New Zealand’s Health System in 2007

1. New Zealand’s Health System in 2007 Progress over the past 14 years or change for the sake of change. A presentation by Jane Holden

2. Where we live.

3. Bay of Islands – Hole in the Rock

4. A Short Review of the Health Structure. Pre -1993 – Area Health Boards 1993 – Creation of CHE’s. SOE’s 1996- Creation of HHS’s ( influence by minor parties ) Development of waiting list management systems. 1999 – District Health Boards. – Multiple health strategies Primary Health Strategy launched. 2003 – Clarity on population health expectations, IDF national prices 2004 – Establishment of ESPI’s as key indicators supposedly linked to funding. 2006/7 – ESPI’s used as incentive for additional funding streams.

5. What was achieved with each change? • CHE’s – separated roles of the funder and the provider. Provided a strong focus on addressing health within business frameworks, focus on assets and dismal state of repair – asset management had clearly been ignored. For the first time hospitals were held to financial account with many running deficits. Focus on hospital services. • HHS’s – created the forerunner to DHB’s by extending the Hospital roles to include public and community health for all providers- strongly political – little operational difference – free GP health of 0-6 year olds.

6. What was achieved with each change? • District Health Boards – new Labour Government • Maintained focus on asset management and reduction of deficits and, • Introduced multiple strategies – Primary health, Maori health, Health of Older people. • Re-linking funder and provider • Introducing focus on population health as DHB primary goal. • Focus on removing waiting lists by re-emphasis on ESPI compliance.

7. 2007 • 21 District Health Boards • ESPI’s used as incentive funding and withdrawn for specific services if they fail to meet the KPI’s. • DHB’s responsible for entire district funding including primary, pharmaceuticals, rest homes, public health, community health as well as secondary and tertiary providers. • Funder and provider relinked. • Price Volume contracts

8. 2007 • Ring fenced funding for mental health – blueprint – Mason report. • Ring fenced funding for specific public health programmes, eg, MenzB, health water • Specific funding programmes for primary health including, high needs patients, chronic care management programmes. • Focus onprimary –secondary integration – eg POAC

9. What are ESPI’sElective Service Performance Indicators. • Nationally consistent tools that measure 8 KPI’s in managing Elective Services for both outpatients and surgical booking lists. • Measurements that allow national DHB benchmarking • Political tools • Indicators for challenging the Ministry for more funding

10. What do ESPI’s measure? 8 KPI’s • DHB services that appropriately acknowledge and process all patient referrals within 10 working days. • Patients waiting longer than 6 months for their first specialist assessment (FSA) • Patients waiting without a commitment to treatment whose priorities are higher that the actual treatment threshold (ATT) • Clarity of treatment status

11. 5. Patients given a commitment to treatment but not treated within 6 months 6. Patients in active review who have not received a clinical assessment within the last 6 months 7. Patients who have not been managed according to their assigned status and who should have received treatment 8. The proportion of patients treated who were prioritised using nationally recognised processes or tools.

12. What do ESPI’s result in? • Patients waiting no longer that 6 months for treatment or assessment • Patients being scored • The removal of waiting lists • The creation of active review lists • The creation of surgical booking lists • Some gaming although relatively limited.

13. Why can’t you cheat the ESPI’s? • All data is electronically transferred to the Ministry of Health on a per patient basis • The ESPI results are MoH generated on the national website. • Significant improvements in ESPI performance from month to month require reports eg. Patients sent back to GP’s without being seen or sudden rise in the ATT.

14. What do ESPI’s look like? • The following is Northlands results by specialty against the 8 KPI’s for August 2007

16. What do National results look like? • These are annualised and on the basis of results staying green on average additional funding is available to either lower ATT or extend the range of services. • Again Northland results.

18. How do you manage ESPI compliance? • Review all waiting lists for outpatients and waiting lists. • Score all patients on a needs basis • Understand potential capacity and volume and plan throughput – when capacity is reached review score of patient – set the ATT at that score eg 90 of THJR • Place around 10% of next group into Active Review and review 6 monthly for up to 6 times-if worse give certainty, if improving refer to GP.

19. Cont. • Return patients below ATT and not on Active review to GP’s with treatment plan. • Apply the same criteria for outpatients. Note Scoring should be consistently applied across the specialty often best done by Clinical Nurse Specialist. ATT can be adjusted by reduction in waiting numbers as well as additional funding.

20. Cont. Once Surgical Booking List established: • Plan operating lists by taking the patients from the group waiting for 6 months and those with the highest scores. • Eventually you are trying to create a list where high scoring patients have short waiting times and lower scoring eligible (those given certainty) wait no longer than 6 months

21. SBL - 6 month wait

22. Summary • Restructuing has bought needed focus although this could arguably been achieved without the structure obsession that the health sector faced for nearly 10 years. • Waiting lists are the most obvious political aspect of health and ESPI compliance regimes have brought a more transparent approach minimising to potential to “game” however, until national ATT ‘s are agreed they are not a reliable as they could be as funding and population health tools.

23. Summary cont. • The most potential development although not yet reached its potential is the primary health strategy • The focus on population health is beginning to bite in terms of national tertiary planning. • The sector is starting to get some traction having had nearly 7 years of structural stability • Deficits are almost gone, waiting times for services are mostly within 6 months so • WHY DID PETE HOGSON LOSE HIS JOB LAST WEEK??

24. Health remains a political football. • Massive industrial unrest is current in the sector • Costs are rising without evidence of productivity gain • He doesn’t apparently have the young fresh face that Labour are promoting for next year’s election.

25. Some of things we do at home