Auckland DHB, compared with 6.0% nationally. There were 36 admissions for pregnancy complications for every 100 live births in Auckland (23% higher than for New Zealand as a whole). Pacific mothers were more likely to be admitted, with a complication rate of 45 per 100 live births. In Auckland s hospitals, 30% of all births were by caesarean section. Māori and Pacific mothers were more likely to have normal deliveries. Figure : Trends in live births for Auckland DHB by ethnicity, Source: Statistics New Zealand registered births (2012). In 2013, 42% of women birthing at Auckland facilities were overweight or obese, including 18% who were obese. This varied across ethnicities, with 60% of Māori and 80% of Pacific mothers being overweight or obese. In the same period, 5.7% of mothers reported that they were smoking at the time of booking with an LMC, and 4.5% at the time of giving birth. Figure : Trend in infant mortality rate per 1,000 live births, Per 1,000 live births 3,000 2,500 2,000 1,500 1, Māori Pacific Asian Other Auckland DHB NZ 33 Health Needs Assessment

75 Source: Statistics New Zealand Infants and Children Infant mortality rates in Auckland were lower than New Zealand as a whole at 3.2 per 1,000 live births, compared with the NZ figure of 5.2 per 1,000 live births in However, infant mortality rates were higher for Māori (6.0 per 1,000 live births) and Pacific (6.2 per 1,000 live births) than for Asian (3.9 per 1,000 live births) and European/Other (3.2 per 1,000 live births) ethnic groups. The rate of sudden unexpected death in infancy (SUDI) at 0.8 per 1,000 live births is lower than the national average of 1.0 per 1,000 live births. The death of a child under 14, after the first month of life, is a rare event with an average of 22 deaths a year in Auckland, with half of these being under one year of age. The most common causes of death in infants were perinatal (the period immediately before and after birth) conditions, congenital anomalies, accidental injuries and sudden infant death syndrome (SIDS). In children older than one year, the most common causes were accidents, suicide, heart diseases, cancer and congenital anomalies. In New Zealand we have some of the highest rates of rheumatic fever of any developed country, particularly amongst Māori and Pacific children. The incidence of rheumatic fever in Auckland DHB was 3.5 per 100,000 population, lower than the national incidence of 4.1 per 100,000 population. There were 195 admissions to hospital in 2013 for every 1,000 Auckland children aged 0-14 years for medical or surgical reasons. The most common acute admissions were for respiratory infections, gastroenteritis, injury, asthma, viral infections and skin infections. In 2012/13, there were 21.5 admissions per 100,000 population aged 0-14 for injuries resulting from domestic assault, neglect or maltreatment of children. A General Practitioner (GP) is often the first point of contact when a child becomes unwell. Enrolling with a Primary Health Organisation (PHO) not only ensures that access to a GP can be quick and easy, but also that the PHO has a history of the child s health ensuring the best possible care. PHO enrolment has a number of other benefits including, but not limited to, reminders regarding routine health checks and upcoming vaccination events. The percentage of children enrolled with a PHO by the age of three months was much lower than average (56% in Auckland DHB against a target of 88% and a national average of 63%). Māori infant enrolment was significantly lower at 47%. The rate of referral by LMCs to a Well Child/Tamariki Ora (WTCO) provider was 99% (59% for New Zealand). Completion of core WCTO contacts within the first year of life was 78%, which was below the target of 86% but a little above the national average of 74%. Auckland is close to achieving the immunisation target of 95% at 8 and 24 months, with 94% of children fully immunised at 8 months of age and 96% fully immunised at 24 months of age. Overall, 75% of fouryear-olds received a comprehensive health check before school entry, compared with the target of 90% and the national average of 91%. Figure : Numbers of deaths amongst Auckland DHB children aged 0-14, Maternal & infant Unintentional injuries Intentional injuries Unknown Neurological disorders Cancer Infection Cardiovascular diseases Sudden infant death Endocrine Under 1 yr 1-14 yrs Source: Ministry of Health mortality data collection Health Needs Assessment

76 6.3.3 Young people In 2014, there were 77,000 young people aged living in Auckland DHB, including 8,000 Māori, 10,000 Pacific, 26,000 Asian and 33,000 European/Others. During , an average of 25 young people died each year in Auckland. Most of these died from injury or suicide. There were 116 admissions to hospital for every 1,000 young people in Auckland. The most common admissions were for injury, complications of pregnancy, undiagnosed signs and symptoms, and digestive system disorders. Figure : Numbers of deaths amongst Auckland DHB young people aged 15-24, combined Suicide and violence Unintentional injuries Cardiovascular diseases Unknown Neurological disorders Cancer Infection Maternal & infant Endocrine Figure : Most common causes of hospitalisation amongst Auckland DHB young people aged 15-24, 2013 Source: Ministry of Health mortality data collection Cause Rate per 1,000 population Injury 28.4 Complication of pregnancy 24.3 Non-specific conditions 13.9 Other digestive system 9.1 Diseases of skin 5.0 Other kidney diseases 5.0 Infectious Diseases 4.7 Other respiratory 3.9 Other diseases nervous system 2.8 Diseases of kidney 2.7 Diseases of musculoskeletal system 2.4 Alcohol abuse 1.8 Source: Ministry of Health data collection (NMDS) 35 Health Needs Assessment

77 6.3.4 Older people There are over 50,000 people aged 65 years or older in Auckland and of these, 6,500 are aged 85 years and older (population projection based on 2013 census). Our older population is predominantly made up of European/Other ethnicities, with 13% of those aged 85 years and older being Māori, Pacific or Asian. The most common causes of mortality and hospitalisation for older people are similar to the population as a whole. In Auckland the leading causes of death amongst older people are IHD, stroke, COPD, lung cancer and diabetes. Cancers altogether account for 25% of deaths. In winter the number of deaths increases and Auckland DHB records 63 extra deaths compared with the number that we expect during the warmer months. The leading causes of hospitalisation are for injuries, IHD and angina, respiratory infections, musculoskeletal diseases and diabetes. In 2013, there were 444 hospital admissions for every 1,000 older people in Auckland. Older people have higher levels of health need and often have multiple health problems. The NZ Disability Survey 2013 found that nationally 59% of people aged 65 years and over have a disability, with 46% having mobility problems, 28% agility problems, 28% a hearing disability, 11% a sight problem and 10% having difficulty with remembering. In Auckland DHB, 18% of older people have ischaemic heart disease, 24% have diabetes, 43% have arthritis and 11% have a mental health disorder (NZ Health Survey ). Around 7% of those aged over 65 years have dementia and this rises to over 25% in people aged 85 years and over. Figure 6.4.1: Hospital discharges per 1,000 Auckland DHB people aged 65+ years, 2013 Female Male Condition Rate Injury 67.5 Non-specific conditions 47.6 Musculoskeletal diseases 18.2 Ischaemic heart diseases 12.3 Chronic lower respiratory diseases 13.7 Diabetes 11.4 Injury 60.3 Non-specific conditions 56.9 Musculoskeletal disease 21.1 Ischaemic heart disease 20.0 Chronic lower respiratory diseases 15.0 Diabetes 14.3 Source: Ministry of Health data collection (NMDS); not age-standardised influenza vaccinations to those aged 65 years and over. Almost two-thirds (63%) of people over the age of 65 have received an influenza vaccine in the last year. Evidence suggests the effectiveness of influenza vaccination in the community-dwelling elderly is modest. There is some evidence that in long-term care facilities, influenza vaccination is effective against complications. (National Specialist Influenza Group 2014). Figure 6.4.2: Falls admissions for Auckland residents per 1,000 population aged 65 years and over, 2013/ Falls are a common cause of hospital admissions for injuries, causing 45 admissions per 1,000 people aged 65 years and over. Older people are more at risk, with the rate ranging from 12 admissions per 1,000 people aged years rising to 191 admissions per 1,000 people aged 90 years and over. Of the patients admitted with a fractured neck of femur, 89% are aged 65 years and over. The large majority of older people in Auckland are able to live unassisted in their own homes. Over half (52%) of people who are 85 years or older receive no funded living assistance, while 26% are funded to live in a rest home or private hospital and 22% have some funded support at home. Many older people continue to work or do voluntary work. Auckland DHB offers free Admissions per 1,000 population Source: Ministry of Health data collection (NMDS) 36 Health Needs Assessment

78 Figure 6.4.3: Proportion of older people receiving support, Auckland DHB, years years 85+ years 96.2% 2.6% 80.9% 52.3% Home with funded support 0.7% 0.5% 12.6% 3.0% 3.5% 15.7% 10.0% 22.0% Rest Home (includes dementia care) Private Hospital (includes psychogeriatric care) No funded assistance Source: HealthPac data collection for residential care claims 37 Health Needs Assessment

79 7 Health services 7.1 Community health care Primary medical care services are often the first point of contact with health services. General practices undertake a number of recommended preventive health interventions including smoking cessation advice and support, CVD risk screening, cervical screening and vaccinations. There are five Primary Health Organisations (PHOs) operating within the Auckland district with 137 general practices and 490 GPs. There are 97 GPs (full-time equivalent) per 100,000 population in Auckland DHB, considerably higher than the national average of 74 per 100,000 population. This varies across the district with 1,900 people per GP in Orakei and 1,500 per GP in Maungakiekie-Tamaki, but only 581 people per GP in the central Waitemata board area. The ratio of GPs per 100,000 population has fallen slightly over the past five years. Overall, 93% of residents are enrolled with a PHO. While people are free to enrol in any practice in the country, 75% of people within Auckland DHB are enrolled with practices in Auckland DHB based PHOs. Only a small proportion of the Auckland DHB population (0.2%) are enrolled outside of the greater Auckland area. The recording of ethnicity in PHO enrolment data contains some errors, but it is clear that Māori and Asians have lower enrolment rates than average with possibly 17% not enrolled. Enrolment rates also vary by age with 25% of year olds and 9% of year olds not being enrolled with a PHO. (Source: Ministry of Health enrolment data.) Three out of four (77%) of the Auckland DHB population have seen a general practitioner (GP) in the last year. Asian people are less likely to have seen their GP and/or the practice nurse. Most people in Auckland DHB (89%) are able to get an appointment with their GP within 24 hours, compared with 86% nationally. One in five people (20%) report problems accessing a GP because of cost, availability of appointments, or transport issues. Overall 11% of adults reported that the cost had prevented them, on at least one occasion in the past year, from visiting a GP. For Māori and Pacific people the figure was much higher at 16% and 18% respectively. Similarly, although overall 4.8% said that cost had prevented them from filling a prescription, the figure was 13% for Māori and Pacific people. (NZ Health Survey) Figure Population per GP by local board, 2011 Source: Statplanet Figure 7.1.2: Enrolment by PHO, October-December 2014 PHO Name Source: Ministry of Health enrolment data Figure 7.1.3: Utilisation of General Practitioner in the past year, 2011/ /13 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Māori Pacific Asian Other All Source: NZ Health Survey Auckland DHB % of Auckland DHB population enrolled with PHO Procare Networks Limited 62% Auckland PHO Limited 11% National Māori PHO Coalition Incorporated Other 10% Not enrolled 7% New Zealand 9% Health Needs Assessment

80 Information about the nature and quality of GP consultations is only available at a national level. Most consultations (88%) are with a GP that the person has seen before. The average consultation lasted 15 minutes and the large majority of people felt their doctor listened to them well and discussed their healthcare with them. Half of the problems GPs were seen for were new problems or short term problems being followed up, about a third were long term problems with only 5% being for preventive care. Two-thirds of people received a prescription from their visit, nearly a third had some form of test and one in six was referred to another health professional Oral health Poor oral health and chronic pain from oral health conditions can negatively affect child growth and development and reduce people s quality of life. Good nutrition and oral health during pregnancy and the establishment of sound oral health behaviours for the infant in the first year of life may prevent childhood dental caries and improve overall child and adult oral health. Auckland children have better oral health than New Zealand children as a whole. However, Māori and Pacific children have poorer oral health than those of other ethnicities. Three out of four pre-school children are enrolled with oral health services in Auckland DHB, which is above the national average although less than the national target of 86%. At five years of age, threequarters (72%) of children are accessing free school dental care. Access rates are lower for Māori (52%). For European/Other five-year-olds, Auckland exceeds the Ministry of Health target for 65% to be caries-free, achieving 71%. We do not meet the target for Māori children (51%) or Pacific children (38%). Five-year-olds in Auckland have an average of 1.6 decayed, missing or filled teeth (dmft). Māori children have an average of 1.9 dmft and Pacific children have an average of 2.9 dmft while European/Other children have an average of 1.2 dmft. Nationally, approximately 66% of children aged 2-11 years brush their teeth twice daily. This is lower for Māori and for those living in in NZDep06 quintile 3-5 areas. Utilisation of community oral health services by adolescents aged years is approximately 73% for Auckland and Waitemata DHBs combined. National data shows that approximately 13% of adolescents aged years have dental decay. Dental decay is more prevalent in Māori and Pacific adolescents and those living in quintile 5 areas. The proportion of adolescents in Auckland and Waitemata DHBs who are caries-free is 45%. Year eight children (12/13- yearolds) in Auckland DHB have an average of 1.0 decayed, missing or filled teeth (dmft). Māori children have an average of 1.3 dmft and Pacific children have an average of 1.6 dmft while European/Other children have an average of 0.7 dmft. Approximately 59% of adolescents brush their teeth twice daily. This is lower for Māori, and those living in quintile 3-5 areas. Approximately one in four adolescents experiences trauma to the upper front six teeth. About 6% of adults have had one or more teeth removed in the past 12 months (due to decay, an abscess, infection or gum disease). Just over half (57%) of European/Other adults, 45% of Māori, 32% of Pacific and 41% of Asian adults have seen an oral health worker in the last year. About half of Auckland residents only visit a dental health care worker for toothaches/dental problems or never. This varies across ethnic groups, with a smaller proportion of European/Other adults (49%) than of Asian (60%), Māori (60%) and Pacific (78%) adults likely to only visit a dental health care worker for toothaches/dental problems or never. Approximately 65% of adults brush their teeth twice daily. Figure : Proportion of Auckland DHB children examined who were caries-free, % 70% 60% 50% 40% 30% 20% 10% 0% Māori Pacific Other 5 year olds 12/13 year olds Source: Ministry of Health Quarterly Non-Financial Indicators 39 Health Needs Assessment

81 7.2 Hospital-based health care Auckland DHB has three major facilities: Auckland City Hospital, Greenlane Clinical Centre and the Buchanan Rehabilitation Centre in Pt Chevalier. We provide emergency, medical, surgical, maternity, community health and mental health services. More than half the work done within Auckland DHB hospitals is for people who live outside Auckland DHB. It is the regional provider for kidney transplantation, neurosurgery, cardiothoracic surgery, ophthalmology, most paediatric surgery, and it is the hub of the regional cancer network. Some specialist services are provided to the whole of New Zealand. These include: organ transplants (heart, lung and liver), specialist paediatric services, epilepsy surgery and high-risk obstetrics Emergency Departments About one in seven of our population has visited a hospital Emergency Department (ED) in the last year. The age-standardised rate of ED attendances by Auckland residents has increased by nearly 60% in six years, rising from 12,300 per 100,000 population in 2007, to 19,400 per 100,000 population in Access to emergency department care is good and 2013/14, 95% of patients were either discharged or moved to a ward within six hours of presenting to the emergency departments. Figure 7.2.1: Emergency Department attendances, agestandardised rate per 100,000 Auckland population ASR per 100,000 population 25,000 20,000 15,000 10,000 5, Source: Ministry of Health national collection (NNPAC) Outpatient services For every 100 males in Auckland DHB there were 67 outpatient attendances and for every 100 females there were 83 outpatient attendances. This includes both consultations with doctors, and treatments such as haemodialysis, physiotherapy and radiotherapy. Pacific people have the highest rates of outpatient attendance (128 per 100 population) and Asian people the lowest (56 per 100 population). Auckland DHB residents have generally similar patterns of use of different outpatient services as residents in other parts of the Auckland region. 40 Health Needs Assessment

82 7.2.4 Admitted patients In 2013, Auckland regional public hospitals provided nearly 203,000 bed days of service for Auckland DHB residents (medical/surgical/maternity, ie excluding mental health and disability support/rehabilitation). This is an average of 560 patients in beds each day. Ninety one per cent of this was provided by Auckland DHB, with 6% provided by Counties Manukau DHB, 2% by Waitemata DHB and 1% by agencies outside the Auckland region. People aged 65 and over make up 10% of the population but account for 27% of medical/surgical admissions and 45% of beds used. The number of people aged 65 years and over is projected to double over the next twenty years and this will cause a large increase in demand for hospital beds. Compared with the New Zealand average, Auckland has a higher admission rate for patients presenting acutely to medical and surgical specialties, but a lower rate for elective admissions. The figures for elective admissions exclude patients who funded their own treatment (through insurance or direct payment). Although the number of admissions per head of population has increased over time, the number of beds used has remained stable, because lengths of stay have reduced, from an average of 3.3 days in 2006 to 2.7 days in Admissions for both adults and children have increased over the last five years. Hospitalisations for medical services are very much dominated by older people, whereas surgical hospitalisation is distributed amongst different age groups fairly evenly. Māori people have lower rates of hospitalisation for elective services, at about 90% of the rate for Pacific and European/Other people while the rate for Asian people is half the rate for Europeans/Others. Figure : Trend in age-standardised admission rates per 100,000 population, medical and surgical specialties, ASR per 100,000 population 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - Acute NZ Elective NZ Source: Ministry of Health national data collection Acute Auckland DHB Elective Auckland DHB Figure : Public hospital admissions per 100 Auckland DHB adults, by ethnicity, Rate per 100 adults 30% 25% 20% 15% 10% 5% 0% Māori Pacific Asian Other Figure : Public hospital admissions per 100 Auckland DHB children, by ethnicity, % 25% Rate per 100 children 20% 15% 10% 5% 0% Māori Pacific Asian Other Source: Ministry of Health national data collection (NMDS) (Not agestandardised) 41 Health Needs Assessment

83 7.2.5 Access to publicly-funded elective surgery The Ministry of Health has set a goal of improving access to elective surgery and equalising access across DHBs. The target for Auckland residents is 13,872 elective surgery discharges for 2014/15. As noted above, the elective hospitalisation rate is still lower than the average for New Zealand, but the gap has been closing since A more tightly-defined measure of access is the Ministry of Health report for selected surgical procedures. This compares the rate for each DHB with the overall rate for New Zealand by calculating standardised discharge ratios. A ratio higher than 1.0 indicates that access is better than the national average. Access to publicly funded cataract surgery for Auckland DHB residents is 9% above the national average, but access to hip and knee replacement surgery respectively is 67% and 89% of the national average. Access to hernia repair is also low at 86% of the national average rate. Access to elective heart surgery is also lower than the national average, at 75% for heart valve replacements and repair and 86% for coronary artery bypass grafts. Figure : Standardised discharge ratios for selected surgical procedures, 2011/ /14 Surgical procedure Coronary artery bypass grafts (CABG) Discharge ratios 2011/ / / Angioplasties The Ministry also sets target intervention rates for a small number of common, effective procedures, in order to improve equity of access across DHBs. Auckland DHB has a higher than average rate of cataract surgery after standardising for age, gender, ethnicity and NZDep06 quintile, at 37 operations per 10,000 population. This exceeds the national target of 27 per 10,000 population. For cardiac surgery, Auckland DHB met the target in 2013 but not in 2014, delivering 5.3 operations against a target of 6.5 per 10,000 population. Hip and knee operation rates continue to fall short of the target, with 17 per 10,000 population against a target of 21. Figure : Surgical Intervention rates per 10,000 population, Auckland DHB residents, 2010/ /14 Rate per 10,000 population Joints (hips/knees) Cataracts Cardiac surgery Auckland DHB Target Heart valve replacements and repair Source: Ministry of Health non-financial indicators Total hip replacement Total knee replacement Cataracts Repairs of hernia Source: Ministry of Health Standardised Discharge Ratios for selected elective surgical procedures) 42 Health Needs Assessment

84 7.2.6 Hospital quality and safety Our hospital services monitor a number of measures of quality and safety. Key amongst these is the hospital standardised mortality ratio (HSMR). For Auckland Hospital, this has remained stable for the past four years at around the average level for comparable hospitals. For Starship hospital, the HSMR level is stable but sits 25% higher than the average for other hospitals. This may be due to its relatively small size and the high complexity of the patients. Hand hygiene in Auckland hospitals is similar to the national average with 76% compliance with the five moments for hand hygiene in The rate of falls in hospital was 4.3 per 1,000 occupied bed days. We also ask patients about their care in hospital and 85% rate it as excellent or very good. Figure : Auckland City Hospital agestandardised mortality ratio trend Source: Ministry of Health Figure : Auckland City Hosptial standardised mortality ratio compared with other New Zealand facilities, Health Needs Assessment

85 7.2.7 Avoidable causes of hospitalisation Avoidable hospitalisation (AH) is a useful measure for examining our ability to improve health and reduce inequalities. Hospitalisation can be avoided by injury prevention, by good quality primary care including management and prevention and by population-based health promotion (such as anti-smoking education). The most common avoidable hospitalisations are for angina, cellulitis, and upper respiratory infections. For women, kidney and urinary tract infections are common. Asthma and diabetes are also common causes amongst Māori and Pacific people. Auckland has a similar avoidable hospitalisation rate to New Zealand as a whole. The Māori avoidable hospitalisation rate is double that of other ethnicities and the Pacific rate is more than double. Asian is lower than European/Other ethnicities. Rates are higher amongst residents of Whau and Maungakiekie-Tamaki than in other local boards. Figure : Age-standardised avoidable hospitalisations per 1,000 population, 2013 Angina and chest pain Māori Pacific Asian Other Cellulitis Upper respiratory infection Gastroenteritis Kidney/UTI Dental conditions < Respiratory infection < Asthma Diabetes Source: Ministry of Health national data collection (NMDS) Figure : Avoidable hospitalisation by ethnic group (age-standardised per 100,000 population), Auckland DHB, 2013 Rate per 100,000 populations 6,000 5,000 4,000 3,000 2,000 1,000 - Avoidable by high quality primary care Injury prevention Source: Ministry of Health national data collection (NMDS) Population-based health promotion Figure : Avoidable hospitalisations by local board area (age-standardised per 100,000 population), 2013 Rate per 100,000 4,000 3,500 3,000 2,500 2,000 1,500 1, Māori Pacific Asian Other Health Needs Assessment

86 8 Data and information sources This section describes the key data sources used in this report. A number of surveys and studies that are specific to certain sections of the report are described in the relevant section. 8.1 Major data sources Ministry of Health The New Zealand Ministry of Health (MoH) manages a number of databases including the Mortality Data Collection, National Minimum Data Set (NMDS), National Non Admitted Patient Data Collection (NNPAC), Cancer Registration data collection and Programme for the Integration of Mental Health Data (PRIMHD). All diagnoses are classified according to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD 10 AM). Hospital discharge data The Ministry of Health collects data on every discharge from a public hospital, in a collection called the National Minimum Data Set (NMDS). Day cases are included in this data but attendances at outpatient clinics or emergency department attendances for care lasting under three hours are not included. Hospital data include patients who die in hospital after formal admission. A general issue with using hospitalisation rates for outcome measures is that reductions in such rates can reflect either a real decrease in incidence, improved primary health care (thus reducing the need for hospital care), or a decrease in access to (or provision of) hospital services. The relative importance of these factors is often not known. This collection is updated continuously. Outpatient data The National Non Admitted Patient Data Collection (NNPAC) provides nationally consistent data on nonadmitted patient activity. Information about the Auckland population s use of outpatient clinics is drawn from this source. Mortality data The mortality statistics maintained by the MoH are based on death certificates completed by medical practitioners, post mortem reports, coroners certificates, and death registration forms completed by funeral directors. Supplementary data are obtained from a variety of other sources (such as public hospitals and the National Cancer Registry). While the total numbers of deaths is available to 2013, detailed information about causes of death is only complete up to Mortality data for 3 years was used in an attempt to ensure sufficient numbers for analysis. Cancer registration data The National Cancer Registry (NCR) was established in 1948 and is now maintained by the MoH. It is a register of people who develop all types of cancer except basal and squamous cell skin cancers. The Cancer Registry Act 1993 requires all pathology laboratories to supply the NCR with a copy of any pathology report with a diagnosis of cancer and related conditions. Programme for the Integration of Mental Health Data (PRIMHD) The information collected by PRIMHD relates to the provision of secondary mental health and alcohol and other drug services, which are funded by the government. Providers include DHBs and, to a limited degree, non government organisations (NGOs). The collection does not include information on primary mental health services. The 2011/12 and 2012/13 New Zealand Health Surveys This national face to face survey was completed in both 2011/12 and 2012/13. The results for the two years were combined to give larger samples and more robust information (Ministry of Health 2013). In 2011/12, the survey had a sample size of 12,370 adults (15 years and older) and 4,478 children (0 14 years). The response rate was 79% for adults and 85% for children. In 2012/13, the survey had a sample size of 13,009 adults (15 years and older) and 4,485 children (0 14 years). The response rate was 80% for adults and 85% for children. Approximately 2000 adults were sampled in the Auckland district for the two surveys. The survey provides information on: selected health risk behaviours (smoking, physical activity and alcohol use) the health status of New Zealanders, including their self-reported physical and mental health status and the prevalence of selected conditions including diabetes the utilisation of health services a number of demographic characteristics such as age, gender, ethnicity and income. 45 Health Needs Assessment

87 Where estimates are provided for Auckland populations they may be either direct survey estimates or synthetic estimates. Since the sample sizes for the overall Auckland population was reasonably large direct estimates can be calculated using only the respondents from Auckland DHB. However, for ethnicspecific estimates, sample sizes were too small so estimates were derived by the Health & Disability Intelligence Unit (HDIU), Ministry of Health from a statistical regression model. These estimates were only available for adults. The main results by DHB (but not by ethnicity within DHB) are available on the Ministry of Health website The Quality of Life Survey This survey was undertaken in 2012 with a sample size of 2,585 adults (18 years and older) across the Auckland Council area. Of these just under 1,000 lived in Auckland DHB wards including Whau and Mangere- Otahuhu. The overall response rate was 57%. The information is available by ward, by age or by ethnicity. The survey covers a wide range of questions on topics that are important to wellbeing. Virtual diabetes register 2013 The Ministry of Health has used data from the community laboratory testing claims system, community pharmaceutical dispensing claims system and from NMDS and NNPaC to construct an anonymised register of individuals diagnosed with diabetes. This can be used to estimate prevalence of diabetes and methods of management. Census and demographic data A New Zealand Census of Population and Dwellings is normally held every five years, but the planned 2011 census was delayed until 2013 because of the Christchurch earthquake. Everyone in the country on census night, including visitors to the country, must fill out an individual census form. This census was carried out in March The New Zealand Census collects limited health information but contains much social and economic information that was useful in describing the factors that determine health. In addition, the census forms the basis for determining Auckland s and New Zealand s denominator populations when calculating rates. Birth registrations This includes all live and still birth registrations from Births, Deaths, and Marriages Health Needs Assessment

88 8.3 References Statistics New Zealand, Census 2013 Statistics New Zealand Population projections updated 2013 (based on 2006 census) Ministry of Health, New Zealand Health Survey 2011/12 and 2012/2013 pooled results Statistics New Zealand NZ, General Social Survey 2012 NZ Quality of Life Survey 2012 (Neilson) Ministry of Health, National Minimum Dataset (NMDS inpatient hospital use) 2013 Ministry of Health, National Non-Admitted Patient Collection (NNPAC outpatient and ED hospital use) 2013 Ministry of Health, Programme for the Integration of Mental Health Data (PRIMHD) 2013 Ministry of Health, Mortality Collection Ministry of Health, Life expectancy 2013 Ministry of Health, Non-financial indicators 2013/14 Ministry of Health, Virtual diabetes register 2013 Ministry of Health, NZ Mental Health Survey 2006 Ministry of Health, NZ Oral Health Survey 2009 Statistics New Zealand, Abortion report 2013 Otago University, NZDEP13 deprivation index by meshbock (based on 2013 census) Goodyear, R & Fabian, A (2014). Housing in Auckland: Trends in housing from the Census of Population and Dwellings 1991 to Available from Massey University 2013, Home affordability Nov 2013 Statistics New Zealand, Rental Affordability , an experimental paper Statistics New Zealand, Offences recorded by police WHO standard population sizes by age group WHO 2003, Social Determinants of Health: The Solid Facts Plunket NZ, Plunket Contract Business Waitemata DHB, Auckland DHB and NZ, 2013/2014 Ministry of Health, Cancer registrations Ministry of Health/HQSP Atlas of Healthcare Variation Ministry of Health, HealthPac claims Ministry of Health, PHO Enrolment collection Ministry of Health, National Maternity Coll Ministry of Health Projections of population sizes for the years after 2013 and estimates of population sizes between the 2006 and 2013 censuses have been made. Projections are made on the basis of assumptions about a number of factors including migration, fertility and mortality. However, projections are not always accurate. Some of the detailed analysis of the 2013 census is not yet available and data from 2006 is shown where this is the case. Health Loss in New Zealand: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study, Wellington: Ministry of Health Ministry of Health, National Cervical Screening Unit, Monthly coverage June 2014; Breast Screen Aotearoa, Coverage June 2014 Action on Smoking and Health (ASH), National ASH Year 10 Snapshot Survey: Youth Smoking in NZ by DHB 2013 Health Promotion Agency Alcohol the Body and Health effects, a brief overview Institute of Environmental Science and Research Limited, Sexually transmitted infections in New Zealand 2013 Accident Compensation Commission (ACC): Claims data Beautrais AL, Collings SCD, Ehrhardt P, et al Suicide Prevention: A review of evidence of risk and protective factors, and points of effective intervention. Wellington: Ministry of Health. Kuschel, Gerda et al, 2012, Updated Health and Air Pollution in New Zealand Study. Auckland, Emission Impossible Ltd, website hapinz.org.nz accessed 19/01/ Health Needs Assessment

89 Appendix 1: Data table Section Indicator Auckland DHB Māori Pacific Asian European/ Other Population projection ,320 39,450 52, , ,340 4,579,530 % of population 100% 8% 11% 30% 51% NZ Our Population National proportions 100% 16% 7% 13% 64% Annual growth % 1.7% 1.4% Under 5 years - number 28,990 4,030 5,230 8,600 11, ,595 Under 5 years - % 6.1% 10.2% 9.9% 6.2% 4.5% 6.6% 65+years - number 52,220 2,160 3,580 9,240 37, , years - % 11% 5% 7% 6% 15% 15% 75+ years - number 21, ,350 3,370 16, , years - % 4.5% 1.7% 2.6% 2.4% 6.6% 6.2% Under 25 years - % 32% 46% 50% 34% 25% 34% 7.1 Population health drivers Deprivation Income, education, employment % living in NZDep13 Quintile 5 (most deprived) areas 18% 27% 40% 21% 12% 20% % leaving school with qualification 88% 76% 70% 90% 79% Unemployment rate 7.9% 14% 16% 10% 5% 7% Median income $31,500 $28,500 Housing Housing affordability (house price vs income - Massey index) House over-crowding (% people needing 1+ bedrooms) % 25% 45% 19% 6% 10% Smoking - % of adults 11% 26% 22% 7% 10% 15% Obesity - % of adults 22% 46% 61% 12% 19% 29% Obesity - % of children 9.8% 20% 30% 4% 4% 11% Overweight - % of children 17% 28% 23% 17% 15% 21% Modifiable risk factors Health Status Overall health Life Expectancy Healthy diet: % eating recommended servings fruit/veges Physical activity: % active 30 minutes per day Breast feeding (Exclusive at 3 months) - % 59% 62% 50% 51% 47% 45% 54% 54% 60% 51% 44% 60% 66% 56% Hazardous drinking - % of adults 18% 38% 24% 4% 25% 17% Self-reported health good, v. good, excellent 91% 90% 86% 91% 92% 90% LE Total population LE Male LE Female Health Needs Assessment

90 Section Indicator Auckland DHB Avoidable deaths per year 620 Māori Pacific Asian European/ Other NZ Avoidable mortality Avoidable mortality rate ASR per 100,000 Potential years of life lost per 100,000 CVD Hospitalisation ASR per 100, CVD mortality ASR per 100, Cardiovascular disease % of pop'n with IHD on triple therapy % of adults medicated for high cholesterol % of adults medicated for high blood pressure 56% 58% 8.3% 10.5% 9.9% 11.7% 6.9% 8% 10.1% 14.6% 14.7% 10.6% 8.7% 11.7% Stroke Stroke mortality ASR per 100, Diabetes Estimated population with diabetes 28,000 % of population with diabetes 6% 5% 12% Indian: 11.5% % of diabetics having annual check % of diabetics on diabetes medication % of diabetics well-managed (HbA1c <64 mmol/mol) % of diabetics receiving retinal screening 72% 69% 53% 60% 5% 6% Mortality ASR per 100, Deaths Hospitalisation ASR per 100, Cancer Mortality rate ASR per 100,000 - lung cancer Mortality rate ASR per 100,000 - colorectal cancer Mortality rate ASR per 100,000 - breast cancer One-year survival rate 79% Respiratory disease Mental Health Breast screening uptake (% of eligible women) Cervical screening uptake (% of eligible women) 71% 70% 89% 69% 75% 56% 84% 59% 86% 77% % of adults on asthma medication 8.1% 13.5% 11.0% 3.9% 9.7% 11.1% COPD hospitalisation ASR per 100,000 Population (PM's Youth MH Project) 46,890 1,611 1, Health Needs Assessment

91 Section Indicator Auckland DHB Māori Pacific Asian European/ Other Suicide ASR per 100, Annual suicides (average ) 41 NZ Injury Sexual health Infants, children and young people Older people Health services Diagnosed with mental health conditions (NZ Health Survey) Injury hospitalisation ASR per 100, % 16% Chlamydia (regional figures) Births per year 6500 Infant mortality rate per 1,000 live births Fertility rate (births per 1,000 women aged 15-49) % of babies with low birth weight 6.1% 6% % of mothers enrolled with LMC at 12 weeks Teenage pregnancy rate (births per 1,000 women aged 15-19) Caesarean sections as % of deliveries at Auckland City Hospital Rheumatic fever incidence per 100,000 pop'n % fully immunised at 8 months Q1 2014/15 % fully immunised at 24 months Q1 2014/15 64% % % 94.7% 97.9% 97.0% 94.1% 92% 95.9% 95.9% 98.6% 98.6% 92.8% 93% % aged > 65 with a disability 59% % aged > 65 with IHD 18% % aged > 65 with diabetes 24% % aged > 65 with arthritis 43% % aged > 65 with a mental health disorder % aged > 85 years receiving funded support at home % aged > 85 years funded for rest home/private hospital % of pop'n aged 65+ receiving influenza vaccination 11% 22% 26% 63% GPs per 100,000 population Community services % of adults who visited GP in last 12 months % of adults unable to visit GP (due to transport, cost, availability) 77% 82% 78% 67% 81% 78% 20% 25% 26% 17% 21% 27% 50 Health Needs Assessment

92 Section Indicator Auckland DHB Māori Pacific Asian European/ Other Acute hospital discharge rate 12,109 11,475 NZ Hospitalbased care Elective hospital discharge rate 2,724 2,922 Avoidable hospitalisations ASR per 100,000 Shorter stays in ED: % admitted or discharged within 6 hours 1,200 1, % 93% Improved access to electives 100% 105% Health targets achievement summary Q1 2014/15 Cancer: % commencing treatment/care within 62 days of referral Increased immunisation: % fully immunised at 8 months % of smokers receiving advice to quit (Hosp/GP) % eligible adults having heart and diabetes checks 62% 96% 92% 96%/100% 95%/88% 92% 86% 51 Health Needs Assessment

93 Health Outcomes In Auckland 7.1 What Should Our Focus Be? Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 88

94 Overview Population Large and growing - 10% of the population of New Zealand live in Auckland DHB region; will be 30% larger in 20 years time Diverse - 31% of our Auckland population is Asian, 8% Māori and 11% Pacific - nearly 200 different languages spoken Poverty - 22% of children under 5 live in the poorest areas (NZDep quintile 5) Aging - 9.6% of the population are over 65 years this will increase to 16% Health 9/10 people rate their health status as good very good or excellent In Top 10 most liveable cities Life expectancy is 82.7 years. Inequalities - Life expectancy gap of 4 years for Māori and 7 years for Pacific Health loss - Cancers, cardiovascular disease and mental disorders are the biggest cause of health loss Diet, smoking, physical activity, blood pressure and cholesterol the biggest causes of preventable ill health 26% of deaths (620) avoidable Utilisation - Increasing utilisation and costs of health care Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 89

95 Determinants of health Education Housing Income Auckland has lower than national rates of early childhood education Average NCEA level 2 achievement rate for Auckland is variable across ethnic groups Asian achievement 86% and Māori 55% The ratio of house prices to income in Auckland has increased to a severely unaffordable level, household crowding and issues with the quality of housing The Auckland region provides more job opportunities and has the highest average household incomes in New Zealand, however when considered with high housing costs, the incomes are lower than many other parts of the country Nationally, the average weekly income is not consistent across ethnicities 7.1 Employment European Māori Pacific Asian MELAA Unemployment rates in Auckland 7.7% - higher than the national average of 6% Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 90

96 Areas of greatest deprivation in Auckland DHB region Waiheke Great Barrier Red - greatest deprivation Green - least deprivation * Note: Gulf Islands not to scale Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 91

97 Life expectancy are we bridging the gap? 4-7 yrs yrs Source: Ministry of Health 2012 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 92

98 Causes of gaps in life expectancy MEN WOMEN 2011 gap most recent cause of death data Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 93

99 Modifiable Risk Factors #3 High Blood Pressure #2 Tobacco smoking 7.1 #1 Adult high BMI #5 High Fasting Plasma Glucose #4 Physical inactivity / low physical activity Lim et al Lancet 2012 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 94

100 Leading Causes of Health Loss Percent of total health loss Total Population Maori Coronary Anxiety and heart diseasedepressive disorders Stroke COPD Diabetes Lung cancer Back disorders Colon and rectum cancers Traumatic OsteoarthritisAlcohol use brain injury disorders Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 95

101 Causes of Death ADHB (2011) Frequency Percent Circulatory disease % Cancers % Respiratory disease 203 8% Diseases of nervous system 140 6% Injury, poisoning 137 5% Mental & behavioural disorders 135 5% Endocrine,nutrition & metaboli 97 4% Diseases of digestive system 86 3% Diseases of genitourinary system 37 1% Other causes % Grand Total % 7.1 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 96

102 Avoidable Causes of Death ADHB (2011) Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 97

103 Healthy Lifestyles Major risk factors - smoking, obesity, high blood pressure, high blood sugars, physical activity and alcohol are the biggest causes of preventable ill health 7.1 ADHB NZ Regular smoking Obese Physically active Hazardous drinking Medicated high blood pressure Medicated high blood cholesterol Smoking - The prevalence of smoking in Auckland DHB was 11.2% according to census the lowest prevalence in the country of smokers in primary care and 97% of smokers in hospital received brief advice to quit Obesity 2/3rds of the population are overweight or obese Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 98

104 Children Births - 6,500 births a year for ADHB women Maternal risk factors maternal overweight highest for Pacific 70% and Māori 60% (overall 40%) gestational diabetes is highest for Indian 16% and Pacific 13% (European 4%) smoking in pregnancy is the lowest in the country (ADHB 4%, national 14%) Mortality - Infant mortality (3.2 per 1,000 live births) and the Sudden Unexplained Infant Death (SUDI) rate (0.8 per 1,000 live births) are both lower than the national rate Rheumatic fever rate is high at 3.5 per 100,000 (national rate 4.1 per 100,000), and 25% of children are living in crowded households Immunisation 94% of children immunised by 8 months B4 School Checks 75% of B4 school checks completed (90% target) Childhood obesity 27% of children overweight or obese Child protection 21.5 hospital attendances for assaults per 100,000 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 99

105 Cardiovascular Disease (CVD) Burden of disease - c. 16,000 patients with CVD - CVD accounts for 32% deaths (815 in 2011) Risk assessment - 90% of ADHB s eligible population has been screened for CVD risk and diabetes CVD Management - 56% of patients with IHD are on Aspirin, Statins, and BP meds, - 50% of Admissions for CVD preventable through good primary care, - waiting times for secondary care are good - cardiac rehab can reduce mortality by 30% CVD Mortality per 100,000 popn 7.1 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 100

106 Diabetes Burden of disease 28,000 people with diabetes in Auckland - diabetes accounts for 3% of the total burden of disease in NZ Management - 69% of diabetics on diabetic medications - only 53% HBA1c well controlled; 28% missing annual review - Self management only 20 courses a year ( ) - capacity constraints in retinal screening & podiatry service Complications - 73 admissions for diabetic ketoacidosis - 33 lower limb amputations in ,558 bed days Diabetes prevalence by ethnicity and age % of diabetes patients on relevant medications Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 101

107 Cancer Burden of disease - Cancer is the second largest cause of death in Auckland (630 deaths per annum) % of deaths avoidable, melanoma, bowel and breast cancers account for the majority of these - One year cancer survival is 78.6%, which is one of the highest in the country. - 2,200 people diagnosed with cancer per year. Screening - 75% of women receive cervical screening and 71% receive breast screening Timely Management - 62% seen within 62 day target (target = 85% by June % 80% 70% 60% 50% 40% 30% 20% 10% 0% Cancer Mortality per 100,000 popn Breast and Cervical Screening Q2 Q4 Q2 Q4 Q2 Q4 Q1 Q2 2010/ / / / Cervical Breast Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 102

108 Mental Health Burden of disease - 12% people suffer from mental illness, 3% have suffered from a serious mental illness. Suicide. - ~ 40 deaths per year as a result of suicide each year in the Auckland DHB district, a disproportionate number of who are young and Māori Access to services - timely access to mental health services in primary care or hospital and effective treatment can reduce the time spent with a mental illness and reduce the associated morbidity and mortality. Suicide rates (age-standardised, by DHB, Percentage of people accessing secondary mental health services by age and ethnicity Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 103

109 Older People People aged 85+ years Growth - Proportion of ADHB population 65+ expected to grow from 11% to 16% in 2034, and double in number Complexity 59% have a disability & chronic disease common, often multiple e.g. 18% IHD, 24% diabetes, 43% arthritis, 11% mental health disorder Frail Elderly 85+ with very high health needs Independence most are independent but ADHB has high numbers of people in ARC Dementia - ~7% in 65+, rising to >25% in 85+ Stroke 8.9 % receive thrombolysis; 70% have timely transfer to rehab; 85% of patients are admitted to a stroke unit 7.1 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 104

110 Access to Primary Care Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 105

111 Hospital Services Utilisation - 328,401 outpatient attendances - 98,000 ED attendances - 23,700 elective discharges Access - 95% of ED patients seen within 6 hrs - Intervention rates achieved for cataracts, cardiac procedures, not joints Quality and Safety - 77% compliance on hand hygiene falls per 1000 bed days - HSMR is decreasing Patient Experience % of patients rate their health as very good or excellent Surgical Intervention Rates per 10,000 population Acute inpatient bed days per 100 population Hospital Standardised Mortality Ratio ADHB compared to 2007 baseline 7.1 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 106

112 What's important for Residents? We asked: What do you think is the most important health issue facing your local community? ADHB residents responded: Housing Exercise Obesity Accessibility Mental health Diabetes Cost/ affordability Smoking Alcohol Aged care/aging Diet Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 107

113 Areas of Focus Reduce inequalities in health Māori and Pacific health reduce the impact of modifiable risk factors particularly smoking, effectively manage long term conditions (CVD and diabetes), ensure equitable service provision support the Auckland Plan significant role in terms of employment, education, active travel etc Support healthier lifestyles Smokefree monitoring and enforcement of smokefree legislation, support for smokers to quit Obesity redesign of the physical environment, roll out of food policies, increased bariatric surgery 7.1 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 108

114 Areas of Focus (2) Effective management of cardiovascular disease and diabetes better management of CVD risk and existing disease, cardiac rehab management of HBA1c, blood pressure and cholesterol, retinal screening coverage, patient education Stroke provision of thrombolysis, dedicated stroke wards, rehab Rapid identification and treatment of cancer cervical screening amongst Māori, Pacific and Asian, bowel screening Access to Mental Health services access to services/ primary mental health Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 109

115 Areas of Focus (3) Give children the best start in life immunisation, WTCO and B4 School checks, early enrolment with PHO Older people falls prevention, integrated proactive care (CARE), alternatives to hospital / aged residential care Meeting future health needs Future population growth and constraints on funding Growth in acute admissions Access to electives surgical intervention rates particularly for hips and knees 7.1 Auckland District Health Board Healthy Communities, Quality Healthcare - Hei Oranga Tika, mo te iti me te Rahi 110

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117 OPEN Funder Report Recommendation: That the Auckland DHB board receive the report. Prepared by: Dr Debbie Holdsworth, Director Funding Glossary 8.1 ADHB - Auckland District Health Board ARC - Aged Residential Care CMDHB - Counties Manukau District Health Board CEO - Chief Executive Officer CFO - Chief Financial Officer CMO - Chief Medical Officer CPHAC - Community and Public Health Advisory Committee BPS - Better Public Service EDAT - Ethnicity Data Audit Tool Plan IDF - Inter district flow describes service provided to DHB population by another DHB provider or NGO FCT - Faster Cancer Treatment Funder - Term used to describe the joint ADHB/WDHB funding team established in July 2013 GMSFFS - General Medical Subsidy Fee-For-Service describes payments made to doctors for a limited number of patient visits of specific types. HOP - Health of Older People HBSS - Home Based Support Services MHSOP - Mental Health Services for Older People MOU - Memorandum of Understanding NHI - National Health Index unique identifier for every healthcare user PCT - Pharmaceutical Cancer Treatment PVS - Price Volume Schedule the detailed funding arrangements for all provider services for the financial year. This includes the level of funded volumes to be provided by the ADHB Provider for each DHB population served. RSR - Regional Services Review TSR - Tertiary Services Review WDHB - Waitemata District Health Board Introduction This is the first Funder report to the Board providing an overview of funder activity and areas of priority where these matters are not already being dealt with in other Board committees. Over time this report will provide a more detailed funder view of provider performance and funding arrangements for the ADHB population. Auckland District Health Board 18 February 2015 Page 1 111

118 OPEN 1 Hospitals 1.1 Overview The Funder is responsible for funding, monitoring and managing provider arm contract arrangements established through the annual price volume schedule (PVS). The contract arrangements include services provided to the ADHB population and all other populations funded via inter district flow funding or national services funding. The monitoring and management function extends beyond volume management. It includes a responsibility to ensure all elements of the service being provided meet the expectations of the Funder. 1.2 Activity Health Targets There is a new cancer target requiring 85% patients referred with a high suspicion of cancer are treated within 62 days of referral by June This is commonly referred to as the Faster Cancer Treatment (FCT) target. The ADHB Cancer service has implemented significant service improvement to achieve and sustain 100 per cent compliance with the historical cancer target relating to waiting times for chemotherapy and radiotherapy. However, the new FCT target relates to the whole system of delivery from referral to treatment and encompasses a range of specialist services beyond the Cancer service including diagnostic and surgical. ADHB s current performance against the FCT is 54.5 per cent and a structured whole of organisation approach will be needed to achieve the required level of increased performance by year end. The Funder will work with the Director of Cancer services and other relevant Directors to establish an appropriate governance arrangement and work plan to achieve this target. The elective health target is established annually by the National Health Board and the ADHB population has one of the lowest publicly funded intervention rates in New Zealand. This has led to a requirement over the last four years to increase the volume of elective surgery each year at a rate greater than demographic growth. Further work is needed to understand why there are lower rates of referral to some services provided by ADHB than is experienced in other populations with a similar demographic profile. Also, a more targeted approach is needed to ensure investment in elective services is prioritised to areas of unmet need and high priority populations. The Funder monitors the performance of both ADHB and other DHB providers who are contracted to deliver services to an agreed volume and case mix plan. The following table shows the year to date elective performance to December 2014 for the ADHB population: Elective Health Target Dec YTD YTD Plan YTD Actual Variance % WIES (PVS Contract) IDF Outflow Other DHB % ADHB Provider (283.9) 96.3% YTD Surgical CWD Total (263.2) 96.7% Discharges IDF Outflow Other DHB (29) 93.5% ADHB Provider (72) 98.9% YTD Surgical Discharge Total (101) 98.5% Auckland District Health Board 18 February 2015 Page 2 112

119 OPEN ADHB population IDF outflow ADHB funds provider and NGO services for the ADHB population via IDF arrangements. The 2014/15 total IDF outflow cost is $108.5m which represents 10.3% of the ADHB s total funding. A number of these arrangements are demand driven and subject to automatic wash-up including all inpatient services, all CMDHB outpatient services, pharmacy and PHO services. The Funder s focus is to ensure that IDF costs are reasonable and any financial risk associated with these arrangements is monitored, managed and appropriately accounted for. The Funder is responsible for ensuring that the ADHB Chief Financial Officer (CFO) is updated monthly regarding the financial upsides or downsides of these services. Appendix 1 provides a more detailed briefing of the 2014/15 ADHB IDF outflow arrangements for the ADHB population. 8.1 ADHB Provider performance The Funder monitors volume performance by the ADHB Provider for all populations and will work to address issues that arise in the delivery of clinical services. A key area of focus for the Funder is the management of long-stay inpatient events. The Funder has started a process to review all patients who stay in ADHB hospitals for longer than 30 days. The Funder will facilitate multidisciplinary team discussions with the relevant ADHB Provider to ensure an appropriate discharge management plan is established. Further work is needed in this area to establish predictors of long-stays so early and timely intervention by senior service leadership can occur. 1.3 Strategic initiatives Annual planning Work is underway to finalise the ADHB Provider PVS arrangements for the ADHB population in 2015/16. The total value of this plan is based on the total allocation of revenue to the provider in 2015/16. The current 2014/15 forecast volumes of the ADHB Provider are not affordable at the new 2015/16 national prices. The Funder is finalising recommendations for the ADHB Executive Leadership Team (ELT) to confirm areas where forecast activity needs to reduce to a level that is affordable for 2015/16. Tertiary services review The Funder has initiated planning to support the ADHB Tertiary Services Review (TSR) and there is an expectation that this process will be accelerated to be completed prior to the scheduled August timeframe. It has been agreed that the TSR will commence in Child Health services. There have been delays in beginning detailed clinical discussions with provider services however these are now scheduled to start in February. We will have a better understanding of the expected timeline for completion by the end of March. Auckland District Health Board 18 February 2015 Page 3 113

120 OPEN Colonoscopy capacity planning There is a regional process underway to assess demand and supply issues for all Northern DHBs. There are many common issues between DHB providers including short term capacity issues. The ADHB Provider has identified issues with internal capacity and the quality of facilities. The Funder will work with the ADHB Provider team to complete an analysis of the ADHB Provider issues and identify short and long term options to meet the needs of the ADHB population. This analysis will form the basis of recommendations to be considered by the Executive and Board by the end of March. National Services The Funder has worked with the Director of Provider Services to establish a functional relationship with the National Services team within the National Health Board. We have an agreement for additional funding in 2014/15 and 2015/16 to address the waiting list back log within the Clinical Genetics service. Proposals for additional 2015/16 funding for key paediatric services including Paediatric Cardiac services, Paediatric Metabolic and Paediatric Rheumatology services are currently being considered by the Funding General Managers of all DHBs. Regional Service Review Programme A regional Advisory Group has been established to oversee the Chief Executive Officer (CEO) and Chief Medical Officer (CMO) endorsed Regional Service Review (RSR) programme. While the Advisory Group is in the early stages of development this regional governance arrangement will ensure a more coherent approach to regional service planning. The Funder is a member of this group alongside the Director of Provider Services from each Northern DHB. The group is responsible for making sure that regional service planning activity occurs collaboratively and delivers clinically sensible and financially sustainable services that are appropriately responsive to the needs of the region s populations. 2. Primary Care A comprehensive report was provided to the Community and Public Health Advisory Committee (CPHAC) in November 2014, outlining progress against National Health Targets, the Integrated Performance Incentive Framework and the 2014/15 annual plan deliverables. Key points of note are: PHOs are on track with achievement of the More Heart and Diabetes Health Checks and Smoking Brief Advice health targets. Maintaining and improving system capability and capacity is an important aim of the IPIF programme. Along with setting standards and expectations for measures and performance, a mechanism is required to assess capability and capacity. The first phase is implementing a selfassessment framework to demonstrate how PHOs meet the Minimum Requirements of the PHO Services Agreement. PHOs are in the process of the self-assessments. A peer review process of the self-assessments will follow. The current DHB and Ministry annual reports include a qualified audit opinion over the performance information from third parties including primary care. The Ministry has been progressing work in this area with the view to implement a long term sustainable solution for both the Ministry and the Sector. As part of this work the Ministry commissioned PwC to complete a review over the data flow and robustness of the Health Target collation processes. The review covered over 65 per cent of Auckland District Health Board 18 February 2015 Page 4 114

121 OPEN PHOs in terms of enrolled population. The key findings from the review indicate: o The system is considered robust in terms of data integrity along the pathway. o No instances of over reporting were found, but there remains the possibility of under reporting. o There are good processes for reviewing data and any submission that looks unusual is queried back with the GP practice, and where required reports rerun. o Areas for improvement were identified, in particular to: o Functionality of patient management systems and reporting tools. o Practice level use of tailored or multiple codes to record information and the impact this has the mapping of their reporting tools. o Under reporting caused by the reports picking up the data fields that overstate the denominator in the targets. o Submission of aggregate information, rather than at patient level. While there are no issues with the current approach, detailed information is preferable to ensure consistency when calculating results. o A solution that meets the OAG and Audit NZ's requirements, and minimises duplication of activity is in development Health of Older People (HOP) An update was provided to CPHAC in February that reports the key areas of focus for the Funder. Specific priorities include the review of Home Based Support Services (HBSS), the trial of the Dementia Care Pathway and universal training of staff in Aged Residential Care (ARC) facilities in comprehensive clinical assessment (interrai). The HBSS revised proposal has been delayed due to the time taken to align the ADHB and WDHB perspectives. 4. Mental Health A substantive update was provided to CPHAC in November 2015 describing activities underway within the DHB to respond to Rising to the Challenge The Mental Health and Addictions Service plan The activities include a range of initiatives underway to respond to the need to improve integration between primary and secondary services. Specific areas of focus for the Funder in the next few months include the development of a regional plan for High and Complex Needs clients, progressing the review of regional Adolescent Mental Health services and the implementation of a revised service delivery model for Eating Disorder services for the Auckland metropolitan region and the Northern and Midland supra region. The Funder has been unable to recruit to the Mental Health manager position and the Mental Health work programme is being led by the Deputy Director Funding and the Funding & Development Manager, Hospitals until such time as a permanent appointment can be made. Auckland District Health Board 18 February 2015 Page 5 115

122 OPEN 5. Women, Children and Youth A detailed scorecard and comprehensive update was provided to CPHAC in February, and will continue to be provided routinely every second meeting from Data and information are provided on the Immunisation health targets and the Rheumatic Fever Better Public Service (BPS) target, as well as a range of other key child, maternal, youth and women s health measures including the IPIF target for cervical screening. Detailed reports have been provided at regular intervals on Rheumatic Fever and Cervical Screening with other information provided in the PFO Updates to CPHAC each meeting. Specific funding matters and papers are brought to the Audit and Finance Committee and/or to the Board as required including on fertility services. 6. Maori Health Tamaki Whānau Ora Centre Plans to develop a whānau ora centre in Tamaki are coming together with agreement reached with Ngati Whatua Orakei just prior to Christmas on an approach. Ngati Whatua Orakei will develop the centre with the ADHB partnering as the foundation leaseholder. The centre will house a new community renal dialysis centre and discussions are underway with the Women, Children and Youth, Community & Long Term Conditions and Mental Health Teams to develop new models of care for key services that could be delivered from such a centre. Project governance is being established and we will provide a detailed progress report to the next Board meeting. Ethnicity Data Audit Tool Implementation of the Ethnicity Data Audit Tool (EDAT) Project is progressing well. The target is to have 95% of general practitioner practices implement EDAT by June Currently 55% of practices have implemented EDAT. Planning Preparations for the development of activities in the Māori Health Plans are well underway. The approach for this planning cycle will be to have activities in the Māori Health Plans embedded in the Annual Plans to enhance accountability and improve responsiveness to Māori health gain across the Auckland and Waitemata DHBs. Engagement with Memorandum of Understanding (MOU) partners, Primary Health Care organisations, Māori providers and key internal stakeholders has begun and will be on-going throughout the planning process. Healthy Babies Healthy Futures Healthy Babies Healthy Futures is a free programme that improves the health of pregnant mothers, babies and toddlers by providing the latest health information, educational activities and access to services that encourage better nutrition and more physical activity. The Māori Health Gain Team is leading the implementation of the programme in four communities (Māori, Pacific, Asian and South Asian). The contract with the Ministry of Health has been extended by 12 months to allow delivery until June Auckland District Health Board 18 February 2015 Page 6 116

123 OPEN 7. Pacific Health A detailed update was provided to CPHAC in February reporting progress against the priority areas of the Pacific Health Action Plan Other areas of focus for the Pacific Team have included: Cancer Navigator roles in the Cancer teams - two Pacific cancer navigators started in their roles in ADHB on 2 nd February Their focus will be on improving Pacific outcomes in line with the national Faster Cancer Treatment target of 62 days. Tautai Fakataha Services Auckland DHB - Tautai Fakataha (ADHB), the Pacific care navigator team commenced 5 January Since that time the team has provided cultural support for a number of children and their families who have presented to Starship. 8.1 Auckland District Health Board 18 February 2015 Page 7 117

124 OPEN Appendix 1 Overview 2014/15 ADHB population IDF outflow Introduction This paper provides an overview of the current IDF outflow arrangements for the ADHB population based on an analysis of the 2014/15 IDF funding arrangements. Annual value of IDF outflow The following table identifies the 2014/15 total funding for the ADHB population and the value of the IDF outflow both in total $ terms and as a % of the total funding. The table shows that $108.5m (10.3%) of ADHB population funding is spent on IDF outflow and $56.4m (11%) of hospital provider funding is spent at other DHB hospitals. Hospital provider outflow costs are 52% of all IDF outflow, HOP = 9%, Mental Health = 14% and Primary Care including NGO arrangements = 25% Table 1: ADHB IDF outflows as share of population funding using 2014/15 IDF forecasts Service Group Total ADHB PBF Total IDF Outflow % IDF Outflow Outpatient $ 151,824,822 $ 15,566, % Inpatient $ 354,943,474 $ 33,341, % Tertiary Adjustor $ 7,300,891 PCTs & Herceptin $ 5,690,881 $ 234, % Hospital Provider $ 512,459,177 $ 56,444, % HOP Inpatient $ 19,661,300 $ 506, % HOP outpatient $ 82,517 $ 82, % ARC $ 64,038,209 $ 8,770, % HOP NGO $ 1,555,746 $ 584, % Total HOP $ 85,337,772 $ 9,944, % Mental Health Provider $ 97,312,328 $ 12,616, % Mental Health NGO $ 33,525,341 $ 1,973, % Total Mental Health $ 130,837,669 $ 14,589, % GMS - FFS $ 2,759,181 $ 744, % Immunisation $ 2,549,257 $ 384, % Laboratory $ 29,156,699 $ 500, % NGO $ 6,988,281 $ 1,497, % Pharmacy $ 101,964,417 $ 10,138, % PHO $ 66,284,912 $ 13,623, % Total Primary $ 209,702,747 $ 26,888, % TOTAL $ 1,054,942,446 $ 108,503, % Auckland District Health Board 18 February 2015 Page 8 118

125 OPEN Summary of 2014/15 IDF outflows for the ADHB population The following table provides a broad description of the range of services being provided for the ADHB population through IDF outflows based on 2014/15 IDF forecast data. Table 2: Overview of 2014/15 IDF outflow arrangements Service Group IDF Outflow Comments Outpatient $15,566,687 Waitemata DHB - $8.8m primarily for School Dental Services ($7.7M), $1.1M range of other activity including ED ($400K). CMDHB - $5.2m for a broad range of outpatient services including $1.3M ED attends(4000 per annum, 11 per day) Inpatient $33,341,992 CMDHB - $25M, 45% ($11.4M) Otahuhu resident activity and 31% ($8M) Plastics activity Waitemata DHB - $4.9M 30% ($1.5M) ADHB western corridor activity, mostly acute services including ED, paeds, orthopaedics, neonates and maternity WIES. All electives pre-approved by Funder before wait listed for surgery Waikato DHB - $800K, all others less than $300K per annum Tertiary Adjustor $7,300,891 ADHB contribution to national pool based on annual technical review PCTs & Herceptin $234,977 Pharmaceutical cancer treatments for patients with ADHB NHI needs ongoing monitoring at NHI level Hospital Provider $56,444,547 HOP Inpatient $506,983 A,T&R services primarily at CMDHB and predominantly Otahuhu - no IDF outflow and no washup between ADHB and Waitemata DHB HOP outpatient $82,517 Unusual occurrence of outpatients associated with HOP services needs ongoing monitoring at NHI level ARC $8,770,134 ADHB residents permanently placed in Aged Residential care facilities after appropriate needs assessment. Cost of ARC remains with DOD at time of admission to ARC facility. Acute costs attributed to DHB of domicile of the ARC facility HOP NGO $584,522 Majority of cost for ADHB PBF share of national contract for Artificial Limb Centre (contract managed by Capital & Coast DHB). Small cost for Aged Concern contract at Waitemata DHB 8.1 Total HOP $9,944,155 Auckland District Health Board 18 February 2015 Page 9 119

126 OPEN Mental Health Provider $12,616,651 Waitemata DHB - $9M including $1.7M methadone services, $7.3M CADS. CMDHB $3.5M subacute beds, MHSOP and broad range of other services likely to reflect Otahuhu cohort No cost for Mental Health services out of Northern region Mental Health NGO $1,973,195 NGO arrangements managed by CMDHB ($1.3M incl crisis respite, community alcohol and drug, refugee services) and Waitemata DHB ($600K) Total Mental Health $14,589,846 GMS-FFS $744,566 Cost of IDF determined using national actual data Immunisation $384,451 Cost of IDF determined using national actual data Laboratory $500,551 Cost of regional laboratory services arrangements including pathology services. Regional contracts allocated on relative utilisation shares subject to wash up, arrangement managed by NRA for the region NGO $1,497,200 Broad group of arrangements with NGO including NGO Fertility service contract managed by Waitemata DHB ($700K), other services including primary care packages, asthma society, national eye bank Pharmacy $10,138,067 Community pharmacy arrangements reflects use of pharmacies by ADHB residents out of ADHB district subject to national wash-up PHO $13,623,532 Cost of enrolments of ADHB population in other DHB s PHOs. Subject to wash-up using quarterly enrolment statistics provided nationally Total Primary $26,888,366 TOTAL $108,503,625 Ongoing monitoring and management of IDF outflow The Funder has established the following arrangements: a performance monitoring framework for ADHB outflow to CMDHB and Waitemata DHB including regular review of waiting lists at CMDHB and reporting at a purchase unit level regular meetings with CMDHB Funder and provider teams regarding ADHB population activity In order to manage and contain elective outflows, the Funder will require all DHB providers to seek pre-approval prior to wait listing ADHB population except for CMDHB. Referral management guidelines will be documented for ADHB population at CMDHB to ensure that CMDHB is managing access according to the expectations including for the Otahuhu residents. Auckland District Health Board 18 February 2015 Page

127 OPEN Opportunities to reduce the level of IDF outflow Potential for development of local ADHB Adult Hand service (acute and elective) limits on service change associated with service transfer due to current Chair moratorium on service repatriation however CMDHB experiences on-going difficulties managing the volume of Hand injuries that present to that DHB acutely. CMDHB may therefore be willing to consider this service change if the ADHB Provider supports the development of this service at ADHB Domicile code accuracy management - all outflow will be monitored via national collections data and supplementary provider reporting where established. NHI audits will be completed on an on-going basis to ensure that the domicile code for events is being appropriately attributed to ADHB 8.1 Auckland District Health Board 18 February 2015 Page

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129 OPEN Strategy and Values for Auckland DHB Recommendation That the Board: Approve that this version of the Strategy for Auckland DHB be taken out for stakeholder feedback Approve that the set of Values be adopted as final Prepared by: Approved/Endorsed by: Julie Helean, Assistant Director Strategy Dr Andrew Old, Chief of Strategy, Participation and Improvement Christine Etherington, Director of Strategic Human Resources Ailsa Claire, Chief Executive 9.1 Attachments: The February 2015 version of the Strategy for Auckland DHB 1. Strategy development A draft of Te Toka Tumai, the Strategic Plan for the Auckland DHB, was presented to the December 2014 meeting of the Board. At that time, comments from Board members were recorded. It was resolved that the next iteration of the plan be circulated to Board members and that Andrew Old proceed with the next stage of completion. The next stage involves taking the plan out for stakeholder consultation. During December and January further work was done based on Board feedback, and changes incorporated into this February 2015 version of the plan. Key points to note are: There is alignment with the Values work, which is progressing concurrently The material supports the Northern Regional Plan The material includes the latest information from our Health Needs Assessment More emphasis is placed on the need for accountability The material (along with our values) has been refined to ensure it can be used to influence people s daily work and position descriptions Further comments from members of the executive team have been added The work has been edited to keep it concise In order to inform the final version of the Annual Plan, this Strategy work will need to be completed by the end of March. The stakeholder consultation will run for two weeks in late February / early March. Any significant changes resulting from that feedback will be drawn to the Board s attention. In the meantime the Auckland DHB planner has the information required to draft the Annual Plan, specifically the high level material that is required for the Strategic Intentions section included in module one. 2. Values for the organisation During December and January the Values work went through more changes, the key ones resulting from the Reo and Tikanga assistance from Naida Glavish, Chief Advisor Tikanga. Naida helped to determine the appropriate word in Māori for each value, explaining their meaning and significance. Auckland District Health Board 18 February

130 OPEN The final set of values is presented as a set of key words presented in Māori and in English; a short statement to explain what each means; and a list of associated behaviours. This short framework is part of much bigger framework which lists the behaviours we d love to see; those we expect to see; and those we don t want to see, for each value. Haere Mai Welcome Manaaki Respect Tuhono Together Angamua Aim high I see you and welcome you as a person Respect, nurture and care for each other A team with colleagues, patients and family Aspire to excellence and the safest care See the person Kind and helpful Teamwork Professional Friendly Respectful Listen and hear Safe Welcoming Protect dignity Communicate clearly Innovate and improve Understanding Appreciative Accountable Encourage excellence Once approved, the values: Haere Mai Welcome, Manaaki Respect, Tuhono Together, and Angamua Aim high, will be communicated across the organisation. Christine Etherington, Director of Strategic Human Resources, has recently joined ADHB, and is responsible for developing and managing a phased programme of initiatives ensuring the values are visible and integrated to support our desired culture. Auckland District Health Board 18 February

131 Te Toka Tumai The Strategy for Auckland District Health Board to 2020 Healthy communities -- World-class healthcare -- Achieved together Hei Oranga Tika mo te i ti me te Rahi Our values underpin everything we do. Haere Mai - Welcome I see you and welcome you as a person. Manaaki - Respect Respect, nurture and care for each other. Tuhono - Together A team with colleagues, patients and families. Angamua - Aim high Aspire to excellence and the safest care. Health is personal. It starts with us; who we are, where we live, learn, work and play. Every one of us has different experiences and aspirations for our own health and wellbeing. People thrive when they feel in control of their lives. Our job is to help people achieve the health outcomes that matter to them, their whānau and communities. You ve told us this is what healthy communities means to you. As a District Health Board we are responsible for improving, promoting and protecting the health of our local Auckland population. We will be tough on the areas causing the greatest ill health and disability. Diseases like heart disease, cancer and diabetes are responsible for many avoidable deaths and long-term consequences. We will work to ensure that eating healthily and being physically active are easy choices to make. To support good health we need meaningful relationships with our patients, whānau, iwi and communities. We also need to work with other agencies on policies that support health and wellbeing. We will only be successful if we work together. At Auckland District Health Board we are unique. While focussed on our local population, we provide specialist services not available elsewhere. We are also a major academic facility, fulfilling a large training and research role for the country. These are strengths and points of distinction as we aspire to deliver world-class healthcare. Being a tertiary and national centre puts pressure on resources and on our ability to serve our own population. It s a delicate balance. By 2020 we will be delivering truly world-class health, healthcare and disability services that are cohesive, equitable and, most importantly, sustainable over the long term. We will clearly show that our efforts have led to an improvement in health status for Aucklanders and that we have made headway in reducing the persistent inequities between groups. To do this, we will think critically about the design and delivery of our services and we will be bold in our innovations. We can only do this by working with and learning from our patients, whānau, iwi, providers, academic institutions, government and non-government agencies, and local communities. This is our vision. Healthy communities, world-class healthcare, achieved together. Hei oranga tika mo te iti me te rahi. Te Toka Tumai is the Māori term for Auckland DHB. It refers to the rock that stands firm in the sea of the Waitemata harbour of Tamaki Makaurau (Auckland). The rock reminds us that the health system needs to be a solid whole, where all the activities across the continuum of health are joined. Te Toka Tumai is our proud and stable foundation when the going is tough. Lives depend on it. 9.1 Ailsa Claire Chief Executive Dr Lester Levy Chair 1 124

132 Auckland DHB has dual roles This strategy is written in the context of Auckland DHB being both a commissioner and a provider of health services. The diagram here shows the roles of both Commissioner (blue) and Provider (green). As a Commissioner, the DHB plans the right configuration of services a decision guided by the health needs of the 475,000 people who live in our district. The Funder contracts with a range of health and disability service providers to deliver the services needed including our own Provider Arm (the hospital and other services). The Provider Arm delivers secondary, tertiary and quaternary services. These hospital-based services are used by people in our district. The Provider also provides services in community setting e.g. some mental health, child health and older people s services. The diagram shows that our Provider Arm also delivers services to people from outside our district. Other DHBs refer to us where they have patients with serious conditions who need specialist work that is only available here at Auckland DHB. Commissioner (planning and funding) Services that the DHB purchases from other providers for our population We are funded to support our local population to increase their health and wellbeing. We do this by providing some services ourselves, and commissioning (purchasing on contract) services from other providers, e.g. rest homes, primary care, dental health, community pharmacies, kaupapa Māori, laboratory Provider Arm: Hospital and community services Our population use our hospital services Some primary care, secondary care, and also tertiary care when problems are more complex Services that the DHB provides for our population, the region and nationally We are a regional and national provider of services. Over half the work done by our provider arm is done for patients living in other DHBs.... this whole system needs to be joined up and sustainable into the future Because of its specialist services, Auckland DHB acts a major teaching hospital, employing hundreds of clinicians in training at any one time

133 Our greatest challenges We completed an updated assessment of our populations health need in This research highlighted the key problem areas for our district. Many of these are not unique to Auckland but we do need to understand what they mean for our population and which ones we need to address with more urgency. This strategy starts with our greatest challenges and follows with five strategic action areas to address them. People are dying of preventable diseases. Healthier lifestyles can prevent deaths and illness. Health services play a key role in supporting people to stop smoking, eat healthily and to exercise more. We need to get tough on the right problems. Everything we do is important but it can t all be a priority. Too many priorities means we don t make headway on the killer diseases. By prioritising our resources we can drive down rates of heart disease, stroke, diabetes, cancer and mental health problems. Excellence requires investment in research and in academic collaborations. Approximately a quarter of premature deaths for our population are avoidable. Of these, half could have been avoided through adopting a healthier lifestyle; a quarter could be prevented by getting problems (like hypertension) managed before they lead to illness; and a quarter could be avoided through getting illnesses treated early on. Eleven percent of adults in our district are regular smokers, with higher rates among Māori and Pacific people. One in five adults are obese, and over half are overweight. Our rate of hazardous alcohol consumption is higher than the national rate across all ethnicities except for Asian. About half our population meet the recommended level for daily exercise, and more than 40% do not meet daily fruit and vegetable guidelines. Heart disease and stroke are two of the largest causes of avoidable premature death in our district. This is an area with a large opportunity for improvement. Seventy percent of cardiovascular disease may be linked to risk factors that we can modify through lifestyle. Screening programmes for cardiovascular disease link people with early signs of problems to treatment. The number of people with diabetes has more than doubled since 2003 and this affects about 6% of our population. People with diabetes need help to manage risk factors, such as blood pressure and blood sugar levels, and encouragement to have eye tests. Māori and Pacific people carry a heavier burden than other ethnicities for heart disease and for diabetes. Cancer makes up 28% of all deaths, with the most significant being breast (in women), lung and colorectal cancers, and prostate cancers in men. Although screening for breast cancer is free, a third of eligible women do not participate. For lung cancer, the continuing reduction in smoking rates is a high priority. One in eight people living in Auckland DHB suffers from some form of mental illness with 3.5 % using mental health services. Māori are particularly affected by mental health problems, being twice as likely as Europeans to use services. Pacific people report anxiety and distress twice as often as Europeans, but do not use mental health services. We need to work with localities and with communities of interest to build the kind of supports and services that we know act as buffers for people living with stress, disadvantage and discrimination

134 The responsibility for good health needs to be shared. An increased focus on prevention and early intervention can prevent or delay the onset of disease and this means working with other agencies. More attention on the young and the old. Too many children are admitted to hospital with conditions that could be prevented or treated earlier. More help is also needed to help people stay healthy as they age. We have persistent inequities in health status. We need to be bolder in our actions to achieve equitable health outcomes across the system. Helping our population to achieve health, independence and wellbeing requires an investment in prevention and early intervention work. This largely happens in local communities, working with partner organisations, iwi and communities. It is hard to balance the need for prevention work along the immediate and growing demand for health services. It is especially hard to resource action that tackles the social determinants of poor health e.g. poverty, isolation, violence and discrimination. Prevention requires a shared responsibility for making Auckland healthy. It means working with other public agencies and services on improved housing, education, employment, and the physical environment, as well as improving access to health services. Patients need to be more in charge of their health and their healthcare. Health professionals need to centre their practice on what matters to the patient and to their whānau. The journey through the health system must be as a sense of working together with the work responding to the patient needs. The more choices we can offer to patients the better. It all rests on the ability of the health practitioner to be attentive to each individual. Similarly, communities are the experts when it comes to defining local problems and solutions. Inequities persist in infant and child death rates and hospitalisation. The infant mortality rate for Māori and Pacific is nearly twice that of European/Others, with the most common causes of death: perinatal conditions, congenital conditions, and sudden infant death. For children aged 1-14, the most common causes of death are cancer, congenital anomalies, accidents and suicide. Children are admitted to hospital most commonly for injuries, gastroenteritis, asthma and infections. The incidence of rheumatic fever is one lower than the national average, however significant inequities are present for Māori and Pacific populations. The percentage of children enrolled with a PHO by the age of three months is much lower than the national average. Immunisation by 8 months of age is low for Māori. The most common causes of mortality for young people aged years are intentional and unintentional injury, cardiovascular diseases and cancer. The most common acute admissions for young people aged years are for injury, abdominal or pelvic pain and skin infections. Older people have greater needs for health services and hospital care, and occupy about 45% of our medical and surgical beds. With the projected increase in the population aged 65 and over, there is a real need to ensure that people retain good health into older age. Maintaining and restoring independence is the key way to manage the demand on hospital services. Older people want to stay in their homes, be independent, free from discrimination and abuse, and be able to participate and contribute to society. The gap in life expectancy is increasing with Māori and Pacific people living (on average) six to eight years less than the European/Other population. Māori and Pacific people are two to three times more likely to be hospitalised than European. More Māori and Pacific people will die from a number of chronic diseases. Nearly 20% of our population live in areas that are highly deprived, and high deprivation is associated with poorer health outcomes. We have failed to make significant impacts for disadvantaged groups with significant inequalities between groups persisting. Some people miss out on the health services they need, while others report a negative experience when they do come for help. We need to be bold in making the health system free from discrimination. We need dedicated programmes and services to redress inequity, particularly for Māori where we have clearly defined responsibilities under the Treaty of Waitangi. Pacific people and those living in poverty also need focused work, along with our significant and growing Asian population

135 We lack a common purpose. We have over 10,000 staff with a tremendous diversity of skill and culture in this mix. We need to develop our people establish a culture that lives our values. More health services are needed in the community, specifically in primary care. The health system is overly focused on the hospital. More services could be provided close to where people live, work and play. Tertiary and quaternary services are essential but expensive. As a hospital of last resort, Auckland carries the greatest burden for the cost of specialist work. Our hospital services must be sustainable over time. Our organisation covers over 10,000 diverse staff. These staff are responsible for planning services, funding services and for direct service provision, support services and research. Regardless of the size and complexity of our organisation, it s vital that we make changes, and at a pace to meet demand, while at the same time being mindful of our important national service, teaching and training responsibilities. Staff need a clear direction for the future, clear expectations and accountabilities, and a work programme aligned with vision and values. It s important to have a strong sense of identity and foundation. Having a clear purpose and shared ways of working helps us measure and track results. We can do more to celebrate this characteristic of Auckland and see it as a strength. We are all accountable for modelling our organisational values. This will make for a better work environment for staff as well as patients. We have to focus on what is most important to people to support their health and wellbeing, and to do this in a way that is financially sustainable over time. Currently we are predominantly a hospital focussed health system. There is significant opportunity to expand our primary and community services to rebalance the system and provide services that are more responsive to people s needs. We know there are services we currently deliver in our hospitals that could be delivered in the community and we will work in partnership across the system to redesign our models of care around the patient. Partnerships across community health and hospital services will help to get the right mix of services and in the right place. We have to move fluidly across these borders because we expect our patients to. The funding we get from government needs to covers health and disability services across the system from work in the community through to specialist services in the hospital. On top of our core funding, our DHB gets paid for the work we do for patients referred from other DHBs. The amount we are paid for some of our high cost specialist work does not always cover the full cost of the treatment. Over half our work is for patients who live outside our district. Although these prices are set nationally, the pricing model has left us having to offset national work from funds that are earmarked for our own population. As a hospital of last resort, Auckland takes patients from all over NZ and the Pacific and carries the greatest burden for the costs associated with specialist interventions. Our funding has to go further. This requires us to get even more value from our staff and resources. We also have responsibility to contribute to wider public service goals of waste minimisation and energy efficiency. In order to manage the growing demand on hospital services, we need hospital clinicians working with their primary health care colleagues. Strong collaborations between hospital clinicians and those working across the span of primary healthcare will strengthen the ability of GPs and Aged Residential Care facilities and Home Based Support providers, and others to care for patients. Primary care workers are well positioned to intervene early, to maintaining good health practice and to help restoring independence when problems arise

136 The Principles of our Approach People come first Values to drive a change in culture Self-determination as our model of care Good governance and accountability Clinical and research excellence, and training Working with localities on issues that matter to them Recognising the strength in diversity Getting tough on problems, not on people, and we focus on the right things The best health systems are oriented to people - patients, their families, whānau, and communities, and to the workforce. Everything we do, from the design of our buildings to the care we provide, will be designed with patients and families first and foremost. We will work with our staff to become the health employer of choice within Auckland. Our values will distinguish the work we do: Haere Mai -Welcome, Manaaki-Respect, Tuhono-Together, Angamua-Aim high. They will be visible through our actions. This recognises that people and communities are the experts when it comes to their health. When people need help from professionals, we ll make it personal, attending to what matters for each person. People are healthier when they have control. Health professionals will enable people to achieve the goals they determine for their health and healthcare. We will move away from fixing people or doing things to people. We affirm the mana of the person and the expertise of the patient. We will attend to the things that matter to each patient. Family and whānau will be partners in the care of the patient. Self-determination recognises the rights of iwi under the Treaty of Waitangi. We will restore self-management and autonomy when people have problems. Rehabilitation and reablement gives people back their lives, and allows them to participate in society. As a good employer, we will invest in our people to build a strong, values-based organisation with robust governance and accountability. Clinical leadership and engagement is embedded in our structure. As NZ s foremost specialist hospital, we strive for excellence. People trust our services, knowing they are getting the best in specialist care and research. We continually search for new ways of working and for interventions that put Auckland DHB at the forefront of health and healthcare. As NZs largest teaching hospital, we dedicate time and resource to developing health professionals for the future. We do this through academic and research collaborations. Communities know what s needed and they can help determine, design and, in some cases, deliver health services locally. We will work with specific localities to help them determine the services they need and the best way of delivering this. Auckland is unique in the diversity of cultures. Our health work includes a great diversity of skills and disciplines. Strength-based and multidisciplinary work helps us see the value in these differences. This ecological approach recognises that there is a place for everyone in the system. Working in teams and working across borders streamlines care for the patient. We need to get vocal about the health problems that matter. Many hospital admissions are avoidable, some through a change in lifestyle, and some through earlier help from primary care. Rather than blaming the individual, we need to work with other policy makers. We will do our bit to create an environment where it is easy for people to be active, to eat healthy food, to be safe and secure, and to engage confidently with services when these are needed

137 Addressing the challenges: Five strategic priorities The most pressing of our challenges can be addressed by focussing on five strategic priorities. We lack a commonality of purpose People are dying of preventable diseases 1. People, patients and whanau at the centre 2. Values and equity underpin everything we do More health services are needed in the community, specifically in primary care We have persistent inequalities in health status 9.1 More attention on the young and the old We need to get tough on the right problems (not people) 3. Guarantee quality and safety 4. Get the best outcomes from resources 5. Hold people, systems and structures to account The responsibility for good health needs to be shared Tertiary and quaternary services are essential but expensive 7 130

138 Our Strategic Priorities 1. People, patients and whānau at the centre Where we are today the case for change The view from 2020 Our values (Haere Mai-Welcome, Manaaki Respect, Tuhono-Together, Angamua-Aim high) compel us to work mindfully with patients, communities and our colleagues. This means we make time to stop, listen and hear what matters to each person. We need a system that supports this. Patients want to control their care and have services tailored to their needs. Greater use of technology will be one key way in which patients can direct their own care in the future. We need to accelerate the ways and means by which patients can access and manage their own health records. Our care pathways are not clearly defined or accessible, and there is variability and inefficiency with an under-use of outcome data. Whānau Ora promises wrap-around help for the patient and whānau, but care is not always coordinated and it s not always delivered where it s needed. We can do more to engage family and whānau in care. We need to ensure cultural concordance and respect. People living in Auckland DHB need more help to keep healthy and help to locate services. The services are not always where people need them i.e. close to where people work, live and play. We have parts of a patient centred system, and we have made a good start, but there is much more we can do. Patients have the information they need to make decisions. The system is oriented so people can determine their own care, and consistently across every interaction. Pathways of care are clear, designed around what matters to patients, and informed by evidence. Where required, there are people to help patients navigate. Communication technology is in place so patients and families can communicate with us in ways that they choose. Patient portals are in place so patients can access the information they need. First impressions of our services, whether by letter or arriving at our front door, are exemplary. Design work with patients has led to easy way-finding around our facilities. Insight, via surveys and other means, drives our improvements. Co-design approaches are embedded. Our measures of success have shifted from things we define as important, to the outcomes determined by patients in their care plans. Patient experience outcomes are a key dimension in the accountability framework. Patients and whānau are intimately involved in service planning and in governance. Family and carers will be a core part of the care team. Patient and family driven care plans, e.g. end of life care plans will be the norm. Locality co-design is visible through consumer and family forums. Comprehensive wellness programmes are in place. We are renowned for our patient-centred approaches, through our personal interactions and being champions for self-determined care, our easy access to patient and family education and information, and our health promoting physical facilities

139 2. Values and equity underpin everything we do Where we are today the case for change The view from 2020 In order to reduce health inequities we need to make sure that our funding follows the need, and we have dedicated programmes and services. We need to work with Te Runanga o Ngāti Whātua to accelerate the plan for Māori health. Systems need to be configured around Māori health gain and our memorandum of understanding with our Treaty partner. We know that staff welcome diversity across culture, professional group, treatment methodologies and disciplines. This is a point of some distinction for Auckland DHB. However along with diversity comes the need for training and supports so that staff feel confident working across cultures and disciplines. The organisation and all our processes need to be culturally safe. Part of the achieving equity will require more work to recognise the role that women continue to play as caregivers and as the mainstay of our workforce. While we collect a lot of data on our performance and health outcomes, we are not good at using it to understand our performance and make positive change. Most of our current data exists at a high level making directorate level action difficult. We need to make much better use of the data we collect. We have a solid foundation to build a values-based culture but there is much work to do to embed it across all parts of the organisation. We have agreed what needs to be done to reduce inequities and are showing positive results in a range of areas. There are published goals and performance targets across the system, including specific measures and timelines, and other health systems are looking to us because we have been so successful. Our health resources follow the need. The health and disability system is more fair and just, and it actively reduces inequity. We know where there are barriers and discrimination in the health system and we are actively stripping these out. We work directly with high need communities and community leaders who know best about the improvements needed to our systems and practices. There is an awareness of the Treaty of Waitangi and a broad social justice agenda in our work. Staff are trained and proficient in cultural competence. There are many more Māori and Pacific people working in the health sector and influencing decision making. The workforce reflects the diversity of Auckland s population. There is transparency in the work we do and in our performance. There is a high degree of accountability across the system for health improvements. We use the information we collect to understand our performance and prioritise our work. Everybody knows our values and understands what they mean for them and their work. People consistently see the organisation living the values, from the Board and senior management right throughout the organisation. We have become the employer of choice in Auckland because we have a strong, values-based culture that people believe in and model. People are proud to work for Auckland DHB

140 3. Guarantee quality and safety Where we are today the case for change The view from 2020 Auckland DHB has a very specialised and skilled staff that, on the whole, provide excellent clinical services. But we can do better. We don t make best use of clinical outcome data and when we do it s not always consistent or timely. We have access to international benchmarking but don t always use this to best effect. We don t routinely use our data to inform our improvement activity and our safety culture tends to be reactive rather than proactive. We have low visibility of the improvements we make. We know we have differences in outcomes for different groups and we need to focus on both identifying and reducing inequity where this exists. Cultural safety needs to be a given. Training across the DHB will make sure everyone is skilled to make a positive difference. Much like other areas, we don t operate as a cohesive unit across the DHB. We could accelerate our learning and improvement by more open and deliberate sharing and collaboration between services. We know we have to make the transitions between services much better and with the patient having much more control in this process. This way of working makes sure that we design services that best fit each patient s needs. We are leading quality and safety work, setting a standard well beyond the expected. The patient feedback cycle has been accelerated so we learn how to improve our performance at every step. We are quick to respond to patient feedback and to complaints. More coordinated and integrated care has led to reduced clinic non-attendance (DNA) and re-admission rates. More people are managing their long term conditions in the community, with enhanced community and primary care assistance when required. People trust our services, knowing we provide the best in specialist care and research. Auckland DHB is synonymous with clinical and research excellence. A strength is our continual search for new and better ways of working. A thirst for inquiry and innovation helps us to stay abreast of growing expectations around treatment. Our academic collaborations are strong. Our practice is reflective which means keeping an eye on continuous improvement. Staff are mindful of their practice and learn from peers and colleagues. Patient experience ratings have improved for prioritised groups and we see a reduction in hospital adverse events such as falls and infections. Well defined outcome measures for all services are in place and used to improve and inform our work. The measures are important to patients and to staff. Safety and clinical outcome data is directing our future actions in a planned and consistent way with a focus on outcome informed improvement. We make good use of international and local collaborations for benchmarking. The benchmark comparisons are consistent and valid for us and drive us to constantly improve. We have fostered a culture of transparency where outcomes are shared with all: patients, staff and stakeholders alike

141 4. Get the best outcomes from our resources Where we are today the case for change The view from 2020 A great many of the resource issues facing us are sector wide issues. We have to do more work with every dollar we get from government and this pressure will likely increase in future. We need to fully understand the scope of work we do as a hospital of last resort. Specialist work needs to be costed accurately and funded appropriately. Work not covered under our existing payment arrangements is done to the detriment of our own population. There is real urgency in addressing this. With our regional partners we will establish the right mix and configuration of specialist work for our region, and will also support the national work on specialist services and price. Some work currently done in hospital could be managed within primary care. Genuine collaborations across primary and secondary care will lead to models of care that reduce reliance on hospital services. Many hospital admissions and re-admissions point to us missing problems at an early stage. We want these problems managed earlier by the person s GP. All DHB staff need an understanding of basic improvement science to help get the best value from our resources. We know from overseas hospitals that our volunteer base could be expanded to occupy a more defined and legitimate place in the health and disability sector. We need to develop our volunteer workforce and open the doors to them. Sustainability requires us to think well beyond health. As one of the country s largest employers we need to show leadership in the use of the country s resources and the waste we create. Hospital services are used more selectively i.e. when these are really needed. Primary care is the hub that manages the care people need and attends to problems early on. Much more early intervention work is being done using a team approach that maximises the potential of all providers: GPs, people working in aged residential care, Home Based Support Services, community services, nurses, allied health, private providers and NGOs. Close and collaborative working relationships are in place with our local, regional and national funders which means that our hospital services are running within the funding allocated. There is real clarity about the tertiary and national services that other DHBs want us to provide for their patients with clear and agreed service specifications for each. Everyone in the system has the information they need to make the best decisions. This includes patients and families and whanau, as well as staff. Through our community partnerships and support we are seeing improved health literacy and a reduction in the gaps between health outcomes for high need groups compared to others. Whānau Ora and wrap around care is tailored to the patient and whānau, and is focused on what matters most to them. These services are well established and contribute to reduced admission rates and better outcomes. All our staff are trained in basic improvement methods and we have a visible culture of improvement where people are always looking to do things better. We will have a highly developed and expanded volunteer programme that is a model for other health organisations to learn from

142 5. Hold people, systems and structures to account Where we are the case for change The view from 2020 We hold considerable accountability as a DHB; however our vision and purpose are not clearly articulated and understood. Our new structure streamlines responsibility in our provider arm with one line of accountability holding each Director responsible for quality health service delivery in their service area. There is an urgent need to support leaders to develop their skills, their teams and the organisation as a whole. We have many great people and departments but we do not function as a whole. Our internal communication needs to improve with information shared more openly and widely. In 2014 we engaged widely around a new set of values for Auckland DHB. These will be embedded through the development and roll-out of an organisational development plan. Our values need to be visible in action and applied across everything we do. Our current IT infrastructure is fragmented, unstable and system-centric. As a health organisation we need to play our part and role model responsible action on climate change, waste minimisation and energy use. We know we are not the best employer we could be. We frequently fall short of the standards we set for ourselves. Our systems sometimes act as barriers to innovation, to equity and they can impede the fundamental human connections so vital to the health system. All of our 10,000 staff, and the population we serve, are clear about why we are here and the difference we are trying to make. We will be acknowledged as an organisation where there is clear line of sight from the Board to the floor with every employee understanding how they contribute. There will be clear lines of communication, responsibility and accountability. Our system is understood and decision making is clear, with accountability both known and enacted across the continuum of care. Our leaders are supported by strong clinical governance. Accountability for decision making includes our primary and community care partners. We honour our responsibilities to manawhenua. Our staff are trained to understand the Treaty of Waitangi and they demonstrate Tikanga Best Practice. This is good cultural competence. There are an increased number of Māori and Pacific people working across the Auckland DHB health workforce. Health professionals are trained to work with patients in ways that motivate and enable them to determine their care. We have transformed our IT infrastructure into one that enables us to function at the highest level, with key information available for patients, families and staff, when and where they need it. Our values have set a path for a change in culture, and we have made a long-term commitment to training and development for all staff and for our leaders. We will have shifted some services and redeveloped others so they are closer to settings that work for the most vulnerable people. Our volunteer base has significantly expanded across the system with clearly defined roles. We have the right mix of specialist services for the region and these are funded sustainably. We continue to generate world-leading clinical research. Auckland DHB is acknowledged as a leader in the public sector for energy use and waste minimisation, and for being a good employer

143 Activity across four settings The hospital is dominant in the health system and is necessarily focused on treating serious problems. The growth in demand on hospital services is not sustainable into the future. While hospital services will always have a vital role in restoring health and independence, in future years we will see a greater focus on community and primary healthcare and disability services. Our environment needs to support good health and independence, especially those settings where people live, learn, work and play. That means being prepared to deliver services differently and in different settings. We need to do more work in the home, locality and community where people are best able to direct their own pathway to health, wellbeing and independence. One health system four settings for health, independence and wellbeing Ho 9.1 Hospital Patients and whānau are partners in treatment and care Staff respond to the things that matter for each patient Patient-focused values in action across the organisation We consistently provide safe, high-quality care The hospital runs within budget Community Services Services are close to home Problems addressed early in primary care Self-management of long-term conditions in the community Rehabilitation and reablement to restore autonomy and wellbeing Collaborations between primary care and secondary care Locality We help to develop healthy communities Support other sectors to make healthy public policy Health is an active partner in joint sector projects Play our role in local initiatives and support these Help to create healthy environments to live in Home People make healthy choices for themselves and whānau There is good health literacy Families are vocal about the help they need People keep active on their problems The home is safe, secure and caring

144 How we measure results Our results will be measured across five key result areas within the framework shown below (those with an asterisk). We will monitor and report on areas outside our direct control as part of our commitment to the overall health of our population and will work with our social sector partners where appropriate. NB: Work is underway to make sure that this framework, and the measures under each area, are consistent with those used by Waitemata DHB. The framework diagram shows the components of good health status that we will track over time. Health conditions, such as diabetes and heart disease, some cancers, and mental health, are very influenced by the kind of society we live in as well as our personal living circumstances. Addressing the determinants of health that lie outside of the direct influence of the DHB are the responsibility of all agencies. Our work is to make sure that the health system performs as one unified whole. The system has a great many components and is responsible for work right across the continuum, from health promotion to specialist interventions and end of life care. The whole system must support people with disabilities, helping with the supports needed to live well and have a good quality of life. All aspects of this work can be measured. The diagram shows that equity sits across everything we do

145 Te Toka Tumai: Our direction at a glance Our Vision Healthy communities -- World-class healthcare -- Achieved together Hei Oranga Tika Mo Te Iti Me Te Rahi NZ Triple Aim Improved health and equity for all populations Improved quality, safety and experience of care Best value for public health system resources Our Strategic Priorities People, patients and whānau at the centre Values and equity underpin everything we do Guarantee quality and safety Get the best outcomes from our resources Hold people, systems and structures to account Action across four settings Home Locality Community services Hospital because good health and wellbeing happens where people live, learn, work and play Key Result Areas Improved Health Status Healthy and Engaged Workforce Patient Safety Better Quality & Experience of Care Economic Sustainability Haere Mai - Welcome Manaaki - Respect Tuhono - Together Angamua - Aim high Our Values I see you and welcome you as a person Respect, nurture and care for each other A team with colleagues, patients and families Aspire to excellence and the safest care Our Purpose To improve the health of the Auckland DHB population, and of all New Zealanders who access our services, through the provision of high-quality health and disability services

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147 Waitemata and Auckland DHB Māori Health Workforce Development Plan Recommendation: That the board approve the Waitemata Auckland DHB Māori Health Workforce Development Strategy That the Board be provided with quarterly reports on progress against the strategy. Prepared by: Tereki Stewart (Manukura Hauora, Te Rūnanga o Ngāti Whātua) Endorsed by: Margaret Dotchin, Chief Nursing Officer, ADHB Waitemata Auckland DHB Māori Health Workforce Development Strategy Getting ready, getting graduates, getting jobs, getting results The development of the Waitemata Auckland DHB Māori Health Workforce Development Strategy was led by Te Rūnanga o Ngāti Whatua who has a Treaty-based partnership with the Auckland and Waitemata District Health Boards. The strategy was developed by a group of Māori health professionals, health workers and managers from both DHB s, primary health care and other health providers. The strategy will be implemented over a three-year period beginning 1 July 2014 and ending in June The strategy focuses on initiatives and proposes actions to achieve scale or more Māori health workers, everywhere by The strategy is designed to maximise the contribution of all health care providers in achieving health equity for Māori. The key objective of the strategy is to increase the number of Māori health and disability workforce from 3-5% to 13% everywhere by The strategy will be achieved by actions in four key areas: Category Getting ready Getting graduates Getting Jobs Getting results Areas for Actions Strategic leadership Expand the Rangatahi programme Align Kia Ora Hauora Work with tertiary education Human Resource management framework Recruitment/employment agency Develop clinical leaders Primary health care Education and training Measure performance Details of the strategy are contained in Appendix 1 - Waitemata Auckland DHB Māori Health Workforce Development Strategy

148 Consultation and Endorsement Significant consultation has occurred throughout the development of the strategy and post completion of the draft document with key individuals and stakeholder groups. Specific consultation and endorsement has been acquired from the following groups: Waitemata and Auckland DHBs Executive leadership Teams District Māori provider collective (a forum of all Māori providers across the district) All PHOs across the district Manawa Ora the DHBs Māori Health Gain Advisory Committee Te Rūnanga o Ngati Whātua (the DHBs Treaty partner) Next Steps The next steps are to develop a Māori Health Workforce alliance steering group between Auckland and Waitemata DHB to implement the strategy. Decisions in relation to the leadership and membership of this group will need to be discussed by ADHB and Waitemata DHB Chief Executives

149 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement. Waitemata Auckland DHB Māori Health Workforce Development Strategy Getting ready, getting graduates, getting jobs, getting results June 2014 (Final Draft for Board Approval) 1 141

150 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement Feedback on this document can be sent to: Tereki Stewart - Manukura Hauora Te Kāhu Pōkere - Auckland Office of Te Rūnanga o Ngāti Whatua 1 Rendall Place, Eden Terrace, Auckland PO Box , Symonds Street, Auckland P F E. tstewart@tihiora.co.nz Suggested citation: Te Rūnanga o Ngāti Whatua (2014). Waitemata Auckland DHB Māori Health Workforce Development Strategy Te Rūnanga o Ngāti Whatua. Auckland Disclaimer: The information provided in this proposal is presented in good faith using the information available to at the time of preparation. It is provided on the basis that the author of the proposal is not liable to any person or organisation for any damage or loss, which may occur in relation to taking or not taking action in respect of any information or advice within this proposal

151 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement Rārangi Upoko - Contents Ngā mihi Executive Summary Areas for action Tīmatanga Kōrero Ngā hua - Objective Whakatupu Rautaki Strategy Development Limitations Implementation Kōrero whakapapa Policy context Māori health workforce data Workforce participation factors The Pipeline What s been done so far? DHB workforce data DHB population data The strategy Actions Risk management plan Appendix 1: Steering Group Appendix 2: National Māori health workforce development strategies Appendix 3: DHB health and workforce development plans Appendix 4: DHB workforce initiatives Appendix 5: Māori recruitment strategy FAQ s References Tables Table 1: Summary of areas for action... 5 Table 2: Factors that influence Māori workforce participation... 9 Table 3: ADHB & WDHB population demographics Figures Figure 1: Māori Health and Disability Workforce Development Pathway... 9 Figure 2: Online job application data fields Figure 3: ADHB Māori workforce data Figure 4: ADHB Māori workforce by clinical/non-clinical roles in Figure 5: WDHB Māori workforce data Figure 6: WDHB Māori workforce by clinical/non-clinical roles in Figure 7: Strategy decision logic

152 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement He mihi tēnei E ngā iwi, e ngā reo, e ngā karangatanga maha, tēnā koutou katoa. Ka rere hoki ngā mihi, ngā tangi, ngā poroporoaki kia koutou kua takahia kētia te ara namunamu o Tāne, ā kua piki atu koutou i te āhurutanga tūturu ki ngā rangi tūhāhā okioki atu. Na reira, moe mai, moe mai, moe mai. Hoki mai kia tātou, tēnā tātou katoa. Nei hoki te mahere rautaki mo Te Hunga Mahi Hauora Māori. Ahakoa roa kē mātou e whakatakoto ana, e whiriwhiri ana ahea ra mātou tukuna atu ai ia koutou. Pānuitia, whiriwhirihia, a muri whakahoki kōrero a emera. Tēnā koutou katoa

153 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement 1.0 Executive Summary This strategy was commissioned by Te Rūnanga o Ngāti Whatua who has a Treaty-based partnership with the Auckland and Waitemata District Health Boards. The strategy was developed by a group of Māori health professionals, health workers and managers from both DHB s, primary health care and other health providers. The strategy will be implemented over a three-year period beginning 1 July 2014 and ending in June The strategy focuses on initiatives and proposes actions to achieve scale or more Māori health workers, everywhere by The strategy is designed to maximise the contribution of all health care providers in achieving health equity for Māori. Both the Auckland and Waitemata District Health Boards have strategic statements and plans related to Māori health workforce development that have been in place for some time. Workforce data suggests that all activity designed to increase the number of Māori in the health and disability workforce has had little impact on Māori workforce participation rates. This is not unique, as national workforce data is also relatively static. This finding suggests that structural and institutional barriers persist in the health and education systems and that the current approach to Māori health workforce development and planning requires change. It is in this context that the establishment of an alliance leadership team modelled on the DHB- PHO alliancing model is proposed. It is clear that Māori have poorer health status than other New Zealanders and that better health outcomes can be achieved through improved access to primary health care. Few DHB workforce development strategies have had a clear focus on increasing the capacity of the Māori primary health care/ community workforce. New models of care and expansion of whānau ora initiatives create opportunities for workforce innovation. Improvement in workforce disparities takes time, a realistic funding commitment and leadership particularly from boards and senior executives. The latter point is critical if any initiatives are to be sustainable. Māori health leadership is essential to changing the traditional DHB-driven model of workforce planning enabling new models and frameworks to develop. This strategy includes 10 areas for action grouped under four broad categories (Table 1). An implementation plan for the 3-year period should be developed to support the phasing of workforce activity and budget planning. 1.1 Areas for action Objective: To increase the number of Māori health and disability workforce from 3-5% to 13% everywhere by 2020 To put this task in context, to increase the number of Māori health and disability workforce from 3-5% to 13% by 2020 means increasing the number of Māori in each DHB by 150 new Māori employees each year. Categories Areas for action Getting ready 1. Strategic Leadership 2. Expand the Rangatahi Getting programme graduates 3. Align Kia Ora Hauora 4. Work with tertiary education 5. Human Resource Getting jobs Management Framework 6. Recruitment/ Employment Agency 7. Develop clinical leaders Getting results 8. Primary health care 9. Education and training 10. Measure performance Table 1: Summary of areas for action

154 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement. 2.0 Tīmatanga Kōrero The New Zealand Public Health and Disability Act 2000 requires District Health Boards (DHBs) to establish and maintain processes to enable Māori to participate in, and contribute towards, strategies to improve Māori health outcomes. Māori Health Plans (MHPs) are fundamental planning, reporting and monitoring documents, which underpin the DHB s efforts to improve Māori health and reduce the disparities between Māori and non-māori. A Māori Health Plan provides a summary of a DHB s Māori population and their health needs. The plan describes the actions the DHB plans to undertake to address health issues in order to achieve indicator targets set nationally, regionally and at district level. Māori health plans are the mechanism by which a Māori health workforce development strategy can be integrated into the DHB s Annual Plan and regional health plans, which provide an overall framework for future planning and states the region s priorities for each year. Integration of workforce development into DHB planning and accountability documents is also a mechanism for ensuring workforce development activity is resourced, monitored and reported on. Improvement in workforce disparities takes time, a realistic funding commitment and leadership particularly from boards and senior executives. The latter point is critical if any initiatives are to be sustainable. There is no silver bullet to address longstanding issues such as low health qualification completion rates or for creating an organisational culture that will attract and retain Māori staff. There are, however a range of short, medium and long term approaches which can improve recruitment or workforce supply, transition through tertiary education, graduate completion, transition into a job and retention once in employment. Some of these are outlined in this strategy. 2.1 Ngā hua - Objective To increase the number of Māori health and disability workforce by 13% everywhere by 2020 Good strategy is a mix of policy and action designed to accomplish a significant challenge. 1 Strategy is dependent on a good understanding of the nature of the challenge, how to approach the problem and focussed coordinated action. Strategy is about making choices (including what not to do) and allocating resources to align with achievement of those choices. 2 Strategy is about having a clear vision that can be implemented to meet the interests of diverse stakeholders. This strategy identifies the policies and actions to be undertaken over the next 3 years by the Waitemata-Auckland District Health Board s. This strategy has been commissioned by Te Rūnanga o Ngāti Whātua who have Treaty-based Memoranda of Understanding with Auckland and Waitemata District Health Boards. The Memoranda provide an opportunity to take a different approach to the way a strategy is developed; implemented and how funding decisions are made. It is in this context that the establishment of an alliance leadership team modelled on the DHB- PHO alliancing model is proposed. The Māori Alliance Leadership Team (MALT) is recommended to oversee implementation of the workforce strategy and monitor performance. It is proposed that the same alliancing principles are applied and that the MALT is engaged in all Māori workforce planning and funding decisions that are best for whānau and best for system. An example of alliancing principles include: We will support clinical leadership, and in particular clinically-led service development; We will conduct ourselves with honesty and integrity, and develop a high degree of trust; We will promote an environment of high quality, performance and accountability, and low bureaucracy; We will strive to resolve disagreements cooperatively, and wherever possible achieve consensus decisions; We will adopt a patient-centred, whole-ofsystem approach and make decisions on a Best for System basis; We will seek to make the best use of finite resources in planning health services to achieve improved health outcomes for our populations; We will adopt and foster an open and transparent approach to sharing information; and We will actively monitor and report on our alliance achievements, including public reporting. Alliance Leadership Team Charter,

155 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement. 2.2 Whakatupu Rautaki Strategy Development Strategy formulation has been organised around three key questions: Where are we now? Where do we need to go? How do we get there? Development of the strategy has included: Where are we now? Where do we need to go? How do we get there? 2.3 Limitations Analysis of current Māori workforce development performance including a stocktake of current workforce development activity A review of regional and national workforce development/ Māori health plans to ensure local, regional and national alignment Review and analysis of Māori health workforce data, data sets and supply/ forecasting assumptions Review of current and future models of care/service delivery that will have impact on Māori workforce objectives Development of strategic alternatives/scenarios, options and intentions Development of a suite of workforce tactics, activities, policies and interventions Consultation on the strategy with key stakeholders. Development of the strategy has not included a formal evaluation of current Māori workforce development interventions. Relevant literature cited is included in the reference list. Data was not collected from Māori health professionals, health workers or consumers. Instead, a steering group of Māori health professionals, health workers and managers from both DHB s, primary health care and other health providers were involved in the development of the strategy (Appendix 1). Ethnicity data is voluntary and based on selfidentification therefore errors may exist. All efforts have been made to ensure accuracy. 2.4 Implementation This strategy will be implemented over a three-year period beginning on the 1 July 2014 and ending on the 30 June Implementation of the strategy should be incorporated into DHB Māori health plans and the Māori Alliance Leadership Team (MALT) should monitor implementation and performance through 6-monthly reports coordinated by a dedicated role. Overall performance will be assessed annually and the strategy revised prior to DHB budget planning. An implementation plan for the 3-year period will be developed to support the phasing of workforce activity and budget planning. A funding commitment for the full 3-year period is recommended. 3.0 Kōrero whakapapa Māori have unique rights that have been incorporated in law and across health, social, economic and environmental policy. As health care consumers, Māori also enjoy the protection of a Code of Rights and an independent Commissioner who promotes and protects these rights under the Health and Disability Commissioner Act There are several cogent arguments for increasing the Māori health workforce. These include: The benefits of a culturally congruent workforce that is more likely to result in better communication, intervention and service outcomes, which would be cost effective. 3 4 Māori workforce development supports the wider goal of increasing workforce participation in education and employment, which contributes to broader socio-economic goals. 5 Investing in the diversification of the workforce is a long-term strategy for service sustainability. 6 Including more Māori in leadership roles also provides an opportunity to look at different ways to deliver innovative services in a resourceconstrained environment. 7 Significant health inequities exist between Māori and Non-Māori populations. 8 Inequities are unacceptable, breaching legislative requirements, and Te Tiriti o Waitangi obligations. 9 Reducing and eliminating inequities requires manifold approaches that must include addressing inequities in access to care, quality of care, access to the socioeconomic determinants of health, and layers of racism, particularly at a structural (institutional) and interpersonal level. Evidence suggests that a diverse and reflective health workforce can improve quality of care, expand access to services, increase safety, and minimise miscommunication leading to improved outcomes for patients. 12 Making available health care providers who are from the same ethnic group, or who can speak the same language as a population facing barriers to access to health services is widely seen as a highly effective strategy for improving provision of services to underserved groups

156 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement In addition to the quality improvement benefits, there is a genuine business need to recruit from our local community. Due to the global shortage of health professionals, importing healthcare professionals is unlikely to be a sustainable option. A steady stream of locally trained health workers that understand our community is a more viable and sustainable option. 3.1 Policy context The origins of government policy on Māori health workforce development extends back to the leadership of Maui Pomare and Te Rangi Hīroa (both of Ngati Mutunga descent), New Zealands first Māori medical practitioners, health administrators and politicians. The merits of Māori nurses caring for their own people was promoted as early as 1897 and articulated in government policy by Maui Pomare in 1908 when he stated these nurses were intended to go forth to care for the sick, to lecture, and to uplift humanity. i Since the late 1990 s a large number of workforce reports, policy documents and workforce strategies have been published. Workforce advisory committees have come and gone and a number of Māori health workforce initiatives have been established to respond to the challenge of increasing Māori in the health and disability workforce. 3.2 Māori health workforce data Improvements in the collection and reporting of ethnicity data provides an opportunity to analyse workforce supply trends, patterns of workforce participation and understand how government policy and strategies influence workforce behaviours or demand for labour. Māori make up 3% of NZ doctors. Between 2006 and 2009, the number of Māori doctors increased from 240 to 330 In 2010, Māori midwives made up 8% of NZ midwifes. Between the number of active Māori midwives increased from 153 to 198 In 2013, 7% of nurses (all scopes) were Māori (n= 3279) In 2010, 4% of physiotherapists were Māori (n=107) In 2010, 4% of dieticians were Māori (n=16) In 2010, less than 2% of all pharmacists were Māori (n=45) In 2010, there were 60 active Māori psychologists representing 4% of all active psychologists (n=1346). Between 2006 and 2010, the number of active Māori podiatrists increased from 6 to 12 Data on the Waitemata and Auckland District Health Board Māori health workforce is included in 4.1. In terms of the regulated Māori health workforce, regulatory authorities collect demographic and practice data as part of the renewal of annual practicing certificates. For the non-regulated workforce, data is embedded in health provider payroll and human resource information management systems, making accurate retrieval problematic. The Ministry of Health is responsible for monitoring the number of Māori in the regulated health workforce. While there have been some improvements, growth in the regulated health professions remains static. Data on the regulated Māori health workforce published in 2011 ii includes: i ii See

157 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement. 3.3 Workforce participation factors Every system is perfectly designed to achieve the outcomes that it gets - W. Edwards Deming Workforce development has evolved from a narrow focus on the individual to a much broader and holistic concept that includes workforce analysis and planning, human resource management and capability development. Māori workforce development requires an understanding of the structural, systems, organisational and individual factors that perpetuate Māori health workforce inequalities. 14 These factors influence access to tertiary education, workforce supply and participation (Table 2). Understanding these factors enables better selection of actions and measures to be included in the strategy. The pipeline model is reflected in initiatives such as Kia Ora Hauora iii, which uses the concept of a road map for individuals to plan their career journey or the Rangatahi Programme in ADHB that maps career pathways for Māori secondary students and tracks the student to graduate achievement (Figure 1). Figure 1: Māori Health and Disability Workforce Development Pathway 9.2 Structural factors System factors Organisation factors Individual factors Historical, social, economic, political and cultural factors that influence Māori participation in society Deficit-model, institutional racism. Factors that relate to the education/ health system and how the system is designed to achieve results. Institutional commitment to improving educational / employment outcomes for Māori Culturally safe and supportive workplaces that recognise and value Māori competencies and support Māori being Māori in the workplace A desire to contribute to Māori development, to work with Māori whanau/ communities to make a difference Table 2: Factors that influence Māori workforce participation 3.4 The Pipeline The pipeline or pathway model provides a framework for workforce planning The pipeline model enables a range of interventions to be considered that are designed to support successful achievement and overcome barriers, particularly to tertiary education programmes. The pipeline takes a student-driven approach and describes the phases a secondary student or adult learner may take to complete their programme of study and enter the workforce. The strategy draws on the pipeline model and recognises that there are a range of factors that influence Māori participation in tertiary education and in the workforce. 4.0 What s been done so far? Both the Human Rights Act (1993) and the New Zealand Bill of Rights Act (1990) recognise that to overcome discrimination positive actions may be needed to enable particular groups to achieve equal outcomes with other groups in our society. These positive actions are called special measures or affirmative action. They are not discriminatory if they assist people in certain groups to achieve equality. Any special measure must be based on information that shows that the present position is unequal iv Both District Health Boards have identified Māori workforce development as a priority in a range of workforce strategies; regional health service plans and Māori health plans (Appendix 2 & 3). Both DHB s have adopted initiatives based on the pipeline model to increase the supply of Māori health graduates (see Appendix 4 for a summary of DHB workforce activity). iii iv

158 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement The majority of this activity focuses on marketing health careers to rangatahi or secondary school students and supporting these students into tertiary education. Both DHB s work with secondary schools and offer secondary school students some form of exposure to hospital or healthcare environments as well Māori health professionals. Both DHB s offer financial support with tertiary education in the form of scholarships; paid course fees or part-time employment. Figure 2: Online job application data fields Academic mentoring and pastoral support is provided largely through the tertiary education provider and may be supplemented by DHB clinical staff. As students come close to graduation, strategies on how to apply for a job or a new graduate programme commence. Support provided during the graduates first year of practice is usually discipline specific. The resources (funding, people and time) to deliver these workforce activities are a mixture of Ministry of Health funded contracts and DHB operational funding. Details of the funding and people dedicated to Māori health workforce development are included in Appendix 4. Both DHB s have policy statements that prioritise the recruitment and selection of Māori job applicants. Ethnicity is one of the data fields able to be selected as part of the online application process (Figure 2). Ethnicity data is also retained on Leader the DHB Human Resource management system. In recognition of the principles of the Treaty of Waitangi and ADHB's commitment to improve health outcomes for Māori, ADHB will take measures to ensure that qualified Māori candidates are given every opportunity for employment. When appropriate, ADHB may adopt special measures to ensure Māori representation and participation at ADHB. ADHB Recruitment & Selection Policy, 2011 WDHB is committed to incorporating the principles of being a Good Employer, and meeting its obligations and requirements regarding the Treaty of Waitangi specifically, and other legislation in general, in its selection and recruitment processes. These principles are incorporated not just to ensure legislative compliance, but also to ensure a robust and diverse workforce that is both representative of the community served, and is of the highest clinical, technical, cultural, and operational calibre. WDHB Recruitment Policy,

159 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement. 4.1 DHB workforce data To increase the number of Māori health and disability workforce by 13% by 2020 means increasing the number of Māori in each DHB by 150 new Māori employees each year. Workforce data from 2005 was requested from both DHB s. The data set extracted from Leader the DHB Human Resource Management system included all employees v who identified as Māori in one or more of the ethnicity fields. Only employees who had positive contract hours have been included. Figure 5: WDHB Māori workforce data In 2013, the majority of the employed Māori workforce in WDHB were in clinical roles or roles that had a direct relationship with Māori whanau with 47% of this workforce formally regulated under legislation (Figure 6). 9.2 Figure 3: ADHB Māori workforce data ADHB Māori staff make up about 3.5% of the workforce by headcount in Data excludes casuals but includes contractors. The number of Māori in the DHB workforce since 2005 by headcount has remained fairly static (Figure 3). Figure 6: WDHB Māori workforce by clinical/non-clinical roles in 2013 It should be noted that the allocation of clinical and non-clinical job categories is based on DHB job titles and may be subject to inaccuracies. Data should be considered a guide only. Figure 4: ADHB Māori workforce by clinical/non-clinical roles in 2013 In 2013, the majority of the employed Māori workforce in ADHB were in clinical roles or roles that had a direct relationship with Māori whanau with 42% of this workforce formally regulated under legislation vi (Figure 4). WDHB Māori staff make up about 5% of the total workforce by headcount in Data excludes casuals but includes contractors (Figure 5). The number of Māori in the WDHB workforce has increased from 230 to 363 employees since There is variability in the way that both DHB s collect and report workforce data. This includes inconsistencies in the application of the Statistics NZ statistical standard for ethnicity data reporting and adoption of the Australian and New Zealand Standard Classification of Occupations (ANZSCO) vii for job classification. Standardisation in both these areas would enable better monitoring and comparison of performance and evaluation of specific activity. 4.2 DHB population data Auckland DHB is equivalent to the area formerly known as Auckland City. Waitemata comprises the historical council boundaries of Rodney, North Shore City and Waitakere. Both districts are urban with areas of high population density. Waitemata also has a significant rural population. v Employees include: permanent; part-time; contractors and fixed term. Excludes casual staff. vi Legislation includes the Health Practitioners Competence Assurance Act 2003 and the Social Workers Registration Act 2003 vii ANZSCO is an acronym for Australian and New Zealand Standard Classification of Occupations maintained by the Australian Bureau of Statistics

160 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement The population profile of metropolitan Auckland is diverse with 233 ethnic groups living in the area. The Auckland and Waitemata DHB populations are broadly made up of: Ethnicity viii ADHB WDHB Māori 13% 10% Pacific 20% 10% Asian 26% 18% Other 40.5% 62% Table 3: ADHB & WDHB population demographics In the future, the proportion of Asian people is expected to increase, Māori and Pacific populations to increase slightly and other population groups are expected to decline. Auckland DHB has over 468,000 people with a projected growth of 19% or 86,000 more people by Waitemata is the largest (550,000) and second fastest growing DHB district with a 20% projected increase in people (119,000 people) in the next fifteen years. ix 5.0 The strategy The strategy focuses on actions to achieve scale or more Māori health workers, everywhere. The strategy is designed to maximise the contribution of all health care providers in achieving health equity for Māori with a focus on primary health care, where key stakeholders believe the greatest gains can be made. Some of the action areas build on existing activities to increase workforce supply and some areas focus on maximising employment opportunities for all Māori health workers. Getting ready Having effective governance, leadership and resources in place to implement the strategy is essential. This includes planning for growth over three years and identifying sustainable funding to offset more short-term initiative or pilot funding from other agencies such as the Ministry of Health. Multiple stakeholders interests, fragmentation of activity, duplication of effort and the lack of a shared strategy is inefficient, increases transactions costs, perpetuates competition and reduces the opportunity for workforce innovation. A collaborative alliance under the leadership of key stakeholders who have the ability to make decisions regarding the allocation of resources and overcome organisational barriers is recommended. So alliancing is about Whole of system change and single system approach vs small scale activity viii Ethnicity data and projections are based on the 2006 Census ix ADHB-WDHB Child Health Improvement Plan Working with initiatives already in place and advancing strategic priorities Finding the balance between leading and leveraging Addressing sustainability and transformation at clinical practice level Improving patient outcomes and experience Getting graduates The supply of Māori health professionals and health workers is the biggest challenge to addressing workforce participation rates. Literature on the topic is mounting, but will not be traversed here x. Most of the current initiatives are based on models of best practice and evidence sourced from the literature. Wherever possible the design and delivery of activity should be based on or contribute to best practice on marketing health careers to Māori; transition into tertiary education and improving academic outcomes for Māori. Increasing graduate supply requires effective partnerships between industry and tertiary education providers. Mitigating the impact of education policies or finding creative ways to support Māori student learning are factors that will enhance graduate success. Getting jobs There are opportunities for work experience and employment in the health sector for Māori everyday. There are also opportunities for training that improves an individual s chance of getting a better job. There are also a number of barriers that make it hard for Māori to walk through the door and into employment. Data suggests that the current recruitment and employment model has resulted in 3-5% employment of Māori in the DHB workforce. To achieve any scale, a review of the special measures or positive actions that have been implemented to overcome discrimination is recommended. Equally, it is more likely that a tailored approach to recruitment and matching Māori applicants with health jobs to compliment the current or traditional system of recruitment may be more effective. Getting results Whānau Ora is about whānau being empowered to develop a plan for our future; and to trust in our own solutions. It is about restoring to ourselves, our confidence in our own capacity to provide for our own to take collective responsibility to support those who need it most. I believe that Whānau Ora x See Ratima M, Brown R, Garrett N, et al. Rauringa Raupa: Recruitment and Retention of Māori in the Health and Disability Workforce. AUT University: Taupua Waiora: Division of Public Health and Psychosocial Studies, Faculty of Health and Environmental Sciences,

161 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement represents a major transformation in the way services are designed and delivered, contracts arranged and the way providers work together. Hon. Tariana Turia Increasing Māori health workforce participation rates is fundamental to improving the quality and effectiveness of care. So is development of Māori clinician leadership and managers who are able to lead entire institutions towards the delivery of equitable and culturally effective health care. A strong primary health care system is central to improving the health of New Zealanders and, in particular, tackling inequalities in health. Primary Health Care Strategy (Ministry of Health, 2001). The strongest case for increasing Māori workforce participation is in the primary and community health workforce. Māori health professionals who understand and are understood and trusted by the communities they work with are more likely to be effective in imparting and receiving information to prevent or modify symptoms and promote health. 7 Cultural competence consists of.. 1. Ko wai e tu ake nei: Knowing yourself 2. Matatau koe i nga tikanga: Knowing your place 3. Matatau koe i nga whanau whanui: Knowing your community. MidCentral District Health Board (2005) The most critical period for brain growth and development is during pregnancy and in the first three years of life - Public Health Advisory Committee (2010) 16 DHB funding and planning teams; clinical service teams and primary health organisation s (PHO s) have a role to play in supporting new and improved models of service delivery and the Māori health workforce required to deliver them. The purpose of the Māma, Pēpi and Tamariki programme is to implement an outcomes-focused, integrated Whānau Ora model of care across the continuum from pre-conception, hapūtanga (pregnancy), birth, pēpi (0-1 year) and tamariki (1-4 years) in high needs communities. This programme will support integrated whānau-oriented community and primary care services that deliver on outcomes for our at-risk and vulnerable Māma, Pēpi and Tamariki. National Hauora Coalition (2010) Finally, results need to be measured. There are a number of tools and approaches to evaluation and what should be measured. However, the benefits of measurement are not gained from the collection of data but how it is used and the actions taken to achieve sustained improvement. 9.2 This requires both clinically and culturally competent practitioners. This is also a requirement under legislation and professional codes of conduct. The purpose of the Health Practitioners Competence Assurance Act (HPCAA) 2003 is to protect the health and safety of members of the public by providing for mechanisms to ensure that health professionals are competent and fit to practice their profession. In particular, section 118(i) requires regulatory authorities to set standards of clinical competence, cultural competence, and ethical conduct to be observed by practitioners of the profession. The strategy proposes incentives to facilitate more Māori into primary health care xi as well as new models of care particularly for pregnant Māori women, our tamariki xii ; long term condition management for pākeke and kaumātua and for developing the Whānau Ora workforce. xi Primary health care relates to the professional health care received in the community, usually from a General Practitioner or practice nurse. Primary health care covers a broad range of health and preventative services, including health education, counselling, disease prevention and screening. xii Refer to the ADHB / WDHB Child Health Improvement Plan:

162 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement. 5.1 Actions The following section describes the detail of the strategy. It should be noted that the strategy incorporates actions from previous workforce and Māori health plans (see Appendix 3) and builds on current workforce initiatives (See Appendix 4). In terms of implementation, establishment of an alliance leadership team is recommended as a priority. A three-year implementation plan that phases activity, identifies budget requirements, allocates accountability and performance measures is recommended to ensure effective deployment of the strategy. The strategy is summarised in Figure 7. Getting ready ADHB, Waitemata DHB and Te Rūnanga o Ngāti Whātua senior management demonstrate leadership and commitment to Māori health workforce development Rationale: a united and clear model of leadership addresses system and organisational factors that influence Māori workforce participation. Getting graduates Recruiting Māori secondary school students and secondchance learners into relevant tertiary education programmes is essential for increasing workforce supply Rationale: There is evidence that a pipeline or student driven approach to workforce development and implementing evidencedbased interventions to overcome barriers xiv to workforce participation will enhance graduate success Actions 1. Strategic Leadership a) The Executive Leadership teams and Boards for the Auckland & Waitemata DHB s approve this strategy and allocate appropriate funding and resources xiii to implement activities over the next 3 years b) A Māori Alliance Leadership Team (MALT) modelled on the DHB/ PHO alliance leadership model is formally established to provide governance over the workforce strategy and its implementation and to monitor performance of the annual workplan. c) All Māori health workforce development roles (fte), funding and resources are aligned to implementation of the strategy and reduction in duplication d) Performance objectives/ KPI s within each DHB are cascaded to relevant senior managers to support deployment of the strategy Actions 2. Expand the Rangatahi Programme a) Expand the Rangatahi programme to cover both the ADHB and Waitemata DHB region and secure appropriate funding to support programme expansion b) Revise the programme to integrate current scholarships, work experience and cadet programme management activities into one comprehensive programme c) Increase target numbers and performance indicators for the programme (across all categories) by 20% per annum d) Market and promote the revised programme to schools in the ADHB & Waitemata region 3. Align Kia Ora Hauora a) Ensure the Kia Ora Hauora regional work programme is aligned to the strategy and market health careers to DHB Māori audiences for the next 3 years b) Work with secondary schools to implement an evidenced-based approach to increasing the number of Māori students achieving in science 4. Work with Tertiary Education It is necessary to work with tertiary education providers to improve Māori undergraduate completion rates through: a) Participation in the recruitment and selection of Māori into foundation/ undergraduate programme b) Increasing the number of Māori undergraduate students on clinical placement particularly in primary care c) Improving academic, pastoral and cultural support for Māori undergraduate students d) Innovative models for increasing the number of Māori clinical and academic teaching staff e) Strategies for information sharing and forecasting Māori workforce supply estimates xiii Resources include access to all DHB services, information, and relevant skills and expertise. xiv Barriers refer to historical, social, economic, political and cultural factors that influence Māori workforce participation

163 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement Getting jobs Both the Human Rights Act (1993) and the New Zealand Bill of Rights Act (1990) recognise that to overcome discrimination positive actions may be needed to enable particular groups to achieve equal outcomes with other groups in our society. Rationale: Barriers need to be reduced and innovate ways established to make it easier for more Māori to walk through the door and into employment in the health and disability sector Action 5. Human Resource Management Framework a) Review current human resource management recruitment policies, procedures and processes to determine how they can be enhanced to support special measures and achieve more equitable employment outcomes for Māori b) DHB s will nominate designated positions that are aimed at and are available to applicants of Māori descent. These positions will usually involve working with and/or providing services to Māori. Applicants must provide evidence in the selection process that they have an ability to communicate effectively with Māori and that they possess relevant and appropriate cultural knowledge 6. Recruitment/ Employment Agency Explore the feasibility of establishing a Recruitment/ Employment Agency for Māori health workers to: a) Improve recruitment from the Māori labour market and candidate care/ talent management b) Reduce the competitive model of recruitment between DHB s and health providers, foster employer collaboration and match Māori candidates to the best job/ employer c) Facilitate fixed-term, casual employment, work experience (paid & voluntary), cadetships for Māori applicants d) Utilise feedback from exit interviews with Māori staff leaving employment to enhance HR processes e) Provide career planning advice and support f) Market and promote the Voluntary Bonding Scheme to Māori graduates

164 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement Getting results Māori leadership will facilitate wider acceptance of Māori thinking, frameworks and ideologies that is likely to lead to more culturally appropriate services for Māori and in the longer term, perhaps even more equitable care Rationale: Retaining Māori staff skills and developing leadership capability is important for improving the quality and effectiveness of services and is a long-term strategy for sustainability. Actions 7. Develop clinical leaders a) Establish a leadership development programme to identify and develop emerging clinical leaders and create opportunities for individuals to take up additional responsibilities (e.g. through secondments; project work; portfolios) to support quality improvement and succession planning. b) Establish a formal Māori clinical network (with secretariat support) across both DHB s to influence system change; models of care and quality improvement xv 8. Primary health care a) Fund a primary health care/community clinical placement programme for Māori undergraduate students across disciplines (not already funded) to enable time for supervision/ learning on clinical placement and to offset clinical slowdown. b) Explore new models of employment including salary subsidies for Māori new graduate nurses (in addition to HWNZ Nursing Entry to Practice programme funding) in primary health care. c) Explore the feasibility of a community-based model of midwifery care Wahine Ora for pregnant women Māori xvi. The service would also integrate clinical placements for Māori undergraduate midwifery students. d) Explore the integration of Māori allied health practitioners xvii (and undergraduate students) into general practice/primary health organisations to support long-term condition management programmes e) Primary Health Organisations and DHB Alliance Leadership teams prioritise Māori health workforce development initiatives in workplans f) Draft and include a clause in all non-government organisation contracts that require the provider to support Māori workforce development activity and ensure the availability of Māori staff to reflect the consumer population 9. Education & training a) Increase access and completion of level 4 to 6 programmes via Hauora Māori (or similar funding) programme purchasing with a focus on upskilling the Whānau Ora workforce b) Increase Māori trainee access to Health Workforce New Zealand funded training and achievement of higher qualifications by 20%. c) Prioritise funding for Māori nurses working towards advanced nursing roles and or designated positions in primary health care. d) Improve access to culturally relevant training, supervision and mentoring to support Māori competencies and Māori being Māori in the workplace 10. Measure performance a) A standardised data set in line with ANZSCO job classification system xviii and Statistics NZ statistical standard for ethnicity xix for workforce monitoring and reporting purposes is adopted. b) Consider processes for the collection and reporting of health workforce data from contracted service providers c) A results-based evaluation or decision-logic framework is designed to support strategy implementation The strategy is summarised in the Figure 7. xv Refer to Waitemata District Health Care Plan (2010). xvi The ADHB-WDHB Child Health Improvement plan identifies that every pregnant woman should be meeting her Lead Maternity Carer by week ten of her pregnancy, at pg 19. xvii Allied health practitioners include, but are not limited to: physiotherapists; occupational therapists; social workers and pharmacists. xviii ANZSCO is an acronym for Australian and New Zealand Standard Classification of Occupations maintained by the Australian Bureau of Statistics. ( xix The Statistical Standard for Ethnicity was developed to ensure that ethnicity is collected consistently for all surveys and administrative collections

165 This document is in draft and is intended as a part of our consultation process. It is not an approved document, and is subject to amendment and refinement 9.2 Figure 7: Strategy decision logic