Long Term Investment Plan

Transcription

1 Long Term Investment Plan DRAFT LONG TERM INVESTMENT PLAN,

2 Table of Contents 1 Executive Summary Overview Our people and their health Our Strategy Our Service Model Our Asset Portfolio Future Portfolio of Investment What this Investment will help to deliver Financial Assessment Summary Our pathway going forward Introduction Who we are What we do Strategic Context Our people and their health Challenges and Opportunities for MidCentral DHB Our Operating Environment Our Governance Structures and Stewardship National Context Regional Context centralalliance the Sub-Regional Context Our Strategy MidCentral DHB Strategy for Success; Together We Choose Excellence Strategic Framework: Our Roadmap of actions: Our Key Enablers Enacting our Strategy Our District s Health Charter Our New Service Model Our vision for the future Our Service Model Integrated Service Teams Planning & Funding Services What the Strategy will mean for people A Service Perspective Older People A Patient Perspective DRAFT LONG TERM INVESTMENT PLAN, Page 2

3 6 Our Health & Disability Services Current Situation Overview of Community-based Services Current Community Based Services Overview of Hospital & Specialist Services Current Hospital Based Services Current workforce Current Asset Portfolio Asset Management Current Asset Summary Major Clinical Equipment Information and Communication Technology Buildings and Infrastructure Palmerston North Hospital site summary Horowhenua Health Centre Seismic Risks Land Our Investment Strategy Our Investment Approach & Logic Issue one: Growing gap between health needs/ expectations and resources Issue two: Variable access to services Issue three: Health providers don t always work together effectively, resulting in disjointed care Issue four: Some facilities and supporting services are not fit-for-purpose Investment Approach to Strategy Implementation Benefits Transforming our services Our Workforce a Key Enabler Required Capital Investment Investment required in Major Clinical Equipment Investment required in Information Technology and Communications Infrastructure Investment required in Facilities and Infrastructure Future Clinical Service Infrastructure needs Service Demand Forecasts Proposed Investment - The Palmerston North Hospital Indicative Business Case (IBC) IBC fit with a long term Master Site Plan Capital Landscape Programme Year Capital Intentions of Projects Projects/Programmes Underway Anticipated projects with business case under development DRAFT LONG TERM INVESTMENT PLAN, Page 3

4 Known but no business case yet Other known investments for which only seed funding is anticipated Other Service initiatives that may require Capex Costs and Affordability Current Financial Position Financing our investment plan Financial Assumptions and Analysis Risks, Constraints, Dependencies and Assumptions Appendices Mapping of MidCentral DHB s LTIP against Treasury's assessment criteria Detail of Scenario Projections Palmerston North Hospital Site Map Regional Governance Structures Strategic Road Map Summary of Community Based Service Providers throughout the district Investment Logic Map Benefits Map Service Demands (Current and Future Forecasts) Forecast Projection Assumptions Summary of Major Buildings and Facilities Palmerston North Hospital Horowhenua Health Centre Asset Condition Assessments Building Age Condition of buildings Map of Seismic Performance Major Clinical Equipment Over $250k Information and Communication Technology Stocktake of Other Current Assets Bed numbers Theatres MRI Utilisation Metrics Capital Landscape detail MidCentral DHB Risk Reporting and Accountability Framework DRAFT LONG TERM INVESTMENT PLAN, Page 4

5 Table of Figures: Figure 1: Capital Landscape Summary Figure 2: Profile of Investment Focus Areas Figure 3: Summary of total investments and funding for 10 year forecast period Figure 4: One Year in our District Figure 5: Our Population Figure 6: Predicted trends in MidCentral DHB population aged 65 and over Figure 7: Predicted trends in ethnicity of MidCentral DHB population Figure 8: Predicted trends in ethnicity of MidCentral DHB population aged Figure 9: Decile ratings of MidCentral DHB population in Figure 10: Trends Influencing Healthcare Figure 11: Key trends and their implications Figure 12: Graph of predicted population growth across Central Region Figure 13: Map of region Figure 14: Central Alliance Shared Aspirations and Principles Figure 15: MidCentral DHB Strategy Enablers Figure 16: Current sector model Future sector model Figure 17: The relationship between internal plans Figure 18: Tama and his whānau s different experiences Figure 19: Martha s different experiences Figure 20: Map of Integrated Health Care Providers in the MidCentral District Figure 21: Capability of Services at Palmerston North Hospital Figure 22: General descriptions of Level of Complexity in Role Delineation Model Figure 23: Professional Profile FTEs Figure 24: Workforce Ethnicity Figure 25: The Health Eco-system Figure 26: MidCentral Ambulatory Sensitive Hospitalisations Figure 27: Status of Key Services Figure 28: Summary of proposed capital investment in major clinical equipment Figure 29: Major Clinical Equipment Capex 10yrs to 2026 cumulative ($000 excl GST) Figure 30: Planned MidCentral DHB enabling technology initiatives Figure 31: Summary of proposed capital investment in ICT Figure 32: ICT Capex 10yrs to 2026 cumulative ($000 excl GST) Figure 33: Summary of proposed capital investment in buildings and plant Figure 34: Building and Plant Capex 10yrs to 2026 cumulative ($000 excl GST) Figure 35: Capital Projections by main asset type Figure 36: 10 Year Capital Intentions of Projects Figure 37: Building and Plant Capex 10yrs to 2026 cumulative Figure 38: Financial History Trend Summary Figure 39: Modelling Assumptions Figure 40: Increases to MidCentral DHB appropriations, by scenario (as at 12/07/2016) Figure 41: Table of Strategic Risks Figure 42: Key risks, constraints, dependencies and assumptions DRAFT LONG TERM INVESTMENT PLAN, Page 5

6 1 Executive Summary 1.1 Overview For the last decade MidCentral DHB has been investing in primary and community healthcare in order to further strengthen services and deliver health gains to our community in the face of changing demand for services and an ageing workforce. As a result we have Whānau Ora and collaborative partnerships with Non Government Organisation providers and a good base of Integrated Family Health Centres (IFHCs), which we consider to be the sustainable foundation of primary and community services into the future. Our recently refreshed Strategy reaffirms our commitment to quality and excellence, to advancing equity for population groups, to achieving joined up services, and people and whānau centred care. This commitment will see us continuing to support the development of community-based services into the future but extending this to a more transformative change through the integration of the traditional primary and specialist services into our communities through IFHCs. This means moving care as close to home as possible. From the patient perspective, this will ensure a better experience, better quality care, and improved outcomes. As well as continuing to develop community-based care, our Strategy requires high performing hospital services. Investment is required in facilities and infrastructure to provide quality healthcare for our people. That will require completion of our Information, Communications, and Technology (ICT) infrastructure investment; periodic refresh of our clinical equipment; developing some key new clinical capabilities; and the significant seismic and functional upgrading of our major buildings. We also need to invest in the development of our workforce as they are a key enabler to meeting the needs of our communities. This level of capital investment will require new equity to be injected. The mid-range funding path is consistent with that being manageable although it would keep significant operating pressure on the near term. 1.2 Our people and their health (DHB) receives just over $600 million and serves a population of 174,000 people. Compared to the national average, people in our district are older, more likely to be living in high deprivation, and more likely to be Māori. The people are spread across five Territorial Local Authorities with a significant number living in rural communities. The health status of the district is below average, with avoidable mortality and morbidity rates slightly higher than the national average. Looking to the future, MidCentral expects modest population growth (4.9 percent over 10 years) but significant change in the age structure. The number of adults in the 65+ age group is expected to double by This age group uses more health services, a tendency that is expected to be compounded by increasing health need associated with long term conditions driven by lifestyle factors. The proportion of Māori and Pacific is also expected to rise, particularly in the 0-24 age group. By 2030 over 50 percent of our population aged under 25 will not record European as their main ethnicity and we must ensure we can provide culturally responsive services for these young people. Other challenges we face include financial sustainability, which has been an issue for the last two financial years, and an infrastructure not fit for purpose. DRAFT LONG TERM INVESTMENT PLAN, Page 6

7 1.3 Our Strategy MidCentral DHB is an effective organisation that strives to provide excellent care for our community. We have strong governance and well established clinical leadership. Excellent relationships exist with partners and intersectoral agencies at the local, regional, and national levels and we are an active participant in regional and national planning. Our DHB has traditionally had a strong strategic direction based on a desire to improve the health of its population. The organisation has recently reviewed its direction and refreshed this in a new Strategy, which outlines our vision of Quality Living - Healthy Lives - Well Communities; what this would look like in the future; and the strategic direction we are taking to get there. Our DHB has also developed a Health Charter which is intended to establish a health agenda across intersectoral agencies and a partnership approach. Our purpose is to provide better health outcomes and better health care for all. In order to do this, our focus is on: achieving equity of outcomes across communities, partnering with people and whānau to support health and wellbeing, achieving quality and excellence by design, and connecting and transforming primary, community and specialist care. We will achieve these strategic imperatives through our key enablers: People - O mātou iwi Our staff and leadership are fundamental to the success of this strategy; they will be responsible for driving our Strategy. Partners - O mātou hoa mahi In order to make change we need to work together across sectors as one team, and this is not possible without the commitment and expertise of our partners. Innovation - Kia Te Auaha To deliver the best health care possible as our landscape continually changes, we need to be innovative. We need to listen to our staff and our partners ideas, working in a cycle of continuous improvement. Stewardship Kia Te tiaki We are all stewards; we have been entrusted with the careful and responsible management of resources, finances, and more importantly our people s health care. Information Kia Te whakamohio Collecting and managing information, analysing data trends, and having systems that can talk to each other will allow us to remain agile, adapt to the changing environment, make evidence-based decisions, and share information with our partners and people. Investing in areas such as telehealth will be important. 1.4 Our Service Model Traditionally health has been thought of as primary and secondary care. Underpinning MidCentral s Strategy is transformation to a different service model, one based around community and hospital settings. In this model, the health needs of people and whānau are addressed in community settings DRAFT LONG TERM INVESTMENT PLAN, Page 7

8 wherever possible. This can be either at home or from Integrated Family Health Centres (IFHCs). These Centres are bases out of which a range of generalist and specialist services will operate in an increasingly joined up fashion. After ten years investment in community services there are now six IFHCs in the MidCentral district serving about 60 percent of the enrolled population. There are IFHCs serving Horowhenua, Manawatu, and Tararua communities. There are two IFHCs in Palmerston North, with MidCentral DHB and Central PHO exploring the options for a third to service the south and western suburbs, which are considered high needs populations. The vision for this IFHC is that it will build on existing arrangements to further a collaborative approach with the social sector and will incorporate Whānau Ora principles. Further investment is required in the IFHCs to ensure they are able to effectively provide the services required to meet the needs of our population, however apart from some seed money we anticipate that this will mostly be provided by third party investors. The other cornerstone of MidCentral s health system is the hospital based services at Palmerston North Hospital and Horowhenua Health Centre. Palmerston North Hospital provides a comprehensive range of secondary acute and elective services, including a regional cancer treatment service that also cares for Taranaki, Whanganui and Hawkes Bay DHBs populations. We are looking to continue to provide high quality, best practice services that meet the growing demand within the resources available. Our current facilities are not up to required standards in many areas and significant investment is needed to ensure we can provide people-centred care in fit for purpose environments. As we work towards transforming to a whole of system approach and further developing integrated services, it is important that we have the right Information and Communications Technology (ICT) infrastructure to support access to quality data and information. ICT is therefore, another area requiring substantial investment. 1.5 Our Asset Portfolio MidCentral DHB s primary assets are our people, our facilities, and our equipment. Our facility assets have a carrying value of $131.6 million and principally comprise the Palmerston North Hospital campus. The campus is well maintained, but deficient in a number of respects. There are parts that are seismically sub-standard which need to be addressed in coming years, and other deficiencies in services such as electrical infrastructure, which are nearing end of life and are being progressively replaced to avoid failure. More significantly, there are a number of major areas that are no longer fit for purpose and which impede the DHB s ability to meet the challenges of the future. We have undertaken a detailed assessment of the major areas of functional deficiency through an indicative business case developed in This involved a robust strategic assessment process. In community settings, the DHB owns Horowhenua Health Centre in Levin, which was commissioned in The Horowhenua Community Practice has outgrown its space within the Horowhenua Health Centre, which requires attention. Otherwise the Centre is in good condition. Other IFHCs and health facility assets in the community, such as those associated with community pharmacies, Aged Residential Care providers, Non Government Organisations, and Iwi/Māori providers are well maintained. They are owned by private operators or trusts and are generally developed and maintained by their respective owners without capital investment from MidCentral DHB. While the physical facilities of IFHCs are generally modern and in good repair, the infrastructure in these centres is still requiring some further development to fulfil the role envisaged within the district s health system. MidCentral DHB s financial assistance for IFHCs targets planning, facilitation, and change DRAFT LONG TERM INVESTMENT PLAN, Page 8

9 management. In addition, MidCentral DHB and Central PHO have both committed to basing their clinical teams out of integrated health care centres. Clinical equipment has been brought up to acceptable condition recently with an investment over the last two years of $13 million to bring the book value to $25 million. ICT is an area in which MidCentral DHB has had to invest heavily over recent years to address moribund infrastructure resulting from a lack of investment in previous years. This situation has improved, but we are still struggling to replace legacy systems. We have a programme of work that is extremely demanding, but still falls short of what is required to support the future health system. We are committed to the Regional Health Informatics Programme (RHIP) and the National Information Technology programme and also need to be responsive to technological advances where they present us with opportunities to improve our services. The current investment in ICT is represented by $1.7 million of hardware and related infrastructure and by $15.8 million in intangible software in use or under development. A major asset for any organisation such as ours is people. MidCentral DHB currently has 2,666 employees (2,159 Full Time Equivalent). To enable success in the future we will invest in a sustainable workforce that meets both current and future capability and capacity needs, and is reflective of the communities we serve. 1.6 Future Portfolio of Investment A Master Health Services Planning exercise was undertaken for MidCentral DHB in 2013, this involved a robust strategic assessment process including the development of an investment logic model. The key investment drivers that were identified in the investment logic mapping workshops remain relevant as we look to the future. These issues, along with consideration of the New Zealand Health Strategy, informed the development of the Strategic Imperatives within the new MidCentral DHB Strategy. To achieve better health outcomes, better health care for all we will transform our services and models of care in line with our Strategy. We want to have high quality community based and hospital based services providing excellent person-centred care for those who need it. We have invested in primary and community care, and commenced investment in the infrastructure to support integration, both locally and regionally, ie implementing clinical pathways and IT systems. This part of the local health and disability sector is ready for the transformation we ve planned and new models of care. Specialist hospital services have not had significant, planned investment. The buildings are well maintained but are no longer fit for purpose, and they are restricting the introduction of new models of care and quality standards. Some ad hoc investment has occurred to address critical service and safety issues; however we now need to move to a co-ordinated approach. A long term facility plan (Campus Strategy and Site Master Plan) is under development, aligned to our Strategy and future demand so investment in hospital services can occur. Investment in ICT and facilities infrastructure is vital to be able to provide people with high quality, integrated services in facilities that are fit for purpose. We have begun to invest in RHIP initiatives, however we have underinvested in both ICT and facilities infrastructure over recent years so major DRAFT LONG TERM INVESTMENT PLAN, Page 9

10 investment is now needed to bring our infrastructure up to standard and to be able to adapt to the future needs of our population. We also need to be responsive to technological advances in equipment where they present us with opportunities to improve our services. Community Based Services, Hospital Based Services, Equipment, Facilities Infrastructure, and ICT are the five core areas requiring investment into the future. The profile of these investment areas appears in Figure 2. A 10 year Capital Landscape programme has been developed to identify future priorities in relation to the capital costs to 2026 to make our facilities fit for purpose into the future. This is summarised below. Figure 1: Capital Landscape Summary Figure 2: Profile of Investment Focus Areas DRAFT LONG TERM INVESTMENT PLAN, Page 10

11 1.7 What this Investment will help to deliver Implementation of this investment portfolio will have the following impacts: Investing in community based services will mean: People, families, and whānau will have access to services and support as close to home as possible. People will have access to culturally relevant and responsive health services. People will live longer, healthier, and more active lives regardless of location, ethnicity, socioeconomic status, age, or gender. Collaborative work between health, social services, and community agencies will improve the health of communities. Long term conditions are detected early and managed appropriately in a place most appropriate for people, families, and whānau. Investing in reconfiguring models of care and hospital based services will mean: People will have a positive experience of care from a joined up health system. People and whānau health outcomes are improved as a result of continuous quality improvement. People will have evidence based, clinically effective healthcare services delivered on time. Population health will improve as a result of research and best practice shared and implemented across services. Consumer engagement will contribute to improved services. Maintaining investment in equipment will mean: Population Health will improve as a result of local innovation and technological advances. People s expectations of high quality services will be met. Investing in facilities infrastructure to ensure it is fit for purpose will mean: People are cared for in a safe environment and protected from harm. People, family, and whānau feel more comfortable and confident in healthcare settings. Fit for purpose facilities will contribute to a high performing health system. Investment in ICT to support our strategy will mean: People can easily access the information they need when they want it. Providers of care can easily access the right information at the right time. People s health is improved as organisations work together, sharing information and knowledge. Services will be more available when people want them, and access to services will be easier. These investments support our Strategy and the achievement of our Strategic Imperatives. The Enablers from our Strategy and their related plans will also have a major influence on achieving these impacts. eg The Organisational Development Plan (People) will guide how our Human Resources are used and the Information Systems Strategic Plan (Information) will provide strategic direction for investment in ICT. DRAFT LONG TERM INVESTMENT PLAN, Page 11

12 1.8 Financial Assessment Summary The capital investment requirement identified in this plan totals $409 million over ten years, with options to be explored in respect of some items. To fund this we have cash and equivalents at June 2016 of $47m and project the benefit of depreciation to be $241m. The balance will need to be derived from operating surpluses and from equity injections. The key aspects of cost that influence the overall financial outcome are the potential rates of increase in healthcare demand from an ageing population, coupled with potential increases in Multi-Employer Collective Agreements, and the ability to suppress cost growth in other inputs. When the burden of additional capital charge is added to that, there are few degrees of choice available to execute long term strategy. In summary, over the ten year forecast period, total investment and funding would be: Figure 3: Summary of total investments and funding for 10 year forecast period $m Low 2.75% Funding Path Scenarios Medium 3.5% High 4.25% Investment Less: Depreciation Surplus (22.7) Existing Cash Applied New Equity Required Residual Cash available at year Providing that our underlying assumptions about operating costs and increases hold, then these funding track scenarios would broadly lead to assessment on the sustainability as follows: Low Scenario The level of capital injection required and the burden of capital cost in the medium to longer term, coupled with a funding track below the aggregate demand and unit cost growth, would place the DHB under extreme financial pressure and compromise our ability to execute our strategy to achieve necessary changes in preventative and other community based care. That funding track would not support a viable service longer term and significant compromise to the robustness of the Hospital Campus would be required. Medium Scenario Operating revenue will initially be insufficient to support operating requirements and the DHB will need to continue focusing on trade-offs between cost cutting and health delivery objectives. Significant tension will exist between short/medium term operations and the achievement of longer term objectives but these are not irreconcilable provide there is agreement that the operating result will be somewhat volatile and struggle to break even in the short to medium term. Toward the end of the planning period the initial cost burden of refreshing our underlying capital will be sufficiently digested that the operating finances will be balanced and consistent with meeting longer term requirements. High Scenario The near term will remain under financial pressure however in the later years of the forecast period funding would become available to pursue strategy for health and wellness in our community while achieving a viable asset base in secondary services. There is potential for capacity to explore options in the later years and eventually return capital or reduce the out-years funding path. The detail of these projections is set out in Appendix DRAFT LONG TERM INVESTMENT PLAN, Page 12

13 It should also be noted that as we transform our services and modify our models of care in line with our strategy there may well be significant shifts required in the way we allocate our Operational Expenditure. We are very much at the start of the planning phase for this service transformation and as decisions are made regarding new models of care, decisions will also need to be made about resource allocation to ensure money is being spent on areas that will achieve the best health outcomes for our population. 1.9 Our pathway going forward This first edition of the MidCentral DHB LTIP is an ongoing work in progress. The LTIP has been prepared with information which will be updated and refined in the near future due to the timing of completing a number of developments and planning activities currently underway. The next steps we will undertake are: The roll out of our Strategy across the organisation. This will include the development of locality plans and service plans which will change the way we provide services. Working with regional and sub-regional partnerships to solidify future service requirements and MidCentral DHB s role in providing these services. Building our community based services to ensure they are meeting community needs and IFHCs are fulfilling their role as the foundation of services closer to home. Updating the business case for our Master Health Services plan and beginning the process to get it underway, in context of an overall site master plan. Implementing ICT initiatives across a range of investment areas. Developing an equity snapshot for our region so that we can make evidence based decisions when developing programmes to address inequities for specific demographic groups. Continuing to build on our contribution to Whānau Ora across the district as part of the Whānau Ora Strategic Innovation and Development Group. The LTIP will remain a living document and will continue to be updated to incorporate new changes as part of the other DHB strategic documents. DRAFT LONG TERM INVESTMENT PLAN, Page 13

14 2 Introduction 2.1 Who we are is one of 20 District Health Boards (DHBs) established under the New Zealand Public Health and Disability Act 2000 to provide health services for our population. MidCentral DHB and its partner organisations have stewardship over annual operating budgets of more than $600 million and over $300 million in asset values. Our organisation has strong clinical leadership and a strong governance board and committees supported by a positive formal relationship with our Iwi Partnership Board, Manawhenua Hauora. We also have sound relationships across sectors with different community and government agencies and have developed a Heath Charter formalising a commitment from ourselves and other agencies to work together to best meet the health needs of our population. MidCentral DHB prides itself on being innovative, advancing integration, and having a significant and ongoing investment in community based heath care. An example is our investment in developing Integrated Family Health Centres with 60 percent of our population covered by these. Another is the work done to support the integration of primary and specialist (hospital) care, and regional services. Over 60 Collaborative Clinical Pathways are now available to community based and hospital based clinicians, and regional Information Technology systems are being established. Some of the challenges we currently face include working within outdated hospital facilities that are no longer fit for purpose and are restricting the introduction of new models of care and quality standards, and, ICT systems that need significant investment to meet current and future requirements. We forecast that our services will need investment in excess of $400 million over the next decade, and a smaller amount in the decade beyond, as we renew our capital infrastructure and invest in new technologies and our people. 2.2 What we do We plan, purchase, and provide publically funded health services for our population. We have an Alliance contracting agreement with Central Primary Health Organisation (Central PHO), which has contracts with all the General Practices serving the MidCentral region. We contract with Aged Residential Care (ARC) and Non Government Organisations (NGOs) including Iwi/Māori health providers. We participate with Whanganui, Hawkes Bay, Wairarapa, Capital and Coast, and Hutt Valley DHBs in Central Region planning activities, and have a services alliance with Whanganui DHB (centralalliance). We provide publicly-funded, hospital, and public health services. Our hospital services include higher secondary/lower tertiary services for our population. Some specialist services are also provided to neighbouring DHBs from the Palmerston North base hospital sited on an 18 hectare campus in the city (see Appendix 14.3 for Palmerston North Hospital Site Map). These services are supplemented by a private hospital in Palmerston North and tertiary services purchased from Hutt Valley, Capital and Coast, Auckland, and Canterbury DHBs. DRAFT LONG TERM INVESTMENT PLAN, Page 14

15 We run specialist outreach clinics in the Horowhenua Health Centre, other locations throughout our district, and in Whanganui. The Horowhenua Health Centre is a DHB owned facility developing into an Integrated Family Health Centre (IFHC) with a General Practice (8,500 enrolled), 4 maternity beds, 24 respite/step down beds, community pharmacy, community radiology services, St John, and the local GP after hours service. A similar facility opened in Dannevirke in 1997 and is now incorporated into the innovative Tararua Health Group Ltd, who are developing this IFHC with refurbished practice sites in Dannevirke, Pahiatua, and Woodville. In total MidCentral DHB has provided seed funding and had a strong facilitation role in the development of seven Integrated Community Health Care Providers currently covering approximately 100,000 enrolled people. Five providers have developed new buildings with private sector funding, two in Palmerston North, and one each in Feilding, Ōtaki and Foxton. They are positioned well to develop and enrol more people and better integrate services. There is a need for another IFHC in Palmerston North to service the south and west of the city and it is planned that this IFHC will be developed with a social sector approach. Community based health care in MidCentral is responsive and innovative and has identified several significant opportunities to achieve returns on investments, to develop new models of care, and to implement quality driven services. Central PHO works closely with the Te Tihi and Raukawa Alliances, and fully supports the Kainga Whānau Ora Alliance pilot project currently underway with 100 Housing NZ high needs whānau/families. Figure 4: One Year in our District DRAFT LONG TERM INVESTMENT PLAN, Page 15

16 3 Strategic Context 3.1 Our people and their health Health trends are analysed through Health Needs Assessments, Demographic Profiles and Epidemiological Studies for specific population groups and these are reported to boards committees and used to inform planning and investment. Figure 5: Our Population The population of our district is predicted to grow to 181,000 by 2025 (+4.9 percent over 10 years) The 2015 Health Needs Assessment identified three important demographic trends impacting our population: The growing proportion of people aged 65 and older, currently at 19 percent of the population (Census 2013 was 14.5 percent for NZ) and set to double to over 60,000 people by We have a comparatively young and growing Māori, Pacific and Asian population by 2030 over 50 percent of our population aged under 25 will not record European as their main ethnicity. Within MidCentral DHB s area, there are some territorial authorities with high proportions of their populations living in socio-economically disadvantaged areas. They are Horowhenua, MidCentral s portion of Kapiti Coast (Ōtaki and surrounds), and, to a lesser extent, Tararua. DRAFT LONG TERM INVESTMENT PLAN, Page 16

17 These trends are important because people who are experiencing socio-economic disadvantage, Māori, and older people are known to have poorer health status than other New Zealanders. MidCentral need to ensure we are taking a Whānau Ora approach to meet the needs of our growing young Māori population. Older people are at higher risk of long term illnesses (like diabetes, high blood pressure, heart disease, stroke and their effects) and socio-economically disadvantaged people have poorer health status higher mortality rates and higher need for health services than the general population (Ministry of Health, 2002) so this must also be factored into future service planning. Figure 6: Predicted trends in MidCentral DHB population aged 65 and over MidCentral DHB population age 65 & over by ethnic mix - stats NZ medium estimates 2013 to ,000 50,000 40,000 30,000 20,000 Maori Pacifc Asian Other Total age 65 & ovr 10,000 0 Figure 7: Predicted trends in ethnicity of MidCentral DHB population 200,000 MidCentral DHB total population estimates 2013 to 2038 Stats NZ medium projections 180, , , , ,000 80,000 Total pop Maori Pacifc Asian Other 60,000 40,000 20,000 0 DRAFT LONG TERM INVESTMENT PLAN, Page 17

18 Figure 8: Predicted trends in ethnicity of MidCentral DHB population aged ,000 MidCentral DHB population age 0 to 24 by ethnic mix - stats NZ medium estimates 2013 to ,000 30,000 25,000 20,000 Maori/Pacific/Asian Other 15,000 10,000 5,000 0 Figure 9: Decile ratings of MidCentral DHB population in 2013 While most adults (88 percent) and almost all children (99 percent) living in the MidCentral district experience good, very good, or excellent self-reported health, there are a number of important health challenges facing our population. Health status is continuing to improve in general, however inequities persist particularly for Māori and Pacific peoples, for individuals and families/whānau who experience socioeconomic disadvantage, and for people living in Ōtaki and Horowhenua. (Health Needs Assessment 2015) 3.2 Challenges and Opportunities for MidCentral DHB The health sector of the future will look very different from the health sector of today. Recent years have seen numerous changes and advances in health care and many of these changes will continue in the future. The rate of technological advances in particular, is likely to speed up dramatically. This will affect the way we live, work, interact with one another, and how we access and use services such as health care. It is important that all health service planning looks at general trends and disruptions as well as the changing demographics of our population. Trends are those ideas and developments that we can see now and that are likely to last for a longer period of time whereas disruptions (also known as discontinuities ) are those events, technologies, or ideas that abruptly and radically change the industry rules and ways in which services are provided. Looking to the future, we can identify five forces that are influencing healthcare: DRAFT LONG TERM INVESTMENT PLAN, Page 18

19 Figure 10: Trends Influencing Healthcare : : Adapted from a presentation by The Advisory Board Company at the Global Forum for Health Care Innovators 2012 Figure 11: Key trends and their implications Trend 1. Greying Patient (and Provider) Not only do we have an ageing population (as described in section 5.1) but MidCentral DHB s workforce is ageing with an average age of 46.7 slightly over the national average of This provides challenges in ensuring we will have the workforce required to meet the growing service demands that come with an ageing population. Implication Growing demand for services and increasing complexity. This will increase the need to enhance the role of community based services ensuring staff are enabled to work to the top of their scope of practice. Ageing workforce planning and recruitment strategies must allow for this. New service models may be required to cater for this increasing demographic and to provide support for older people in their own homes. 2. The rise of chronic disease The number of people with longer term conditions, higher complexities, and comorbidities is growing which puts more pressure on services. Need to enhance role of community based health services. Need to further promote prevention and self management. Need to work with other agencies and different sectors to mitigate factors having a negative effect on people s health, such as damp homes. DRAFT LONG TERM INVESTMENT PLAN, Page 19

20 3. Information Revolution Information technology developments have the ability to transform care through making information more accessible to care providers and also empowering people, their families, and whānau by giving them ownership of their health information. 4. Blessing and Curse of Technology Technological advances and clinical innovation are transforming care and providing great benefits for patients but are often very expensive and may be superseded within a few years. 5. New Health Care Consumer Health care consumers have increased expectations of the care they receive and have access to health information via the internet. They are generally better informed of treatment options available to them. Increasingly the older health care consumers are living away from family support. Increasing need to adopt mobile technologies. Increased ability for self management (home). Increased need to enable access to reliable trusted information to support self management. Need to work with other agencies to ensure our communities have consistent access to high speed broadband, particularly in rural areas. Increasing treatment options. Need for workforce training to keep up to speed with advances. Increasing need for robust prioritisation tools and systems. Need to develop national standards and regional approaches in this area to ensure value for money and affordability. Growing demand for expensive interventions (scope and cost). Pressure on services to provide expensive and clinically marginal interventions. Need to enhance clinical networking. Need to empower people to better manage their health. Need to work with other agencies to mitigate social isolation and to develop more older person and dementia friendly communities. 3.3 Our Operating Environment Our Governance Structures and Stewardship The stewardship of MidCentral DHB s resources is effected through a tiered approach to encourage a system-wide perspective in service planning, investment choices, and operational decisions. The strategic focus on prevention is reflected in the high levels of Board interaction with our Iwi partners, Manawhenua Hauora, with Central PHO, and the engagement with other sector and social sector agencies. The Board committee structure has recently been amended to support implementation and achievement of the DHB s Strategy with three key committees, being: Healthy Communities Advisory Committee (Community and Public Health Advisory Committee), which has responsibility for ensuring we have strategic and other plans in place to address the health needs of the district, and monitoring the effectiveness of such plans; Quality and Excellence Advisory Committee (Hospital Advisory Committee), which is charged with monitoring delivery of quality health care within our hospital and health services, including integration with other health and disability providers and our social sector agencies; DRAFT LONG TERM INVESTMENT PLAN, Page 20

21 Finance, Risk and Audit Committee, charged with oversight of risk management and financial stewardship across the DHB s activities. These committees, together with the Clinical Advisory Council and Consumer Advisory Council, individually and jointly provide perspective and focus on the appropriateness and outcomes of planning and investment activities as support to the Board decision making process. The Chief Executive and Executive Leadership Team are supported by two investment governance groups, each of which includes a cross-section of members bringing insight from Medical Officers/Clinical Directors, Nursing, Allied Health, Māori, Funding, Consumer, Administrative and Financial Management perspectives: The Strategic Capital Governance Group has the purpose of facilitating the development and execution of long term investment strategies that appropriately link with organisational strategy; advising on allocation of capital investment across asset portfolios; and providing rigour to evaluation of major investment proposals. The Information and Communications Technology (ICT) Governance Group is mandated to guide the development and refresh of the ICT Strategic Plan, ensuring that this and consequent strategic investment reflects the strategic needs and direction of the DHB and is compatible with regional and national initiatives. The operational activity of the DHB includes a continuous business improvement programme to seek out opportunities for ongoing effectiveness and efficiency and to support investment benefits realisation National Context In planning and funding health services we must respond to and balance the national health goals and targets set by government, the directions outlined by the refreshed New Zealand Health Strategy, the attendant Road Map of Actions and other national strategies, including: He Korowai Oranga Māori Health Strategy Ala Mo ui Pathways to Pacific Health and Wellbeing The New Zealand Disability Strategy Health of Older People Strategy Community based Health Care Strategy 2000 Rising to the Challenge: Mental Health and Addiction Service Development Plan Living Well with Diabetes: A Plan for People at High Risk or Living with Diabetes The vision of the refreshed NZ Health Strategy is for All New Zealanders to live well; stay well; get well. Our responses to the five strategic themes in the refreshed NZ Health Strategy within our own strategy are: People-powered - Mā te iwi hei kawe our strategy emphasises involving consumers and staff in co-designing our services, ensuring our consumers understand their choices and striving to make it easy for them to access all information relevant to their health and well being, including DRAFT LONG TERM INVESTMENT PLAN, Page 21

22 their own health records and electronic access to making appointments and clinical support and advice. Closer to home - Ka aro mai ki te kāinga we are striving to understand our population, and look to invest in what works to support our people living well, staying well, and getting well. Our services are being designed to integrate effectively and are increasingly provided at the most convenience locations possible, including building the breadth of community based services. Value and high performance - Te whāinga hua me te tika ongā mahi we work to the quadruple aim incorporating Quality/Safety/Experience of Care/Value for Money/Equity of Outcomes building a high performance and quality improvement culture with clear lines of responsibility across our system. We are experimenting with investment approaches to address the significant and complex social and related health issues in our district also with a view to achieving equity of health outcomes. One team - Kotahi te tīma we are transforming services to work as one team in a high-trust system. This will see us working together with the person, their family and whānau at the centre of care; using our workforce in the most effective and most flexible way; developing leadership, talent and workforce skills throughout the system; strengthening the roles of people, families, whānau and communities as carers; and effectively collaborating with researchers. Smart system - He atamai te whakaraupapa we aim to grasp the opportunities that emerging technologies present; search the world for successful innovations and willingly sharing our own; assemble and use our data in effective ways that build on evidence and instil quality into our practice; and actively search for the most cost effective and future proofed technology solutions in collaboration with our centralalliance and Regional/National partners. The Ministry of Health and DHBs are charged with giving effect to the overarching goal for the health sector of Better, Sooner, More Convenient health services for all New Zealanders. The high level health system outcomes are that all New Zealanders live longer, healthier, and more independent lives and the health system is cost-effective and supports a competitive and productive economy. These priorities must be incorporated into our Long Term Investment Planning firstly at a Central Region level, as well as ensuring that we identify and prioritise relevant local priorities to meet the health needs of our population in the MidCentral DHB Annual Planning and delivery priorities. We are committed to continuing to plan, purchase and provide health and disability services that are informed by and reflect these national goals, priorities and policy drivers Regional Context The Central Region is one of four regions in New Zealand and MidCentral DHB is one of six DHBs located within the Central Region. The other DHBs are Hawke's Bay, Wairarapa (the smallest), Hutt Valley, Whanganui, and Capital and Coast (the largest). DRAFT LONG TERM INVESTMENT PLAN, Page 22

23 Figure 12: Graph of predicted population growth across Central Region In 20 years the Central Region s population is predicted to have 86,000 more aged 70+ (growth of 89 percent). Population growth will be highest in the older age groups as the population ages and lives longer. Younger age groups will decrease in numbers and change significantly in ethnic makeup. Figure 13: Map of region The Central Region s population is 895,000 (19 percent of NZ total). In 20 years this population is predicted to grow to 950,500 (growth of 6 percent). The estimated population growth will not be evenly distributed across DHBs, with Capital and Coast DHB experiencing the greatest increase and Whanganui DHB s population expected to decrease. MidCentral s population will increase in the older age groups. The Central Region DHBs jointly fund the Central Region Technical Advisory Service (TAS) to support the six Central Region DHB s functions so that we are able to meet objectives in respect to regional planning and delivery. The Central Region has two hospitals to which MidCentral residents are referred for tertiary-level specialist services Hutt Valley (burns and plastic surgery) and Wellington (cardiac surgery and neurosurgery), while specialist services for children may be bought from Starship Hospital in Auckland, and others with spinal injuries may be referred to Burwood Hospital in Christchurch. MidCentral DHB is a provider of regional cancer treatment services for the populations of Whanganui, Wairarapa, Hawke s Bay, and Taranaki DHBs. There are also sub-regional arrangements in place with our neighbouring DHB, Whanganui, for a range of other services that we provide to their population. While each of the six DHBs is individually responsible for the provision of services to its own population, working regionally enables us to better address our shared challenges in sustaining a health system DRAFT LONG TERM INVESTMENT PLAN, Page 23

24 focused on keeping people well and providing equitable and timely access to safe, effective, high-quality services, as close to people s homes as possible. Regional commitments and collaboration is demonstrated through the regional clinical leadership networks and the regional governance arrangements of the DHB Chairs and Chief Executives. Our DHBs commit to working together at a regional level to make the best use of available resources, strengthen clinical and financial sustainability, and increase access to services. The regional governance structure is outlined in Appendix To document thedhbs regional collaboration efforts and align service and capacity planning, we produce an annual Regional Service Plan 1, (RSP) that includes national priorities for regional delivery, locally agreed regional priorities, and outlines how DHBs intend to plan, fund, and implement these services at a regional and sub-regional level. Our RSPs have a specific focus on reducing service vulnerability, reducing costs, and improving the quality of care to patients. RSPs over the next few years are expected to consolidate MidCentral DHB s role as a major provider of secondary services and a provider of some tertiary services for the region. They will strengthen the relationship between ourselves and Whanganui DHB and support the development of some specialist services in our district such as those planned in cardiology. In the 2016/17 Central Region RSP the priority areas are: Elective Services Cardiac Services Mental Health and Addictions Stroke Services Health of Older People Major Trauma Hepatitis C Cancer Services Diagnostic Imaging. There is also a priority focus on the enablers of: Information Technology, Workforce, and Quality and Safety. Regional planning for workforce development is outlined further in Capital planning continues as a critical strategic activity for the RSP. Medium to major capital decisions are tested regionally to ensure that the expected benefits of collaboration are maximised. Investing in strengthening our MidCentral hospital facilities over coming years will increase our ability to provide resilience for the region should Wellington Hospital be affected by a major disaster Regional Workforce Planning Under the leadership of the Regional Director of Workforce Development, the Central Region DHBs have a Regional Services Programme (the Programme) in place to jointly address workforce priorities, and enable the region to cultivate existing collaborative and cohesive networks for developing workforce initiatives and innovations. The Central Region is also committed to aligning to the refreshed New Zealand Health Strategy by 1 The Central Region Regional Service Plan for 2016/17 can be found on our website at or that of the Central Technical Advisory Service at DRAFT LONG TERM INVESTMENT PLAN, Page 24

25 progressing workforce priorities which consolidate the good work already done, while at the same time helping to create a more coherent and resilient strategy for the future. The Programme has key actions with supporting milestones for each health professional group midwifery, medicine, nursing, allied health, scientific and technical. In addition, there are key actions and milestones for the following: Cultural responsiveness supporting the cultural development of the workforce with recruitments made to develop a workforce that reflects our population demographics. Kaiawhina supporting the national project through a regional support framework. Mental Health and Addiction implementing the workforce plan. Advance Care Planning improve regional ACP awareness and training in identified high-need priority areas. Talent management and succession planning appropriately enable regional workforce talent management and succession planning. 3.4 centralalliance the Sub-Regional Context MidCentral and Whanganui District Health Boards have been working together for many years as neighbouring districts within the Central Region. For a number of years, there has been cross representation on the Boards. In 2009 we established a formal partnership approach known as the centralalliance. In the past few years, Whanganui and MidCentral have worked together in a number of service areas, with mixed results. Recently the centralalliance has been developing a Strategic Framework which includes a strong commitment to working together. The framework describes shared aspirations and principles, what is known about the combined population and its health needs, and most importantly, what needs to be done differently to secure a solid future for the combined health district. Figure 14: Central Alliance Shared Aspirations and Principles DRAFT LONG TERM INVESTMENT PLAN, Page 25

26 Strategic intentions in the framework include: Working together on building capacity and capability in community based health care. Reorganising some clinical services to free up investment for community based services. Working together on strengthening our clinical services. Improved scale in low volume services contributes to financial efficiency if services can be provided at a lower cost. Reorganising some clinical services to maximise use of our combined resources so services can be provided closer to home. Make sure all our plans result in a shift in investment to the right place. Make sure all our plans are based on equitable access across the combined district. Pool our collective workforce, facilities, and equipment to maximise use of the collective resource. Monitor and measure our performance collectively. The strategic framework will formalise a commitment for the two DHBs to work together on activities such as: planning the best way for clinical services to be organised; developing consistent models of care and clinical pathways; Information Technology; sharing specialist resource across the combined district; workforce education and development; providing many services jointly rather than individually; and looking critically at our combined physical resources to make sure we do not invest unnecessarily into more bricks and mortar. The centralalliance Strategic Framework sets the overall direction (the why). The centralalliance is also working on a Memorandum of Understanding which guides the way the DHBs will work together (the how). Attention is now turning to Priority areas for development (the what). In the first round three high priority areas are: Women s Health Renal Urology These priorities have been informed by service coverage and viability issues. Looking forward, centralalliance expects to have a major impact across the range of medical and surgical specialties. It will also drive attention to the key areas that account for poor health outcomes child health, health of older people, long term conditions (cardiac, respiratory, diabetes and renal). DRAFT LONG TERM INVESTMENT PLAN, Page 26

27 4 Our Strategy MidCentral DHB aspires to be a high performing DHB that provides quality health services and the best possible health outcomes for our population. We need to continue to be proactive and innovative in adapting to changing health needs and responding to new trends and disruptions. We need to transform our services to provide integrated care across multiple settings and we need to exercise good stewardship so that we live within our means. 4.1 MidCentral DHB Strategy for Success; Together We Choose Excellence Over the last twelve months MidCentral has reviewed its current position and future requirements and has refreshed its strategic direction. This culminated in the Board adopting a new Strategy for Success that will guide the organisation s development over the next five to ten years. Our Strategy will guide our future work to make a positive contribution to the health outcomes of our population, and guide us to make the necessary changes to continuously improve our health system, as part of the wider health sector and social service network. The plan is consistent with the goals of the New Zealand Triple Aim as well as the direction of the New Zealand Health Strategy. Our Strategy is the key driver for our Long Term Investment Planning. It will also underpin all other aspects of our work, including organisational redesign, service redesign and business improvement. It will be progressively enacted Strategic Framework: Our vision is: Quality Living Healthy Lives Well Communities. As a district health board, we have summarised our purpose as: Better health outcomes, better health care for all. In doing so, we acknowledge our key role in contributing to the best possible health and wellbeing for individuals, whānau, families and communities. We have agreed on four values: compassion, respect, courage and accountability. These values will guide us and underpin everything we do, from the way we interact with each other as staff, to how we care for our people, families, whānau, and more broadly our communities and partners. DRAFT LONG TERM INVESTMENT PLAN, Page 27

28 Our Strategy has four Strategic Imperatives that we will be focusing on over next five years: Achieve equity of outcomes across communities Partner with people and whānau to support health and wellbeing Achieve quality and excellence by design Connect and transform primary, community and specialist care. We see the achievement of these Strategic Imperatives as a shared responsibility; our staff, service users and communities, health and social service partners and providers need to commit to these priorities if we are to make a difference to the health and wellbeing of individuals, whānau and communities. We have agreed a number of statements about the future we want to create: People, families and whānau have a positive experience of the healthcare system. People are experts in their own lives and are partners in their healthcare. All people and whānau have a health care home. An integrated health care system operating as one team. More services closer to home. Our health care system is grounded in continuous quality improvement and clinical excellence. Our people are recognised for innovative approaches to healthcare. Everyone has the opportunity to achieve equitable health outcomes. We will have an adaptable and responsible healthcare system. People make healthy choices and stay well Our Roadmap of actions: The Roadmap outlines what we need to do to work towards achieving our four strategic imperatives. Each imperative has three to four objectives which are in turn followed by a series of approaches that are intended to be carried out within a five year timeframe. The roadmap is a living document to be updated annually serving as a guide for planning and prioritising the work required to deliver our strategy (this can be found in Appendix 14.5) Our Key Enablers The roadmap is further supported by five key enablers, each of which links to another strategy or plan: People - O mātou iwi Our staff and leadership are fundamental to the success of this strategy; they will be responsible for driving our Strategy. This will be driven through the Organisational Development Plan. DRAFT LONG TERM INVESTMENT PLAN, Page 28

29 Partners O mātou hoa mahi In order to make change we need to work together across sectors as one team, and the success of this is not possible without the commitment and expertise of our partners. This will be driven by the Health Charter. Innovation - Kia Te Auaha To deliver the best health care possible as our landscape continually changes, we need to be innovative. We need to listen to our staff and our partners ideas, working in a cycle of continuous improvement. This will be driven through the Organisational Development Plan. Stewardship Kia Te tiaki We are all stewards; we have been entrusted with the careful and responsible management of resources, finances and more importantly our people s health care. This is the subject of the Business Improvement Programme and the Long Term Investment Plan. Information Kia Te whakamohio Collecting and managing information, analysing data trends, and having systems that can talk to each other allows us to remain agile, adapting to the changing environment, making evidence-based decisions and sharing information with our partners and people. Figure 15: MidCentral DHB Strategy Enablers Enacting our Strategy The MidCentral Strategy was approved by the board in September Over time the strategy will come to underpin all strategy and planning work within the DHB. This includes multiple year plans such as Long Term Investment Plans, Locality Plans and Portfolio Plans through to our Annual Plan. These are discussed further in Section DRAFT LONG TERM INVESTMENT PLAN, Page 29

30 4.2 Our District s Health Charter Over recent years MidCentral DHB has developed an appreciation of the role of intersectoral agencies as partners in improving health and health outcomes. This has been given life through the creation of a Health Charter for the district which is a companion to the MidCentral Strategy. The Charter has been co-designed with a wide a range of health and social service agencies, education providers, health professionals and leaders, advocates and local councils. They were brought together around the concept of a joint vision for a more integrated cross sector system providing collaborative health and social services. At its heart, the Health Charter is about intersectoral collaboration and communities working together to enhance lives. Once signed off by key partners and executed, the MidCentral Charter will become a foundation document for how future services are planned, funded, and delivered as a system. This will fundamentally challenge current thinking and processes. Health and wellbeing for all, with people and whānau at the heart of all we do. From silos to engaged and collaborative endeavours across communities. People. Owners. Partners. The Charter is based on: People as owners in charge of their lives. Partners supporting people to be healthy and well. Owners and partners working together. Building respect and trust. Getting better all the time. This commitment is currently being piloted in the MidCentral district through the Te Tihi o Ruahine s Kianga Whānau Ora Alliance, now into its second year and aiming to work with 100 Housing NZ whānau/families in a collaborative cross sector response. DRAFT LONG TERM INVESTMENT PLAN, Page 30

31 5 Our New Service Model 5.1 Our vision for the future... MidCentral DHB s Strategy is for an integrated health service, where people can access services easily and as close to home as possible, and where a person s health journey is seamless regardless of how many different providers are involved. The home will play a much larger role as a place for the provision of clinical care. Community-based services and community based care will also play a far greater role and will be equipped to meet a wide range of health needs. Hospitals will be freed up to focus on inpatient treatment and more complex care. The integrated approach will mean health professionals will be empowered to work across all levels in order to coordinate patient care and enable seamless access to the most appropriate care options. Figure 16: Current sector model Future sector model The outlook in the medium term will go even further down this pathway. Sophisticated clinical decision making tools, fronted virtually by a familiar face and running across a high speed internet network, will be the first point of contact for health advice. People will be able to realise a true sense of ownership in managing their own health, and really feel like members of a community health team. They will be able to readily plan and receive care when they need it, as close to home as possible. They can communicate with their health professionals by , webcam or in person whatever suits. For at-risk parts of the community, such as older people and chronically ill, there will be telediagnosis, biosensing at home, and telemedicine kiosks, supported by rapid response teams. Most health care will be provided in the local Integrated Family Healthcare Centres (IFHCs). These sophisticated community based health providers will be able to diagnose and treat most of the acute and chronic illnesses and also run a network of in-store clinics located in convenient places frequented by the community. Mindful that technology is not an option for everyone, community health centres will also provide extensive outreach services, Whānau Ora home care, and school-based programmes. There will be a particular focus on ensuring good access to quality services for the most deprived population groups, reflecting the higher level of health need this population experiences. Local multisectoral community development networks will commission most health services in conjunction with other public services such as housing, education, and employment. They will be better enabled to tackle inequalities in health by using a holistic, Whānau Ora approach to dealing with the health and social needs of families and local communities. This approach will result in much improved health outcomes for Māori, Pacific peoples and those who are socio-economically disadvantaged. Hospital services will also be revolutionised. There will be a network of local, sub-regional and regional DRAFT LONG TERM INVESTMENT PLAN, Page 31

32 hospitals operating as one, truly collaborative regional health network. This network will be underpinned by a mobile clinical workforce adopting a think regional and act local mindset; shared information technology; and a highly effective, eco-friendly transport system. Workforce crises, service disruptions, safety issues, inequalities, and fragmentation will become a thing of the past by means of true regional and national collaboration, clinical leadership, and an uncompromising quest for service excellence and quality of care. 5.2 Our Service Model Bringing our new Strategy to life and creating the vision outlined in the previous section requires a fundamental change in the way local health and disability services work together moving from a silo approach to an integrated model. This in turn requires changes to the way our services are organised, which includes both changing the organisational structure and the way we plan and fund services Integrated Service Teams In terms of organisational structure, in 2016/17 MidCentral will be establishing Integrated Service Teams in a number of portfolio areas. These teams will work across key areas, bringing together a range of provider-arm and NGO services, hospital and community services, clinical leadership, the consumer voice, and service management. They will involve careful service planning which will eventually extend to include commissioning plans. This alignment of providers and inclusion of funder functions in a planned and progressive manner will be led by a service leadership team comprising portfolio management, operational management and clinical directorship. The initial cohort of portfolios has been identified as: Mental Health and Addictions Child Health Elder Health Cancer and Palliative Care An integrated service/portfolio model requires the development of a holistic approach to the planning, commissioning, delivery, and evaluation of services aligned to the health outcomes being sought. Essential will be the relationships with community based care, iwi providers, and the NGO community. In developing and giving effect to this holistic approach it is critical that key stakeholders and healthcare partners have a strong voice in the design, development, and delivery of those services, therefore each service is underpinned by a comprehensive engagement strategy that ensures: All relevant providers and potential providers understand, have the opportunity to influence, and are committed to, the developed service plan. Māori are actively engaged in, influence, and contribute to the development and design of services and approaches to health care provision, and that service plans and models of care reflect and are aligned to the principles of Whānau Ora. Consumers and communities have a strong say in how healthcare services are delivered to meet their needs and aspirations. Internal stakeholders (service staff, other relevant MidCentral DHB business units) are engaged in the development of the service plan to enhance commitment to delivery against that plan as it is implemented. DRAFT LONG TERM INVESTMENT PLAN, Page 32

33 Each Integrated Service Team will establish an integrated model for their portfolio, together with an implementation plan, which details: the engagement Approach the health Outcomes Sought the services needs assessment the current Service Environment the future vision for the service leadership arrangements service design and configuration a procurement and delivery plan the approach to monitoring and evaluation. Although the new approach to clinical service planning is focused initially on the abovementioned portfolios, MidCentral Health is continuing to strengthen and enhance other clinical services. This includes (but is not limited to): the implementation of recommendations in the MidCentral DHB Renal Plan; development of a CathLab Business Case and sub-regional Cardiology services; the reconfiguration of Diabetes services; developing Urology sub-regional services; Radiology demand and capacity planning; integrating and aligning District Nursing with community based services. It is envisioned that this approach to service planning will be rolled out across all clinical services over the medium term Planning & Funding Services Fundamental to our new service approach is recognition that each service, and each locality, in our district is unique. A new framework has been developed that can be applied to any clinical or non clinical service area who wish to design or redesign how health care services should be delivered, and to what level, in order to meet the health needs of their target population(s). The methodology will ensure each Service Model developed for each portfolio is unique in meeting the needs of the service it has been developed for. It will inform resource requirements within the context of our Strategy and thus the future investment opportunities, challenges, and changes that need to be addressed through the discipline of service planning and performance evaluation that follows. The framework outlines the common underlying concepts and components that need to be considered when changing or creating models of care. It also ensures that the key priorities within our strategy are considered at every level of planning and all Models of Care work towards achieving our Strategic Imperatives. The framework, in conjunction with its process of implementation, is a tool to guide the development of models of care. In recognition of the different needs of the localities within our district, Locality Plans will also be developed. Plans will be done for each territorial local authority area. These will identify the specific requirements and health needs of that community. Locality Plans and Portfolio Plans will be closely aligned and will inform investment decisions. DRAFT LONG TERM INVESTMENT PLAN, Page 33

34 Figure 17: The relationship between internal plans Needs Assesment MoC Timeframe Leadership Scope Integrated Service Model Approach Level Priority Locality Plans 1 5 years Service Leadership Team Specific Communities High Level Sets priorities for Communities Horowhenua Portfolio Plans 3-5 years Service Leadership Team Population Focus Continuum of Care High Level Sets priorities for target group Child Health HOP MHAD Cancer PC Service Plans 1-3 years Service Leaders and Manager Service Specific Operational Focus DRAFT LONG TERM INVESTMENT PLAN, Page 34

35 5.3 What the Strategy will mean for people A Service Perspective Older People I can t believe how quickly the equipment has arrived and what a difference it has made. I now feel safe and I am even able to walk to the dairy again. Mary* is one of the older citizens in our community with frailty so much so it was affecting her ability to do everyday things like going to the dairy for milk. Mary is benefiting from the new Health of Older People team working with the Kauri Healthcare Integrated Family Health Centre. Ten years ago, MidCentral DHB and the Central PHO recognised older people required more support, particularly those with frailty. Many services and systems were put in place. In the rural areas of Tararua and Horowhenua, Health of Older People teams were established, working alongside the local Integrated Family Health Centre. This year, the establishment of Kauri Healthcare a large integrated family health centre in Palmerston North city - was seen as an opportunity to look at what could be done in an urban setting. Palmerston North Hospital s specialist geriatrician, Dr Syed Zaman, is leading the pilot of the Palmerston North Health of Older People Team. A team like this means we can take a holistic view of the person not just their medical problems, but also their medications, functional ability and social support network. We have a clinical nurse specialist, a physiotherapist, an occupational therapist, a social worker, a GP with an interest in geriatrics, administration support and a geriatrician. We perform all our assessments in the patient s home so we have the privilege of seeing how they cope at a very practical level. The pilot began in December 2015 and by the end of June 2016 the team had seen 112 of Kauri Healthcare s older patients with frailty whose GP felt would benefit from this type of assessment. The best thing that s happened to the health services in 90 years, was how 90 year old Mollie* summed it up. Within two weeks of being referred to the team, Mollie had been seen by all members of the team. She had been given strengthening exercises, a walking frame, had an Advance Care Plan completed, parking card provided, an assessment for long term support completed, and had ramps in place so she would safely get in and out of her house. The Health of Older People team is based on the principle of specialists working alongside the general practice teams to provide short term advice and expertise and upskill the general practice team. Each patient then continues under the care of their general practice team. Close monitoring of the pilot continues and if all goes well, it is anticipated more teams will be put in place, with each supporting two large IFHCs. There are also plans to enhance geriatric care in areas that are often the first point of contact for older adults, like the Emergency Department so they not only get the treatment they need, they are safely transferred back to the care of their general practice team. *Real names not used. DRAFT LONG TERM INVESTMENT PLAN, Page 35

36 5.3.2 A Patient Perspective The following two pages describe the stories of two individuals experiencing services within the traditional model and current facilities vs their experiences in the future once our new Strategy and investment portfolio have been implemented (services have been transformed and facilities made fit for purpose). Figure 18: Tama and his whānau s different experiences Experience in traditional system: LONG TERM INVESTMENT IMPACT Tama has asthma. He has been missing school regularly due to being unwell but hasn t been to his GP for a year. Tama s whānau are well connected with their local General Practice and use a patient portal to book an appointment for him. The GP identifies Tama as a child who would benefit from the community child health asthma programme. Tama s parents take him to the Emergency Department one evening struggling to breathe. They arrive to a very busy ED where there is very little room. Stressful environment Tama and his parents are invited to a specialist clinic at their local IFHC at a time suitable for them. At the clinic a comprehensive health check is done and an action plan is created. Tama is admitted to the children s ward for 3-4 days. He is in a room with three other children and is very scared. When his whānau come to visit at the same time as other visitors it seems crowded and noisy. inadequate facilities Time is spent with a nurse from the Child Heath Community Team who gives intensive education about asthma management. A social worker also works with Tama, his whānau, and the nurse to look at other factors in Tama s life affecting his health. Tama is discharged and goes back home with his parents to a very damp house. His whānau are still unsure how to deal with his asthma. Revolving door Experience with new service model (the Child Health team has already started to implement many of these changes): Tama, his whānau, and his school are given copies of the action plan for his asthma management. The whānau is also linked to the Healthy Homes programme to help them reduce damp in their home. Tama remains an unwell child who continues to miss school often due to illness. He presents to ED at least 2-3 times a year. Tama and his whānau are much better able to manage his asthma and know they can contact the nurse if they have any questions. Tama rarely misses school and loves getting involved more in sport. People centred Care closer to home Collaborative Approach Empowered to self manage DRAFT LONG TERM INVESTMENT PLAN, Page 36

37 Figure 19: Martha s different experiences Experience in 2016: LONG TERM INVESTMENT IMPACT Martha is in her 70s. She faints one morning and is feeling very unwell. Her husband schedules her an appointment with her Dannevirke GP that afternoon. The GP is worried about the underlying cause of the fainting and calls an ambulance to take Martha to ED at the hospital in Palmerston North (almost an hour away). She is hoping Martha will be given a CT scan. Experience in 2026: Martha is in her 70s. She faints one morning and is feeling very unwell. She stays in bed and gets her husband to schedule an appointment with her Dannevirke GP through the patient portal. Martha has to wait in a crowded, busy waiting room. She hears the stories of all those being triaged around her. Martha is also triaged in the waiting room. In another two hours blood is taken. It is 6 hours (now 2am) before Martha sees a doctor who tells her that the blood tests were normal, she doesn t need a scan and can go home. Disconnected care Martha sees her GP and blood tests are taken at the local IFHC. The GP is also able to consult with a specialist over the phone who can see Martha s history via the connected electronic record system. A CT scan is booked 2 days later. The next week Martha is still feeling very unwell and makes another appointment with her GP. The GP finds abnormalities in the blood tests and manages to book Martha in for a CT scan back at the city hospital two weeks later. Martha has an anxious wait. When Martha arrives for her CT scan the waiting room is very welcoming and comfortable and helps ease her nerves. The CT scan reveals an issue that requires hospitalisation to treat. Martha travels to Palmerston North for her CT scan and an issue is found needing hospital treatment. Martha is admitted to a room which she shares with three other people. The toilets are further down the corridor, which she struggles to get to due to a bad hip. Martha finds it hard to sleep and when her family visit the room is crowded and there is little privacy. Not fit for purpose Martha is admitted to a ward where she has a room with a shared bathroom it is a positive healing environment and there is plenty of room for family to visit. Admission was easy as staff had access to her medical records and medications. When Martha is discharged she is told she needs to collect some medication from the hospital pharmacy on her way out. Martha and her husband struggle to find the pharmacy and have to ask two people for directions before they get there. When Martha is discharged she has had a good explanation of her follow up plan and this information is also accessible to her GP through a connected electronic system. Martha collects her medication from the hospital pharmacy right next to the exit. Connected Care Person centred environment Seamless journey DRAFT LONG TERM INVESTMENT PLAN, Page 37

38 6 Our Health & Disability Services Current Situation 6.1 Overview of Community-based Services Primary and community services have been an area of priority investment for MidCentral DHB since 2004 with the intention of bringing about transformational change to achieve a high performing health system. This has been driven by a commitment to address the generally poorer than expected health status of our communities, the anticipated future increase in demand for health services associated with demographic change, and identified risks associated with capability and capacity gaps in primary care particularly, the historically small General Practitioner roster in the district. MidCentral s approach to primary and community services aligns with Barbara Starfield s vision of comprehensive community based care as the foundation of a sustainable responsive health care system. The evidence... shows that community based care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which community based care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups. Contribution of Community based Care to Health Systems and Health - Starfield et al: Mill Bank Quarterly September MidCentral s development activities began with the Primary Health Strategy in 2004, extended to the Toward 2020 programme in 2007, and the Better Sooner More Convenient Business Case in The key themes in these programmes of work have been: Expanding capacity in the community sector through the establishment of around 80 new clinical roles (particularly specialist nursing, allied health, pharmacy, and lifestyle change) and the development of Non Governmental Organisation providers. The movement to integrated primary health care teams as compared to the traditional GP/nurse/receptionist model of primary care. Improving primary and community capability through a major professional development programme, initially focused on nursing but extending out to inter-disciplinary professional development. Development and promotion of new Models of Care and new ways of working, particularly with reference to long term conditions, urgent care, Health of Older People, and Child Health. Support for the development of general practice, particularly business support through Central Primary Health Organisation (PHO), investment in ICT and other infrastructure, the Productive General Practice programme, etc. Achievement of integration between primary and specialist services, using tools such as the Collaborative Clinical Pathways programme (Map of Medicine). Development and strengthening of community and primary leadership and governance through arrangements such as Central PHO Clinical Board, Alliance Leadership Team, Alliance Management Team, and participation in (and sometimes leadership of) Clinical Network District Groups. Community and primary care leadership is now well embedded throughout the DHB. Support for the development of Integrated Family Health Centres across the district. DRAFT LONG TERM INVESTMENT PLAN, Page 38

39 In addition to this, we have worked on the organisational architecture of the district to give us a structure that supports the district and the direction of travel. This has seen the evolution of Central PHO to be a single PHO covering all of the MidCentral district and only the MidCentral district. MidCentral DHB has developed a very close relationship with Central PHO and together the two organisations have been partners in the development of community and primary services. Central PHO was the lead agency for the Better, Sooner, More Convenient Business Case. The two organisations have linked strategies and plans, collocated services, and in some cases shared staff. The development of primary and community services in the MidCentral district has revolved around five priority areas: Long term conditions Acute care needs Mental health Child and youth health, particularly vulnerable children Health of Older people, particularly frail elderly MidCentral DHB and Central PHO have made extensive use of national and international expertise and best practice. For example, NHS change programmes from the UK, Kings Fund advice (eg the future role of specialist services) etc, Professor Ed Wagner on long term conditions and Professor Ross Baker on high performing health systems. This has involved use of reference materials and models, but also MasterClass visits to international sites and visits by international experts to the MidCentral district. It is important to point out that with attention increasingly focused on integration, programmes run across community and specialist services. This includes MasterClass visits and the Transformational Leadership Programme, both of which have mixed cohorts of clinical leaders and managers from across specialist and community services, including NGOs. There is also cross participation on governance boards, and leadership. 6.2 Current Community Based Services Central PHO now has 28 contracted general practice teams. Overall the district has a small GP roster with one of the highest patient to GP ratios in the country. In the practices, GPs are supported by a well developed primary health care nursing workforce, including Clinical Nurse Specialists and Nurse Practitioners who are well integrated into clinical practice across the district. Enrolment rates in the MidCentral district are about 90 percent. There are a number of people in border communities who are enrolled with out-of-district PHOs. In particular, Ōtaki people enrolled with Kapiti PHO practices. In general people are able to enrol with a practice in the MidCentral district. From time to time constraints arise in particular communities, but Central PHO supports the management of this situation. The evolution of IFHCs has improved the situation with the new centres looking to increase their registers. The enrolled population is distributed across the wider district, with 57 percent enrolled in Palmerston North City, 17 percent in the Horowhenua District, 12 percent in Manawatu District, 10 percent in Tararua, and 4 percent in Ōtaki. Consult rates within the district are generally high by national comparison and there are indications that they are at capacity. People may experience delays in obtaining appointments with their general practice teams. This is causing some issues for after hours and acute demand pressure on the hospital. DRAFT LONG TERM INVESTMENT PLAN, Page 39

40 Whānau Ora MidCentral has well established Māori providers and two registered Whānau Ora projects. One of these, Te Tihi O Ruahine is based in Palmerston North/Manawatu/Tararua and incorporates most of the Māori providers actively supported by the DHB Māori Directorate and Central PHO. It is highly active and innovative, and doing exciting work in the intersectoral/social investment space. Integrated Health Care Providers A key platform in MidCentral s approach has been the development of Integrated Family Health Centres (IFHCs) and Integrated Community Health Centres (ICHCs). These centres are developed to provide a one stop shop for a wide range of health services. This includes General Practice and specialist outpatient services (currently provided mainly in hospitals) supported by appropriate diagnostic facilities (laboratory and radiology) and pharmaceutical service. The district now has seven centres covering about 65 percent of Central PHO s enrolled population with another centre being planned. Over time the proportion of people enrolled with these integrated centres is expected to keep growing. Figure 20: Map of Integrated Health Care Providers in the MidCentral District Refer to Appendix 14.6 for further information about the community services in each TLA within our district. DRAFT LONG TERM INVESTMENT PLAN, Page 40

41 This emphasis on integrated health centres is consistent with the national direction of providing services Closer to Home, one of the strategic themes in the refresh of the NZ Health Strategy completed last year. MidCentral DHB and Central PHO have actively supported the development of IFHCs and ICHCs in the area through the provision of both financial assistance and support in kind (eg project management). Financial assistance has been targeted at planning, facilitation, and change management. In addition, MidCentral DHB and Central PHO have both committed to basing their clinical teams out of Integrated Health Care Centres. With the exception of Horowhenua Health Centre (which is a DHB owned facility), neither the DHB nor Central PHO have contributed capital to integrated health care provider projects. It is estimated that in the past decade over $35 million of private sector funding has gone in to the development of IFHCs and ICHCs in the MidCentral district. Other Community Providers Within the district, there is a well established, comprehensive range of non-government owned organisations and community health providers. These include, but are not limited to, community pharmacies, a community laboratory, community radiology services, dentists, optometrists, age residential care providers, home support service providers, and mental health providers. These have all had investment in their services over recent years and have been supported by the DHB to increase the scope and quality of services provided. Collectively, they work well together and with general practice, participating in activities such as the Collaborative Clinical Pathways Programme, Alliance Leadership Team, and the Palliative Care Partnership. 6.3 Overview of Hospital & Specialist Services Capacity management within all New Zealand Hospitals necessarily means balancing the competing forces of acute and elective requirements against bed capacity and staff resources. This has been a key focus for investment in hospital services. In the 2014/15 year, MidCentral DHB implemented targeted patient flow improvement strategies to enable staff and bed resources to be used so that they effectively met patient needs. Work focussing on the patient s journey through the hospital. It identified blocks in the process, specifically, that it was not the care provided by individual services that was an issue, but the process of transition from one service to another was highlighted. The process changes resulted in a reduction in the average length of stay, for example, general medical patients stay decreased by 1.2 days through: Improved access to beds including rehabilitation and community placement. Senior staff providing extra support to maximise the patient journey. Supporting people to take responsibility for their own health. The achievement of the Shorter-Stays Target and a sustained reduction in Medical Services Average Length of Stay enabled an overall improvement in bed availability. More patients received treatment within existing resources; the number of patients requiring readmission to hospital for treatment rate DRAFT LONG TERM INVESTMENT PLAN, Page 41

42 remained static whilst at the same time the number of patients seeking general medical treatment increased. When looking at the overall demand profile in 2016, as part of the refresh work done for the Master Health Service Planning Indicative Business Case, most service assumptions still hold except for Emergency Department (ED). ED, in line with national and international trends had been experiencing a 1 percent increase in presentations and admissions, however, for the financial years of and there was little or no growth. Since July 2015 there has been an increase of over 10 percent in ED presentations which has subsequently increased acute admissions to hospital. This increase, coupled with a similar increase in surgical demand has placed considerable pressure across MidCentral Health to maintain and enhance patient flow. This significant increase needs to be understood further as part of future demand projections for facility planning. Over the past five years, increasing focus has been given to integrating services with primary and community health care, and increasing access to specialist services. This has included the provision of specialist services in the community, and providing GPs direct access to specific diagnostic tests or waiting lists. Further integration work, and the introduction of new models of care, will need to be supported by investment in facilities and ICT infrastructure. 6.4 Current Hospital Based Services Palmerston North is a regional hospital, providing higher secondary/lower tertiary services. It has continued to develop its role as a sub-regional hub with significant capability in oncology and haematology services. It provides a range of speciality and sub-speciality services, many of which are provided to other DHB districts. The table on the following page shows the scope and level of complexity of services provided at Palmerston North Hospital in relation to the New Zealand Role Delineation Model. DRAFT LONG TERM INVESTMENT PLAN, Page 42

43 Figure 21: Capability of Services at Palmerston North Hospital Maternity and Neonatal Services 4.8 Emergency Emergency Medicine 5.0 Maternity/Obstetric Care 5.0 Neonatal Services 4.5 Medicine 4.6 General Medicine 4.0 Paediatric Speciality Services 4.5 Cardiology 4.0 Paed Medicine and Specialties 4.5 Dermatology 4.0 Paed General Surgery 4.0 Diabetes and Endocrinology 4.0 Paed Cardiology and Cardiac Surgery 4.0 Gastroenterology 5.0 Paed Oncology and Haematology 4.0 Genetics 4.0 Paed Neurology and Neurosurgery 4.0 Infectious Diseases 4.5 Paed ENT/ORL 4.0 Immunology 0.0 Paed Orthopaedics 4.0 Neurology 5.0 Palliative Care 5.0 Older Adults 5.0 Renal Medicine 5.0 Health of Older Adults 5.0 Respiratory Medicine 4.5 Mental Health for Older Adults 5.0 Rheumatology 4.0 Clinical Support 6.0 Oncology and Haematology 5.8 Pathology and Laboratory 5.0 Medical Oncology 6.0 Pharmacy 6.0 Radiation Oncology 6.0 Diagnostic Imaging 6.0 Clinical Haematology 5.5 Patient Clinical Support 6.0 Surgery 4.7 Anaesthetics 6.0 General Surgery 5.0 Operating Suites 6.0 Cardiothoracic Surgery 0.0 Interventional Radiology 5.0 Otorhinolaryngology (ENT/ORL) 5.0 Critical Care Services 4.0 Gynaecology 5.0 Coronary Care Unit 5.0 Neurosurgery 0.0 Ophthalmology 5.0 Maxillofacial 4.0 Orthopaedics 4.0 Plastic Surgery 40 Urology 5.0 Vascular Surgery 0.0 Figure 22: General descriptions of Level of Complexity in Role Delineation Model RDL Level Descriptor Description 1 Primary Services Community based services provided by primary practitioners. 2 Community Services General and convalescent services, providing sub-acute care and access to acute services. 3 Acute and Elective Specialist Services Specialist services providing acute and elective care to communities. 4 More Specialist Services Large services with some subspecialisation. 5 Major Specialist Services Large services with multiple subspecialties and subspecialty support. 6 Supra Specialist and Definitive Care Most complex services of any subspecialty. Will be a provider of Services definitive care (does not transfer to another centre). 2 This table appears on pg 35, NZ Role Delineation Model Central Region Assessment, May 2015 DRAFT LONG TERM INVESTMENT PLAN, Page 43

44 6.4.1 Current workforce As at 30 June 2016, MidCentral DHB employed a headcount of 2,666 with an equivalent FTE of 2,159. Around 40 percent of our staff work part-time. MidCentral DHB s staffing levels have steadily increased over the past five years, with cumulative growth over that period of 17.5 percent. The most significant growth (27.7 percent) has been in allied health, scientific, and technical roles. Over the past 6 7 years we have also seen MidCentral DHB s vacancy levels reduce to low levels for most health professional groups, and we have been able to recruit previously hard to fill specialties. As at 30 June 2016, our staff stability rate continued to be very high at 99.7 percent, above our monthly target of >99 percent. Our annualised turnover rate is 10.5 percent. MidCentral DHB s workforce is ageing with an average age of 46.7 slightly over the national average of Figure 23: Professional Profile FTEs Professional Profile FTEs % Total Medical % Nursing and Midwifery % Allied Health % Support 41 2% Management/Admin % Total 2, % We have seen a steady increase in the proportion of Māori, Pacific and Asian staff over the last five years, resulting in a more ethnically diverse workforce. However, when compared with the ethnicity profile of the community we serve, we are still significantly under represented with respect to both Māori and Pacific staff. The increase is pleasing, but work is still required to more closely match our ethnicity profile with that of the community. Figure 24: Workforce Ethnicity Ethnicity Profile FTEs %FTEs Population % NZ European 1,278 59% 72% NZ Māori 150 7% 18% European 136 6% 0% Pacific 25 1% 3% Asian % 5% Other 164 8% 1% Not Stated 198 9% 1% Total 2, % 100% DRAFT LONG TERM INVESTMENT PLAN, Page 44

45 7 Current Asset Portfolio 7.1 Asset Management MidCentral DHB has a well functioning asset management system that links future programmed replacement with asset condition. These processes are incorporated into the Board s Capital Policy Document. In relation to the planning process MidCentral DHB has implemented processes whereby each Health Service has developed or is developing a Clinical Services Plan (CSP) where appropriate, and from this a Clinical Service Asset Plan (CSAP) is produced. Then each CSAP is aggregated to link into the DHB Asset Management Plan (AMP) and then into the Annual Plan (AP). This process is outlined below by the diagram. DHB AMP CSAP CSP Business Cases Reviews Strategies The first comprehensive AMP was completed in October 2005 and AMP updated periodically since. A major refresh was undertaken in and provided a key focus on highlighting the needs of replacing aged and inefficient clinical equipment and also highlighted the need of doing something about the MidCentral DHB facilities. This led to the Indicative Business case in 2014, Reform from within: Transforming Hospital Services at MidCentral. The Asset Management Plan is currently managed by Spotless Services under contract to the DHB, and covers the buildings and plant and the clinical assets. It is currently being updated. The implementation of the Asset Management process has allowed the MidCentral DHB to gain insight into the organisation s asset structure as it is now and where it needs to go in the future. Asset management planning is now incorporated in the business functionality of the majority of the services. DRAFT LONG TERM INVESTMENT PLAN, Page 45

46 7.2 Current Asset Summary Clinical equipment has been refreshed over recent years and is now in a good state with ongoing programmed asset management. Over the past five years there has been a significant investment across the DHB to meet the demands on Regional Assets under the Central Region Information Systems Plan, to update our IT Hardware infrastructure and make significant investment into the Clinical Asset profile to replace aged assets. Within our building and infrastructure assets the focus has been on maintaining assets rather than upgrading to meet future needs. This has meant that some of our current specialist buildings are now not fit for purpose. There has been a planned process of building resilience in essential core infrastructure. This programme has been, or is in the process of, progressively replacing at risk assets with resilient capacity providing essential utilities (steam, electricity, networks and water) to the site. The approach to building site resilience is aligned with the development of the Master Health Services Plan (Indicative Business case) to maintain the asset without growing it. Within the building and services asset portfolio there has been significant funding incurred to progressively allow us to meet the Seismic Assessment processes required by the Ministry and Local Territorial Authorities. Further work will be required in this aspect over coming years. We have invested with the roll out of the National Programme for School Dental Caravans and also invested in the replacement of the Regional Breast Screening Vehicle. Within the DHB we manage our normal passenger carrying fleet under a lease programme which is managed by Fleetwise Ltd under contract to the DHB, ensuring our fleet is modern and up to date with an optimised operating cost but no capital demand. 7.3 Major Clinical Equipment In general MidCentral DHB has maintained a satisfactory capital and operating spend on its clinical equipment. This means that there is not a significant catch up spend required as there is in buildings and ICT. Major clinical assets are all currently in a good functioning state. Assets scheduled for replacement are nearing the end of their recommended life and are on a planned replacement programme. Over the past three years there has been a substantial investment in Medical Imaging and Nuclear Medicine. Both of these areas are candidates for further major investment. Assessment of options is now underway to identify the best strategy as an outsourced MRI on site is committee to only a further two years of service. Oncology services are highly capital intensive. A business case for replacement of the radiation oncology pre-treatment CT scanner is currently pending approval and further investment in treatment planning software is required. In addition, the four Linear Accelerators are now within the last five years of useful life and represent a significant capital requirement. The substantial potential investment in this area will be preceded by a strategic evaluation of oncology services in a regional and national context. Due to the national programme for the redevelopment of Child and Adolescent Dental Services there has been significant investment in mobile and fixed facilities, with the replacement of one vehicle DRAFT LONG TERM INVESTMENT PLAN, Page 46

47 following an accident being managed currently and planned replacement of two remaining older mobiles to the new standards over the next two year. Over the past two years there has also been significant investment in replacing theatre lights, theatre tables, and anaesthetic equipment. A detailed replacement programme for hospital beds has been undertaken and this will be on-going. Overall, over the past four years the Board has driven a programme to catch up on delayed and deferred Clinical Equipment and has now achieved reasonably sound condition for the majority of the Clinical Equipment. 7.4 Information and Communication Technology The current state is characterised by disparate, fragmented, and in some cases obsolete, clinical and administrative information systems. Like most DHBs throughout New Zealand, MidCentral DHB has previously underinvested in ICT to date, although substantial work has been put into rectifying this over the last few years. The future need is for investment to remedy the consequences of the previous under-investment, particularly around completing the replacement of the legacy systems and obsolete hardware. There has been significant investment in the Regional Health Informatics Programme and we have a well progressed programme of work building resilience into core site ICT infrastructure which once completed will be fit to support local service needs in conjunction with outsourced Infrastructure as a Service (IaaS) capacity. The Ministry of Health has released the refreshed New Zealand Health Strategy 3 which, in conjunction with our DHB Strategy, will guide the capital investment strategy as we develop a new patient centered Information Systems Strategic Plan (ISSP). 7.5 Buildings and Infrastructure Palmerston North Hospital site summary MidCentral DHB s main facilities are located on the Palmerston North hospital campus (see Appendices and for an outline of current buildings and facilities and facility maps). The main buildings were built in two periods: the 1970s and 2000s The 1970s buildings The major hospital buildings were erected in the 1970s. These facilities have significant functionality and capacity issues. The nature of the buildings is such that there is little ability to reconfigure the spaces, and any future-proofing allowed for in the design has long since been utilised. The condition of the buildings is otherwise however, generally very good due to an effective ongoing maintenance programme. 3 DRAFT LONG TERM INVESTMENT PLAN, Page 47

48 Rider Levett Bucknall (RLB) conducted re-lifing analysis on the main 1970s building (Building B) in 2014, which includes the main clinical services block, housing medical surgery wards, radiology, Med Lab Centre, ambulatory care, and surgery, and encompasses 29,350 square meters gross floor area. RLB estimated that the building s current remaining service life was 9.95 years (now 7.95 years). They found that the cost-benefit is unfavourable for extending the life of this building for five or ten years as the cost per year is comparatively high, but MidCentral DHB may want to consider making repairs to extend the life by 25 years (with an estimated cost of, on average, $3.5 million per extended year). Additionally, subject to achieving an acceptable functional configuration, these buildings may have potential to be seismically upgraded once critical services have been decanted out of them following the Hot Floor construction The early 2000s buildings The last significant upgrade was completed in the 2000s. This work enhanced the Emergency Department, created additional outpatient capacity, established important linkages between and within buildings, and increased the rehabilitation, women s health, child health and mental health facilities capacity. Since that time needs have changed, and these facilities are now no longer fit for purpose. In addition, technology advancements and changes in care and treatment methods, the learnings of the Christchurch earthquake, and improved standards of care have changed facility requirements. As a result, most of these upgraded facilities also have material capacity and functionality issues, as well as seismic performance issues, which are outlined later in this plan. RLB estimates that for the building built in the year 2000 (Building A) which includes ED, main entrance and endoscopy and encompassing 5,055 square meters gross floor area, current remaining service life is years. The cost to extend the life of this building for 5 or 10 years is comparatively low (compared to their intrinsic value), but the cost per year increases significantly for 25 years due to major items requiring replacement Palmerston North Hospital Capacity Palmerston North hospital has a total of 397 physical beds (excluding outpatients). A breakdown of the capacity per service is provided in Appendix Outpatients has 123 clinics consisting of: 56 various ambulatory care; 4 child health, 7 women s health; 13 mental health; 4 speech language therapy; 16 Regional Cancer Treatment Services (RCTS); 13 Child, Adolescent and Family Mental Health Services (CAFS); 5 elder health; 3 physical therapy; 2 occupational therapy clinics. The hospital also has seven theatres and two procedure rooms Current facility issues are significant There are a number of issues with Palmerston North hospital facilities which were identified and explored in further detail during the Indicative Business Case (IBC) for hospital redevelopment, which was approved to proceed to a full business Case by the DHB Board in 2014, but later put on hold DRAFT LONG TERM INVESTMENT PLAN, Page 48

49 subject to the MidCentral DHB strategic planning review. Further details about this business case can be found in section These issues are predominantly building configuration and space constraints which: impair gains in productivity and efficiency; limit modern clinical practice; create risks to service quality; and lead to poor patient experience. In the main, these problems are caused by one or a mix of: demand exceeding capacity; the inability of the facilities to accommodate technological or model of care changes; the layout of services causing inefficient patient flows Horowhenua Health Centre Horowhenua Health Centre was developed in 2007 to replace Horowhenua Hospital. It includes: a four bed maternity suite, 24 bed respite/step down/rural inpatient beds, an extensive range of visiting specialist outpatient services, and Horowhenua Community Practice. A community pharmacy, community radiology services, phlebotomy, Central PHO service teams, some clinical teams, and the Horowhenua General Practice after hours services also operate from this facility. The current configuration of the Practice rooms is not ideal from a clinical flow perspective and will limit the potential for growth. There is a need for some capital spend to get the Practice location in the Health Centre best positioned for the future, recovery of which would be built into lease rates. A summary of the buildings at Horowhenua Health Centre can be found in Appendix Seismic Risks Several of the buildings on the Palmerston North hospital campus have been identified as having poor seismic performance particularly those holding IL4 services (defined in the following paragraph). This creates a significant non-compliance issue and would impact on the ability of critical services to be provided from the hospital in the event of a major earthquake. It is the responsibility of MidCentral DHB to determine what critical functions it needs to deliver in an emergency and to ensure that these are delivered in an appropriate IL4 building4. IL4 buildings are defined as those with special post disaster functions, eg medical emergency or surgical facilities. MidCentral DHB has determined that the following services are essential to be provided within an IL4 building to ensure continuity in a significant seismic event: Operating Theatres, Sterile Supply Unit, Intensive Care Unit (ICU), Critical Care Unit (CCU) and High Dependency Unit (HDU, Radiology, Telephone Exchange, and an Emergency Department. 4 Under the Civil Defence Emergency Management Act (CDEM), MidCentral DHB has responsibilities to ensure hospital and health services are ready to function to the fullest possible extent during and after an emergency. DRAFT LONG TERM INVESTMENT PLAN, Page 49

50 MidCentral DHB has had its buildings subjected to a seismic assessment by Structural Engineering Consultants from Holmes Consulting, OPUS International Consultants and Calibre Consulting, on request of the National Health Board. This involved an Initial Evaluation Procedure (IEP) followed by Detailed Assessments on buildings considered potentially earthquake prone and less than 33 percent National Building Standard. The results of this assessment were that those buildings currently housing IL 4 functions are not earthquake prone which is defined as being less than 33 percent of current Code, but require strengthening work to meet the IL4 performance criteria. The DHB has received legal advice that it is required to develop a plan to ensure that these buildings, or any new buildings intended to be used for IL4 purposes, do meet current IL4 building standards. Therefore, investment is required in order to ensure that the facilities housing these services meet the standards required for IL4 buildings. MidCentral DHB has notified the National Health Board of its Plan of Action for the Palmerston North hospital site through the seismic quarterly reporting process. In addition to designated IL4 functions, it is important that other site buildings do not cause harm, nor create a post-earthquake risk that threatens injury or unduly limits the effective functioning of critical services. A programme of strengthening and demolition of earthquake prone buildings has taken place over the past three to four years, and currently, further remedial work is either planned or underway on three non-clinical buildings and infrastructure services. However, our main Palmerston North Hospital (PNH) campus Clinical Services and Ward Block does not meet current building standards for buildings intended for emergency and surgical services post disaster; that is, IL4 buildings. This major issue is addressed in the MidCentral DHB Board s PNH Indicative Business Case, Transforming Hospital Services at MidCentral. The proposal is to construct a new IL4 critical services facility ( Hot Floor ) housing: Operating Theatres Sterile Supply Unit ICU/CCU/HDU) Emergency Radiology Telephone Exchange Emergency Department See Appendix for map of Seismic Risk. In conjunction with development of the Hot Floor Detailed Business Case, the long term Campus Strategy will consider options for improving remaining seismic issues. DRAFT LONG TERM INVESTMENT PLAN, Page 50

51 7.1 Land Divestments/Disposal The Board has not identified any specific area of land for sale at this time. However a site optimisation exercise is planned in the Campus Strategy to ensure we are optimising the efficiency of our property, particularly noting the current intensity of building stock spread across the site. The Palmerston North Hospital campus is circa 18 hectares which comprises a series of precincts/building groups based on current use, and an area of land predominantly used as car parking. Retention of Land for Future Proofing Outlying sites previously owned by the DHB have been rationalised by disposal or re-purposing into IFHCs. The remaining holding is the Palmerston North Campus. It is considered prudent to retain the integrity of the campus for future investment opportunities in relation to regional DHB initiatives/projects as its best value use is for health related activities. If any future disposal occurs, the next best use of land would be a mix of commercial and/or residential development. As these may bring long term restrictions and reverse sensitivity impacts, our preference is to retain ownership of underlying land but be open to potential commercial arrangements with third party investors to develop health related activities. The nature of its geographic location lends itself to regional distribution and support initiatives, being central to accessibility and transportation systems to the surrounding DHBs, there is potential to reduce costs for all regional DHBs in the provision of support services eg central food production unit, central warehousing etc. in partnership with an outsourcing service provider or investor. Allied Laundry Services Ltd is an excellent example of a regional initiative (servicing seven DHBs from a centralised Laundry based at Palmerston North Hospital). Health Care There may also be future opportunity to explore purpose built facilities as part of a joint venture with external health care providers who wish to locate in proximity to the hospital. DRAFT LONG TERM INVESTMENT PLAN, Page 51

52 8 Our Investment Strategy This Long Term Investment Plan has been developed in the context of the Government s national requirements, our own Central Region and MidCentral /Whanganui Alliances (centralalliance) and in partnership with Central PHO, our Community based Health Care Alliance Contract Partner. It assesses and plans for the effective use or disposal of the existing capital stock of our region, and derives a plan for the capital investment required over the next 10+ years, in both the public and private health sector, attributing where possible the predicted source of the required capital and how it will be financed from the returns the expenditure enables. As illustrated in Figure 15, MidCentral DHB is one part of the broader health eco-system, which includes Central Government, other health boards, and international influences such as refugee settlement. This LTIP has been influenced by, and needs to be read in conjunction with, the investment planning of other relevant agencies both national and within the Central Region and the private sector. Figure 25: The Health Eco-system 8.1 Our Investment Approach & Logic In 2013, MidCentral DHB established its investment logic. It was developed with clinical and senior management input and was further reinforced in 2015 when the DHB s Strategic Framework was updated. The investment logical comprises four issues: Issue one: The growing gap between health needs/expectations and resources means the way services are currently organised is not sustainable both clinically and financially. DRAFT LONG TERM INVESTMENT PLAN, Page 52

53 Issue two: Variable access creates gaps in care, drives inappropriate use of services, and increases demand on some critical services. Issue three: Health providers don t always work together effectively, resulting in disjointed care for patients. Issue four: Some facilities and supporting services are not fit for purpose, limiting ability to provide services safely, efficiently, and effectively. The Investment Logic Map, shown in Appendix 14.7, describes these problems and the key benefits that can be gained from dealing with them Issue one: Growing gap between health needs/ expectations and resources Population trends in the district (and in particular the growing older population and growing Māori population) will mean that, overall, demand for health services will continue to grow and staff will need to be culturally competent. Expectations for the standard of care of services have also increased with time (from the perspective of patients, their families/whānau, and healthcare providers). The current MidCentral DHB health system will need to rearrange its models of care to keep pace with the needs of an ageing population, a growing young Māori population, the changing burden of disease and rising patient and public expectations. Supply of health services will not be able to meet this growing demand if the sector remains organised as is currently the case nor do we wish to continue a hospital-centric approach and simply grow our supply of hospital services (such as ED beds, inpatient beds, etc) to meet demand. Resources are already significantly stretched in areas and some critical targets are not being met, and the system could respond in a much more appropriate manner to meet the health needs of our population. We also know we will simply not have the workforce to support the increasing demand in services. Our current workforce is similar to the national average profiles, but our workforce is slightly older and steadily increasing (45.9 for females nationally versus 46.8 for MidCentral DHB and 45.6 for males nationally compared to 46.3 for MidCentral DHB males). We have seen a steady increase in the proportion of Māori, Pacific, and Asian staff over the last five years resulting in a more ethnically diverse workforce, however, when compared with the ethnicity profile of the community we service, we are still significantly under represented with respect to both Māori and Pacific staff. We need to continue to build the ethnic diversity of our workforce and the cultural competency of staff to meet the needs of our population. Therefore, new models of care are being worked through that will require more focus on prevention and self-management, ensuring that people access community based care in a timely way, and that community based care has the capacity and capability to manage more complex health issues. The key enablers in our Strategy of Information (ICT), People (workforce) and Stewardship (funding models) are critical to this. All four of the Strategic Imperatives in the Strategy have objectives and approaches to address this issue. DRAFT LONG TERM INVESTMENT PLAN, Page 53

54 8.1.2 Issue two: Variable access to services There are certain communities in the MidCentral district that have poorer access to community based care health services (such as the Horowhenua population where 60 percent of the population lives in Decile 1-4 areas and over 45 percent of their population identified as high need via the capitation formula). These access issues invariably arise from a combination of rurality, social, cultural and demographic factors and the system s inability to address these appropriately. The health care system s inability to appropriately engage disaffected communities in preventative and early health care results in poor access to services for some communities. This is believed to be contributing to poorer health outcomes and a greater use of acute hospital services by such communities, particularly the ED. The Ambulatory Sensitive Hospitalisations (ASH), ie those admissions that were avoidable if early community based care intervention had been received) and amenable mortality rates (ie those health issues that the health system can impact on directly) for Horowhenua residents are significantly higher than others in the district, Manawatu District residents are also somewhat higher further suggesting variable access to health services. Figure 26: MidCentral Ambulatory Sensitive Hospitalisations The MidCentral DHB also has a low rate of GPs per 100,000 population, resulting in further access issues for some populations and the need to consider a much greater reliance on the introduction of new models of care that support improved integration, patient journeys, better utilisation of information technology, and improved access points. In 2014 there were 65 Full Time Equivalent GPs per 100,000 in our region compared to 75 per 100,000 nationally. 5 Rates ranged from 60 per 100,000 in Taranaki and Counties Manakau to 94 per 100,000 in Auckland. 5 Information obtained from The New Zealand Medical Workforce in 2013 and 2014 Report by the Medical Council of NZ DRAFT LONG TERM INVESTMENT PLAN, Page 54

55 In MidCentral DHB s Strategy, objectives and approaches have been developed to address this issue and strive towards equity of health outcomes across communities Issue three: Health providers don t always work together effectively, resulting in disjointed care The way in which our services are configured with the separation of community based care from hospital-based clinicians, and between clinicians and support providers in the community often inhibits the provision of timely and high-quality, integrated care to people who need a range of services relevant to their needs. This is particularly stark for those with complex health needs and/or multiple health needs (whose numbers are rising due to the ageing population). This causes difficulties for people in navigating the care system, with services provided for them often disjointed. Consumer complaints consistently refer to issues with navigating the health system. It is not uncommon for hand-over processes to be cumbersome and inadequate, for people to be required to have repeated diagnostics, for people to bounce from one provider to another, and for people to miss out on vital community support services that they are assessed as needing to have and should receive. All of the above impacts on the person and their carers experiences, and creates poor use of resources by providers. There is duplication of resources at times, such as multiple providers making home visits at the same time, or people falling through the gaps and not receiving the appropriate care. The organisational-centric approach can even result in some people being operated on more than once when multiple conditions could have been addressed at the same time. Our DHB is supporting a number of initiatives that aim to improve integration of health services which is a key means for addressing this problem including the implementation of integrated services models, development of IFHCs, shared electronic records, and clinical networks. Many of these initiatives are still in planning stages or in their infancy which is why this problem still features as a priority. The draft strategic plan outlines some approaches for improving how health providers work together to Connect and transform primary, community and specialist care Issue four: Some facilities and supporting services are not fit-forpurpose There are a number of issues with the Palmerston North hospital facilities, as identified in the 2007 Clinical Services Plan and subsequent engagement processes, which limit the ability of services to be provided in a safe, efficient and effective manner leading to significant workarounds and poor service flows to maintain safety. In the main, these issues are caused by either demand exceeding capacity, the inability of the facilities to accommodate technological or model of care changes, and lay-out of services causing inefficient patient flows. The following issues are of particular concern: ED facility is often beyond full capacity and there are significant design issues; The surgical pre-admission, recovery, Day of Surgery Admission (DOSA) and Short Stay units do not have sufficient capacity and do not support effective patient flows; Current utilisation of the inpatient ward by the Regional Cancer Treatment Service (RCTS) is nearing capacity; High acuity patients are managed across multiple locations, and there are capacity and functionality issues within these different units (such as Intensive Care Unit and Coronary Care Unit); DRAFT LONG TERM INVESTMENT PLAN, Page 55

56 One area for managing high risk infectious diseases is at the top of the tower block and people arrive with the infectious diseases at the bottom; There is a lack of isolation in some areas such as the children s ward; Cardiology services are not co-located, which creates efficiency, capacity, and cohesiveness issues, and the lack of a dedicated Catheterisation Laboratory (CathLab) is a major barrier to local service delivery; and Clinical and administrative information systems are not currently meeting needs. In addition, several of the buildings on the Palmerston North hospital campus have been identified as having poor seismic performance see Appendix for map. The above issues relate to providing fit for purpose facilities to meet current service demands yet when facility investments are being planned we must also ensure that we are investing in the best infrastructure to meet future needs. There are other issues with the facilities, including the wards and ambulatory services requiring internal reconfiguration. Since the original work was done a number of other significant facilities issues have emerged. In terms of supporting services, MidCentral is committed to the overarching strategy of a shared health care record. This is also central to the National Health Information Technology plan which was developed by the National Health Information Technology Board (now the National Digital Advisory Board). Our ICT investment will focus mainly on the Regional Health Informatics Programme (RHIP) projects, Neonatal Clinical Information Systems (NCIS) and Maternity Clinical Information Systems (MCIS), but also priorities for the National Digital Advisory Board to support the national Electronic Medical Record Adoption Model (EMRAM) programme, namely e-pharmacy. Other internal or local ICT project investment will be governed by the ICT governance board, focusing on improving integration across the health sector, maximising patient experience and supporting the MidCentral DHB strategy as part of the New National Health Strategy MidCentral is strengthening its Local Area Network (physical, configuration, digital, wireless) to avail itself of the future trends in Cloud computing. This will certainly alter the way the clinical workforce manages day to day clinical issues, with the use of portable technology allowing clinicians to be able to access patient records in a timely and appropriate manner as well as diagnostic functionality. It will also allow patients much greater access to their own information and allowing improved health literacy and self-management of their care. DRAFT LONG TERM INVESTMENT PLAN, Page 56

57 9 Investment Approach to Strategy Implementation Figure 2 below shows the five main investment areas we need to focus on to transform our services in line with our strategic direction. It summarises the last ten years, the current state, and why investment is needed. Figure 2: Profile of Investment Focus Areas 9.1 Benefits The potential benefits of successfully investing to address these issues were identified as part of a second facilitated investment logic mapping workshop. These are as follows: Benefit 1: Better health outcomes Benefit 2: Improved patient and carer experience Benefit 3: More affordable, efficient and resilient health services The benefits reflect the Strategy of MidCentral DHB. Key performance indicators have been identified for each of the benefits to ensure that investments are appropriately targeted at the outset, and that the impact of investments (in terms of achieving the benefits) can be measured over time. The six KPIs are as follows: DRAFT LONG TERM INVESTMENT PLAN, Page 57

58 Equity of access, particularly to community based care and aged residential care. This should reduce unnecessary presentations to ED and hospital admissions. Collaboration between organisations and across sector. The identified measure for this is use of collaborative care pathways and shared care records. People-focussed services, to be measured in part through improved patient understanding and certainty of their care plan. Access to the right services at the right time. This requires, amongst other things, better transfers between providers/services. Business continuity: hospital operations are sustainable (both clinically and financially) for business as usual for the foreseeable future, and the hospital can continue to provide critical services in the event of an emergency. Financial stability: the facilities, models of care and supporting strategies (such as the workforce strategy) enable the DHB to provide efficient, value for money services. The Benefits Map is in Appendix Transforming our services In line with our Strategy, we are currently developing a framework for a more integrated approach to service planning which works across all health settings. This will enable us to achieve more connected primary, community, and specialist care and provide a better journey for those using health services. Targeted services investment includes both inpatient and outpatient services primarily at Palmerston North Hospital. Figure 27 below shows key services requiring major investment; with enabling major clinical equipment, information technology and communications infrastructure, and facilities infrastructure outlined in the following sections. Figure 27: Status of Key Services Key Services Proposed Investment Description Status as at September 2016 SHORT TO MEDIUM TERM INVESTMENTS (2016/ /21) Mental Health and Addictions Child Health Elder Health Cancer and Palliative Care The upgrade or development of a new adult acute mental health unit to replace current substandard facilities and address service demand. Development of integrated service teams to align service delivery. Development of integrated service teams to align service delivery. Development of integrated service teams to align service delivery. Conceptual options developed Substantial progress Early implementation Early implementation Maternity Services Investment in service improvement programme continues. Planning recently done in Obstetrics. Dental Services Investment in electronic clinical record Titanium. Implementation 2016/17 Clinical Imaging Phased approach is planned for radiology Early stage analysis development with key capacity needs being MRI and CT. Gastroenterology Early stage of planning for Bowel Screening programme that is scheduled to start in Early stage analysis DRAFT LONG TERM INVESTMENT PLAN, Page 58

59 Cardiology Development of a Cardiac Catheterisation Business Case in Laboratory. development Respiratory Options for community integration. Planning stage Endocrinology /Diabetes Planning for improved service integration. Planning stage Renal Urology ENT/ORL Ophthalmology Education and Training Tertiary and Quaternary Services Expansion of haemodialysis unit on PN Hospital Site. Continued phased development of models of service delivery. Continued phased development of models of service delivery. Continued phased development of models of service delivery. Organisational Development plan is currently being developed. Likely that substantial investment will be needed in education and training in IDFs Unsure of level of investment required but must be taken into consideration going forward. Planning Stage Planning Stage Planning Stage Planning Stage Initial planning started Unknown Key Hospital Services Proposed Investment Description Status as at September 2016 LONG TERM (2021/ /27) Clinical Imaging Redevelopment of as per master health services Planning stage plan. Anaesthetic and Intensive Redevelopment as per master health services Planning stage Care plan. Emergency Department Redevelopment of existing emergency department Planning stage as per master health services plan. Radiation Oncology Redevelopment in line with concept plan for Early planning Cancer Health Services, as per master health service plan. Medical Services Progressive relocation of ambulatory services to Planning stage IFHCs and Telehealth approaches. Development of acute assessment unit alongside Emergency Department as part of the aster health services plan. Surgical Services Development of new operating theatre and procedural suite in line with master health services Planning stage Tertiary and Quaternary Services plan. IDFs Unsure of level of investment required but must be taken into consideration going forward. Unknown In addition to the above prioritised investments, there are other identified service needs which will be addressed via other operational strategies including risk and demand management. Smaller investments will be considered as part of annual renewal and lifecycle investments. An integral part of our new integrated approach to service planning is ensuring ongoing investment and linkages with primary care. The investment to date in primary and community care, particularly IFHCs, positions the district well for the future from a Community Based Health Care perspective. Now DRAFT LONG TERM INVESTMENT PLAN, Page 59

60 planning needs to take place to ensure we have a coordinated health system that provides a seamless journey between community based and hospital based services. Over time it is expected that IFHCs will increase their coverage by expanding their capacity or by absorbing smaller practices. However, it is not expected that IFHCs will completely replace all small GP teams. We expect that some small practices will remain but that these will be affiliated with IFHCs to get the benefits of scale, clinical nurses etc. In future we also expect to see the scope of IFHCs broaden out, through the addition of specialist services and with more involvement in social care. The latter will likely involve intersectoral partners and be along the lines of social investment models. An example of this is the Te Tihi Whānau Ora partnership between two local Iwi and Central PHO. It is demonstrating significant promise and has approval to work with 100 Housing NZ whānau/families to develop integrated health and social services. Government planning suggests this is the way of the future and that health care services cannot exist in isolation. While MidCentral is well down the track with its IFHC infrastructure further change is required to get them fit for purpose for new ways of working. This will require further investment. The following are the key change requirements: Developing facilities or different business models to serve the remaining 57,000 people. Workforce strategy to attract and retain the required Community based Health Care workforce. Model of Care reconfiguration and Collaborative Clinical Pathways work. Enabling IFHC to improve Ambulatory Sensitive Hospitalisations, reduce Emergency Department presentations and decrease adverse clinical variation. Revised contracting and alignment of incentives. Support the development of further Palmerston North IFHCs and the reconfiguration of Horowhenua Health Centre premises to optimise clinical flow and enable growth. Standardised General Practice Patient Management System implementation and integration with hospital systems. Develop and implement decision support software. Achieve integration across the health sector and with the social services sector. The investment required to support these imperatives is not insignificant. To some extent they can be achieved within existing budgets or from funding sources external to health. The pace of change will be limited by the funding available, and the mix of public private capital to fund these investments has not yet been identified Capacity Requirements The trends of our population growth show that there will be increased demand on health services in the future, however we plan to manage this demand as much as possible in community settings. The demand for hospital services will increase but we intend to manage this for most services through shortening the length of stay for people in hospital. The major need is not for extra bed space, it is for reconfiguration of ward blocks to meet the health needs of those requiring hospitalisation Regional Considerations Regional engagement and planning happens within the Central Region governance and decision making structure (outlined in Appendix 14.4) to consider regional requirements and impacts. MidCentral Health DRAFT LONG TERM INVESTMENT PLAN, Page 60

61 are engaged in strong regional clinical networks such as Cancer, Cardiac and Stroke. This includes development of regional strategies across the care continuum. These are clinically led work streams. A key output of this work is good patient outcomes and cost effective service delivery. It aims to address fragmentation and variation across the region. This work will continue to progress Our Workforce a Key Enabler MidCentral DHB is continuing its transformation to be a high performing health system which meets the immediate and future demand of its population. An important part of transforming and integrating our health system is having a sustainable workforce and a workplace environment which meets the needs of our population, and fully achieves our vision and values. We need to be able to do things differently, building on the achievements we have made to date. To this end, we will be developing and implementing an Organisational Development Strategy which will set out a clear vision and programme of work to create the required internal environment to support the achievement of our strategic imperatives. MidCentral DHB is currently developing a Horizon Scan across all clinical areas (with an emphasis on clinician workforce requirements to meet future service demands). This will be completed by the end of This process includes bench marking against peer services in Hawkes Bay and Bay of Plenty (with Capital and Coast being used for Cancer Services). Clinical Directors and Medical Heads, in conjunction with other professional leads, are providing the future outlook for each service and this will be used to create an overview and a service by service plan which will then be updated every six months MidCentral DHB s Organisational Development Strategy MidCentral DHB s Strategy will be supported by our Organisational Development Strategy, which will set out a clear vision and programme of work to create the required internal environment to support the achievement of our strategic imperatives and the transformational change required. This will also be supported by the Cultural Competency Programme which is currently under development with the Māori Heath Directorate and Central PHO. The Organisational Development Strategy will incorporate workforce development initiatives previously included in MidCentral DHB s separate workforce strategy. Work on the Organisational Development Strategy has commenced. We have a wealth of information from the 2015 staff safety culture survey, from staff forums and from the workshops that have contributed to the development of our strategic framework, to begin to build a clear framework for our Organisational Development Strategy. Key areas of focus within the strategy, which will outline a 3 to 5 year work programme aimed at creating an internal environment that proactively supports and contributes to the achievement of our strategic priorities, will be: Building a positive and productive work environment, which will include a very strong focus on establishing and maintaining expected standards of behaviour and conduct, including giving meaning and effect to our values. Developing credible, capable and engaged leadership across all areas including clinical, functional, technical and change leadership. Ensuring we have a sustainable workforce, including diversity initiatives, and workforce planning. DRAFT LONG TERM INVESTMENT PLAN, Page 61

62 Developing clear and appropriate decision-making frameworks, an authorising environment and clear accountability structures. Building capability across all areas of our workforce, including the identification and growth of talent, supporting career structures, and cultural competence. Working together, better and smarter, including a strong focus on innovation, quality improvement, and utilising cross-functional teams Future Requirements It is important that the health sector works, wherever feasible, with other agencies when considering future workforce requirements. MidCentral DHB has long recognised the need to work together across agencies to help those with more complex needs. The Health Charter (Section 4.2) describes the joint vision for a more collaborative and integrated cross sector approach to the provision of health and social services. Over the past ten years, MidCentral DHB has continued with its direction to build community based and community capacity to support people receiving care closer to home, and releasing hospital and specialist capacity to focus on the delivery of more complex care. Looking to the future, MidCentral DHB is faced with an ageing population, a growing Māori population, and increasing demand for health services, and it is essential that we continue with initiatives to build and retain a workforce capable of meeting the needs of our population into the future. We will continue with our direction of transforming our health service, and building further community based and community capacity to support people receiving care closer to home. There will continue to be an increasing emphasis on the specialist senior medical workforce, trained in the delivery of specialist services in the community, to match MidCentral DHB s, and the regions, population needs (such as has already started being implemented in the child health area). There will be further development of the general practitioner, but with maintenance of sufficient numbers of specialists in all of MidCentral DHBs clinical services. Our senior medical officers, and other health professional groups, will need to be educated and totally comfortable working in multidisciplinary teams who are more broadly rounded and competent beyond their current technical/clinical skills. Acknowledging the challenges required to grow and develop our existing workforce and exploring new ways of working to meet the future needs of our population; our Organisational Development Plan and our future workforce planning will address these challenges. DRAFT LONG TERM INVESTMENT PLAN, Page 62

63 10 Required Capital Investment 10.1 Investment required in Major Clinical Equipment MidCentral DHB will continue its investment programme in clinical equipment, such that the hospital and ancillary services have the standard of equipment necessary to deliver in the quadruple aim. This will include the provision of equipment in IFHCs to ensure that they are positioned to support the delivery of more specialist services closer to home. The projected investment on clinical equipment is an average of $7.4 million pa for the next 10 years, which should in large part be covered by associated depreciation provisions other than the front loading of Linear Accelerator costs. Figure 28: Summary of proposed capital investment in major clinical equipment Figure 29: Major Clinical Equipment Capex 10yrs to 2026 cumulative ($000 excl GST) DRAFT LONG TERM INVESTMENT PLAN, Page 63

64 10.2 Investment required in Information Technology and Communications Infrastructure MidCentral DHB is in the later stages of the work programme under an ISSP developed, and updated annually from The overhaul of physical IT infrastructure is well advanced with the end in sight, the build of core and common shared systems under the Central Regional Health Informatics Programme (RHIP) is in progress and will complete over the next year or so; and migration towards shared applications, such as RHIP and the National Oracle Solution, will move the imperative away from traditional information technology approaches. A new Information Services Strategy for the next phase of our existence is still to be completed. It is likely to be people centred and outward focussed. It will need to investigate increasing opportunities through the smart application of technology such as telehealth to improve care. It will also look at the following themes: Legacy system replacement nearing completion The major components of necessary local infrastructure overhaul are well advanced, with further progress planned in the next year to deliver a future state including core components of: Application virtual server farm; the application virtual server farm on the Palmerston North Hospital campus is a highly available environment with redundancy and resilience designed into the host servers, switches, networking and storage. This provides automated failover capabilities across both sites being, Site-A, the main server room on Site-B, and the basement hub. SQL server farm; the SQL server farm comprises 4 physical servers (hosts). This server farm is due for immediate replacement as is aged and with demand exceeding capacity. Once the SQL farm is upgraded, capacity will be available to handle any immediate / short-term needs. There will be a requirement to support planned systems and incremental growth until such time as compute and storage is transitioned to infrastructure as a service (IaaS) and the architecture is designed to facilitate that eventual transition. Storage Area Network (SAN); the storage system consists of two separate sites which are updated simultaneously. The virtual server farm has been stretched across two sites and allows for the transfer (using virtualisation technology) of servers between sites in the event of a disaster recovery (DR) issue. The SAN looks after storage for the organisation at a local level. Network; the local area network delivers data and wireless across the DHB, and is also progressively delivering voice-over-ip (VoIP) telephony. All cabling from wall outlets to network switches is progressively being upgraded to Category 6A cabling at Palmerston North Hospital. The network comprises ~120 Cisco core, distribution and edge switches and are being installed over the next three years. The completed environment will be compatible with either ongoing ownership or transfer to TAAS. Infrastructure environment; In 2014/15, Information Systems environmental infrastructure was upgraded to replace ageing equipment and increase capacity. Wide area network; MidCentral DHB is part of Connected Health - a national wide area network. Two data circuits join MidCentral DHB to Connected Health. These were installed in August 2016 and are expected to meet current and future regional system requirements. DRAFT LONG TERM INVESTMENT PLAN, Page 64

65 End user computing; MidCentral DHB currently supports 1565 desktop computers, plus other devices like laptops, tablets and smartphones, which run ~ 150 applications and provide access to > 150 applications. Our future environment is expected to demand highly available capacity for mobile devices both for clinicians and others. Our network and wireless upgrade project is designed to deliver this. People powered This theme is about communicating well and supporting people s navigation of the system, including through the use of accessible technology such as mobile phones and the internet. MidCentral DHB will need investment in the training and infrastructure to move rapidly from legacy systems, through a desktop model to a fully mobile delivery of services. Acknowledging that most of the residents of the district have already completed this transition and they will assume the DHB has as well, so further investment will be required to manage this expectation gap. We will need to deliver the investments required to deliver smart precision medicine with the information held within the regional and national databases. MidCentral DHB will need to continue to expand on its current investment in Artificial intelligence to support point of care decision making by clinicians. Value and high performance Ambitions within this theme include: delivering better outcomes relating to people s experience of care, health status and best-value use of resources; striving for equitable health outcomes for all New Zealand population groups; measuring performance; well and using information openly to drive learning and decision-making that will lead to better performance. For MidCentral DHB to deliver on this, it will need to successfully deploy the regional databases as described in the Smart System theme below. MidCentral DHB will need to have transitioned to being a mobile first, empowered by artificial intelligence workforce. Most of the care will need to have moved into the community. As well as the change in technology, investment in developing staff and upgrading of work processes will need to occur. One system Operating as a team in a high-trust system that works together with the person, family and whānau at the centre of care. Using our health and disability workforce in the most effective and most flexible way. The key investment required is the development of trust across the sector, so the artificial selfimposed barriers are removed. Their removal would allow patient benefit and reduction in system cost. Smart system Increase New Zealand s national data quality and analytical capability to make the whole health system more transparent and provide useful information for designing and delivering effective services. MidCentral DHB has commenced a strategic review of this area of the business. DRAFT LONG TERM INVESTMENT PLAN, Page 65

66 MidCentral DHB is implementing CostPro, to provide item level costing. MidCentral DHB has invested in developing analytic capacity within the organisation; it needs to deliver a return on that investment through developing an analytic strategy. As part of an overall strategy decisions about the analytic product suite needs to be considered. The PHO is currently undertaking an investment to replace their near end of life but venerable combination clinical and administration system. When the PHO has completed that investment decision and implemented the result, then MidCentral DHB will need to work with the PHO to allow the free transfer of information across the district. MidCentral DHB has commenced the overhaul of ICT governance structures, but this group is in its early stage. To establish a national electronic health record that is accessed through certified systems including patient portals, health provider portals and mobile applications. For MidCentral DHB in the first instance, this will be based on replacing the legacy PAS system and developing integrated electronic systems like the regional clinical portal. This will achieved by continuing to engage in the RHIP program of work both core and common streams. i) A single regional clinical data repository (CDR), accessible by all providers. ii) A clinical workstation (CWS) using the Orion Concerto suite of products. iii) A patient administration system (PAS) using the isoft WebPAS product. iv) A radiology information system and image archive using CareStream s products. There will need to an investment in the change management and staff education for the RHIP project to deliver its potential. Particularly with regards to WebPAS there will be significant changes to work practices and a major transition in staff workflows. There will need to be a continued investment in upgrading the software, based on previous lessons learnt as each DHB joins the formal programme. The overall cost of the regional programme of work and associated investments for MidCentral DHB is projected to be $46 million over the next ten years. This cost does not include the costs of internal DHB staff time that would be required as part of the change management process. Maternity Clinical Information Systems continue to be a concern in terms of functionality, user engagement and changes to the clinical process. To resolve these issues with this national system, further local investment ~$500,000 is required and to work with external partners like the Ministry of Health. Develop capability for effectively identifying, developing, prioritising, regulating and introducing knowledge and technologies. The ICT governance group has been established (outlined in Section 3.3.1). Working with regional and local partners to create opportunities through collaboration as well as shared governance. DRAFT LONG TERM INVESTMENT PLAN, Page 66

67 Proposed ICT investment programme Figure 30: Planned MidCentral DHB enabling technology initiatives Investment Areas Regional Information Systems Hospital Services Enhanced Community based Care Community Health Services Integration Patient and Whānau engagement Support Initiatives Regional clinical data repository and portal (Concerto) Regional patient administration system Regional radiology information system Health informatics Hospital operations centre information system (resource optimisation Medical ordering Electronic, eprescribing of medication in the hospital (and community settings) Electronic, eadministration of medication in the hospital (and community settings) Mobility services Order Set Management Clinical Documentation Updated hospital pharmacy system Telehealth services Health informatics Shared Information Platform Patient and Clinical portals Electronic, ereferrals between community based and secondary Health informatics Mobile care teams Technology platform to enable Information sharing and analytics Health informatics Self-management for stable Long Term Conditions Remote monitoring for unstable conditions Health informatics Replacing the DHB s obsolete telephony system Upgrading the DHB s communications cabinets Implementing wireless technology to support clinician mobility Upgrading the web platform Moving to a fully electronic document management system Figure 31: Summary of proposed capital investment in ICT DRAFT LONG TERM INVESTMENT PLAN, Page 67

68 Figure 32: ICT Capex 10yrs to 2026 cumulative ($000 excl GST) 10.3 Investment required in Facilities and Infrastructure Future Clinical Service Infrastructure needs In 2014, the Master Health Service Plan Indicative Business Case (IBC) modelled future demands and population trends (refer ). A light refresh was done by SAPERE consulting Group in August 2016 using new population projections from the 2013 census and more recent clinical data to check whether the previous forecast of underlying activity is still relevant. The SAPERE conclusions are that discharges forecasted are similar to 2014 and most service assumptions still hold. The following areas identified still need to be explored more closely for future planning: Paediatrics ward space CCU/HDU/ICU Theatre and procedure rooms Medical and Surgical Short Stay units ED physical space taking into consideration the recent spike (15/16 year) in ED presentations and admissions This supports the indicative conclusions for the redevelopment of the Palmerston North Hospital Campus. Graphs of current and future service demands for clinical services are provided in Appendix DRAFT LONG TERM INVESTMENT PLAN, Page 68

69 Service Demand Forecasts Graphs of current and future service demands for clinical services are provided in Appendix They show the following trends: Demand is expected to steadily increase in: Geriatric Admissions, ED presentations, ED Admissions, Medical Total Admissions, Surgical Total Admissions, RCTS Total Admissions, Mental Health Total Admissions, Paediatric Health Total Admissions; and ICU Admissions and Transfers In. A small amount of growth in service demand is expected in: Total Medical Line Beds, and Gynaecology Total Admissions. Demand is expected to remain relatively steady for: Psychogeriatric Admissions, Maternity Admissions, Well Newborn Admissions, Neonatal Admissions, and Physical Disability Admissions. A slight decrease is expected in Caesarean Total admissions after Elective Surgery Capacity A Central Region led audit of current public capacity was undertaken. The output of this was used to determine what, if any, regional capacity is available/appropriate to use to meet MidCentral Health/our region s future requirements. In our work under the centralalliance with Whanganui we will be considering whether some of the surgeries currently being done in Palmerston North for Whanganui residents can be done in Whanganui. MidCentral DHB is also considering the hirage of theatre space in a local private hospital. There is no appetite for subcontracting work to the private sector as this has proved problematic in our region Proposed Investment - The Palmerston North Hospital Indicative Business Case (IBC) Background Extensive work went into developing the Reform from within: Transforming Hospital Services at MidCentral Palmerston North Hospital - Indicative Business Case completed and approved by the MidCentral DHB Board and made available in September This document recommends an initial spend of $106 million (2014 costings) upgrading critical services at Palmerston North Hospital over the next five years, with further work and costings required to complete the campus reconfiguration identified in the attendant Master Health Services Plan, ie all outpatient and inpatient areas. The Indicative Business Case (IBC) was developed with our iwi partners, our clinicians, our management, our consumers, our neighbouring District Health Boards (Whanganui in particular), our Community based Health Care partners and our Board. We also worked closely with central government agencies, the Ministry of Health and Treasury officials in particular, to ensure a common understanding of the proposed way forward. The SAPERE Consulting Group supported us with detailed analysis and service demand forecasting. DRAFT LONG TERM INVESTMENT PLAN, Page 69

70 The IBC represents over a year of discussions, analysis and modelling to arrive at a short list of options for how we might address our material seismic, functional and capacity issues through both our facilities and the system redesign essentials necessary to drive improved efficiency and quality performance. The Indicative Business Case was endorsed by both the MidCentral and Whanganui District Health Boards in August Plans to advance this work to the stage of a detailed business case were parked due to a change in the MidCentral DHB Chief Executive Officer position in 2015, and the Board decision to refresh the MidCentral DHB Strategic Plan. The IBC and attendant plan whilst remaining highly relevant to our capital planning is currently being refreshed prior to seeking final approvals and proceeding to the implementation phase. This will be done in the context of an overall site master plan The Indicative Business Case developed the indicative business case to provide an indication of the preferred way forward for investment in the Palmerston North hospital campus facilities. It built the case to develop a detailed investment proposal further to address key facility issues. The initial phase focused on critical services, with the need to address functional and material issues with inpatient and outpatients areas to be done as a second stage as part of an overall site master plan. This indicative business case was a first deliverable in a formal two-stage approval process. With Board approval of the IBC achieved, a detailed business case needs to be prepared to recommend a preferred option that optimises value for money and to seek approval to finalise the arrangements for successful implementation. The IBC revisited and strengthened the strategic case, set out the economic case and identified the provisional steps for a detailed business case Recommendations The indicative business case proposed that the only viable option for MidCentral DHB to address its key seismic, material and functional issues for the identified IL4 Critical Services was to undertake capital redevelopment of $105.7 million (2014 costings) to address these key issues (identified as Option 1B throughout the IBC document). This preferred option resulted from an analysis of a number of long list options, all of which were ultimately discounted as not being able to adequately address our facility issues. To address seismic issues only, would cost MidCentral DHB $75 million, including make-good work. This option would severely compromise functionality and capacity, resulting in significantly lower or negative returns on investment. The preferred option The preferred option was identified as a medium Brownfield build (Option 1B, Section 6.4 of the IBC) to address the collection of issues facing MidCentral DHB. We proposed to build a Hot Floor of theatres, procedure rooms, a critical care unit (CCU), cardiology interventional services, Sterile Support Unit (SSU), Emergency Department (ED), emergency radiology, and telephony within a new facility that meets seismic compliance. Other services requiring refurbishment will be planned in decanted space. In particular the new build would address the core issues of importance Seismic and Building Code Level 4 (IL4) compliance and do so in a way that leads to much improved productivity. We want to use DRAFT LONG TERM INVESTMENT PLAN, Page 70

71 the opportunity to future proof our Palmerston North campus and to continue our strategy of a community based and community led health sector. We propose to carry this preferred option into the detailed business case. Rationale The indicative business case also articulated the need for significant changes in the way services are currently configured and delivered, to ensure that we realise the benefits available in operational efficiencies, improved patient experience, and improved quality. Building a new facility without addressing the issues of how well our patients flow through the system, and experience that system, would counteract some of the benefits we identify as supporting the business case - except of course for the seismic issues. The analysis that supported the IBC suggested that we can no longer provide safe and patient-focused specialist services from our current facilities: We have outgrown them both materially and functionally and our productivity and efficiency is severely compromised. It is increasingly difficult to advance new models of care and standardisation of practice within facilities that limit patient flow. The recent seismic assessments note they are no longer fit for purpose for those services we have deemed to be critical in a natural disaster. A wide range of options was considered The IBC considered our options for addressing our facility issues. We undertook a careful process of analysis. The appropriate levels of intervention which are necessary and realistic to expect for our population (and Whanganui where appropriate) were established. We determined the broad geographical scope of interventions across the facilities network and potential for greater service delivery in other locations, including Whanganui and the private sector. We have assumed different models of care for the future, and in particular reducing the inpatient footprint towards community care, maximising community based care to further deliver interventions, and integrating care across settings. We have built productivity and efficiency gains into our assumptions - but only to the level of bringing MidCentral DHB back to an average national benchmark level. We have listened to our clinicians and our consumers. The IBC was not premised on attracting volume from other DHBs other than interventional cardiology, for which we proposed further analysis with central region partners about the possibility of establishing a sub-regional service with Whanganui. Our business case is, however, premised on maximizing capacity and revenue within the MidCentral DHB and the financial modelling was predicated on that. The IBC proposed that a detailed business case would consider in depth the minimum necessary to address the above issues we certainly do not have grand plans for a hospital-centric model of care for our population, nor would that be sustainable. The IBC set out that our organisational commitment remains to financial prudence and affordability, while ensuring we can commit to a 21st century health system founded on excellent specialist care where required, improved patient experience and a continued focus on supporting the care of our patients through appropriate community based services. Matters identified for further investigation DRAFT LONG TERM INVESTMENT PLAN, Page 71

72 The IBC identified a number of significant areas for further investigation if we are given approval to move forward to a detailed business case. We recently contracted the SAPERE Consulting Group to recheck of the service demand forecast assumptions, which were based on the 2006 census for the IBC. This work resulted in the following assumptions update: - Discharge forecasts are remarkably similar to the 2014 forecasts and most service assumptions still hold. This is particularly so in General Medicine and Rehabilitation - More detailed modelling is recommended for: - Child Health (Paediatric) ward space; - Intensive Care Unit (ICU), Critical Care Unit (CCU) and High Dependency Unit (HDU) needs; - Theatre capacity. The 2015/16 year spike in Emergency Department (ED) attendances needs to be better understood for the next stage of planning. Preliminary work suggests that ED attendances are likely to stabilise at a higher level than previously around the 42,000 to 45,000 presentations p.a. level, as opposed to the 40,000 p.a. level previously established. This will be dependant of the ability of community based health care to manage demand in the community. Other matters identified for further work up in the IBC: We need to: Clarify what surgical and associated support services can be done with Whanganui. Planning will be clearer on a service by service basis given the development of our joint centralalliance Strategic Plan with Whanganui DHB which identifies the range of specialist clinical services both DHBs could collaborate on. The draft Plan is undergoing a public consultation process across both DHBs. In terms of consideration of the preferred option, there is a need to focus on the detail of the expected productivity gains across the surgical and medical systems, but particularly in theatres. We will also need to initiate a theatre productivity improvement plan to achieve efficiency gains. Preoperative services and in particular the optimal facility design and space layout for improved flow across pre- and post-operative services will be further developed. Confirm (or otherwise) the assumptions behind the establishment of interventional cardiology at MidCentral DHB for both the MidCentral DHB and Whanganui populations in partnership with Central Region DHBs and the Central Region Cardiac network (though it should be noted that such a decision does not impact on the proposed establishment of a Catheterisation Laboratory in the indicative business case). Ambulatory care design will be further advanced now that the general model of organising acute and elective flows is clear, and given that we have 3 larger IFHCs in the immediate Palmerston North and Feilding area. Cancer day services and the physical reorganisation of the cancer services around a patient perspective will take considerable space planning with potentially a modest capital investment. However, until we are clear about the preferred option, the options for improving cancer services will not be able to be further defined. Follow up work on these areas is current work in progress. DRAFT LONG TERM INVESTMENT PLAN, Page 72

73 IBC fit with a long term Master Site Plan The indicative business case prioritises a series of investments (both capital and service changes) within a broader Master Health Services Plan. It identified short term critical issues to be addressed (described as Option 1B), but identifies need for a path for addressing other functional and material issues around our wards, ambulatory care, women s health and cancer services (Option 1C) over the longer term. The longer term issues (those specified in Option 1C) were not included in the IBC costings. It was assumed that they would be dealt with via a separate business case process should our board and government approve this as an option. As a preliminary step in progressing the IBC we will undertake a further holistic assessment of property needs to generate a Campus Strategy and Site Master Plan. This is intended to ensure that all identifiable requirements and emerging deficiencies are considered and that a process for resolution is developed. The Indicative Business Case for the Palmerston North Hospital Campus redevelopment will be further developed into a full business case over the next 12 months. Figure 33: Summary of proposed capital investment in buildings and plant Figure 34: Building and Plant Capex 10yrs to 2026 cumulative ($000 excl GST) DRAFT LONG TERM INVESTMENT PLAN, Page 73

74 11 Capital Landscape Programme MidCentral has drafted a Capital Landscape programme. The facilities, clinical and ICT teams used a structured approach to identify future priorities and related capital costs over the 10 years to 2026 to make our facilities fit for purpose into the future. The MidCentral DHB indicative capital programme is currently at $410 million over the next decade. Between $203 million and $236 million can be financed from depreciation depending on timing and portfolio mix. This means that over $200 million will need to be financed by other means. The aggregate $410 million identified consists of $282 million buildings, $74 million in clinical equipment, and $50 million for ICT and $3 million for dental caravans. The Master Health Services Indicative Business Case for an acute services Hot Floor contributes $107 million to this total; Mental Health Facilities between $5 million and $20 million depending on our ability to optimise this; and an indicative marker of $60 million for eventual resolution of ward requirements. Figure 35: Capital Projections by main asset type = Buildings and Plant = Clinical/other equipment = IT and Software = Dental Caravans Figure 1: 10 year capital landscape forecast DRAFT LONG TERM INVESTMENT PLAN, Page 74

75 MidCentral DHB has substantial deferred maintenance and capital investment that now presents as: Earthquake/seismic strengthening or rebuilding work to ensure compliance standards are met for both the Building Code and the Civil Defence Emergency Management Act; Old electrical services infrastructure requiring progressive replacement; Inappropriate and/or out of date design which seriously hampers service delivery and productivity and which degrades the consumer experience; An information technology infrastructure that was obsolete and is now in the final stages of updating but with the need to complete core applications implementation. Summary of sources of capital funding: Internal DHB funding: Current cash on deposit balance of about $40 million Annual Depreciation expected to form the majority of internal funding Future Operating Surpluses modest levels forecast in the 2016/17 Annual Plan Asset sales not considered to be material over the periods Potential external funding sources: Leasing Philanthropic funding Private sector investment Private public partnerships In the absence of the ability to borrow commercially, any deficiency in funding after exhausting the preceding avenues would need to be sourced from the Ministry, either as borrowing or a capital injection of equity Year Capital Intentions of Projects The table on the following page describes projects planned valued at over $500,000 for ICT and over $5 million for all other projects. DRAFT LONG TERM INVESTMENT PLAN, Page 75

76 Figure 36: 10 Year Capital Intentions of Projects DRAFT LONG TERM INVESTMENT PLAN, Page 76

77 Projects/Programmes Underway Ambulatory Care Upgrade Scope: Work began in 2015 after a review of the facility identified that there was insufficient space to meet outpatient service requirements and the department was considered not fit for purpose. The project will result in greater comfort for patients and staff as well as supporting improved efficiency. It involves the relocation of non-clinical services to other areas of the hospital, the relocation of some clinical services and the alteration of existing areas within Ambulatory Care. The relocations allow room to be freed up so that all clinical services can be collocated in one area. Budget: $1 million is budgeted in 2016/17 and $1 million in 2017/18 Timeframe: This project is planned to be completed in 2017/ Facilities Infrastructure Refresh/Seismic Scope: Ongoing work is being done to ensure that support infrastructure such as boilers, electrical systems, and lighting are replaced/refreshed in a timely manner to continue to meet quality standards and adequately support the provision of services. Seismic work is also programmed. Ward refurbishments are also scheduled over the 10 years. Budget and Timeframe: Over the next 10 years approximately $73 million has been budgeted. $ million of this is for Electrical Infrastructure, $9 million has been budgeted for ward refurbishment (1 million per year from 2017/18 to 2025/26) and $6.6 million is for incidental seismic work. See the Buildings and Plant Capital Landscape detail in Appendix for a breakdown of individual programmes of work Regional Health Informatics Programme (RHIP) Completion Scope: The scope and initial focus of CRISP (now known as RHIP) Business Case is to achieve both Phase 1 of the Central Regional Information Systems Plan s goals and part of Phase 1 of the National Health IT Plan. These goals are based around regional consolidation of information systems which lay the foundations for a shared care programme of work (Phase 2) implementing patient vitals, e-events, care plans and decision support. Phase 1 foundations includes: 1. The implementation of the Orion Concerto regional clinical workstation (portal) and data repository for hospital clinicians in the region with access by primary care and other community healthcare providers. 2. The implementation of a regional patient administration system (CSC s WebPAS) commencing with replacement of the three end-of-life patient administration systems at MidCentral, Wairarapa and Whanganui DHBs. 3. The implementation of a regional Picture Archiving and Communication System (PACS) (CareStream) to provide greater access to radiology reports and images across the region together with a regional PACS archive to minimise storage costs. This activity supports the vulnerable radiology service. DRAFT LONG TERM INVESTMENT PLAN, Page 77

78 4. The implementation of a regional radiology information system (RIS). 5. The implementation of electronic referrals (ereferrals). ereferrals are created electronically within the GP s practice management system (e.g. Medtech32, Houston, Intrahealth/Profile and MyPractice) and routed to the DHB s ereferrals management systems. 6. The establishment of a regional infrastructure to give clinicians one logon, one password, and fast and convenient access to information. 7. The implementation of a service management framework to ensure that services design and management, release control, supplier and resolution processes are coordinated for regional systems. Budget: $5.029 million has been budgeted between 2016 and Timeframe: This project is planned to be completed in 2018/19. Business Case approved by Ministry of Health September Replacement of ICT Communication Cabinets Scope: The refurbishment of ICT communication cabinets prepares 45 communications cabinets for new network switches and associated cabling to support a fit for purpose wide area network to deliver data, voice over IP telephony and wireless across the Palmerston North campus. Budget: $3.87 million has been budgeted between 2016 and Timeframe: This project is planned to be completed in 2017/18. Business Case approved by MidCentral DHB Board in August epharmacy Scope: epharmacy replaces the current obsolescent Homer Pharmacy Management System. This is also a prerequisite to replacing the Homer Patient Administration System (of which the Homer Pharmacy Management System is a module) with WebPAS. Budget: $3.87 million has been budgeted between 2016 and Timeframe: This project is planned to be completed in 2017/18. Business Case approved by MidCentral DHB Board in August Hospital Operations Centre Scope: A (digital) Hospital Operations Centre allows the organisation to: better understand workload and provide suitably skilled and safe staffing levels in the delivery of care; ensure existing resources are utilised in the most efficient and effective way; better support resource and production operational efficiencies in the financial year and beyond; maximise bed availability and eliminate blockages to patient flow; DRAFT LONG TERM INVESTMENT PLAN, Page 78

79 provide daily monitoring of the hospital s activity and a co-ordinated organisation wide response to variances in patient demand and supply of resources; provide a prompt and co-ordinated response to events impacting the daily hospital operation; utilise information about patient demand and resource supply information for planning and forecasting purposes (short term and long term); be able to better manage the hospital during exceptional circumstances. Budget: $2.04 million has been budgeted between 2016 and Timeframe: This project is planned to be completed in 2017/18. Business Case approved by MidCentral DHB Board in August Anticipated projects with business case under development Campus Strategy and Site Master Planning Projects Scope: We have commenced the development of a Campus Strategy and Site Master Planning project to ensure that we take a holistic view of needs and opportunities to optimise overall investment. This will refine or revalidate the Indicative Business Case for the Palmerston North Hospital Acute Services Hot Floor which will be further developed into a full business case over the next 12 months. It will also include analysis of other hospital facilities including CSB reconfiguration and future ward requirements. Budget: A total of $167 million has been budgeted across two areas. $107 million approximately of capital expenditure on buildings and plant is forecast to be required for the Hot Floor (IBC). $60 million has been budgeted for Future Wards/CSB Relife ($1 million in 2021/22, $1.5 million in 2022/23, 2.5 million in 2023/24, $20 million in 2024/25 and $35 million in 2025/26). Figure 37: Building and Plant Capex 10yrs to 2026 cumulative MCDHB - Building & Plant capex 10 yrs to 2026 cumulative 160, , , ,000 80,000 60,000 40,000 20,000 0 IBC Other Building work IBC Timeline: A detailed business case for the Hot Floor will be developed over the next 12 months. The project is planned to take place over the next decade with the major investment required from 2019/ /23. The future ward/csb relife isscheduled for 2021/ /26. DRAFT LONG TERM INVESTMENT PLAN, Page 79

80 WebPAS Scope: WebPAS is a patient administration system which will be used by all Central Region DHBs. Implementation of a regional solution commences with MidCentral, Wairarapa, and Whanganui DHBs migrating from their legacy systems. Budget: $3 million has been budgeted for 2016/17 in the capital landscape, however, the cost is now predicted to be $3.5 million and a business case is being developed for this extra cost. Timeframe: This project is planned to be completed in 2016/17. Original Business Case approved by Ministry of Health in September 2011 ($1.6 million) however, another business case is being developed to gain approval for extra funding required National Oracle System Scope: The National Oracle System replaces MidCentral DHB s current financial and inventory management system (J D Edwards). Budget: $2 million. Timeline: Project to be completed Business case completed but not endorsed/approved yet Emergency Department redevelopment Scope: To reconfigure the ED waiting room facilities. The provision of a fit for purpose physical space will mitigate safety and compliance risks and support staff in their efforts to perform more focussed and private clinical assessments, and improve patient streaming. Budget: Invest up to $1,980,000 capex (estimated) Timeline: 2016/17 financial year Business case completed but not endorsed/approved yet CathLab Business Case and sub-regional Cardiology services Scope: Establish a dedicated cardiac catheterisation laboratory on site at Palmerston North Hospital within the existing footprint of the facility. This will improve access to services locally with the establishment of a Percutaneous Coronary Intervention (PCI) service for which patients are currently required to travel to Wellington. Currently our patient flow and outcomes are determined by capacity at Capital and Coast Health. Access for diagnostic angiography is also currently restricted by Medical Imaging DSA room capacity resulting in our inability to meet MoH targets for acute angiography, and some elective diagnostics. This investment should result in improved inequalities and reduced ageadjusted ischaemic heart disease morbidity and mortality rates. DRAFT LONG TERM INVESTMENT PLAN, Page 80

81 Budget: A total of $8 million has been budgeted for this project - $6.5 million for CathLab facility and $1.5m for equipment (CathLab DSA Machine). Timeline: 2017/18 and 2018/19. The business case is currently being workshopped with external project support Mental Health Redevelopment Ward 21 Scope: An options paper has been developed which scopes the relative costs of an indicative re-design or rebuild the Ward 21 facility. The imperative to progress a new facility is driven by a number of known faults and safety issues identified in the current environment as not fit for purpose. These are associated with adverse events which triggered an external review of the mental health and addictions service. Star 1 Scope: Design deficiencies in the high needs area of Star One unit were identified in a recent Ombudsman s office report under the OpCat legislation (Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment). These will need to be addressed with some urgency. Budget and Timeline: $20 million is the maximum anticipated scope for this project however more cost effective solutions will be investigated. The project has been budgeted for Following identification of a preferred option it is expected that required approval processes would proceed during Q3 2016/ Facilities for Bowel Screening Programme Scope: Facilities must be developed to house the Bowel Screening programme which is being rolled out nationally. Budget: $3.2 million has currently been budgeted. Timeline: 2017/ MRI Scope: Our MRI provision is currently outsourced and a business case is currently under development to look at the best options for provision of MRI services in the future when our current contract expires. Options being looked at include re-contracting the same provider or bringing services in-house. Initial indications are that bringing the services in-house will be the most cost effective and clinically effective model, however further analysis needs to be undertaken. Budget: $2 million ($1 million in 2017/18 and $1 million in 2018/19). Timeline: 2017/18 and 2018/19 DRAFT LONG TERM INVESTMENT PLAN, Page 81

82 Known but no business case yet Regional Cancer Treatment Services (RCTS) Scope: The services based on the Palmerston North Hospital Campus have a pressing need for new and reconfigured facilities to enable the service to cope with the projected growth, help it attract and retain the required high value clinical staff, and achieve operating efficiencies. This will be considered within the Campus Strategy and Site Master Planning Projects. Our Linear Accelerators are also due for replacement in coming years to ensure we can continue to provide quality regional services. Budget: $22.5 million has been budgeted between 2017 and 2022 for the new Linear Accelerators and the required building upgrades to go with them. Other oncology equipment replacement items in the budget include: $769,000 on breast screening equipment in 2024/25, $1.74 million on a CT scanner Radiotherapy in 2016/17 and $1.2 million on a Radiotherapy Planning System (Monaco) in 2016/17. Further improvements to the Regional Cancer Treatment Service facilities have not been included in the capital landscape as a separate project and it is possible that we could attract substantial philanthropic funding to support developments required in this area. Timeline: CT scanner Radiotherapy and Radiotherapy Planning System (Monaco) are scheduled for replacement in 2016/17. Linear Accelerators are scheduled to be replaced in 2017/18, 2018/19, 2019/20 and 2021/22. Breast screening equipment is to be replaced in 2024/ Medical Imaging Equipment replacement Scope: In order to ensure that our medical imaging equipment is up to the required standard for the provision of quality services various items are scheduled for replacement over the 10 year period. The largest of these items is a CT scanner due to be replaced in 2018/19. Budget: $1.74 million has been budgeted for the CT Scanner. Other equipment replacements in the budget total $5.639 million over the 10 year period. Timeline: CT Scanner replacement in 2018/19. Other equipment scheduled to be replaced between 2016 and MidCentral DHB Renal Plan implementation of recommendations A review has been undertaken in 2016/17 which recommends a new model of care supporting the development of more community based services supported by fit for purpose hospital based services. The recommendations include two facility initiatives requiring urgent attention to improve infrastructure to deal with the growing demand for renal services (4 percent growth annually since 2013). A formalised implementation plan identifying all initiatives to be implemented is being completed with external project support. Initiative 1 Scope: Establish a 3 chair haemodialysis station at Horowhenua hospital within the footprint of Star 4. Initially 3 days per week for 3 patients per day increasing to 12 patients. This will enable people living in the Horowhenua to receive treatment closer to home and will also reduce the burden on the Palmerston North unit. DRAFT LONG TERM INVESTMENT PLAN, Page 82

83 Initiative 2 Scope: There is also a pressing need to reconfigure the in-centre dialysis unit at Palmerston North Hospital as the current layout does not provide a positive patient experience or an acceptable clinical environment. It is overcapacity, and the environment is high risk for patients and staff. There is also no room for growth. This project needs to happen over the next 2-3 years prior to a medium to long term solution being part of the Campus Strategy and Site Master Planning Project. Capex Budget for both initiatives: $5 million ($100,000 in 2016/17 with $2.4 million and $2.5 million allowed for in the 2017/18 and 2018/19 budgets respectively). Timeline: 2016/17 for Initiative 1 and 2017/ /19 for initiative Reconfiguration of Horowhenua Community Health Centre Scope: The Horowhenua Community Health Centre was built in 2007 whilst seismically sound this building needs some internal reconfiguration to enable the General Practice to grow, potentially absorbing some practices currently operating in the community, and for General Practice to be better integrated with the specialist clinics operating from that site. Budget: $2 million. Timeline: 2017/18 and 2018/ Pharmaceutical Robotics Scope: A business case needs to be developed to optimise investment in pharmaceutical robotics to improve efficiencies in relation to dispensing medication to hospital patients. Budget: $800,000 has been allocated in the current capital landscape Timeline: 2018/ Other known investments for which only seed funding is anticipated There is an ongoing need to rebuild community based healthcare to ensure the model of care will meet future needs, however, MidCentral DHB would only be contributing seed funding to these projects. Further Integrated Family Health Centre development serving Palmerston North probably in the vicinity of $10 to $15m. This will be funded through community and private sources. We are expecting to provide seed funding of up to $1 million, which will be towards planning, project management, set up and change management costs. Budget: up to $1 million Timeline: within 1 3 years The Ōtaki Medical Centre will need to expand, probably doubling in size over the next decade, and further integrating a range of health and social services into a single site. This will accommodate growth in the GP team and expansion of its role going forward, and achieve better integration between community based and specialist services operating from the site. Budget and timeline: not yet specified. DRAFT LONG TERM INVESTMENT PLAN, Page 83

84 Other Service initiatives that may require Capex As we transform our models of care, other service initiatives are generally expected to be funded through Operation Expenditure; however there may be a requirement for small amounts of Capital Expenditure in their implementation. The level of expenditure required on these projects is currently unknown. Projects currently under development include: a Diabetes Configuration Project, a District Nursing Integration Project, Implementation of an out of hours Teleradiology service, Urology sub Regional services and Radiology demand & capacity planning. DRAFT LONG TERM INVESTMENT PLAN, Page 84

85 12 Costs and Affordability 12.1 Current Financial Position MidCentral DHB finished the financial year to 30 June 2016 with an operating deficit of $2.3 million and with financial assets (cash equivalents and deposits) of $41.4 million net of Trust funds. Recent financial performance and financial strength can be summarised as follows: Figure 38: Financial History Trend Summary Year ended 30 June $m Revenue Surplus/-Deficit Capital Investment Less Depreciation Net Investment over Depreciation Fixed and Intangible Assets - cost Accumulated depreciation Net book value Financial Assets Equity The recent trend in performance is indicative of the increasing pressure on hospital based services which constrains MidCentral DHB s capacity to undertake the essential investment to redress infrastructure deficiencies Financing our investment plan The limiting factor to the investment is the ability to maintain a positive operating result after taking into account the additional operating expenses associated with required investments. Unless the assets invested in are able to secure returns on investment in excess of the cost of capital, or have substantive strategic importance despite lower returns being achievable, our prioritisation process will eliminate them. Increasing demographic demand trends and input cost pressures will further exacerbate this issue. The cash position at the end of 2015/16 was $41 million on deposit and the Annual Plan projects modest surplus forecast for the years to 2019/20. However, the sustainability of that will be influenced by the achievable funding track relative to the cost pressures on the DHB. The annual depreciation at the end of 2015/16 was $14.6 million with a projected $17.2 million in 2016/17. This, together with surpluses generated, will limit the internal funding on investment. This forms a base for the depreciation estimates and internal funding estimates, updated by the impact of new investments. DRAFT LONG TERM INVESTMENT PLAN, Page 85

86 The depreciation funding available is projected to rise from $17.2 million in 2016/17 to $29.8 million in 2025/26. Funding from sale of DHB assets is not envisaged to be material over the next decade. Scenario analysis shows there is a high degree of short term pressure on Operating Expenditure, limiting our ability to generate operating surpluses and consequently our ability to self fund significant investment Financial Assumptions and Analysis For the purpose of LTIP funding projections, Treasury advised a set of funding assumptions to test the current fiscal and economic conditions as alternate scenarios to that of the Capital Investment Committee guidance, which indicated a mid-point (4.5 percent) revenue growth per annum from 2020/21 onwards. For the purpose of LTIP funding assumptions, overall DHB funding increases will be assumed at $340 million in each of the next three years, in line with the 2016/17 DHB funding signal. Thereafter the mid-point scenario posited (at a 3.50 percent increase) ranges from $460 million in 2020/21 to $566 million in 2026/27 for all DHBs. For all scenarios we have adopted base assumptions in respective cost and volume impacts as follows: Figure 39: Modelling Assumptions Modelling Assumptions for increases in key variables: Other revenue 2.00% FTE growth 1.25% MECA increases 2.00% Other cost growth 1.50% Cost inflation 2.00% Outside providers 2.75% Capital charge 6.00% Working capital increase 1.50% Capital charge top slice funding 2 yrs Minimum Cash Balance $5m We have also assumed that all additional capital will be by way of equity injection and supported by short term top slice funding to offset the challenge of capital changes following equity injections. While these funding assumptions do not represent an official signal of future DHB funding, the three funding increase scenarios enable DHBs to test the affordability of the LTIP percent p.a. is the low growth scenario and shows funding increases that are in line with overall DHB funding increases over the past three years (2013/ /16) percent p.a. is the high growth scenario and was chosen based on a 1.5 percent increment from the low growth scenario. These increases may be unsustainable given the current Government s fiscal strategy. 3.5 percent p.a. is the mid-point scenario within the 1.5 percent band between low and high growth paths. The following table presents these scenarios for MidCentral DHB. DRAFT LONG TERM INVESTMENT PLAN, Page 86

87 Figure 40: Increases to MidCentral DHB appropriations, by scenario (as at 12/07/2016) The capital investment requirement identified in this plan totals $409m over ten years, with options to be explored in respect of some items. To fund this we have cash and equivalents at June 2016 of $47m and project the benefit of depreciation to be $241m. The balance will need to be derived from operating surpluses and from equity injections. The key aspects of cost that influence the overall financial outcome are the potential rates of increase in healthcare demand from an ageing population, coupled with potential increases in MECAs. When the burden of additional capital charge is added to that there are few degrees of choice available to execute long term strategy. Figure 3: Summary of total investment and funding over the ten year forecast period $m Low Medium High Investment Less: Depreciation Surplus (22.7) Existing Cash Applied New Equity Required Residual Cash available at year Providing that our underlying assumptions about operating costs and increases hold, then these funding track scenarios would broadly lead to assessment on the sustainability as follows: Low Scenario The level of capital injection required and the burden of capital cost in the medium to longer term, coupled with a funding track below the aggregate demand and unit cost growth, would place the DHB under extreme financial pressure and compromise our ability to execute our strategy to achieve necessary changes in preventative and other community based care. That funding track would not support a viable service longer term and significant compromise to the robustness of the Hospital Campus would be required. Medium Scenario Operating revenue will be insufficient to support operating requirements and the DHB will need to focus on cost cutting at the expense of health delivery. Significant tension will exist between short/medium term operations and the achievement of longer term objectives. High Scenario The near term will remain under financial pressure however in the later years of the forecast period funding would become available to pursue strategy for health and wellness in our community while achieving a viable asset base in secondary services. There is potential for capacity to explore options in the later years. The detail of these projections is set out in Appendix DRAFT LONG TERM INVESTMENT PLAN, Page 87

88 13 Risks, Constraints, Dependencies and Assumptions MidCentral DHB has risk management methodologies embedded through the levels of the organisation, with robust processes for operational risk and incident analysis and reporting and with board level strategic risk review and enterprise risk management. The governance structures outlined in section support the effective management of risk. The Risk Management Policy and supporting procedural framework are consistent with the approach of ISO Identified risks are assessed for impact and consequences and evaluated within the accountability framework which appears in Appendix Within the context of this Long Term Investment Plan there are also identifiable high level risks reflecting the strategic thinking that has underpinned formulation of our strategic direction: Figure 41: Table of Strategic Risks Strategic risks Item Description & Risk Category Inherent Risk Patient Safety Patient health and experience Critical deteriorates because clinical needs are not identified, or quality services not delivered or 25 service levels are not adequately available or funded. Risk Mitigations Care Capacity & Demand programme. Patient safety as an integral component of culture. Supported by a number of operational controls. Ensuring compliance with quality standards. Financial Sustainability Community health needs and models of care Health and Safety for staff, contractors and volunteers Culture, accountabilities and escalation Inability to absorb cost growth within forecast funding path. Inability to fund future capital requirements. Future models of care are not aligned with the health needs of the community. Participants in service delivery are exposed to avoidable unsafe situations that compromise their health in some way. Organisation culture or subcultures undermine the achievement of strategic goals. Critical DRAFT LONG TERM INVESTMENT PLAN, Page Critical 20 Critical 20 Critical Prudent financial management. Quality information to inform budgeting, planning and forecasting. Capital Structure. Contract Management. Procurement Process. New processes for developing models of care are more people centred. Needs assessments regularly undertaken and models of care adjusted accordingly. Consumer and community representation in model of care development. A safety culture. Internal Policies. Programmes. Partnerships. Compliance Advisory Group. Organisational Development Plan develops appropriate culture. 15 Workforce pressures Capacity or skills mix of the Critical Workforce planning and

89 Capacity to support innovation Information Sharing, Privacy and Security Relationships/Partnering Infrastructure and Facilities Crisis management workforce not aligned with the requirements for efficient future delivery. Energy and focus is not available to create and support innovations to improve future organisational outcomes. Increased integration and future models of care increase the risks from exchange and protection of information. Integration with communities, NGO s, other Government agencies and others influencing health outcomes are not effective in improving health in our community. Inability to provide required care due to failure or inadequacy of premises or essential services. We are not adequately prepared to respond to a significantly disruptive or catastrophic event when needed. 15 Critical 16 Major 15 Major 15 Major 15 Major 5 alignment strategy. Innovation encouraged through specific programmes. Staff are rewarded for innovative ideas. Relevant information policies. Auditing. Network penetration testing. ICT Governance Group. Health Charter. Manawhenua Hauora partnership. Integrated approach to developing locality plans, portfolio plans and models of care. Development of Campus Strategy to ensure fit for purpose facilities into future. Seismic upgrading. Strategic Business Continuity Policy & Supporting Plans. Incident Management Structure established, trained and tested. Risks of not investing: Failure to invest in health and wellbeing in the community setting results in deteriorating health outcomes for our population and increasing demand for secondary intervention in chronic and preventable conditions; Failure to invest in capital for our hospital based services will result in suboptimal service provision. It would inhibit our ability to provide resilient and responsive services and would result in avoidable service failure and inability to perform essential functions under stress conditions; and Investment occurs in ad hoc manner in response to critical issues. It is reactive, not necessarily aligned to the DHB s strategy and is done to rectify current issues rather than to meet future needs. DRAFT LONG TERM INVESTMENT PLAN, Page 89

90 Risk appetite The development of enterprise risk management within MidCentral DHB is currently identifying Board risk appetite across the spectrum of strategic risks. That will be followed by targeted strategies to move residual risk levels to agreed tolerable levels where necessary. The table below outlines key risks, constraints, dependencies and assumptions associated with the main investment categories. Further detail is being developed in respect to each of the major projects within the categories, as their business cases are being developed. Figure 42: Key risks, constraints, dependencies and assumptions associated with the main investment categories Investment area Risks Constraints Dependencies Key Assumptions ICT - integrate fully across community based /community and secondary/tertiary providers, interoperate with other national data repositories and implement shared care records in accordance with the Phase 2 vision of the National Health IT Plan. 1. Technological development moves quickly these may overtake our ability to plan and implement. ICT. 2. Project management is high risk, inability to attract and retain the required talent and run effective project management disciplines, inability to achieve gains available through use of ICT through poor change management or otherwise Our ability to attract train and retain staff with the required expertise. Organisational ability to cope with the change required. The pace that the regional DHBs and other partners can move at may be a constraint. Supplier ability to meet our deadlines and affordability requirements. Other regional DHBs collaborate and participate. Consumer, clinician and other staff buy in to and leadership of the use of ICT based new ways of working Lead by National and Regional ICT plans. Based on current best practice. Indicative Business Case - Buildings and Plant create an acute services Hot Floor at Palmerston North Hospital. Demand varies from forecasts. Best practice changes overtaking service design. Scoped solutions not optimised. Quality failures in design and build (eg steel quality). Quality of Project Management. Ability to derive value from investments, physical space available, decanting requirements, ability to maintain services during build Business case approval, regional DHBs and local IFHCs collaboration. Based on regional service design and assuming IFHC development in place. Other Buildings and Plant optimise the rest of P North Hospital site. Emerging and rapidly changing needs compromise site utilisation with short term fixes. Time delays may impede service delivery and development. Organisational ability to cope with multiple projects. Ability to derive returns to service capital funding. Clearly defined future models of care and service planning. Regional and IFHC service design, demand management in Community based Health Care. Seismic building design requirements need to be met. DRAFT LONG TERM INVESTMENT PLAN, Page 90

91 Investment area Risks Constraints Dependencies Key Assumptions Clinical Equipment mainly business as usual replacement as scheduled but with some new business cases. Achieving the balance between over and under investment at the right time in technology evolution. Size of clinical services constrains ability to support some high cost equipment. Regional and sub regional planning to ensure service viability and ability to service capital cost of required equipment Expert input into the clinical equipment maintenance and replacement programme IFHC development - Continuing to invest in IFHC development, including transitioning services from hospital to community settings particularly to support long term (chronic) conditions management and prevent acute demand. Potential to destabilise specialist services services fail to integrate at IFHC GP team fails to engage effectively or change their model of care as required. Government capitation funding policy makes alignment of incentives difficult. Physical space, time and equipment constraints for DHB specialist staff, IFHC ability to manage change in the midst of the busyness of business as usual. IFHC Boards and General Practice Teams and DHB clinical staff all collaborate. Achievement of the quadruple aim. High Trust agreements can support aligning incentives. Government policy of closer to home will deliver better results, IFHC will be able to recruit and retain the required GPT staff which will expand to include new disciplines in the GPT. ICT & Indicative Business Case this work will have an operational cost associated with it. Need for increased operational expenditure and depreciation associated with major capital programmes. Funding limited to funding envelope and Vote Health, and has to be offset by competing demands eg demand growth from demographic pressure. Business improvement programme and ongoing success in managing acute demand. Investment will provide efficiencies to offset additional costs. Funding will increase consistent with demographic changes. Ongoing value for money/living within our means across all services. DRAFT LONG TERM INVESTMENT PLAN, Page 91

92 14 Appendices 14.1 Mapping of MidCentral DHB s LTIP against Treasury's assessment criteria Criterion Requirement and basis for assessment Future focus The LTIP covers a period of at least 10 financial years Strategic Alignment Specificity (over desired results) Durability, reliability Clarity over the implications for others Be integrated with, and provide the investment context for, agency short to medium term plans Provide a sound basis for regular investment performance reporting and for an agency's annual report to Parliament Provide a reliable focus for the investment decisions and activities of the agency or sector Enable integrated decision making and co-ordination of the resources of the agency and other parts of the State services How this is addressed in this LTIP The LTIP covers the period and will be renewed on a minimum 3 yearly basis. Because MidCentral DHB is at the start of the LTIP Planning process the first update will be next year. The starting point has been the refreshed NZ Health Strategy and Roadmap of Actions which determined the direction the recently updated MidCentral DHB Strategy. Outputs of the Regional Clinical Services plans and ICT plans have been incorporated as appropriate although further work is required to further refine the alignment with the MidCentral DHB investment portfolio. Investment requirements have been assessed in respect of strategic imperatives at a local, regional and national level. Prioritisation of projects will be further reviewed and timing of projects changed accordingly. The Whanganui/MidCentral DHB Health Needs assessment was completed in 2015 and has informed service planning. Whilst the investments identified in MidCentral DHB s LTIP are still at early stages of planning, reporting on the desired impacts from the projects undertaken is an imperative. Detailed measurement and reporting frameworks will be further developed through the individual business case processes. All major investments under development are following the Better Business Case approach and Capital Investment Committee process. Whilst there is currently a relative degree of uncertainty in this LTIP due to concurrent development of other planning documents and the early stage of investment business case development, the LTIP outlines a sound investment decision process in line with Treasury and MOH expectations. Future iterations of the LTIP will have greater clarity on investment needs and incorporate refinements to the process. The LTIP outlines regional planning and governance processes which the plan and attendant business cases will be subjected to. Alignment with regional and national strategy is set out in Sections and Stronger regional and national alignment is planned as the LTIP processes are developed further. All major investment projects require early involvement of the regional and national stakeholders. DRAFT LONG TERM INVESTMENT PLAN, Page 92

93 Visibility, Value Affordability Procurement choices Asset (vs. service performance) Capital efficiency Reveal sufficient details of proposed investments and disinvestments, as reported to the Treasury in the government project portfolio dataset, to enable Investment Ministers and the corporate centre to fulfil their respective roles Reveal the impact of investment intentions on the agency's forecast financial statements, taking account of expected costs and funding sources such as asset disposals and the use of baseline and depreciation funding over the planning period Consider what capabilities will involve third party suppliers and provides an overview of how these supplier relationships will be managed Reveal the expected impact of investment intentions on future asset performance, in terms of meeting changes in demand, enabling level of service improvements, and renewing assets Reveal assets that are expected to be surplus to requirements, and whether such assets will be subject to formal Crown disposal processes. High level summaries of each of the key investment areas are set out in Sections 9 to 11. The detailed list of capital projects in the investment portfolio for the ten year LTIP is provided in Appendix It is noted that a significant part of the investments in the portfolio are about replacing, maintaining, upgrading and refurbishing existing assets to enable services to continue to be provided. The balance of investment is to achieve better service integration and configuration enabled by physical facilities and technology investments. Financial statements are provided in Section 12. This approach has been informed by both top-down and bottom up planning and the investment logic followed is illustrated in Appendix Individual business cases will detail how investments will achieve returns on capital deployed. Investments will be procured in accordance with the guidelines in MidCentral DHB s Procurement Policy. Options for public private partnerships or longer-term relationships with preferred investors or suppliers will be considered within the business cases put forward for each of the investment proposals. MidCentral DHB will also be exploring opportunities for sale, leaseback and service maintenance of assets where it makes sense as driven by technology or risk management factors. The main drivers for asset performance are the future demand requirements set out in Section Some scenario analysis from a service provision perspective has been considered in the CSP recently completed and partially incorporated as appropriate in this LTIP. Due to timing for LTIP completion, this has not yet been fully translated to the investment portfolio perspective. This will be considered in future LTIP iterations. No surplus assets are currently identified at MidCentral DHB and the investments set out in this LTIP are not expected to create any surplus assets. Disposals (should any be required within the ten year planning horizon), would be undertaken in line with MidCentral DHB s Capital Disposal and Salvage of Assets Policy and in accordance with the DHBs Operating Framework. DRAFT LONG TERM INVESTMENT PLAN, Page 93

94 14.2 Detail of Scenario Projections Projections based on tested appropriation scenarios: DRAFT LONG TERM INVESTMENT PLAN, Page 94

95 DRAFT LONG TERM INVESTMENT PLAN, Page 95

96 14.3 Palmerston North Hospital Site Map DRAFT LONG TERM INVESTMENT PLAN, Page 96

97 DRAFT LONG TERM INVESTMENT PLAN, Page 97

98 14.4 Regional Governance Structures The Central Region DHBs manage the delivery of the priorities in the RSP through regional programmes of work and clinical networks. Each of the 12 regional programmes has a steering group, which is clinically led and has representation from the appropriate functional disciplines in order to provide advice to the business owner and programme manager. The Central Region DHBs regional governance framework is shown below 6. Please note that this structure is being reviewed. Central Region leadership frameworks Regional Governance Group This group comprises the Chairs of the six Central Region DHBs and an independent Chair. The key accountabilities are to: approve the regional strategy for submission to individual DHBs; appoint the directors of TAS; monitor progress and performance against Regional Plans; drive the regional collaboration agenda; act as an escalation point for matters of strategic importance. Te Whiti Ki Te Uru (Central Region Māori Relationship Board) This regional forum comprises the six Chairs of the Māori Relationship Boards in the Central Region DHBs. A key objective for this Board is to provide advice to the Regional Governance Group on regional priorities for Māori health and provide effective iwi/māori health leadership. Central Region CEOs This group comprises the six CEOs of the Central Region DHBs. A key objective of this group is to recommend the regional strategy to the Regional Governance Group and DHBs. 6 This Figure appears on pg 38, Central Region Regional Service Plan 2016/17 DRAFT LONG TERM INVESTMENT PLAN, Page 98

99 Regional Executive Committee (REC) (currently under review) This group is the overarching executive and clinical leadership committee for the region, reporting to the regional CEOs. It comprises senior management and clinical representatives, including primary care, and consumer representation from across the region. Its objective is to ensure that the region takes a coordinated approach to planning and delivery. Regional Capital Committee A Regional Capital Committee comprises the DHB CEOs, Chief Finance Officers and a Clinical Director to represent the various key stakeholders and the different professional perspectives that they bring to such decision making. It allows DHBs to explore opportunities and assess priorities for regional capital investment. Some of the Regional Capital Committee s key accountabilities are to: develop and maintain a 10-year regional Capital Plan; engage with the Ministry and the Capital Investment Committee early in the capital planning process; provide regional scrutiny for individual business cases costing over $500,000; ensure that regional benefits have been fully explored; reduce fragmentation and unnecessary duplication. Regional ICT Governance A Health Informatics Strategic Advisory Group is being established and will provide oversight and governance across regional ICT initiatives. The group will be chaired by the General Manager Health Informatics at TAS and include multi-disciplinary representatives across the health care spectrum. The role of the group will be to provide leadership and advice on ICT issues to the region s CEOs. Central Region Quality and Safety Alliance In addition to REC, this group has been established to provide strong clinical leadership for quality and safety across the continuum of care levels. Members include the Chief Medical Officer, Director of Nursing, the Director of Allied Health, Director of Midwifery and consumer, Māori, Pacific, primary care and quality managers representatives. DRAFT LONG TERM INVESTMENT PLAN, Page 99

100 14.5 Strategic Road Map Objectives and Approaches for achieving equity of outcomes across communities: Objectives and Approaches for partnering with people and whānau to support health and wellbeing: DRAFT LONG TERM INVESTMENT PLAN, Page 100

101 Objectives and Approaches for connecting and transforming community based, community and specialist care: Objectives and Approaches for achieving quality and excellence by design: DRAFT LONG TERM INVESTMENT PLAN, Page 101

102 14.6 Summary of Community Based Service Providers throughout the district Manawatu District Feilding IFHC Feilding IFHC was officially opened in February It includes a general practice team, midwifery, community radiology, and community pharmacy. It also includes MidCentral Health and Central PHO clinical teams such as school dental, mental health, district nursing. It has the capacity to be a base for the extension of outpatient and day surgery services into the Manawatu area and has aspirations to include a phlebotomy service. The general practice team operating from the Centre is Feilding Healthcare Partners. It was formed from the amalgamation of the four pre-existing general practices. Feilding Healthcare Partners began with a register of 17,000 in 2015, which increased to 19,000 in September It is intended that the register be further increased through the addition of more doctor, nursing and administration resources. Feilding IFHC was developed by the Manawatu Community Trust. It is a $10 million privately-funded, purpose built facility constructed on DHB owned land (the former Clevely Health Centre site). Horowhenua District Feilding IFHC Horowhenua Health Centre was developed by MidCentral DHB in 2007 to replace Horowhenua Hospital. The Health Centre comprises a four bed maternity suite, 24 bed respite/step down/rural inpatient beds, an extensive range of visiting specialist outpatient services, and Horowhenua Community Practice (8,500 enrolled patients). A community pharmacy, community radiology services, phlebotomy and the Horowhenua General Practice after hour s services also operate from this facility. It is also the base for Central PHO s service teams in the Horowhenua and for MidCentral Health s clinical teams such as District Nursing and Community Mental Health. Horowhenua Community Practice is owned by Central PHO. Traditionally general practice teams in the Horowhenua were very vulnerable, with regular practice closures. Central PHO took an ownership role with the intention of stabilising and rebuilding general practice in the Horowhenua. This has been very successful. Horowhenua Community Practice (HCP) operates within the Horowhenua Health Centre. The current configuration of the Practice rooms is sub optimal from a clinical flow perspective and will limit the potential for growth. There is a need for some capital spend to get the Practice location in the Health Centre best positioned for the future, recovery of which would be built into lease rates. DRAFT LONG TERM INVESTMENT PLAN, Page 102

103 Te Waiora Community Health Centre was opened in July It is a partnership between Te Rūnanga o Raukawa and Central PHO. This building cost approximately $3m and was semi philanthropically funded by local business people Mr and Mrs Ellison, this being the key to enabling the project to proceed. The project combined 3 small pre-existing practices and has 5,166 people enrolled as at July Te Waiora Community Health Centre Other community based services in the Horowhenua include four smaller practices based in Levin with a total enrolled population of 12,313. There will be some level of need to develop or support the development of facilities that meet the needs of this patient grouping into the future. The existing facilities that house the three remaining practices are currently fit for purpose, but are in general too small to absorb many more patients or are in need of refurbishment to enable them to do so. Some DHB/PHO support may be required to facilitate the optimum solution to serve the future of Community based Health Care in Levin Ōtaki (part of Kapiti Coast District) Ōtaki Medical Centre is a Very Low Cost Access (VLCA) Practice based in Ōtaki township. It services 6,430 enrolled patients. Whilst the building housing the Medical Centre itself is moderately new and well equipped, it will be space constrained for future development. The existing premises operate the General Practice and house Central PHO clinical staff who run clinics and home visits from the site. The Ōtaki Pharmacy is just across the road. There may need to be some level of support or facilitation, potentially with local Raukawa Iwi who own the Marae next door, to enable a fully-fledged IFHC to develop for Ōtaki. Palmerston North City The 89,835 people enrolled under Central PHO in Palmerston North City are served by: Kauri Health Care IFHC 18,593 enrolled Radius the Palms IFHC 16,974 enrolled 21 smaller Practices 54,268 enrolled Most of the 21 smaller Palmerston North practices will probably require some level of support and facilitation to transition from their current GP owner operators to the type of Community based Health Care business likely to be able to meet the needs of the enrolled population into the future. In general these businesses are operating from small cottage settings with one or two GPs and a small GP team. Many of these GPs are likely to retire or commence their retirement transitions over the next decade. MidCentral DHB/Central PHO may be able to extend their working life by facilitating and supporting this transition. DRAFT LONG TERM INVESTMENT PLAN, Page 103

104 Kauri IFHC, Palmerston North The Palms Medical Centre, Palmerston North Kauri IFHC in Featherston Street, opening August 2016 with a privately funded investment value of over $10m. Likely to serve over 20,000 enrolled people and enable localisation of outpatient and day surgery services in the future. The Palms Medical Centre was developed by the late Dr Ralph Saxe with private sector funding in The facility houses a wide range of health services, including the General Practice, a Community Pharmacy and Radiology service, physiotherapy, and some secondary outpatient clinics. The Radius at the Palms Practice services about 17,000 enrolled people. The community pharmacy is closely linked to the practice. Both the Kauri and Radius facilities provide significant scope for bundling health and social services into a community IFHC setting. Tararua District The Tararua population is serviced by the Tararua Health Group (THG) which has 14,331 enrolled patients and Dr Short s Dannevirke surgery with 785 enrolled. Approximately 2,000 Tararua residents are enrolled elsewhere and about 400 of the Tararua enrolled are domiciled outside the Tararua District. THG operates the Dannevirke Community Hospital in collaboration with MidCentral DHB - services include: eight inpatient beds; three maternity beds (a midwife is available and always on call.); X-ray and ultrasound services; Physiotherapy services and GP after hours services. Within the hospital, you are looked after by your own GP while you are an inpatient. THG operates another Practice site in Pahiatua and some outreach clinics. The Practice buildings in both Dannevirke and Pahiatua have been recently refurbished and are currently a good fit with future needs with minor capital investment only required. Dannevirke Community Hospital DRAFT LONG TERM INVESTMENT PLAN, Page 104

105 14.7 Investment Logic Map The investment logic map is below: DRAFT LONG TERM INVESTMENT PLAN, Page 105

106 14.8 Benefits Map Transforming the health system across Mid Central DHB DRAFT LONG TERM INVESTMENT PLAN, Page 106

107 Service Demands (Current and Future Forecasts) Please note: This set of graphs is based on speciality areas, not ward admissions. Elderly D01 Geriatric Admissions Note: STAR 3 Rehab ward incorporated into STAR2 in 2009 increasing bed capacity from 25 to of these still retained for under 65 years of age D41 Physical Disability admissions D01 Geriatric Admissions Actual Forecast Population Trend D21 Psychogeriatric Admissions Population trend much higher than forecast could imply unmet demand as capacity constraint of 15 beds (and longer length of stay). Also possibly change of clinical decision to admit these patients? STAR1 ward now under Mental Health Service rather than Elder Health. 250 D21 Psychogeriatric Admissions Actual Forecast Population Trend 0 DRAFT LONG TERM INVESTMENT PLAN, Page 107

108 Emergency Presentations ED presentations have increased by 8 percent in financial year compared to previous financial year. The prior 2 years had shown no increase. Note: EDOA opened in ED Presentations Actual Forecast Population Trend Admissions ED Admissions Actual Forecast Population Trend DRAFT LONG TERM INVESTMENT PLAN, Page 108

109 Medical Admissions MAPU opened end of Length of Stay reduction project from December 2014 onwards led to significant reduction in Medical average length of stay Medical Total Admissions Actual Forecast Population Trend 0 Beds Note: Medical line ALOS also includes HITH discharges. This can have the effect of increasing ALOS by approximately 0.1 day on average. 140 Total Medical Line Beds Actual Forecast Beds Population Trend Beds Beddays adjusted for ALOS change -0.3 days 20 0 DRAFT LONG TERM INVESTMENT PLAN, Page 109

110 Medical Age 65 Plus Beds 120 Medical Line Beds for Age 65Plus Actual Forecast Beds Population Trend Beds 20 0 Medical Age Under 65 Beds 35 Medical Line Beds for Age Under Actual Forecast Beds Population Trend Beds 5 0 DRAFT LONG TERM INVESTMENT PLAN, Page 110

111 Surgical Admissions For surgical sub specialties S00, S20, S24, S25, S40, S45 and S70 (Acute, Arranged and Elective). Elective targets generally increase by 2 to 3 percent per annum. Note: not all acute admissions require theatre operations therefore separate calculations are needed to determine operating theatre capacity requirements into the future Surgical Total Admissions Actual Forecast Population Trend Health Specialty Code S00 S15 S20 S24 S25 S30 S40 S45 S70 Health Specialty General Surgical Services Cardiothoracic Surgery Dental/Maxillo-Facial Surgery Maxillo-Facial Surgery Ear, Nose and Throat Surgical Services Gynaecology Services Ophthalmology Orthopaedic Services Urology Services DRAFT LONG TERM INVESTMENT PLAN, Page 111

112 S30 Gynaecology Admissions 1800 S30 Gynaecology Total Admissions Actual Forecast Population Trend Caesarean Admissions 700 Caesarean Total Admissions Actual Forecast Population Trend DRAFT LONG TERM INVESTMENT PLAN, Page 112

113 Maternity P60 and P70 Maternity Admissions 3500 P60 and P70 Maternity Admissions Actual Forecast Population Trend P61 and P71 Well New-born Admissions 3500 P61 and P71 Well Newborn Admissions Actual Forecast Population Trend DRAFT LONG TERM INVESTMENT PLAN, Page 113

114 Regional Cancer Treatment Service Large IDF component from other DHBs using MidCentral DHB Regional Service. Population demographics from other areas not included here. M30 and M50 Admissions 3000 RCTS Total Admissions Actual Forecast Population Trend 0 Mental Health Y03 and Y04 Admissions 900 Mental Health Total Admissions Actual Forecast Population Trend DRAFT LONG TERM INVESTMENT PLAN, Page 114

115 Paediatric Please Note: these figures are based on health speciality and do not include young people under surgical care. M55 Admissions 3500 M55 Paediatric Health Total Admissions Actual Forecast Population Trend P42 Neonatal Admissions P42 Neonatal Admissions Actual Forecast Population Trend DRAFT LONG TERM INVESTMENT PLAN, Page 115

116 Rehab Originally separate STAR 3 ward with 12 beds until this was reduced to 8 beds and then incorporated into STAR 2 ward in D41 Admissions D41 Physical Disability Admissions Actual Forecast Population Trend ICU ICU Admissions and Transfers In 900 ICU Admissions and Transfers In Actual Forecast Population Trend Average Length of Stay in ICU is 4.25 days. Current bed requirement is 6 increasing to 9 by Note: Currently 2 beds available for HDU patients plus 4 resourced ICU. The inclusion of more HDU type patients in recent years will be included in source data and therefore contribute to predicted increase in ICU attendances. DRAFT LONG TERM INVESTMENT PLAN, Page 116

117 Forecast Projection Assumptions Excludes Extraordinary Events Does not take into account any major unforeseen events occurring eg natural disaster, major flu outbreaks OR ward closures due to infection outbreaks, refurbishment etc. Future advancements in medical technology, changes in clinical management practices and/or community based health initiatives which may reduce hospital admissions cannot be accounted for in these forecasts. Generally business as usual volumes. Capacity Constraints Current capacity constraints may affect forecasts based on historical data potentially hiding some unmet demand for services. Calculations for Palmerston North Hospital Calculations are for Palmerston North Hospital (Facility 4311). DRAFT LONG TERM INVESTMENT PLAN, Page 117

118 14.10 Summary of Major Buildings and Facilities Palmerston North Hospital The main Clinical services and Wards are contained in buildings described herein: A Block - Front Entrance and ED B Block - Clinical Services and Wards C Block - Children and Women s D Block - Elder Health and Mental Health A Block No. Levels: 2 plus part basement and roof top plant room Area: 5,190 m² (approx) Built/Age: 2001 Structure/ Walls: Reinforced concrete column and beam. Extensive glazing Roof: Metal Floors: Reinforced concrete Seismic Rating: Building assessed under both IL4 (50-55 percent NBS) and IL3 (75-80 percent NBS) criteria due to mixed nature of services performed therein Principal Occupancy/Use: Ground: Main Entrance, Emergency Department, Ambulance Entrance, Cafe, Travel Office, Main reception, Private Pharmacy, Orderly and Security offices. Level 1: Gastro and Renal departments, Doctors rooms, Clinical Library and Lecture Room. Utility Plant and Services: All key services in the A Block are managed, monitored and alarmed through a BMS (Building Management System) B Block No. Levels: 3 podium section (including basement) 4 two tower blocks Area: 30,083 m² (approx) Built/Age: 1976 Structure/ Walls: Reinforced concrete frame and walls Roof: Bitumen membrane over concrete metal over plant rooms Floors: Reinforced concrete Other Features: The building has two tower blocks, with a podium between these tower blocks. There are a number of seismic joints between various sections of this building. Seismic Rating: Building assessed under both IL4 (40-50 percent NBS) and IL3 (60-75 percent NBS) criteria due to mixed nature of services performed therein Principal Occupancy/Use: Basement: Extensive plant rooms and Medical Records (storage) Ground: Ambulatory Care and Clinics, Radiology, Nuclear Medicine Level 1: Theatres (7), Sterile Supply Unit, Medlab Towers: Wards all levels, ICU,CCU, HDU Roof: Plant rooms DRAFT LONG TERM INVESTMENT PLAN, Page 118

119 Utility Plant and Services: All key services in the B Block are managed, monitored and alarmed through a BMS (Building Management System). Services are distributed throughout the B Block via the basement/tunnels, risers and ceiling spaces. B Block has several, large plant room areas in its basement (supplying key services to most of the main hospital block) C Block No. Levels: 4 (including basement) Area: 5,101 m² (approx) Built/Age: 2000 Structure/ Walls: Reinforced concrete frame - concrete and Lucabond panel walls Roof: Metal Floors: Reinforced concrete Seismic Rating: IL3 >67 percent NBS Principal Occupancy/Use: Basement (small) Air handling plant Ground Children s Ward, Children s Clinic and Women s Clinic Upper Levels Women s Health, Birthing, Neonatal. Utility Plant Services All key services in the C Block are managed, monitored and alarmed through a BMS (Building Management System) D Block No. Levels: 1 Area: 4,153 m² (approx) Built/Age: 2001 Structure/ Walls: Timber frame cement panel walls Roof: Metal Floors: Reinforced concrete Seismic Rating: IL3 81 percent NBS Principal Occupancy/Use: Mental Health, Geriatric, Psycho Geriatric and Rehabilitation. Utility Plant Services All key services in the D Block are managed, monitored and alarmed through a BMS (Building Management System) Other Palmerston North Hospital Buildings and Facilities Aside from the major clinical buildings described as Blocks A-D MidCentral DHB owns a number of other buildings principally (but not exclusively) on the Palmerston North Hospital site. These include a wide range of buildings in terms of age (1930s-2010), construction, size and use DRAFT LONG TERM INVESTMENT PLAN, Page 119

120 Laundry Rehabilitation and Gymnasium Kitchen Hospital Administration Linear Accelerator Towers IT Building Boiler House Community Health Buildings Education Centre Link Block Blood Donors Building Ex-Ambulance Station Northside Building Dangerous Goods Store Facilities Maintenance Building Chapel Vehicle Workshop Clinical Records Building Board Offices Building Medical Museum Transit Flats Transitory Care Building Te Whare Rapuroa Pullar Cottage Staff Housing Nursing Development Service Tunnels Boiler House/Kitchen Infrastructural Assets General Key services/utilities are monitored/managed/alarmed through a Building Management System (BMS) at Palmerston North Hospital. A network of tunnels run beneath Blocks A, B and C, with a tunnel also connecting this network to the boiler house. A tunnel connection also exists between the boiler house and kitchen. Several key/core services are reticulated through these tunnels including electricity, steam, medical gases and vacuum, natural gas, hot water and cold water Horowhenua Health Centre No. Levels: 1 (plus small mezz plant room) Area: 5,002 m² (approx) Built/Age: 2007 Structure/ Walls: Main Building Timber/steel frame and timber/brick/fibre cement panel walls Roof: Metal Floors: Reinforced concrete Seismic Rating: IL3 >67 percent NBS Principal Occupancy/Use: 28 Inpatient and Maternity Wards Consulting Rooms Dental Clinic Physiotherapy General Practitioner Practices and PHO Blood Lab Radiology Commercial Pharmacy Café Offices Three stand-alone flats used for offices and storage DRAFT LONG TERM INVESTMENT PLAN, Page 120

121 14.11 Asset Condition Assessments (as required in Ministry of Health Guidelines) Condition Property Clinical Very Good 53.00% 94.00% Good 20.00% 3.00% Moderate 17.00% 1.00% Poor 2.00% 1.00% Very Poor 8.00% 1.00% 100% 100% DRAFT LONG TERM INVESTMENT PLAN, Page 121

122 Building Age DRAFT LONG TERM INVESTMENT PLAN, Page 122

123 Condition of buildings DRAFT LONG TERM INVESTMENT PLAN, Page 123

124 Map of Seismic Performance DRAFT LONG TERM INVESTMENT PLAN, Page 124

125 Major Clinical Equipment Over $250k Clinical Asset Purchased Cost ($000s) NBV ($000s) Planned Replacement ($000s) Current Status Monaco Planning Workstation/System /17 1,200 Functioning nearing end of life CT Scanner /17 1,100 Functioning nearing end of life XSTRAHL Superfacial X-Ray / Functioning at required level Linear Accelerator (LA1) , /18 3,200 Functioning nearing end of life Linear Accelerator (LA3) , /20 3,200 Functioning at required level Linear Accelerator (LA4) , /19 3,200 Functioning at required level Linear Accelerator (LA5) ,975 1, /22 3,200 Functioning at required level Gamma Camera , /22 1,100 Functioning at required level Lumenis Holmium Laser / Functioning at required level Fluoroscopy Unit (rm 4) / Functioning nearing end of life Philips Optimus (Rm 3) / Functioning at required level Digital Subtraction Angiography (Rm5) , /22 1,500 Functioning at required level Digital Diagnostic Eleva (Rm6) / Functioning at required level Digital Diagnostic Eleva (Rm11) / Functioning at required level Digital Diagnostic Eleva (Rm12) / Functioning at required level Somaton CT Scanner , /22 1,250 Functioning at required level Digital Diagnost 4.1 (Rm2) / Functioning at required level Digital Diagnost 4.1 (Rm10) / Functioning at required level Mobile Breast Screening Van / Functioning at required level Dental Caravans (9) ,897 1, ,800 3 old ones planned replacement (one underway August 2016) National std ones to be replaced progressively from Total 23,701,540 8,813,834 DRAFT LONG TERM INVESTMENT PLAN, Page 125

126 Information and Communication Technology Application Virtual Server Farm This farm comprises 6 physical servers (hosts) containing a total of 537 GHz of CPU processing power and 2,304 gigabytes of RAM and supports 220 virtual servers. It was installed in There is no spare capacity at present as the farm is supporting the SQL server farm. Once the SQL farm is upgraded, capacity will be available to handle any immediate / short-term needs. There will be a requirement for additional capacity to support planned systems and incremental growth. SQL Server Farm The SQL server farm comprises 4 physical servers (hosts) containing a total of 537 GHz of CPU processing power and 512 gigabytes of RAM. This server farm is due for immediate replacement as is aged and at capacity. Expected capacity requirements for the short term is six physical servers. Storage Area Network (SAN) Current capacity is 110 terabytes on each side of the SAN, with ability to increase this to one petabyte either side. Network The local area network delivers data and wireless across the DHB, and is also progressively delivering voice-over-ip (VoIP) telephony. All cabling from wall outlets to network switches is progressively being upgraded to Cat 6 cabling at Palmerston North Hospital. The network comprises ~120 Cisco core, distribution and edge switches and are being installed over the next three years. The edge switches are housed in 45 communications cabinets which are being progressively refurbished. With the move to VoIP telephony, modern, fit-forpurpose communications cabinets are essential for consistent service delivery. By end of 2016, 20 of the new cabinets will be in place, and application will then be made for capex to complete the next tranche. Dual path fibre optic cabling in place across Palmerston North Hospital campus. The Horowhenua Health Centre has its own local area network which is linked to the IT centre in Palmerston North. Other outlying areas, such as Breastscreening, Pahiatua, Feilding, etc also have links to the IT centre. There are 430 wireless access points in place across Palmerston North Hospital campus. DRAFT LONG TERM INVESTMENT PLAN, Page 126

127 Infrastructure Environment In 2014/15, Information Systems environmental infrastructure was upgraded to replace ageing equipment and increase capacity. The upgrade comprised: A new Standby generator A new 5,000 litre diesel storage tank New air conditioning equipment Upgraded fire protection systems Under-floor seismic strengthening Electricity upgrade and new switchboard Wide Area Network MidCentral DHB is part of Connected Health - a national wide area network. A 200 megabit per second data circuit (which is the community based link) and a 100 megabit per second data circuit (secondary link) join MidCentral DHB to Connected Health. These were installed in August 2016 and are expected to meet current and future regional system requirements. There are two 100-megabit links which provides MidCentral DHB access to the internet. Capacity is adequate to meet current demands but it is expected that this will increase, eg nursing staff access to YouTube for training purposes. End User Computing The computers are used by DHB staff for clinical, clinical support and administrative purposes. Computers used by end users. They are predominantly, desktop computers but there is an increasing demand for mobile or thin client devices. MidCentral DHB currently has: 1565 desktop computers (majority on Windows 7, progressively moving to Windows 10) 209 laptops 19 tablets 22 thin clients 152 3G ipads in use with an additional 350 to come online as wireless is rolled out 64 3/4G iphones 400 other cell phones in use DRAFT LONG TERM INVESTMENT PLAN, Page 127

128 14.12 Stocktake of Other Current Assets (as required in Ministry of Health Guidelines) Bed numbers Department CRITICAL CARE Current beds / space (physical) Notes: Emergency Department 26 includes 5 in halls used in high demand ED Observation 5 excludes 3 recliner chairs Assessment Planning Unit (MAPU/ SAPU) Acute Assessment Unit ICU 6 ICU HDU HDU/CCU 6 CCU Surgical Services Theatre 7 Theatres not beds Procedure theatres Day stay surgery 5 Trans Care Short stay surgical beds 6 17 Surgical 76 CathLab includes 4 beds used in high demand only and additional staffing resource dependent Wards Inpatients Medical 78 Wards Gynae Obstetrics/ Delivery Suite 8 Deliv WSU Closed Paediatrics 22 Children s ward includes 8 beds used in high demand and additional staffing resource dependent Well newborn 24 maternity Unwell newborn/ Neonates 17 NNU includes 3 used in high demand Regional Cancer Treatment Service 18 W23 includes 2 used in high demand Mental Health 39 STAR 37 W21 + STAR1 STAR 2 24 in wd 21 and 15 in Star 1 - any additional beds used are not in official bed spaces includes 9 beds used in high demand and additional staffing resource dependent Theatres We have 7 Operating Theatres, 1-3 and 5-7 are Elective Theatres and Theatre 4 is the Acute Theatre MRI 1 MRI machine owned by a company who operates onsite. DRAFT LONG TERM INVESTMENT PLAN, Page 128

129 14.13 Utilisation Metrics (as required in Ministry of Health Guidelines) MRI Totals for last three years: , , ,885 Beds For last three years occupancy rates are as follows: 2015/ percent 2014/ percent 2013/ percent Theatres 9,908 operations took place in our 7 main theatres in 2015/2016 Financial Year. This is a rate of approximately 1400 per Theatre (Acute and Elective). Parking Paid Parking Scheme at Palmerston North Hospital 934 Staff parks 668 patient/visitor parks Infrastructure Utilities Electricity consumption (PNH and HHC) = 12m Kwh PA Gas Consumption (PNH and HHC) = 90,000 GJ PA Water Consumption (PNH and HHC) = 112,000m 3 PA DRAFT LONG TERM INVESTMENT PLAN, Page 129

130 14.14 Capital Landscape detail DRAFT LONG TERM INVESTMENT PLAN, Page 130

131 DRAFT LONG TERM INVESTMENT PLAN, Page 131

132 DRAFT LONG TERM INVESTMENT PLAN, Page 132

133 14.15 MidCentral DHB Risk Reporting and Accountability Framework BOARD Financial Risk & Audit Committee DRAFT LONG TERM INVESTMENT PLAN, Page 133