Future health - connected communities and regional services

1. Future health- connected communities and regional services Presentation to NZIHM Meeting Wellington, 14 May 2009 Presented by: Andrew Campbell-Stokes, Manager Regional Clinical Services Programme (TAS)

2. Overview • Future of healthcare • Critical issues • New service models • Clinical networks • The path going forward The brief: Regional Clinical Services Plan, with an emphasis on the place of clinical leadership and networks in the transformation of health. This raises interesting challenges about managing change, adaptive leadership, and cultural change .

3. A Future Scenario The year is 2020. One in every five people living in the lower North Island is 65 years old or older. In some areas, such as the Wairarapa, Levin and Wanganui, the percentage of elderly is as high as one quarter of all residents with a considerable number being in the 85+ age group. Amazing technological advances that have characterised the first two decades of the 21st century have not only extended our life expectancy, but have also radically changed the way we live and interact with the health system...

4. A great deal of health care is provided in people’s homes, and a sophisticated online system fronted virtually by a familiar face and running across the 2nd generation Internet network, is the first point of contact and health advice. Citizens are able to realise a true sense of ownership in managing their own health, and really feel like members of a community health team. They can readily plan and receive care when they need it, as close to home as possible. They can communicate with their health professionals by email, webcam or in person – whatever suits. For at-risk parts of the community, such as elderly and chronically ill, there is telediagnosis, biosensing to home and telemedicine kiosks, supported by rapid response teams.

5. Most health care is provided in the local, integrated ‘community health and wellbeing centres’ that arose from advances in the Primary Health Care Strategy of the mid-2000s. These sophisticated primary health organisations are 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. Local multisectoral ‘community development networks’ commission most health services in conjunction with other public services such as housing, education and employment. They are better enabled to tackle inequalities in health.

6. As result of brave andvisionary plans adopted by District Health Boards in the late 2000s, hospital services have also been revolutionised. They are now provided by a network of local, major sub-regional and regional hospitals operating as one, truly collaborative regional health network. This network is 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 that have plagued the sector in the previous decade have been overcome by means of true regional and national collaboration, clinical leadership and an uncompromising quest for service excellence and quality of care…

7. Health system of the future… • Will be very different from today’s • Will be shaped by: • Demographic changes • Burden of chronic illness • Technological advances (accelerating rate of change) • Societal and workplace changes • Clinical service innovations • Financial sinking lid

8. Health workforce of the future… • Will be very different from today’s • Currently 5:1 workers for every person 65+ • 2026 – expected to be 3:1 • Average age of NZ health workforce 45 yrs • 1 std deviation is 5 yrs • 2/3 between 40 and 50yrs • How will healthcare be provided in 2026?

9. Imperative for Change • There is growing evidence that the current health systems of nations around the world will be unsustainable if unchanged over the next 15 years. Globally, healthcare is threatened by a confluence of powerful trends – increasing demand, rising costs, uneven quality, misaligned incentives. If ignored, they will overwhelm health systems, creating massive financial burdens for individual countries and devastating health problems for the individuals who live in them. • PricewaterhouseCoopers, HealthCast 2020: Creating a Sustainable Future, 2005

10. Implications and challenges Transformational change will be required… Treasury Address to DHBs for DSP Workshops, October 2008 • By this, we mean: re-thinking how we provide health care in more cost effective ways • Looming demographic changes suggest next 10-15 years might be a ‘golden window’ • Does the sector have enough sense of urgency?

11. Financial Sustainability Net financial results for 2004/05 – 2009/10

12. Current service model is... • Clinically and financially unsustainable • Unable to tackle inequalities • Struggles to achieve required improvements in quality • Provider-centric rather than patient-centric • Fragmented rather than integrated • Unfit for future healthcare environment

13. Critical Issues* • Workforce • Availability • Distribution • Development • Access to services (including inequalities) • Managing demand • Resources and infrastructure including IT • Service quality and safety • Funding • Service coordination and planning * Based on survey of clinical departments in the Central Region

14. Greater coordination and collaboration across DHBs should not be left to serendipity nor should it be forced by a clinical failure or a rushed reaction to adverse publicity. Regional and national service planning is essential. Ron Paterson Health and Disability Commissioner February 2008

15. Fragmentation • Marama is 50 years old and lives in a rural part of the lower North Island. She is at home watching television with her family when she feels a sudden pain in her chest. Marama’s family calls the ambulance and the ambulance crew, suspecting a heart attack, take Marama on a two-hour trip to the nearest public hospital. • After arrival to the hospital, tests confirm Marama has had a heart attack and needs a cardiac procedure called an angioplasty. This procedure requires special equipment and needs to be done by a cardiologist trained in this type of work. In the Central Region, this is available only at Wellington Hospital. However, there is no available bed for Marama in Wellington and she must remain in her local hospital in order to meet the criteria to receive the procedure as an inpatient. After a seven day wait, Marama is transferred by air ambulance to Wellington Hospital and has an angioplasty and insertion of a stent. • After a short hospital stay, Marama is discharged and is told that she and her family will need to take care of transport arrangements. Public transport is not an option because transport operators feel there is too much of a risk after the cardiac procedure. So Marama waits in a public waiting room while a family member travels the five hours to pick her up. She finds the car ride home difficult and frequently feels uncomfortable, needing to stop and ‘stretch her legs’, and get some fresh air. • Once home, Marama feels better but receives no contact from any health professional, either from the two hospitals or from general practice. No follow-up or cardiac rehabilitation is provided. Two months later, Marama has another heart attack....

16. Current Model

17. A new service model is required...

18. [The future...] is very positive with significant support for the development of the regional focus and the investment in infrastructure. The opposite without. Clinician, Capital & Coast DHB [Clinical networks...] may allow clinicians to become more expert at their work by seeing a wider range of patients in multiple work areas within the region. May allow clinicians to provide wider range of services by developing more special interests. Clinician, Hutt Valley DHB

19. Future Model

20. High Level Strategies for the Region Clinical networking Seen as an answer to sustainability, quality & access issues Community-based services Requires strong and sophisticated primary health care infrastructure Clustering Consolidation of certain (acute) services Differentiation (of roles) Experience curve Specialised hospitals, elective hospitals

21. Common Enablers • Primary and community health infrastructure • Transport and accommodation infrastructure • For patients and families/ whanau • For clinicians • Regional clinical leadership and networking • Standardised processes and clinical protocols • Information and communication technology • Regional decision making • Shared back-office functions

22. Fully Integrated Collaborative Model Three Centre Network or ‘Tahuhu’ Status Quo Strategic Pathway

23. Hospital Types Three Centre Network • Major Risks: • (Long term) sustainability of services (e.g. Hawke’s Bay) • Political risk / acceptability

24. Roadmap for Change

25. Connected Health service • Bob is 75 years old and lives in a provincial part of the Central Region. He has just returned home following hip replacement surgery at his local hospital a day earlier. His recovery goes well and he is well cared for by a visiting nurse and a physiotherapist from the local community health centre. • Using the email and his personal on-line health record, Bob also keeps in touch with his GP who is keen to ensure that Bob takes his regular medication. Since his first heart attack nearly twenty years ago, Bob has changed his lifestyle and tries to keep his blood pressure and cholesterol levels in check. However, a few weeks later, Bob experiences severe chest pain while playing golf. • The ambulance crew suspect a heart attack and, using a clinical predictive tool, determine that Bob would benefit most from a cardiology procedure called Percutaneous Coronary Intervention. In line with the regional treatment protocol, they fly Bob directly to the nearest major acute hospital where the interventional cardiology team is ready for action. Bob undergoes an urgent angioplasty procedure and has a stent inserted into a coronary artery. • Following a night in the ICU, Bob feels better and is transferred back to his local hospital for step-down care and rehabilitation. The cardiologist from the nearest major acute hospital checks up on Bob using a telemedicine link and gives appropriate advice to his colleagues at the local hospital. After a few days, Bob is ready to return home where he is followed up by a specialist cardiology nurse from the local community health centre. His recovery is uneventful and he returns to his normal activities within weeks.

26. Role of clinical network? What was the cardiology network’s role? • It agreed which hospitals should provide which treatment procedures • Network members provide the integrated service • It developed the predictive clinical tool • It provided cardiology specifications for the regional EHR and developed the communication and IT tools (collaboratively) • It implemented regional contingency plans • It developed business cases for additional service investment and workforce • It monitors regional Quality, Safety and Access KPIs • It takes a holistic view of the care continuum to ensure effective prevention, early detection and rehabilitation occurs

27. Clinical Networks • Linked groups of health professionals and organisations • Working across different parts of the sector (primary, secondary, tertiary) and across existing professional and service boundaries • Usually multi-disciplinary (i.e. employing a range of health professionals including doctors, nurses, pharmacists, psychologists, physiotherapists) • Aimed at ensuring equitable provision of high-quality, clinically effective services

28. Health Care Networks: A Continuum of Network Form Informational Networks Co-ordinated Networks Procurement Networks Managed Networks Source: Presentation by Dr Nick Goodwin, London School of Hygiene and Tropical Medicine 2006

29. Implementing Clinical Networks Who: • Clinicians and managers from hospital and primary /community health • Health service providers and planning and funding • Maori, Pacific Peoples & consumers What: • Monitoring outcomes of treatment to demonstrate safety and quality • Service integration for patient centred treatment & care, efficiency and effectiveness • Service planning for population need and service sustainability

30. Benefits of Clinical Networks Why? • Neutral, crosses organisational boundaries • Clinical leadership and ownership • Bring people together for common/shared understanding • Allows for robust discussion • Regional - size (6 or 7 DHBs) enables change to occur • Models an integrated, collaborative regionalised health service But… • is not a perfect model • not for every service and • has limitations and criticisms

31. Current Examples • Central Cancer Network • Central Region Cardiology Network • Plastic Services Service Leadership Group • Central Region Renal Network • Mental Health & Addiction Network (emerging)

32. Next Stage – Planning for Implementation

33. Roadmap for Change

34. Roadmap building blocks so far...

35. Principles re-confirmed 25 May 2009 Using the Plan - Three Principles agreed to by Boards • All Central Region DHBs will participate and share in an enduring, joint effort to achieve the vision of the RCSP • Each Central Region DHB will ensure that their local planning and decision making is aligned with the direction, aims and objectives of the RCSP • All decisions of regional importance will be made jointly, using an agreed regional decision making process and structures

36. Regional Decision making RCSP proposed a structure and process

37. RCSP Guidance & Oversight • Steering Group • Interim • Multi-professional membership • Regional work being brought together, a “clearing house for regional activity” • Clinical Leadership Group • Clinical leadership a priority • Currently has 53 members • Nucleus is CMA/DON, • Clinical Networks Chairs and Clinical Directors

38. Path going forward Roadmap building blocks • Creating a watershed for regional focus Regional decision making • Moderating the power of veto Resources - economic climate friend or foe? Beginning a new (?) construct/conversation Culture – change through small steps Need for champions and adaptive leaders

39. Questions??