Better Sooner More Convenient Primary Care - New Zealand Doctor

Business Case
Better, Sooner, More Convenient Primary Care
February 2010
Business case EoI V38 AC 25Feb10 Page 1

Kua tawhiti ki te haereka,
Kia Kore e haere tonu
He tino nui rawa ou mahi
Kia kore e mahi nui tonu.
We have come too far, not to go further.
We have done too much, not to do more.
Business case EoI V38 AC 25Feb10 Page 2

1 Caveats/status
This business case is a work-in-progress. Many clinicians and managers have contributed to its
development, and to the thinking and analysis that lies behind it. That does not mean they all
agree with everything in it.
The business case has been endorsed by the respective boards of the DHB and the PHO, but
not yet endorsed by the Ministry of Health.
The business case presents a number of options for future delivery of health services. These
are options for consideration and input, rather than proposals ready for formal consultation.
If and when the business case gets to the point of being a proposal, the necessary formal public
and employee consultation processes will be undertaken, prior to any decisions being made in
regards to implementation.
On Thursday 25th Feb 2010 the board of the DHB passed this resolution:
"That the West Coast District Health Board endorses the direction of travel envisaged in the
“Better, Sooner, More Convenient Primary Care” Business Case, subject to necessary further
analyses, development, revision and consultation, and with particular focus on: budgets and
financial sustainability; the West Coast Model of Care (Sustainability Project); and governance
arrangement;
and
That the West Coast District Health Board authorises management to proceed with its continuing
development and its submission to the Ministry of Health."
On the same day the PHO board passed this resolution:
"The board endorses the direction of travel envisaged in this business case, subject to necessary
further analyses, development, revision and consultation, and authorises management to
proceed with its continuing development and its submission to the Ministry of Health for their
approval."
Business case EoI V38 AC 25Feb10 Page 3

2 Executive summary
The drivers for change are:
Clinical sustainability: the current model of care in most health centres requires GP
numbers we have not been able to achieve consistently on the West Coast for at least
five years, and leads to long waiting times for appointments (often > three weeks) and
lack of continuity and consistency of care.
Limited integration of community services with primary care leading to lack of
co-ordination and consistency of care and some duplication of services.
Financial: primary care medical practices and community services owned by the DHB
contribute significantly to the DHB overspend each financial year. Hospitals in Reefton
and Buller together also contribute significantly to the DHB overspend each financial
year.
What will be different as a result of implementing this business case?
Three Integrated Family Health Centres (IFHCs) will be established based in Westport,
Greymouth and Hokitika with associated clinics in rural areas. Each of these will become
a one-stop-shop in terms of accessing primary and community health services.
We will bed in a team based partnership model for core general practice care so that
the majority of first contact care and long term condition care is provided by
appropriately skilled nurses supported closely by GPs and, in time, Nurse Practitioners
(NPs). This is likely to mean resident (non locum) GP:patient ratios of 1:2000 and
increased practice/rural nurse:patient ratios from 1:1180 to 1:900 (with additional GP
and nurse time for more rural areas and to reflect teaching commitments).
Development of a Māori team within each IFHC that will focus on improving access and
health outcomes for Māori.
Devolution of community nursing, allied health and mental health services into the
IFHCs, or the IFH system, with integration of reception, appointments, electronic
clinical records, care pathways and discharge planning, and consequent reduction of
duplicate service provision.
Full implementation of a best practice, proactive approach to the management of long
term conditions (LTC), including mental health.
Development of a strong primary care/community care organisation able to lead &
manage the Integrated Family Health System (IFHS) within the available budget.
We are committed to achieving important changes in health care, as reflected in the significant
targets set out below.
Business case EoI V38 AC 25Feb10 Page 4

Current situation By three years
Waiting times for a routine appointment in Average of 10 days Maximum 3 days
general practice
Integrated Family Health Centres 0 3
Fully integrated community nursing and
Not present
In place
primary care nursing
Introduce nurse practitioners to skill mix Many nurses with 3 nurse practitioners
potential as nurse
practitioners interns
Patients supported in the long term
1,419 2,500
condition management
Reduction in Ambulatory Sensitive
Hospitalisations (ASH) & inappropriate ED
attendances
ASH rates at NZ average
ED Triage 5 = 81
patients/week
5% reduction in ASH
rates
35% reduction in ED
triage 5
PHO Performance Programme clinical
79% >90%
indicators met
Financial situation $5.4m deficit $1.4m deficit
2.1 Assessment criteria summary
1. The nature and expected magnitude of benefits that will flow from the proposed service
improvement initiatives, including how the proposal expects to:
Support the delivery of The key health targets are an integral part of this plan. Activities
the Government‟s key to improve our performance and monitor changes have been
health targets;
incorporated in the planning documents as follows:
shorter stays in emergency departments: See Appendix Three:
Acute care
improved access to elective surgery: See appendix Seven:
Integration - HealthPathways
increased immunisation: See Appendix Four: Keeping people
healthy
better help for smokers to quit See Appendix Four: Keeping
people healthy
better diabetes and cardiovascular services. See Appendix
Five: Long term conditions
Business case EoI V38 AC 25Feb10 Page 5

Contribute to health
sector productivity and
quality improvement;
Lead to the rapid
establishment of
Integrated Family
Health Centres in
appropriate locations;
Support the shift of
services from
secondary care to
primary care;
Reduce acute demand
on publicly funded
hospital services;
Health sector productivity will be improved by the following
initiatives:
Change in model of primary care with greater role for nurses
leading to better access to care, (see Appendix Two: Core
general practice redesign).
Closer integration of community based services and primary
care, with a multidisciplinary approach and shared electronic
clinical records will lead to decreased duplication and better
targeting of services : (see Appendix Six: Integration – DHB
community based services).
Stratification and targeting of services for those with long
term conditions so that those with the highest need receive
the most support and those with lesser needs receive lesser
support. (see Appendix Five: Long term conditions).
Increased support for patient self care will lead to less
demand for services. (see Appendix Five: Long term conditions
and Appendix Four: Keeping people healthy).
Use of HealthPathways will streamline referral processes: (see
Appendix Seven: Integration – HealthPathways).
Direct access to radiological investigations with less need for
FSAs: (see Appendix Eight: Improved access to diagnostics)
Development of patient pathways for the frail elderly and
closer links between Care Link (West Coast's NASC) and
IFHCs will lead to more focused care. Appendix Eleven: Frail
older people
The approach to quality improvement and safety across the system
and within IFHCs is covered in Section 5.9.
IFHCs will be established covering the whole region within three
years: (see Section 6.2 and Appendix Thirteen: IFHCs – Facilities).
A shift of Community based services to the Integrated Family
Health System is proposed: (see Sections 5.1, 5.4 and Appendix Six:
Integration – DHB community based services).
The Acute Care plan will result in less use of the emergency
department for triage 5 patients and more appropriate care in
IFHCs. (see Appendix Three; Acute care).
Currently, the primary care system on the Coast is not in a good
position to take on clinical tasks currently performed in secondary
care settings. Similarly, Greymouth hospital services are generally
Business case EoI V38 AC 25Feb10 Page 6

staffed on a capacity model – in which staff costs do not vary with
reductions in activity. However, in the medium term, with the
strengthening of the primary care sector, and the development of
more activity based staffing for some services, associated with a
closer working relationship with Canterbury DHB, there may be an
opportunity to move some clinical work from the hospital setting
into IFHCs. (see Appendix Seven: Integration – HealthPathways).
Ensure a wider range of
health services are
delivered
A wider range of services that improve access will be available
within IFHCs, leading to better access as described in Sections 5.1,
5.4 and Appendix One: Core general practice redesign.
Support better
management of patients
Long term condition management is a key aspect of this plan. (see
Appendix Five: Long term conditions).
with chronic conditions
to slow disease
progression;
Increase the use of the
wider primary health
care workforce and
This is a key aspect of the development of the IFHCs: Sections 5.1,
5.4 and Appendix Two: Core general practice redesign and Appendix
Six: Integration – DHB community based services.
support
multidisciplinary teams;
Provide for workforce
development, training
and innovation in the
Key initiatives have been developed for recruitment, retention,
professional development and quality initiatives as described in
Appendix Twelve; Workforce.
primary care setting;
Achieve the above
objectives in a way that
is cost effective and
assures quality and
Extensive modeling around the cost effectiveness of primary care
has been carried out: (see Section 9.2.).
Quality and safety issues are addressed in Section 5.9 and
Appendix Twelve; Workforce.
safety for users of
services.
2. The capability and capacity of the respondent to deliver major service improvement
initiatives in support of these benefits, including:
Ownership and
governance
arrangements;
Robust ownership and governance arrangement are core to the
success of this plan and potential options are summarised in Section
7. Both DHB and PHO boards wish to take a considered approach
to this and require a more in depth paper to be developed prior to
their making a decision by 30 April.
Strength and
The PHO has strong clinical leadership:
experience of the
clinical leadership;
Dr Greville Wood, FRNZCGP, Chair Clinical Governance
Committee (also Regional Co-ordination Rural Medical
Immersion Training Programme, University of Otago)
Dr Jocelyn Tracey, FRNZCGP, PhD, PHO Clinical director and
Business case EoI V38 AC 25Feb10 Page 7

Financial strength and
viability;
Change management
ability and experience
in the health sector
across the primary and
secondary sector;
Information
management experience
that enables new
models of care, and
improves quality and
efficiently deliver
services.
GP Liaison
Helen Reriti, RN, Clinical Manager, WCPHO
Also involved from a DHB perspective have been:
Vicki Robertson, FRANZCOG, Chief Medical Officer
Jane O‟Malley, PhD, Director of nursing and midwifery
Maureen Frankpitt, Nurse manager community and primary
health care
Karyn Kelly, Associate Director of Nursing, Clinical Practice
Development
Janette Anderson, Physiotherapy team leader
(see also Section 5.6).
This business case has been costed on a preliminary basis and
opportunities to reduce expenditure towards breakeven identified.
However, we note that these potential initiatives and costings are
subject to further review and consultation before decision can be
taken.
West Coast DHB is substantially in deficit. Its primary and
community services are responsible for a considerable proportion of
the DHB‟s projected deficit. (see Sections 4.2 and 9.).
The PHO is in a position of financial strength and has allocated
funds for change management. (see Section 10.3.).
Both DHB and PHO senior management have an in depth
understanding of the local situation and of both drivers and
barriers to change. In addition, both organisations draw on outside
expertise as required, including the likes of LECG and PHOcus on
Health. These two organisations have assisted with the
development of this plan, and have extensive experience in change
management in primary and secondary care throughout New
Zealand.
The PHO has a considerable track record of utilizing enrollment and
clinical services data to identify service gaps, and to design and
implement responses/projects to address such gaps. The PHO has
made successful use of the PHO Performance Programme to assist
practices with their continuous quality improvement initiatives. GP
facilitation has been key to this success.
Specific information systems developments have been prioritized,
beginning with the adoption of MedTech 32 as the PMS and clinical
notes platform for all community and primary care services. (see
Appendix Fourteen: IFHCs – information technology)
3. The strength of relationships between the various parties, and partnership
arrangements with key stakeholders, including;
The degree of
engagement and/or
Wide consultation has occurred with front line staff: GPs, primary
care nurses, secondary care clinicians, community nurses, allied
Business case EoI V38 AC 25Feb10 Page 8

support from DHBs,
specialist clinicians,
practitioners from a
range of disciplines;
Experience in
meaningful engagement
with consumers and the
community.
health, and with DHB senior management team (see Section 5.6).
While given the time frames this has not been extensive, input
from community, iwi and Māori providers has been obtained (see
Section 5.7). Each IFHC will establish a community reference group
who can assist in the development of plans for their districts.
These groups will include local mayors (or their representation),
community leaders, business leaders and iwi leaders.
Business case EoI V38 AC 25Feb10 Page 9

3 Table of contents
1 Caveats/status .................................................................................................................................................. 3
2 Executive summary .......................................................................................................................................... 4
2.1 Assessment criteria summary ............................................................................................................. 5
3 Table of contents ........................................................................................................................................... 10
4 Introduction .................................................................................................................................................... 12
4.1 Strategic context ................................................................................................................................. 12
4.2 Financial context ................................................................................................................................... 12
4.3 Secondary services sustainability ................................................................................................... 13
4.4 Population & health status .................................................................................................................. 14
4.5 West Coast PHO .................................................................................................................................... 17
4.6 Changes underway ................................................................................................................................ 20
4.7 West Coast region service delivery issues ................................................................................... 21
5 Future model of care ................................................................................................................................... 23
5.1 The desired patient care pathway/model of care ..................................................................... 23
5.2 Goals for better, sooner more convenient ................................................................................... 25
5.3 Reducing inequalities ........................................................................................................................... 27
5.4 Service specific model of care developments............................................................................. 28
5.5 Enablers .................................................................................................................................................. 35
5.6 Clinician engagement ........................................................................................................................... 36
5.7 Community engagement ...................................................................................................................... 37
5.8 Evidence for this model ..................................................................................................................... 38
5.9 Quality, safety and evaluation .......................................................................................................... 41
6 Business model ............................................................................................................................................... 44
6.1 Business concept .................................................................................................................................. 44
6.2 Locality Integrated Family Health Centres................................................................................. 48
6.3 Service outputs and outcomes ......................................................................................................... 49
7 Governance, Ownership & Management .................................................................................................. 53
7.1 Options .................................................................................................................................................... 53
7.2 Assessing the options ......................................................................................................................... 55
8 Contracting arrangements .......................................................................................................................... 56
8.1 Role of the IFHS ................................................................................................................................. 56
8.2 Annual health service plan ................................................................................................................. 56
8.3 Contracted providers within IFHCs. .............................................................................................. 57
9 Financial sustainability ................................................................................................................................ 58
9.1 Status quo financial situation........................................................................................................... 58
9.2 Addressing affordability ................................................................................................................... 59
9.3 Impact on the DHB .............................................................................................................................. 60
10 Implementation plan ..................................................................................................................................... 62
10.1 Project governance and management ............................................................................................. 62
10.2 Change management ............................................................................................................................ 62
10.3 Investing in change .............................................................................................................................. 64
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10.4 Key milestones....................................................................................................................................... 65
10.5 Objectives, key activities and workplans ..................................................................................... 66
10.6 Work in progress items ...................................................................................................................... 70
10.7 Risks and Mitigations .......................................................................................................................... 70
Business case EoI V38 AC 25Feb10 Page 11

4. Introduction
4.1 Strategic context
On 10th September 2009, the Chair of the West Coast DHB wrote to the Minister of Health as
follows:
The recently released report by LECG (Analysis of options: Models of care for West Coast
District Health Board, 16 Nov 09) gives some flesh to the bones of the first suggestion - closer
working relationships with Canterbury DHB (CDHB) in the provision of secondary hospital
services, which are increasingly likely to be concentrated in Greymouth.
This business case begins to flesh out the second of the two strategic options suggested in the
above letter to the Minister. It articulates the sector's aspirations for better, sooner and
more convenient primary care services for the residents of the West Coast. It explores how
the medical centres on the West Coast on the one hand, and the various community delivered
services of the DHB on the other hand, might be better integrated so that patients' experience
of the health care they receive on the West Coast is significantly improved. It explores how
primary and community care together, might make a greater contribution to improving the
quality and timeliness of health care, while helping save scarce resources. It outlines how a
different mix of clinical skills will be aligned in a service delivery model to more efficiently and
effectively match a variety of patient needs for care.
4.2 Financial context
A major system wide problem for the West Coast health care system is its parlous financial
situation. West Coast District Health Board (WCDHB) was allocated $106m of government
funding in 2009/10, but is projected to spend more than $114m.
Business case EoI V38 AC 25Feb10 Page 12

Annual government health funding per person on the West Coast is over $1,000 higher than the
NZ average ($3,255, compared to $2,248).
On top of this, WCDHB spends another, additional $250 per head (cf. national average of $50
per head overspend).
That is, West Coasters actually receive $3,500 per head, as spent by their DHB, well ahead
(>50%) of the NZ average of $2,300 per head.
The WCDHB's current financial forecast for 2009/10 is as follows:
Provider revenue - 73,468,409
Provider expenses 88,141,662
Provider deficit 14,673,253
Funder surplus - 5,422,748
DHB total deficit 9,250,505
As a result WCDHB is under significant pressure to reduce expenditure.
4.3 Secondary services sustainability
A series of independent reviews have identified core critical mass problems in providing acute
secondary services on the West Coast. WCDHB is currently consulting on a set of
recommendations from LECG proposing greater integration of secondary care with Canterbury
DHB and movement to a rural hospital centre of excellence focus. There is a developing
Business case EoI V38 AC 25Feb10 Page 13

consensus that significant change is required to maintain clinically and financially sustainable
hospital services. It is important that the community and primary services receive the same
level of scrutiny and leadership.
4.4 Population & health status
The West Coast is a region of contrasts; on one hand it is a region of great natural beauty but
on the other hand is home to one of the most socio-economically deprived populations in New
Zealand. The geographic nature of the region, being bordered by the towering Southern Alps on
the east and the Tasman Sea on the west, leads to the West Coast being the most rural and
isolated region in New Zealand. The total land area covered by the West Coast District Health
Board is 23,283 square kilometres and great distances separate many towns, with the distance
between Karamea in the north and Haast in the south being 516 kilometres. The West Coast
and its people are also very much influenced by the history, environment and climate of the
region.
Health Profile
Consistent with the above demographic and socio-economic issues is the picture of higher
morbidity and mortality rates and lower life expectancy on the West Coast compared with the
New Zealand average. However, life expectancy in the West Coast DHB area improved between
1995/97, 2000/02 and 2002/2007 for both males and females and the overall mortality rate
for the West Coast DHB reduced from 8.6 deaths per 1,000 population in 1995/1997 to 6.2
deaths per 1,000 population in 2005/2007. However, over the last decade the West Coast
DHB‟s overall mortality rate remains above the national average rate. Westland District had
the highest mortality rate in 1995/97 but this had reduced to the lowest in 2000/02 and
remains the highest in 2005/2007. (However, this apparent large reduction for Westland
District may be partly due to high variability in mortality rates, which often occurs for small
populations). Analysis of mortality data for West Coast DHB residents between 2001 and 2005
reveals that the leading causes of death were cardiovascular disease, respiratory disease,
cancers (particularly lung, colorectal, prostate and breast) and dementia (these cases have
increased in recent years due to the aging population).
The overall rate of hospitalisation is also high. Analysis of hospitalisation data showed that
there were nearly 7,500 discharges of West Coast DHB residents from publicly funded
hospitals in 2007. (This includes West Coast DHB residents discharged from hospitals outside
the West Coast DHB area). Some of the leading causes of hospitalisation were diseases of the
digestive system (13.3%), diseases of the circulatory system (8.8%), injury, poisoning and
certain other consequences of external causes (8.8%), and pregnancy, childbirth and the
puerperium (7.8%).
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Ambulatory Sensitive Hospitalisations (ASH) are hospital admissions that could potentially have
been avoided through community-based or primary health care services. Standardised
Discharge Ratios for 0-74 year olds show that ASH rates for the West Coast DHB do not tend
to differ significantly to the rates for New Zealand as a whole. Lead causes of ambulatory
sensitive admissions for the West Coast population over the recent years in terms of total raw
hospitalisations are angina and chest pain; cellulitis; upper respiratory and ENT infections;
diabetes; congestive heart failure; dental conditions; myocardial infarction; gastroenteritis;
pneumonia; asthma; skin cancers; epilepsy; kidney and urinary tract infections; and stroke. This
pattern has largely continued in the twelve months to 31 December 2008.
The West Coast Māori Health Profile 2008[1][1] revealed that West Coast Māori have a similar
social profile to the West Coast non Māori but in terms of health, West Coast Māori have a
poorer overall health status than the non Māori in the region; this is demonstrated by a range of
indicators, including cardiovascular disease, cancer, diabetes and respiratory disease indicators.
Though in many instances West Coast Māori have lower mortality and morbidity rates than
Māori nationally, it is to be noted that the West Coast Māori are under-represented among
primary care utilization data and have higher rates of smoking, which is a key risk factor for a
range of morbidities such as cancer and cardiovascular and respiratory diseases. Discrepancies
between hospitalisation and mortality rates for cardiovascular disease, and registration and
mortality rates for cancer, point to these being additional important areas of unmet need for
West Coast Māori.
The health status of children and young people on the West Coast is poorer than the New
Zealand average. In particular, children have among the worst oral health status in the country,
and the West Coast has the lowest rate of caries-free five-year-old children in New Zealand.
The relatively high rate of dental decay in young children is a concern, especially with the
absence of fluoridation. For children aged 0-14 years the leading causes of death are extreme
immaturity (pre-term and low-birth weight babies), respiratory distress syndrome and
meningitis. For young people aged 15-24 years motor vehicle crashes account for half of all
deaths, and other injuries and accidents account for one third of all deaths. The main causes of
ambulatory sensitive hospitalisation for West Coast children aged 0-4 years are respiratory
infections (29%), gastroenteritis (20%) and asthma (12%).
West Coast residents have higher smoking rates compared with other areas in New Zealand.
The 2006 Census showed that a higher proportion of West Coast DHB residents (23.4%) were
regular smokers compared with New Zealand as a whole (18.9%), with Buller District home to
the highest proportion of smokers (25.7%). The recent New Zealand Health Survey 2006/07**
showed that 28.2% of West Coast residents are current daily smokers compared to 19.1% of
New Zealand as a whole. Amongst West Coast Māori, 43.3% of women and 39.6% of men smoke.
[1][1] West Coast „Te Tai O Poutini‟ Māori Health Profile 2008, prepared by Community and Public Health West
Coast
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A 2007 Ministry of Health report[2][2] suggested that tobacco smoking, alcohol consumption,
oral health status and avoidable hospitalisation are among the key health issues for the West
Coast DHB as these rates are high compared with New Zealand as a whole. The West Coast
cryptosporidiosis rate is also high compared with New Zealand as a whole but this may not be as
serious. Notifiable disease rates vary due to factors other than disease prevalence, such as
variations in the extent to which these conditions come to the attention of medical
professionals and variations in the completeness of reporting. With these data limitations
noted it is still possible that the high cryptosporidiosis notification rate indicates that there is
a water quality issue in the West Coast DHB area that may affect population health.
Population Profile
The West Coast occupies 8.5% of New Zealand‟s total landmass and is home to a growing
population of 32,200 people[3][3]. The population is distributed across three Territorial Local
Authority (TLA) areas: Buller, Grey and Westland Districts. The West Coast DHB is the most
sparsely populated DHB in the country with a population density of 1.3 people per square
kilometre, less than 10% of the New Zealand average. A total of 57.7% of the West Coast DHB
population live in urban areas, the main population centres being Greymouth, Westport and
Hokitika. Between 2001 and 2006 the West Coast DHB population increased by 3.4%, with
Westland seeing the fastest growth rate (8.1%). Some Census Area Units had growth rates of
over 25% between 2001 and 2006 including Waiho, Totara River, Arnold Valley, Otira, Fox
Glacier, Coal Creek, Hokitika Rural and Greymouth Rural.
Notwithstanding, the long term population projections indicate that the West Coast region as a
whole will observe declining population numbers but with a growing older population. Population
estimates suggest that the child and youth populations decreased slightly between 2001 and
2006 but during the same time period there was significant growth among the older adult
population (40-64) and older people (65+). The West Coast DHB population has a slightly older
age structure compared with New Zealand as a whole, with a higher proportion of people aged
65 years or more compared with the national average. The Māori population on the West Coast
shows a different age structure and growth pattern however; nearly one in ten of the West
Coast population is Māori and there are more Māori aged under 45 years. Subsequently this will
be reflected in the expected future increase for all Māori age groups over 25 years of age.
More detailed ethnicity data analysis of the West Coast population shows that over 300 people
identified as being of Asian ethnicity, nearly 200 were Pacific Island people and nearly 70
identified as Middle Eastern/Latin American/African (MELAA). Overall 9.3% of the population
identify as Māori, Pacific people make up less than 1% (0.9%) of the region's population, with
the balance falling into other ethnicity groups
[2][2] “An indication of New Zealanders Health” (Ministry of Health, 2007)
[3][3] Statistics NZ Quarterly Regional Updates, March 2008. This number indicates a growth of 0.5% since the
2006 census count.
* A Portrait of Health. Key Results of the 2006/07 New Zealand Health Survey, 2008.
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The base populations of the three districts are shown below.
Table 1: Population & Age Distribution at 2009 (based on 2006 census) by TLA
TLA Age group Number Percentage
Buller District 0 - 14 1850 18.5%
15 - 39 2600 26.0%
40 -64 3850 38.5%
65+ 1700 17.0%
Total 10000 100.0%
Percentage of West Coast population 31%
Grey District 0 - 14 2850 20.7%
15 - 39 4100 29.7%
40 -64 4850 35.1%
65+ 2000 14.5%
Total 13800 100.0%
Percentage of West Coast population 42%
Westland District 0 - 14 1600 18.1%
15 - 39 2640 29.9%
40 -64 3370 38.2%
65+ 1220 13.8%
Total 8830 100.0%
Percentage of West Coast population 27%
West Coast total 32630
The Buller area has a higher proportion of over 65 year olds and is also more deprived relative
to the district as a whole.
4.5 West Coast PHO
The PHO is a community trust, governed by a board of nine trustees. Its founding document is
its trust deed, which sets out its objectives as being:
(a) "to improve, maintain and restore the health of people living in the West Coast Region;
(b) "to provide or ensure the provision of accessible primary health care services to the community of
the West Coast Region;
(c) "to provide or ensure the provision of effective, high quality integrated health services for the
community of the West Coast Region;
(d) "to assist members of the community of the West Coast Region (particularly those on low
incomes and with high health care needs) who have difficulty gaining timely and appropriate
health services;
(e) "to work with the West Coast District Health Board and community groups within the West Coast
Region to achieve any of the above Objects;
(f) "to support any institution, society or other body of persons whether incorporated or not whose
objects are similar to the objects of the Trust set out above, provided that any such entity is
established for charitable purposes in New Zealand."
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It's trustees are derived from three sectors as follows: community, Māori and providers (three
from each):
three community trustees are appointed from each of the three District Councils
two Māori trustees are appointed from each of the two runanga
one Māori trustee is elected - by the Māori health providers electoral college
three provider trustees are elected - each of the general practitioner, practice nurse
and practice administration staff electoral colleges elect one trustee.
The PHO provides some health services itself, but also subsidises patient care through its
substantial funding for the eight medical centres across the Coast. Five of these practices are
owned by the DHB, two by health professionals, and one by the PHO itself.
The PHO's statement of strategy and priorities is:
The purpose of the PHO is to promote and enable better health for the population on the West
Coast and actively work to reduce health inequalities amongst at-risk and disadvantaged groups.
The PHO will strengthen and grow its organisational functions as funder, service provider, and
service co-ordinator within primary care, as a means to achieving this end and in alignment with
the Government‟s Primary Health Care Strategy (PHCS).
STRATEGIC OBJECTIVES ARE TO
Work with local communities and enrolled populations
Identify and remove health inequalities
Offer access to comprehensive services to improve, maintain, and restore people‟s health
Co-ordinate care across service areas
Develop the primary care workforce
Continuously improve quality using good information and evidence
WE WILL FOCUS ON
Improving the management of patients with chronic care conditions
Closing gaps of inequality for Māori
Improving access to mental health services, including for young people
Improving quality of life, eg. by cancer support
Improving immunisation rates
Enhancing disease prevention programmes
Improving the co-ordination of services both within and across services
BY USING KEY MECHANISMS AND ENABLERS SUCH AS
Better engagement with the community, families/whanau and individuals
Improved collaboration at strategic and planning levels with the DHB and Community &
Public Health
Greater integration with other organisations and NGOs
Supporting GP practice teams
Supporting individuals and whanau
Enhanced health promotion
Adoption of efficient business/service models
Most of the West Coast's resident population is enrolled in the PHO's eight practices. The
distribution in the recent Oct-Dec 09 quarter was as follows:
Business case EoI V38 AC 25Feb10 Page 18

Māori/Pacific Not Māori/Pacific
Dep 5 Not Dep 5 Dep 5 Not Dep 5 Total
Karamea 0 36 17 520 573
Buller Medical Services 192 408 1,790 4,801 7,191
Greymouth Family Health 11 76 147 990 1,224
Greymouth Medical Centre 107 403 703 4,848 6,061
High St Medical Centre 67 288 656 5,214 6,225
Reefton Medical Centre 35 154 206 1,576 1,971
South Westland Area
Practice 0 139 0 1,425 1,564
Westland Medical Centre 122 772 505 4,178 5,577
Total 534 2,276 4,024 23,552 30,386
1.8% 7.5% 13.2% 77.5% 100.0%
The PHO's net equity as at Dec 09 was $1.1m and its recent operating financial performance is
as follows:
Revenue
Financial performance Jul – Dec 09
First level services & practice VLCA 2,387,473
Administration 197,072
Health Promotion 100,516
Services to Improve Access 115,223
Long Term Conditions 344,159
Other clinical services 31,201
PHO Performance Programme 166,186
Rural Premiums & Reasonable Rostering 769,001
Professional & practice development 35,884
Mental Health & MSD 228,878
Cancer Services 146,370
GP Liaison 40,000
HEHA (breastfeeding support) 43,872
LTC Collaborative Funding 37,139
Expenditure
First level services & practice VLCA 2,387,473
Administration 341,157
Health Promotion 83,643
Services to Improve Access 92,159
Long Term Conditions 200,873
Other clinical services 12,936
PHO Performance Programme 87,193
Rural Premiums & Reasonable Rostering 742,784
Professional & practice development 16,281
Mental Health & MSD 198,638
Cancer Services 124,539
GP Liaison 24,819
HEHA (breastfeeding support) 38,766
LTC Collaborative Funding 32,139
4,642,974
4,383,400
Surplus 259,574
Business case EoI V38 AC 25Feb10 Page 19

4.6 Changes underway
A number of initiatives have been implemented over the last three years to address some of the
health needs and service delivery concerns on the West Coast.
PHO based initiatives:
development of health promoting practices and a wide number of high profile health
promotion activities, including Smokefree, Heart Week, men‟s health days, Green
prescription, Tai Chi classes, community activity programmes
breastfeeding co-ordinators and peer support programme
kaiawhina role to improve access for Māori in the Buller district
long term condition management programme incorporating targeted care, self
management support, delivery system redesign and clinical information systems
primary mental health assessments and brief intervention counselling
navigation support for those with cancer
Māori health plan
PHO Performance Programme with GP facilitator
immunisation enhancement.
DHB based initiatives in primary and community care:
Māori health needs analysis
investment in nursing competency and role extension
movement to models of care in which nurses provide front line services where
appropriate
greater use of nurses – with nurse to GP consult ratios being the highest for any DHB in
NZ
closer working relationships with Canterbury in many services
movement to more community based mental health service delivery – with reduction to
five acute inpatient beds on the Coast
delivering a predominately community based mental health service delivery model,
enhancing community based support services delivered by NGOs and reducing acute
inpatient beds to five
establishment of an academic practice to co-train rural GPs and rural nurses and
sourcing CTA support for pilot training programmes
development of an IT platform which provides for a single shared patient record across
DHB practices with access through Healthviews to hospital sourced health information
such as discharge summaries, PACS radiology, lab results
through After Hours funding providing West Coast-wide after hours triage phone
support.
Business case EoI V38 AC 25Feb10 Page 20

4.7 West Coast region service delivery issues
Key problems identified by the steering group, advisory group, reference group and
stakeholders that face the West Coast health care system are:
Workforce shortages
Difficulties in recruiting and retaining staff (especially GPs and allied health staff) has led to
high turnover, excessive reliance on locums and under staffing. This is exacerbated by the
relatively deprived nature of the community, the low population density and high on-call
requirements in rural areas.
Leading to poor access to care:
Difficulty in staffing GP roles has resulted in enrolled patients being unable to book routine
appointments within an acceptable timeframe (waits of longer than 3 weeks are typical in some
practices) and patients new to town unable to enroll in any practice. Difficulty in resourcing
also results in a tendency towards responding reactively to acute presentations and allowing
these to take precedence over proactive, planned care of patients with chronic conditions –
reducing the possibility of managing future demand. Again, the Coast geography mitigates
against easy access, with many people living more than 60 minutes travel time away from major
urban centres.
Service fragmentation
Services operate in partial silos resulting in:
lack of continuity of care
difficulties navigating through the system
duplication of assessment, needless administration, disparate treatment policies and
protocols, and poor sharing of clinical information.
Within primary care, there is frequent use of locums, and high dependence on Emergency
Department (ED) services at Buller and Greymouth. People often see a different GP or nurse
each time and thereby experience poorer quality care. Further, when GP numbers are
insufficient, and nursing staff are used as sole caregivers for most primary care consults,
without changes to the overall model of care to ensure adequate GP support, quality processes
and professional development, there is a risk of people operating outside their scopes of
practice and of avoidable harm to patients.
Services are not co-located in some areas, making it particularly difficult for the frail older
people or those without transport. When services are co-located, they are often not
integrated, meaning that opportunities to schedule, for instance, a physiotherapy appointment
at the same time as a diabetes annual review (to reduce the travel burden) are missed.
Service fragmentation leads to duplication in reporting and management infrastructure – and
siloed funding streams – reducing the ability to innovate and to use funding flexibly.
Business case EoI V38 AC 25Feb10 Page 21

Inequalities in health outcomes
Māori remain under-enrolled in the PHO (particularly in Grey District) leading to poor access to
proactive care for Māori.
More generally, lack of community knowledge of the health system in general, and in particular
about:
how best to access care (including after hours)
what enrolment means (enrolment in health system)
what services they can expect.
how to care for self/whanau with common ailments
what constitutes a healthy lifestyle
how to support a whanau member/oneself in managing long term health conditions such
as heart disease and or diabetes
leads to poorer health outcomes and greater use of secondary health resources by Māori and
those living in deprived areas.
Affordability of services
As noted, the current configuration of services is unaffordable for the taxpayer funder, as well
as delivering suboptimal outcomes.
Business case EoI V38 AC 25Feb10 Page 22

5 Future model of care
5.1 The desired patient care pathway/model of care
This section describes the vision for the new model of care that will be in place once the goals
and objectives have been achieved. The intent is that, over time, total transformation will occur
consistent with the "Better, Sooner, More Convenient" framework.
From a patient perspective:
Patients are enrolled with an IFHC as their health care home. Within each IFHC are smaller
units of health care teams normally comprising two to four nurses, and one to two doctors
working in partnership to look after a population of people. Patients know the doctors and
nurses in „their‟ health care team, a smaller unit within the IFHC that provides continuity and
consistency of care and builds trusting relationships.
The care provided is patient centred and holistic. All patients of all ethnicities and
socio-economic groups feel valued and respected. Service is personal and friendly; patients do
not feel lost in a large impersonal health centre.
Patients know how to access care, the hours of opening, after hours arrangements, types of
appointments available, and are happy to be guided as to which health professional can best
meet their needs on any occasion. For acute care and long term condition management their
first port of call is usually one of the nurses in „their‟ team, and they know that back up from
GPs is available when required. For complex consultations longer appointments are available with
their GP. Patients with serious problems are able to be seen within twenty-four hours, or sooner
– particularly for children and frail older people whose condition is unstable. Routine and
preventive care appointments are provided within three days. Laboratory tests samples are
collected on site and x-rays nearby and, if the pharmacy is not on site, home deliveries are
available.
For Māori, particularly those who have disengaged from the system, there will be a Māori nurse,
and supporting kaiawhina or health navigator in each IFHC, who can provide outreach services
and support whanau to access care, and have their health needs met in a culturally appropriate
manner that incorporates Māori models of care such as Te Whare Tapa Wha 1 , and Te Wheke 2 .
Often people manage their own health problems, following nurse phone advice from national
health lines, accessing information on recommended websites, or following their written care
plans. Pharmacists assist patients with the management of minor ailments. Many people will be
involved in community programmes provided by the IFHS, such as Green Prescription, smoking
1 Durie, M. Mauri Ora, Wellington. 1990
2 Cited at: http://www.Māorihealth.govt.nz/2004/taaria_1.php#
Business case EoI V38 AC 25Feb10 Page 23

cessation, self management education groups. Others are helped to access NGO support and
community group activities.
Messages about keeping healthy are everywhere in the community: libraries, shopping centres,
pharmacies, schools and IFHCs. While health promotion messages and displays are zany and fun,
people will also have the information they need to make healthy lifestyle choices. It is the
norm to eat healthily, breastfeed one‟s babies, be physically active and not to smoke. Children
are immunised, older people and those with long term conditions have annual flu vaccinations, and
those in the at risk age groups have annual or five yearly cardio vascular risk assessments and
diabetes screening. Smokers are screened for chronic respiratory disease.
For those with complex health problems there is a range of extra care available. The IFHC
is considerably more comprehensive than the traditional medical centre; it incorporates a range
of medical, nursing and allied healthcare professionals some of whom are permanently based in
the IFHC as part of the wider multi disciplinary team and others who may visit on a daily or
sessional basis. Whether staff are employed by the IFHC, the DHB, the PHO, another NGO, or
in private practice, patients know that the shared electronic health record means they do not
need to repeat their story to each new person they see, and that their care is well co-ordinated.
Nor do they need to wait for referrals to be processed and prioritised: appointments to see
other members of the multi disciplinary team (MDT) can be made on the spot, and can be
scheduled all for the same trip to the IFHC.
People with complex needs, such as those with LTCs and frail older persons, are assessed by
Care Link (West Coast's NASC) assessors at the IFHC and have a plan made for how the
different members of the MDT can contribute to their care. They have a key worker they can
rely on to co-ordinate their care and if they need help in navigating the health system and
accessing the social support and benefits they need, they will also have a health navigator to
Business case EoI V38 AC 25Feb10 Page 24

support them. Help with understanding medications is available from pharmacists via medication
reviews.
Those with mental health problems are assessed by a mental health co-ordinator within the
IFHC who will help them select the package of care they need to get well, ranging from
community support, through brief intervention counseling, to admission to community mental
health services. They receive their care in the IFHC and this lessens their sense of
stigmatization. Their GP knows what care they are receiving and is able to provide support and
ensure their physical needs are not neglected.
The community knows that their health centre has been Cornerstone Accredited, has quality
systems in place and is keen to receive feedback so that the services can be steadily improved.
Community, business and iwi leaders meet regularly with senior clinicians and management to
work together to improve health services and increase community understanding.
If hospital based care is required, information flows electronically to and from specialists, and
the care provided is consistent with, and a continuation of, that provided in the IFHC.
And most of the time, for most people and their families, with most problems, whatever their
age, their GP and nurse team will be there, helping them on their life journey.
5.2 Goals for better, sooner more convenient
The vision of Better, Sooner, More Convenient primary care is one that, if implemented well, will
address the current issues with health care delivery on the West Coast.
The following eight goals arise from this vision:
1. Partnership with the community
2. Sooner: improving access to primary care
3. Better: improving continuity of primary care
4. Better: improving consistency of care
5. Better: improving co-ordination of care between general practices, hospitals and
community providers
6. More convenient: community based care in integrated family health centres
7. Greater clinical leadership
8. Living within the available funding.
For each goal objectives and key activities were developed. Then as a tool to managing change
towards the desired model of care, a number of working groups were established, each working
towards the overall goals and objectives and developing a different aspect of the model of care.
Clinical leaders from all disciplines, as well as PHO, DHB and provider arm managers were
Business case EoI V38 AC 25Feb10 Page 25

involved in the working groups. Each group developed a detailed plan that includes deliverables
(implementation phase, year one, two and three and output and outcome measures). The working
groups will continue to take responsibility for the implementation of these plans so that the
goals and objectives of this business case can be realised and a new model of care implemented.
The work plans cover the following aspects, and are included in full in the appendix.
Work plans that relate to care delivery:
core general practice redesign
acute care
keeping people healthy
long term conditions
integration: Health Pathways
integration: DHB community based services
improved access to diagnostics
referred services
mental health
frail older people.
Plans for the enablers - support, systems and facilities - required to deliver the new model of
care:
workforce
IFHCs – facilities
IFHCs - information & communications technology
change management.
The following schema shows the way that the various work plans support the strategies, targets,
goals and vision of this plan:
Business case EoI V38 AC 25Feb10 Page 26

LEVERS
VISION
Better, sooner, more convenient
To improve health outcomes for the West Coast community, within the available budget
OUTCOMES
Targets Goals
Better
Community / patient
focused care
Improved health
outcomes for people
with long term
conditions
Better
Continuity, consistency,
coordination of care
Increased
immunisation and
screening rates
Shorter wait times to be
seen by GP/PN team
Sooner
Improved access to care
Reduced levels of
Ambulatory Sensitive
Hospitalisations / ED
attendances
More convenient
Integrated care in IFHCs
Services live within
available funding
STRATEGIES
Bed in team based delivery
model for primary care
- Improving multi-disciplinary
teamwork
- Increased collaboration between
general practices
- Move to 1:2000 GP ratio, 1:900
PN ratio
Service specific strategies
- Long term conditions
- Frail elderly
- Mental health
- Integration
- Acute care
- Keeping people healthy
Workforce
Integrate PHO and DHB
community services
- Integrated clinical pathways
- Reduced administration and
management costs
IFHCs
- Develop 3 IFHCs at Westport,
Greymouth & Hokita
- 1 stop shop for community &
primary care
- Shared health record
Clinical
relationships
Delegation to
PHO/Trust
Flexible
outcomes
based contract
The objectives, key activities and associated work plans for each of the eight goals are set out
in the change management section.
5.3 Reducing inequalities
This plan aims to improve services for Māori in that it:
has an emphasis on reducing inequalities between the health outcomes of Māori and
other New Zealanders
builds on Māori staff capacity and capability to improve the uptake of services
commits to building the capacity and capability of non Māori staff to improve the uptake
of service by Māori
links in with Māori community based programmes
includes initiatives that will improve access for Māori
utilizes accurate ethnicity data and reports separately by ethnicity so as to stimulate
effective service delivery for Māori.
The Health Equity Assessment Tool was used to identify how the development of IFHCs could
decrease inequalities in access and health outcomes. The results are shown in the Appendices.
Business case EoI V38 AC 25Feb10 Page 27

The DHB Māori Health Unit reviewed the plans from the various workstream, providing guidance
on how they could be better designed to reduce inequalities. The work plans in the appendices
each contain a section on how the plan will reduce inequalities.
5.4 Service specific model of care development s
5.4.1 Future general practice model of care
Specific developments related to general practice are set out in „Appendix Two: Core general
practice redesign‟. This describes a process whereby practice teams will work together to
develop improvements/alternatives to what is currently not working - in terms of access, safety
of care and financial viability.
An important realisation is the likely need to deliberately move to a strategy whereby
experienced practice and rural nurses see most general patients (including dispensing under
standing orders), and GPs provide back up support, supervision and are available to see complex
patients whose diagnosis and care plan is less clear. Currently a version of this model of care is
in place at some practices, but often in an unplanned way – as an ad hoc response to a shortage
of GPs. The new model of care accepts that the West Coast generally has ratios of 1 GP to
2000 patients, and provides the necessary supports in the form of additional practice nurses
and consistent policies and processes to make this model safe and rewarding for patients and
staff. However, this model is not yet set in stone and if alternatives are proposed that have as
good or better outcomes in terms of access, safety of care and financial viability, they will be
considered.
We have calculated the likely activity levels and associated FTE requirements to support this
model of care. Detailed FTE calculations are presented in the Business model section of this
report. Of note, we calculate that the number of current GPs on the Coast would be about right
(particularly with this number as permanent GPs), whereas we find that we are under resourced
in practices nurses and rural nurses to deliver the new model of care. In general, the model
assumes that most people see a practice nurse, and then, if necessary a GP. This will require
changes to the way GP and nurse time is scheduled and will take some time to implement fully,
with some practices being more ready to move to this model than others.
Importantly, we expect that GPs will continue to see around 65% of patients presenting with an
undifferentiated condition (general consults). Most will be seen briefly – as a 5 minute adjunct
to a practice nurse consult, but we have also allowed for 25% of patients (the more complex) to
have a 20 minute consult with the GP.
5.4.2 Multidisciplinary approach
Patients will remain „under the care of their general practice team‟ within the IFHC, even when
health professionals other than the GP and practice/rural nurse, are significantly involved in
care for particular patients (and, in some cases, members of the 'expanded team' may well be
Business case EoI V38 AC 25Feb10 Page 28

providing the majority of care). That is, referral to and/or engagement of workers, other than
the GP and practice/rural nurse, in a patient's care, will not see a transfer of responsibility for
care away from their general practice team. Nor will the involvement of more health
professionals see the proliferation of separate sets of clinical notes, or of parallel but
disconnected care pathways.
The augmented workforce of medical, nursing and allied health care professionals will
nevertheless see themselves, and be seen by others, primarily and intrinsically as part of that
IFHC team; they will talk about „us‟ rather than „them‟ when referring to these centres.
The patients‟ health needs will be cared for, according to their complexity/severity, by the
member(s) of the IFHC team best suited to meeting these needs as per the following diagram 3 :
As members of a single primary/community services team, health professionals at the IFHC will:
have the same catchment population boundaries for the purpose of workload and
resource planning
use common appointment booking systems (eg. rather than referring patients to each
other, will be able to book appointments directly)
use a single common clinical record
develop patient pathways for those requiring multidisciplinary care
develop shared policies and processes
work together in a partnership model.
An IFHC might comprise a multi-disciplinary team that looks like this:
3
Sourced from Primary Health Care Advisory Council. Progress Report of the Council‟s work to provide advice to the
Ministry of Health and District Health Boards on Primary Health Care Service Models. Nov 2009
Business case EoI V38 AC 25Feb10 Page 29

5.4.3 Future well child service model
Currently well child service provision is fragmented between Plunket, primary care, Māori health
NGO providers, LMCs and Community nursing services. The advent of IFHCS creates the
opportunity to bring these carers together, so that care is streamlined, information is shared
and families get the right level of follow up.
Initial discussions with NGO service providers indicate a willingness to collaborate in order to
achieve better health outcomes and better use of resources. More detailed discussions and
project planning will occur in year one of the implementation phase.
5.4.4 Future mental health service model
[NB. The Mental Health component of this plan was written on the basis of funding being
available to employ Mental Health Co-ordinators in each IFHC. It became apparent on 23 rd
February that this funding was not going to be available. While aspects of this plan may still be
able to be implemented within existing resources and funding, this will require discussion with,
and support from, clinicians from community mental health services, primary mental health
services and primary care. Given the time now available a revision to this plan was therefore not
attempted; this review will done by June 30, 2010.]
Significant changes are proposed for mental health services. Most secondary mental health
services provided by the West Coast DHB are, in fact, community based. Over time it is
proposed that these will increasingly be based in IFHCs to enhance the connection with core
primary care. This process will commence in 1 July 2010 with the devolution of funds for three
primary care based primary mental health co-ordinators who, over time, will conduct almost all
Business case EoI V38 AC 25Feb10 Page 30

The
Community
Health
System
Delivery System
Design
Clinical
Information
Systems
Equity in
Health
assessments for patients with mental health conditions, irrespective of whether patients are
then referred for primary or secondary mental health interventions. Currently, there is one
assessment role in primary care, and it only assesses patients for entry to brief intervention
counselling provided by the primary mental health team.
This devolution will reduce the separateness of (and associated stigma that typically goes with
referral to) secondary mental health services, prevent patients falling through the 'gap'
between primary and secondary mental health services, and further strengthen the provision of
mental health services in primary care settings.
After year two, provided developmental milestones are achieved, it is anticipated that mental
health services will be fully devolved to the PHO/community provider, to enable further
integration of service delivery.
5.4.5 Future management of long term conditions
The WCPHO and DHB have invested significantly in development of a best practice framework
for management of long term conditions (LTCs). The developments to date, and future targets
are detailed in „Appendix 5 Long Term conditions‟. The framework is summarized in the
schematic below.
Chronic conditions management – the WCDHB
framework,
The Patient’s Journey
Environment
Healthy
At Risk
Acute
Event
Initial
management
Long term
clinical and
Self
management
End of Life
Care
Healthy public
policy and
creation of
supportive
environments
Non-italics=
existing service
Italics= proposed
service
Healthy
Schools;
Smoke free;
HEHA:
Community
events;
Breast feeding;
Men‟s health;
Green Rx;
Health
promoting
practices
CVD and
diabetes
screening,
follow up
for those at
highest risk
Smoking
cessation
Diagnosis,
hospital
admission
Pre-hospital
fibrinolysis
Diabetes
Pulmonary
rehabilitation,
Cardiac
rehabilitation,
Arthritis and
diabetes
education/
support
groups
PHO LTC: Focus on,
CVD, diabetes ,
COPD: clinical and self
management support
CareLink and AT&R
assessments and MDT
review for more
complex
Cancer
navigators
Palliative
care
funding in
primary
care
UNDERPINNED BY THE WEST COAST‟S 7 PILLARS OF CHRONIC CONDITIONS MANAGEMENT
Business case EoI V38 AC 25Feb10 Page 31

The programme is both based on the Wagner Chronic Care model 1 (self-management support,
community support, delivery system redesign, clinical information systems and decision support)
and the Kaiser Triangle stratified care approach 4 . The Programme meets the National Health
Committee‟s objectives 5 of providing effective chronic care management and co-ordination
through using a population health approach to care delivery, based on level of need, both clinical
need and need for self-management support. There is a focus on those with conditions that are
frequent or severe, and these are addressed by national evidence based clinical guidelines and
are responsive to enhanced primary care management, and have outcomes that can be tracked
over time to measure improvement (cardiovascular disease [CVD], diabetes, and Chronic
Obstructive Pulmonary Disease [COPD]).
The DHB and the Ministry of Health both approved the content of the long term conditions
(LTC) management programme in late 2008, including giving permission to allocate all LTC funds
(diabetes annual review, Care Plus, some Section J contract lines and some SIA funding) into a
global budget for this programme.
The programme is based on all patients with diabetes, CVD or COPD having an annual review
from the time of diagnosis, and then based on their clinical condition and ability to self manage,
a decision is made as to the level of care they require for the following year, based on clinical
need and self management competency.
Implementation of the programme has gone well in 2009 using the IHI Breakthrough Series
methodology. A recent evaluation 6 of the implementation showed high acceptance by practices
and increases in the numbers of patients with LTCs managed in a proactive and planned manner –
now 1419 in Care plus, 1061 in level 1, 300 in level 2 and 27 in level 3.
The key objectives of the next stage of LTC management are:
To increase implementation of the programme so that over 70% of all patients with
COPD, CVD and/or diabetes have an annual review followed by a timely package of care
appropriate for their level of need.
Development of a Māori team within each IFHC who will focus on improving access and
health outcomes for Māori.
To review the management of Level 3 patients and enhance the integration between
general practice care and AT&R, Care Link and nurse specialist care and allied heath
To enable and empower people in the community to obtain, process and understand
health information and services needed to make appropriate decisions about their
health.
To develop health navigator support services for Level 3 patients who have difficulty
accessing health care and social services
4 World Health Organisation Innovative Care for Chronic Conditions: Building Blocks for Action: Global Report 2002
WHO document no. WHO/NMC/CCH/02.01.
5 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee
Wellington May 2005
6 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010.
Business case EoI V38 AC 25Feb10 Page 32

To better integrate the support provided to patients by CNSs, allied health and medical
centres, eg. through better communication and information sharing.
To link with the activities described in the health promotion work stream.
The expected outcomes from this programme are set out in the table below.
Outcome measures – for all and for Māori
Indicator Baseline Target – Yr 1 Year 2 Year 3
% diabetes HbA1c

staff, allied health, residential care, home care agencies etc. This includes
InterRAI and other assessments.
- A triage function for logging all cases and sending simple routine cases directly
to the appropriate service while ensuring complex cases receive multidisciplinary
assessment,, case management through Chronic Conditions Programme and/or
CareLink, and/or referral to specialist services
- Clear, agreed protocols for accessing services
Co-locate Care Link with the IFHC, and link staff to specific primary health teams,
thereby giving those teams easy access to expert assessment (interRAI), communitybased
support packages and a case management function for people with long-term
disabling conditions.
Set up a restorative home-based support service based on need, accessed through
CareLink and closely linked to primary and community health services,
Make best use of specialist Health of Older People (AT&R) resources:
- set up clear pathways to ensure timely transfer to specialist services for frail
older people and anyone with a stroke
- a greater proportion of AT&R staff time available for consultation and support
for primary health services, home care services and residential care.
A three year implementation plan to achieve these objectives has been developed and is detailed
in the Appendix Eleven.
5.4.7 Link with Secondary services/health pathways
HealthPathways is web-based information system developed by Canterbury DHB Planning and
Funding in conjunction with local clinicians. GPs and hospital clinicians identified the importance
of current information in securing the best care for patients within existing constraints
(workforce and fiscal) and developed HealthPathways to provide this information, with a primary
focus on general practice care.
Currently, the primary care system on the West Coast is not in a good position to take on clinical
tasks currently performed in secondary care settings. Similarly, Greymouth hospital services
are generally staffed on a capacity model – in which staff costs do not vary with reductions in
activity. However, in the medium term, with the strengthening of the primary care sector, and
the development of more activity based staffing for some services, associated with a closer
working relationship with Canterbury DHB, there may be an opportunity to move some clinical
work from the hospital setting into IFHCs.
The main driver for implementing Health Pathways on the Coast at this point is to improve
consistency and quality of care. (see Appendix Seven for further detail).
Business case EoI V38 AC 25Feb10 Page 34

5.5 Enablers
A key aspect of this business case is greater integration of services. Currently, medical centres
on the one hand, and community nursing and allied health and mental health on the other,
operate as mostly separate, parallel systems, even though their respective patient cohorts
overlap significantly. This separateness is underpinned and exacerbated by several structural
factors - the various sets of services use different, unconnected information management
systems (and for different purposes), are housed in multiple, separate buildings, and are owned
& operated by various different entities with very different drivers and constraints. This
project envisages changes in each of these three areas (information technology, facilities,
organisational structures) as key enablers of change.
5.5.1 Future facilities
Renovated or new facilities will be a key enabler of better integration of services in many parts
of the West Coast region. This business case entails two smaller and two larger facility
projects.
The first smaller project is in Greymouth, Grey District, where a proto-IFHC is emerging in the
form of Greymouth Medical Centre's rural primary health training facility. This 'academic
practice' is to be located on the Greymouth Hospital site next to the Emergency Department
(ED). In it, health professionals (and health professionals in training) will work across the
primary practice and the ED. This practice will be operational from 1 July '10.
The second smaller project is in Franz Josef in South Westland, Westland District, where a
joint DHB/St Johns Ambulance facility on St Johns' land is proposed. This facility is larger
than the four other clinics in South Westland, and is likely to become the hub of the South
Westland practice.
The first of the larger projects is in Westport, Buller District, where existing medical centre
and hospital facilities, though located on the same site, are widely dispersed and in various
states of poor repair. The aim is to build a brand new, substantive IFHC, to replace the existing
medical centre and hospital buildings, as the hub of IFHC services district wide for the
foreseeable future. This facility is likely to be a 2011/12 project.
The final project, and the largest and most complex, is the substantive IFHC proposed for
Greymouth. It will subsume/replace the proto-IFHC described above, and is envisaged to bring
the three Greymouth medical centres, various other private providers and the DHB's community
nursing, allied health and community mental health services all together into a single integrated
facility. The IFHC could possibly be located on the Greymouth Hospital site, and even be
physically connected to it. This project, if built on hospital land, would need to dovetail with
the proposed redevelopment of Grey Base Hospital - from which arises some of the complexity
of this project.
Business case EoI V38 AC 25Feb10 Page 35

Appendix Thirteen gives considerably greater detail re these proposed facilities, together with
associated development timelines & funding sources.
5.5.2 Future information systems
One of the key elements of the West Coast Integrated Family Health Centre project is the
electronic integration of health services, supporting an integrated model of service delivery
across a range of geographically isolated service delivery locations.
We will ensure that the right level of access to clinical information is available at each point of
care encountered by patients, and that all appropriate clinical information follows the patient
from carer to carer as they travel through a patient centred network of care, all in a way that
minimises waste and duplication and whist safeguarding patient privacy. Activities to support
this approach include shared electronic clinical records between primary and community
providers, hospital clinicians being able to access primary care clinical records, primary clinicians
accessing summary information in the secondary care system (eg. discharge summaries,
diagnostic results), medical telemetry (eg. videoconferencing, remote consultations and remote
diagnosis).
An individual‟s health information is a taonga – it has great value and is sacred to them. It is
therefore essential to ensure that health information is secure and that a patient's wishes are
adhered to regarding its availability. The PHO and DHB will develop clinical audit protocols and
processes that ensure use is monitored and inappropriate access detected.
This fits with national strategies around the development of integrated Electronic Health
Records (EHR) and with patient access to the same. However, West Coast does not propose to
be a leader in these major developments. Our approach is more tactical, as described in
Appendix Fourteen, but this approach places us well to implement integrated EHR when it
becomes available.
Further information on IT support is provided in Appendix Fourteen.
5.6 Clinician engagement
A wide range of clinicians from general practice, community nursing, allied health and secondary
care have been involved in the development of this plan:
Establishment of large advisory group including range of disciplines from community and
hospital based services that met weekly over three months to provide input and
feedback.
Involvement of a large number of clinicians in each workstream (see details within each
work plan in the appendices).
Business case EoI V38 AC 25Feb10 Page 36

Two rounds of meetings with front line general practice teams, particularly focusing on
models of care.
Wide dissemination of draft documents for input.
Input over three meetings of the PHO Clinical Governance Committee which includes
clinicians, lay and iwi representatives.
Input from the Primary Secondary Care Liaison (GP Liaison) committee at two meetings
that focused on the EoI.
One-on-one meetings with private practice owners.
Meetings with community pharmacists.
Two open meetings with Senior Medical Officers.
Open meeting with all hospital based clinical leaders.
Of note in this process was the acceptance by the majority of clinicians of the need to change,
the willingness to embrace new models of care that provide better care (continuity, consistency,
co-ordination), sooner care (improved access with decreased waiting times) and more convenient
care (one stop shop approach). While there were some understandable concerns about what this
might mean for future roles and working conditions, there was very little patch protection, a
willingness to look outside the square, and a commitment to work together to develop new
systems and processes of care.
Change management strategies are described further in Section 10.2. Project advisory and
reference group membership is detailed in Appendix Fifteen.
5.7 Community engagement
Given the time frames of this EoI direct community engagement has been less than ideal.
However the following consultation activities were able to take place:
Presentation and discussion of the EoI with the DHB Board at two board meetings.
Detailed discussion of the EoI papers at three PHO board meetings (on the board are
representatives from the three Coast TLAs, representatives from both runanga and the
Māori provider).
Input over three meetings of the PHO Clinical Governance Committee which includes
community, and iwi and Mori provider representatives.
Representation on the EoI Advisory group from NGOs, Māori providers, DHB General
Manager Māori.
Open meeting with NGOs to explain the process and receive their feedback.
Meeting with Greymouth mayor.
If and when the business case is approved, wider community consultation will need to be
undertaken regarding a number of the aspects that this business case envisages and/or
proposes should change (in line with the DHB's statutory requirements). Given the West Coast
Business case EoI V38 AC 25Feb10 Page 37

community's keen interest in their health services, and the scale of changes proposed, it will be
important to engage fully with the community.
In the implementation phase, each IFHC will establish a community reference group or link into
established community engagement groups who can assist in the development of plans for their
districts. These groups will include local mayors (or their representation), community leaders,
business leaders and iwi leaders.
5.8 Evidence for this model
A number of reports and papers have informed the development of the overall model of care:
The 2008 WHO report on Primary care: Now more than ever 7 stresses the overall importance
of a strong primary heath sector and in particular the need to bring care closer to the people,
the importance of primary care taking responsibility for the health of a defined or enrolled
population, and the need to strengthen the primary care providers‟ role as co-ordinators of care.
The paper on primary healthcare service models, produced by the Primary Health Care Advisory
Council 8 , was helpful in developing a model for stratifying the different types of care needed by
the population. Well people with simple problems need fast and efficient care by either a GP or
nurse. Complex long term problems need a proactive approach, often the input of a
multidisciplinary team and a defined key worker. The trick is to keep the efficiencies of
traditional general practice while moving to a model of care that works better for those with
complex problems.
In regard to nurses taking on roles traditionally done by GPs, much as been written that
suggests that moves in this direction can be safe and appropriate for patients. Horrocks et al 9
concluded that for patients requesting same day appointments for minor illness that health
outcomes were equal and patient satisfaction better for nurse practitioners than for GPs.
Consultations were longer and more investigations ordered. On the other hand Cochrane
recently published an extensive review that concluded 10 :
“The findings suggest that appropriately trained nurses can produce as high quality care
as primary care doctors and achieve as good health outcomes for patients. However, this
conclusion should be viewed with caution given that only one study was powered to assess
equivalence of care, many studies had methodological limitations, and patient follow-up
was generally 12 months or less.
7 WHO report on Primary care: Now more than ever, 2008. Pg52
8 Primary Health Care Advisory Council. Progress Report of the Council‟s work to provide advice to the Ministry of
Health and District Health Boards on Primary Health Care Service Models. Nov 2009
9 Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can
provide equivalent care to doctors. BMJ 2002; 324: 819-23.
10 Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care.
Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub2.
Business case EoI V38 AC 25Feb10 Page 38

While doctor-nurse substitution has the potential to reduce doctors' workload and
direct healthcare costs, achieving such reductions depends on the particular context of
care. Doctors' workload may remain unchanged either because nurses are deployed to
meet previously unmet patient need or because nurses generate demand for care where
previously there was none. Savings in cost depend on the magnitude of the salary
differential between doctors and nurses, and may be offset by the lower productivity of
nurses compared to doctors.”
The results of the changes of the model of care outlined in this plan will be monitored carefully
in regards to both patient safety and cost to the health system.
The need for new models of integrated care for the aging population and those with long term
conditions has been well described by Rosen and Ham 11 :
“With an aging population and an increasing prevalence of chronic disease, ever more
people require care and support services from organisations that cross the boundaries
of health, social care, housing and voluntary organisations. A wealth of studies report
that people with chronic, complex health problems – particularly older people – are often
confused by the array of services they are faced with, receive duplicate interventions,
and find it hard to understand where to turn with specific problems. They value
initiatives to co-ordinate care and simplify their journey through the health and social
care systems.
Equally, with pressure to deliver elective care in community settings and prevent
avoidable ill health, integration and collaboration between generalists and specialists –
GPs, consultants, specialist nurses and other clinicians – is increasingly important.”
They advise that any project involving integration of services:
Makes improved patient care the main objective of every proposal.
Develops clearly articulated and shares goals.
Involves local primary care networks and clinicians in developing the strategy.
Takes time and effort to build the relationships, trust and clinical leadership required in
integrated teams.
Measures clinical and social outcomes so that the effect of changes can be reviewed and
programmes modified.
Is careful to unbundle the true costs of any services before devolution occurs.
Develops robust governance arrangements from the start.
Establishes the right incentives for services and clinicians to want to be involved.
11 Rosen R, Ham C. Integrated Care: lessons from evidence and experience. Report of the 2008 Sir Roger Bannister
Annual Health Seminar by R Rosen, Nuffield Trust , C Ham, University of Birmingham
Business case EoI V38 AC 25Feb10 Page 39

Similarly Glendenning 12 observes that integration is more likely when the following are present:
joint goals
tight knit highly connected professional networks
high degree of mutual trust
joint arrangements which are part of „core business‟ rather than marginal integration at
the edges
joint arrangements covering operational and strategic issues and shared or single
management arrangements.
Degeling and Erskine 13 describe the importance of changing governance arrangements if true
integration of services is to occur:
“Efforts to establish and maintain networks [voluntary connections across
organisational boundaries] are often purely rhetorical. …all too often tangible
achievements on the ground are minimal …” (pg 35) … “Despite their membership in a
network, for most network partners their employing organisation remains their primary
affiliation.” (pg 36)
“Put simply, effective joined-up “local-to-local” collaboration requires equivalent joinedup
governance at the centre …” (pg 36)
“… there is evidence showing how trust and network stability depend on the extent to
which network partners (by way of contracts) have formalized what they can expect of
each other and have established robust governance arrangements through which
partners can be held to account. … These findings suggest that a network‟s
effectiveness depends to a large extent on the degree to which its membership has
been able to institutionalize both its internal operations and its independent existence
from its sponsoring organisations.” (pg 37)
“… the more that service settings (as between primary, acute, community and social
services) are constituted as separate and distinct organisations, the more beliefs will
differ about what should be done and who is best placed and equipped to do it. The
“service gaps” than then result are unlikely to be resolved by, for example, “better
networking”. Because the new service models for long-term conditions of necessity
challenge the biases of existing approaches to service delivery in acute, community and
social care settings, mere administrative solutions (such as the establishment of a
network) are rarely able to produce what is required. Rather policy and funding
authorities are likely to find that success will depend on the extent to which they have
set in place new institutional arrangements and patterns of resource allocation … that
will support the required forms of service integration between different service
settings.” (pg 41)
12 Glendenning, C (2002) „Breaking down barriers: integrating health and care services for older people in England‟,
Health Policy 65: 139–151.
13 Degeling P, Erskine J. Chapter 2. New models of long-term care and implications for service redesign. In Rechel B,
Wright S, Edwards N, Dowdeswell B, McKee M. Investing in hospitals of the future. World Health Organisation, on
behalf of the European Observatory on Health Systems and Policies Investing in hospitals of the future. 2009
Business case EoI V38 AC 25Feb10 Page 40

Nick Goodwin, Kings Fund 14 , in his recent presentation to the Ministry of Health concluded from
the international literature that:
“There is a lack of rigorous evaluations of polyclinics in other countries. Contextual
differences are important.
Co-location of professionals is not sufficient to guarantee integrated care - in the
same polyclinic, and between polyclinics and hospitals.
Risks to professional development and motivation.
Issues of patient choice and continuity of care, and how these are to be
safeguarded within a polyclinic-based system
Caution needs to be exercised in basing policy on international experience. “
His advice for successful integration was:
“Strong clinical leadership – quality focus
Team working
Cluster services & diagnostics around patient needs
Investment in change management & process redesign
Maximise benefit of new technologies and IT”
The writings of these people have guided the development of the models of integrated care in
this business case.
In addition a large number of other reports and journal articles are referred to in the Evidence
section of each of the work plans in the appendices.
5.9 Quality, safety and evaluation
Quality philosophy
The integrated family health system will take a quality improvement and systems
approach to all activities.
Quality improvement will be an integral part of the annual business plan, for each IFHC
and the overall organisation.
The focus will be on activities that relate directly to improved health outcomes and
reducing inequalities.
Quality framework
The framework used to categorize quality improvement activities is as follows 15 :
14 Nick Goodwin. Powerpoint presentation to Ministry of Health, Wellington. 15 March 2010
15 Adapted from the Voyage 2 Quality in primary care framework being developed by the Wellington School of Medicine
Business case EoI V38 AC 25Feb10 Page 41

Structure Process Outcomes
Facility environment Clinical care
Health status
Facility systems
Relationships
Equity
Patient experience
Cost
The following table demonstrates expands on this by identifying which aspects of the quality
framework are addressed by the various work plans:
Domain Quality activity Work plan
Structure – facility environment Cornerstone accreditation of each IFHC Workforce
Structure – facility systems QI teams and clinical governance systems
in each IFHC
Better after hours arrangements
Process - clinical care HealthPathways care guidelines
Electronic decision support for LTCs
MDT Professional development activities
Active feedback loops
Patient pathways
Process - relationships Core general practice teams
Facilitated planning sessions
MDT teams
Shared mental health assessments
Integrated health promotion activities
Outcomes- health status PHO Performance Programme indicators
Long term condition programme
indicators
Public health indicators
Outcomes - equity All access and clinical indicators reported
for Māori and rest of population
Outcomes – patient experience Measure access delays
Develop a community satisfaction
questionnaire
Outcomes - cost Align clinical and financial incentives
Monitor effects of changes to model of
care on finances
Workforce
Acute care
HealthPathways
Long Term
Conditions
Workforce
Workforce
Integration:
community based
services
Mental Health
Frail elderly
Direct access to
diagnostics
Core general
practice care
Integration:
community based
services
Mental health
Frail elderly
Mental Health
Keeping People
Healthy
Workforce
Long Term
Conditions
Keeping People
Healthy
Core general
practice care
Long Term
Conditions
Core general
practice care
Referred services
Business plan
Business case EoI V38 AC 25Feb10 Page 42

Quality domains
Each new initiative will be assessed to ensure that the following domains of quality have been
addressed 16 :
evidence based
patient centered
organisational and staff competency and capacity
outcomes and Continuous Quality Improvement approach
financial viability.
Safety
The following safety initiatives are part of this plan:
Significant event auditing (a required aspect of Cornerstone Accreditation).
Safe clinical care: all primary and community providers caring for the same patients use
the same electronic clinical notes.
Safe prescribing: hospital discharge medications copied to pharmacies and adopting
electronic prescribing when available.
Safe feedback: The development of active feedback loops so that any concerns about
the quality of patient care will be fed back to the health providers concerned in a
constructive, educational environment.
Monitoring and evaluation
The PHO has a strong track record in evaluating programmes regularly (either internally or
externally) particularly any new or resource intensive initiative.
The work plans in the appendices all have associated output and outcome measures (with
baselines and targets) that can be used for both quality improvement and evaluation purposes.
Regular monitoring and reporting against these measures will become part of the regular PHO
quarterly report.
In addition every six months a half day 'review of progress' workshop will identify any early
risks to the successful implementation of the plan, and address any issues that have arisen.
We have supported the application to the Health Research Council by Dr Jeff Foote and
colleagues at the Institute of Environmental Science and Research (ESR) Ltd to carry out a
systems analysis on the effectiveness of this business case.
16 Adapted from the RACGP Quality framework http://www.racgp.org.au/qualityframework
Business case EoI V38 AC 25Feb10 Page 43

6 Business model
6.1 Business concept
The business concept involves the development of Integrated Family Health Centres (IFHCs)
based at Westport, Greymouth and Hokitika, with satellite clinics at the surrounding rural
centres. The IFHCs would be run by the West Coast Integrated Family Health Service (IFHS).
The preferred options for the future organisational structure of the IFHS involve a not-forprofit,
non-government organisation, which may or may not be the PHO in a modified form, or a
new entity jointly owned by the existing PHO and DHB. For the sake of brevity, these various
options are shortened to "the IFHS" in this document, and that phrase should be read as
"whatever form of NGO/Trust takes on the provision of community/primary services in the
future". The IFHS would employ many staff and contract with others. The IFHS would also
provide district wide community services that are not based at a particular IFHC. Over time
more services would be devolved to the IFHS, as it builds experience and improves
performance.
The range of services to be provided in and through IFHCs comprises:
the services historically provided by general practices - management of acute and
chronic primary presentations by enrolled patients
the services historically provided by the non-hospital/community based subset of the
DHB provider arm - district/community nursing and allied management of complex
patients, including post discharge.
The building of new facilities is likely to be required in Greymouth and Westport, while
renovations will be required in Reefton. Facilities changes in Hokitika and South Westland are
not planned at this stage.
Services will continue to be delivered in each of the three Territorial Local Authority districts:
Buller (Westport), Grey (Greymouth) and Westland (Hokitika). Current smaller/outlying clinic
locations include:
Karamea
Ngakawau
Reefton
Moana
Whataroa, Hari Hari, Franz Josef, Fox Glacier and Haast.
The approach is described in broad terms in the schematic over page and then reviewed in more
detail below.
Business case EoI V38 AC 25Feb10 Page 44

Preventative
Acute
LTC management
Restorative
West Coast Integrated Family Health Network
West Coast DHB services: Grey Rural Hospital Centre of Excellence, Mental Health, ATR, other secondary services
West Coast PHO District wide community health services: clinical nurse specialists, some allied health,
Buller IFHC
Greymouth IFHC Westland IFHC
Centred on Westport, outreach to Karamea, Ngakawau, Reefton. Pop 10,000, budget $$$$$ Nominal
budget holding for referred services pharms, labs…
Infrastructure: Integrated reception, common scheduling, 1 pt record, 1 manager, 1 nurse leader, 1 GP
leader, integrated policies & processes, common catchment.
Core Primary & community team
Staffing
Programs
Medical staff: GPs/rural hospital medicine specialists and nurse practitioners
Nursing staff: practice nurses, rural nurses, district nurses, well child/school
nursing, , enrolled nurse/aids,
Allied health: physiotherapists, midwives, pharmacist, mental health therapist,
MRTs,
Support: community health worker/navigator / kaiawhina roles
Administration: reception, office manager
Service co-ordination: NASC, discharge planning, LTC care management, Immunisation outreach,
MH assessment and co-ordination
Home based care: personal Inpatient beds Pharmacy dispensing services, medication
care, MOW
reviews
Mental health services: local CMHT, link to primary MH, visiting MH specialist teams
Visiting specialist clinics (medical, nursing, allied health).
Visiting Age care AT&R
Centred on Greymouth,
outreach to…, pop 13,500,
budget $$$$$$
As for Buller – services
customised in size & range
to fit local population
needs
Centred on Hokitika with
outreach to …., pop
8,500, budget $$$$$
As for Buller – services
customised in size &
range to fit local
population needs
Shared District Wide Support Services
Clinical leadership: nursing, medical & allied health professional development, clinical governance, supervision, performance review, education, standing orders, etc
Service commissioning: needs assessment, programme development and implementation across localities for LTCs, acute/after hours, mental health, etc,
Corporate services: Finance, IS, HR, property, supply chain management.
= provided by DHB = provided by IFHS
Business case EoI V38 AC 25Feb10 Page 45

Preventative
Acute
LTC management
Restorative
West Coast Integrated Family Health Network
West Coast DHB services: Grey Rural Hospital Centre of Excellence, Mental Health, ATR, other secondary services
West Coast PHO District wide community health services: clinical nurse specialists, some allied health,
Greymouth IFHC
Buller Westland
Centred on Greymouth, some outreach to Reefton?. Pop 14,000, budget $$$$$ Nominal budget holding for referred services pharms, labs…
Infrastructure: Integrated reception, common scheduling, 1 patientt record, 1 manager, , 1 nurse leader, 1 GP leader, integrated policies &
processes, (common catchment); charter committing multiple tenants in facility to collaborate on model of care
Core Primary & community team
Staffing - 3 separate medical centres initially, divided into teams of 5-7 (i.e., with 2-3,000 patients per team)
Programs
Greymouth Family Health
2,000 patients; 1 team
Medical staff: 1 GP
Nursing staff: 2 practice nurses
Greymouth Medical Centre
6,000 patients; 2-3 teams
Medical staff: 3 GPs
Nursing staff: 6 practice nurses
High St Medical Centre
6,000 patients; 2-3 teams
Medical staff: 3 GPs
Nursing staff: 6 practice nurses
Nurse practitioners
Nursing staff across the 3 practices: district nurses, well child/school nursing, enrolled nurse/aids,
Allied health (public & private) across 3 practices: physiotherapists, midwives, pharmacist, MH therapist, MRTs
Support across the 3 practices: community health worker/navigator/ kaiawhina roles
Administration across the 3 practices: reception, office manager
Service co-ordination: NASC, discharge planning, LTC care management, Immunisation outreach, MH assessment and co-ordination
Home based care: personal care, meals on
Pharmacy services, medication reviews
wheels
Mental health services: local CMHT, link to primary MH, visiting MH specialist teams
Visiting specialist clinics (medical, nursing, allied health).
Visiting Age care AT&R
Shared District Wide Support Services
Clinical leadership: nursing, medical & allied health professional development, clinical governance, supervision, performance review, education, standing orders, etc
Service commissioning: needs assessment, programme development and implementation across localities for LTCs, acute/after hours, mental health, etc,
Corporate services: Finance, IS, HR, property, supply chain management.
= provided by DHB = provided by IFHS
Business case EoI V38 AC 25Feb10 Page 46

Preventative
Acute
LTC management
Restorative
West Coast Integrated Family Health Network
West Coast DHB services: Grey Rural Hospital Centre of Excellence, Mental Health, ATR, other secondary services
West Coast PHO District wide community health services: clinical nurse specialists, some allied health,
Westland Virtual IFHC
Buller Grey
Covering both Hokitika and South Westland. Pop 8,500, budget $$$$$ Nominal budget holding for referred services pharms, labs…
Infrastructure:, common scheduling?, 1 pt record, co-ordinated management & clinical leadership (details to be determined), integrated policies &
processes, common catchment; current separate facilities remain (very different geography, and existing modern buildings, make a physical IFHC
unlikely; there's also already a high degree of integration of the nursing workforce in South Westland already)
Core Primary & community team
Staffing - 2 separate medical centres – with the Hub and integrated community services at Hokitika
Programs
Westland Medical
5,500 patients; 1-2 team
Medical staff: 2 GPs
Nursing staff: 4.5 practice nurses
South Westland
1,700 patients; 1 team
Medical staff: 1 GP
Nursing staff: 5 practice/rural/(district) nurses
Nurse practitioners
Nursing staff across the 2 practices: district nurses?, well child/school nursing, enrolled nurse/aids,
Allied health (public & private) across 2 practices: physiotherapists, midwives, pharmacist, MH therapist, MRTs
Support across the 2 practices: community health worker/navigator/ kaiawhina roles
Service co-ordination: NASC, discharge planning, LTC care management, Immunisation outreach, MH assessment and co-ordination
Home based care: personal care, meals on
Pharmacy services, medication reviews
wheels
Mental health services: local CMHT, link to primary MH, visiting MH specialist teams
Visiting specialist clinics (medical, nursing, allied health).
Visiting Age care AT&R
Shared District Wide Support Services
Clinical leadership: nursing, medical & allied health professional development, clinical governance, supervision, performance review, education, standing orders, etc
Service commissioning: needs assessment, programme development and implementation across localities for LTCs, acute/after hours, mental health, etc,
Corporate services: Finance, IS, HR, property, supply chain management.
= provided by DHB = provided by IFHS
Business case EoI V38 AC 25Feb10 Page 47

6.2 Locality Integrated Family Health Centres
Each locality IFHC would operate a comprehensive set of locality Multi Disciplinary Team
services under a unified management structure. In the first phase the likely components are:
primary care services
rural A&E services
rural inpatient medical services (other than Grey)
rural nursing services
clinical nurse specialists (incl. diabetes and respiratory education and management)
community / district / whanau / public health nursing services
immunisation services (inc HPV & outreach)
well child services (inc B4 school & VHT)
Carelink/service co-ordination services
home based care services
community allied health services
mental health brief intervention and co-ordination services
sexual health services.
In those districts where services are co-located, they are also integrated in the following
ways 17 :
single reception for all services
common scheduling, allowing staff to book patient appointments with each team
member, rather than „referring‟
1 patient management system and 1 (electronic) clinical record (using MedTech in the
absence of any other system)
1 operational IFHC manager (no separate „practice manager‟), supported by 1 nursing
leader, 1 GP leader, and team leaders for specific services (eg. mental health), also
supported by an office manager to cover admin requirements
shared clinical and management decision making
integrated policies & processes
shared continuous quality improvement and professional development systems
common catchment population/ boundaries
a single combined services budget, includes nominal budget holding for pharms and labs.
The locus of care is primary and community services, with access to other services (including
hospital services) co-ordinated through these teams. The locality manger is accountable for
financial and clinical outcomes hence all others are either subcontractors or employees of the
IFHC locality manager.
17 In the virtual Westland IFHC some of these integration activities will still be realised
Business case EoI V38 AC 25Feb10 Page 48

The core services are provided or purchased by the PHO. Some visiting specialists services are
provided by the DHB.
A number of other services could potentially be part of the IFHC. It is proposed that while
these may not be included in phase one, initiatives to promote integration and shared decision
making should commence in year one, on the understanding that a number of these might be
devolved to the IFHC in year three. Detailed planning around these will commence in year two.
Service
AT&R services
Maternity
Mental health
services
Outpatient services
NGO services
Aged residential
care
Transport services
Pharms, labs,
radiology
Development
Close working relationships in IFHC, possible future devolution
Close working relationships in IFHC, possible future devolution
Close working relationships in IFHC, future devolution subject to
achieving progress milestones
Input to service planning and development, possible devolution of some
first, follow ups and minor procedures
Close working relationships in IFHC, possible future devolution
Move to partial budget holding in NASC
Interface
Nominal budget holding with gain/loss sharing
6.3 Service outputs and outcomes
We have developed a population based activity model to derive the expected number of visits,
and service provision response for the major service categories given the population of each of
the TLAs, and the proposed model of care. This model requires further validating but provides
an indication of the FTEs required in each IFHC. Note that the model has not yet been
adjusted to reflect different rurality / travel times issues. Expected volumes of services are
shown in the table below:
Summary
Visits /year
Service visits /yr Buller Grey Westland Total
ACC 0.5 4,615 6,415 4,078 15,108
Immunisation 0.3 3,065 4,215 2,612 9,892
Scripts 0.5 5,000 6,900 4,415 16,315
General 3.7 37,900 51,000 31,930 120,830
Diabetes 0.1 668 845 559 2,072
CVD 0.1 760 930 597 2,286
COPD 0.0 328 397 257 982
B4 school chks 0.0 132 204 114 450
Sexual health 0.1 1,300 2,050 1,320 4,670
Pharms reviews 0.1 725 885 581 2,191
cvd risk asst 0.0 393 488 331 1,212
District nursing 0.7 7,080 8,730 5,600 21,410
Primary MH 0.1 1,058 1,436 954 3,447
Physio 0.3 2,830 3,770 2,506 9,106
Other - - - - -
Total 6.4 65,854 88,265 55,852 209,972
Business case EoI V38 AC 25Feb10 Page 49

The table shows that general, undifferentiated primary care consults are the biggest single
component of service in the IFHCs.
Based on the model of care described earlier in this paper, estimates of average required
minutes per visit, and the % of visits requiring intervention by the various types of health
professional have been developed for each service line (adjusted for age). This then generates
FTE requirements in total and for each IFHC, based on the district population.
Total required FTEs for the West Coast region are shown below
Summary
DHB total FTEs
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist Physio
ACC 1.4 - 3.6 0.5 0.8 - - 0.3
Immunisation 0.9 - 2.8 - - - - -
Scripts 1.5 - 0.4 0.5 - 0.7 - -
General 11.2 - 26.1 3.7 8.7 0.0 - 1.4
Diabetes 0.2 - 0.8 0.1 0.2 0.0 - -
CVD 0.2 - 0.9 0.1 0.2 0.0 - -
COPD 0.1 - 0.4 0.1 0.1 0.0 - -
B4 school chks 0.0 0.3 - - - - - -
Sexual health 0.4 - 1.0 0.1 0.3 - - 0.1
Pharms reviews 0.2 - - 0.2 - 0.7 - -
cvd risk asst 0.1 - 0.5 0.0 - - - -
District nursing 2.0 17.6 - - - - - -
Primary MH 0.3 - - - - - 2.3 -
Physio 0.8 - - - - - - 3.1
Other - - - - - - - -
Total 19.4 17.9 36.4 5.3 10.3 1.5 2.3 4.9
GP total 15.6
Total required FTEs for the Buller IFHC are shown below
Summary
Buller FTEs
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist PHYsio
ACC 0.4 - 1.1 0.2 0.2 - - 0.1
Immunisation 0.3 - 0.9 - - - - -
Scripts 0.5 - 0.1 0.2 - 0.2 - -
General 3.5 - 8.1 1.2 2.8 0.0 - 0.4
Diabetes 0.1 - 0.3 0.0 0.1 0.0 - -
CVD 0.1 - 0.3 0.0 0.1 0.0 - -
COPD 0.0 - 0.1 0.0 0.0 0.0 - -
B4 school chks 0.0 0.1 - - - - - -
Sexual health 0.1 - 0.3 0.0 0.1 - - 0.0
Pharms reviews 0.1 - - 0.1 - 0.2 - -
cvd risk asst 0.0 - 0.2 0.0 - - - -
District nursing 0.7 5.8 - - - - - -
Primary MH 0.1 - - - - - 0.7 -
Physio 0.3 - - - - - - 1.0
Other - - - - - - - -
Total 6.1 5.9 11.3 1.7 3.2 0.5 0.7 1.5
GP total 4.9
Business case EoI V38 AC 25Feb10 Page 50

Total required FTEs for the Grey IFHC are shown below
Summary
Grey FTEs
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist PHYsio
ACC 0.6 - 1.5 0.2 0.3 - - 0.1
Immunisation 0.4 - 1.2 - - - - -
Scripts 0.6 - 0.2 0.2 - 0.3 - -
General 4.7 - 11.0 1.6 3.7 0.0 - 0.6
Diabetes 0.1 - 0.3 0.0 0.1 0.0 - -
CVD 0.1 - 0.4 0.1 0.1 0.0 - -
COPD 0.0 - 0.2 0.0 0.0 0.0 - -
B4 school chks 0.0 0.1 - - - - - -
Sexual health 0.2 - 0.4 0.0 0.1 - - 0.0
Pharms reviews 0.1 - - 0.1 - 0.3 - -
cvd risk asst 0.0 - 0.2 0.0 - - - -
District nursing 0.8 7.2 - - - - - -
Primary MH 0.1 - - - - - 1.0 -
Physio 0.3 - - - - - - 1.3
Other - - - - - - - -
Total 8.2 7.3 15.4 2.2 4.3 0.6 1.0 2.0
GP total 6.6
Total required FTEs for the Westland IFHC are shown below
Summary
Westland FTEs
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist PHYsio
ACC 0.4 - 1.0 0.1 0.2 - - 0.1
Immunisation 0.2 - 0.8 - - - - -
Scripts 0.4 - 0.1 0.1 - 0.2 - -
General 3.0 - 6.9 1.0 2.3 0.0 - 0.4
Diabetes 0.1 - 0.2 0.0 0.0 0.0 - -
CVD 0.1 - 0.2 0.0 0.1 0.0 - -
COPD 0.0 - 0.1 0.0 0.0 0.0 - -
B4 school chks 0.0 0.1 - - - - - -
Sexual health 0.1 - 0.3 0.0 0.1 - - 0.0
Pharms reviews 0.1 - - 0.0 - 0.2 - -
cvd risk asst 0.0 - 0.1 0.0 - - - -
District nursing 0.5 4.6 - - - - - -
Primary MH 0.1 - - - - - 0.6 -
Physio 0.2 - - - - - - 0.8
Other - - - - - - - -
Total 5.2 4.7 9.7 1.4 2.7 0.4 0.6 1.3
GP total 4.1
The table below shows modeled versus current FTEs for the whole region.
Total DHB
Actual Budgeted Modelled c.f budget c. f. actual
GPs 16.4 24.3 15.6 -8.7 -0.7
Practice/rural nurses 26.3 33.0 36.4 3.4 10.1
reception /admin 22.0 22.0 19.4 -2.5 -2.5
District nurses 18.9 19.3 17.9 -1.4 -1.0
Business case EoI V38 AC 25Feb10 Page 51

Generally the modeled FTEs, although they are a reduction on budgeted GP numbers, reflect
current actual FTEs overall. However, some practices are well under the required GP numbers,
and some are over. This will take some time to work through.
Business case EoI V38 AC 25Feb10 Page 52

7 Governance, Ownership & Management
This business case assumes that a West Coast based entity, (probably not-for-profit,
non-government, e.g., a community trust) assumes responsibility for the operation of the
community based, non hospital services, currently operated by the DHB, including primary care
services. Such an Integrated Family Health Services (IFHS) entity will be able to implement
the degree of integration required to achieve the proposed model of care and realise the
required financial savings.
7.1 Options
Four governance, ownership and management options have been considered:
Option A – status quo
Option B - DHB cancels PHO contract, and absorbs PHO role into its own structures.
Option C - PHO assumes responsibility for current DHB primary and community services
and runs IFHCs and (former) DHB wide community services; PHO trust deed
and the make-up of its governance board changes to reflect its different role;
DHB retains planning & funding, and secondary (hospital) services delivery
roles.
Option D - DHB/PHO „joint venture‟ or (in the interim) alliance contract for delivery of
primary & community services; DHB retains planning & funding, and secondary
(hospital) services delivery roles.
The status quo option is not further described, as the prima facie case is that two entities
running parallel structures is not cost effective.
These options B, C and D are depicted in schematics below.
Business case EoI V38 AC 25Feb10 Page 53

Option B: DHB takes over current PHO functions
DHB Board & CEO
DHB
funder
DHB
secondary
services
Shared
corporate
services
GM primary &
community
Region-wide services
IFHCs
Under this option the DHB cancels the PHO contract and takes full responsibility for delivery
of integrated primary and community services.
Option C - PHO assumes responsibility for current DHB Primary & Community services
DHB Board & CEO
PHO Board
DHB
funder
DHB
secondary
services
Shared
corporate
services
GM primary &
community
Region-wide services
IFHCs
Under this option the DHB devolves to the PHO responsibility for delivery of integrated
primary and community services. The makeup of the PHO board, and its associated trust deed,
would need to adapt to this expanded role.
Business case EoI V38 AC 25Feb10 Page 54

Option D: PHO/DHB jointly owned Primary & Community services entity
DHB Board / CEO
PHO Board
DHB
funder
P & C Trust or
alliance contract
DHB
secondary
services
Shared
corporate
services
GM primary &
community
Region-wide services
IFHCs
Under this option the DHB and PHO Boards form an alliance either using contractual
arrangements or a joint venture entity, to achieve integrated management of primary and
community services. Over time, the continued need for the parent bodies could be assessed.
7.2 Assessing the options
In any of options B, C and D, a West Coast based entity assumes responsibility for the operation
of the community based, non hospital services, currently operated by the DHB, including primary
care services, and the current functions of the PHO.
The option of the PHO disappearing, and the DHB assuming responsibility for the entirety of
primary and community services (Option B) is not attractive to either the existing PHO or to
private providers. This option is also unlikely to assist the sector in managing within available
funding. It could also lead to less local influence and orientation, should the West Coast DHB's
understandable moves to work more closely with Canterbury DHB, lead eventually to its own
disappearance as an independent entity.
Therefore, most thinking has been focused on developing Options C and D. Both of these come
with some possibilities for interim steps and a staged approach. For example, it may be that the
DHB might continue to employ and remunerate staff, and the focus of effort in the first year
be on integrating actual service delivery (rather than on changing organisational structures).
The PHO and DHB boards have established a joint management and clinical working party to
consider the costs and benefits of the organisational options and to come up with firm
recommendations to their respective boards by 30 April 2010.
Business case EoI V38 AC 25Feb10 Page 55

8 Contracting arrangements
8.1 Role of the IFHS
The Integrated Family Health Service (IFHS) would lead the development of community and
primary care services, and would be accountable to the DHB for the financial and clinical
outcomes of the delegated services. It would work closely with the DHB to achieve a smooth
interface with secondary services, including the development of integrated care pathways
between primary and secondary services (building off the Canterbury DHB pathways). The two
would also share corporate support services in the interim.
The IFHS will both employ staff directly, and will contract with individual providers to achieve
the outcomes. It will establish district development and support services (in many cases jointly
with the DHB) to ensure professional development and support for specific workforce groups
(eg. allied health staff) and will put in place overall policies an processes (eg. use of HML to
triage all after hours calls, use of common standing orders policies). The IFHS will be in a good
position to compare performance between the three IFHCs and address issues at an early stage.
The IFHS also has the role of prioritizing service provision – taking the tough decisions about
what will not be provided so as to live within the available funding. An advantage of an NGO
entity in this respect is its inability to run continuing deficits and to rely on the Government as
a funder of last resort.
8.2 Annual health service plan
The proposal is that an annual health services plan be agreed between the DHB and IFHS,
setting out:
inputs
outputs
outcome targets
reporting schedule
information access arrangements
facilities leases
payments from and to the DHB
services to be provided
quality standards
sharing of corporate costs.
Business case EoI V38 AC 25Feb10 Page 56

The IFHS will need the ability to balance gains and losses across service lines. Hence a flexible
contract arrangement on a funding for outcomes basis is proposed. Specifically the provider will
have the flexibility to use gains in one service area to offset losses in others.
The DHB and IFHS provider will jointly review and reach agreement on major service delivery
decision that will impact on each other, including a review of inpatient services at Buller.
Provided satisfactory progress is being made, then mental health service responsibility will be
contracted to the IFHS from the end of year three. This will allow other changes to be bedded
in.
8.3 Contracted providers within IFHCs.
The proposed approach to engaging the workforce within the IFHCs has three major
components:
Existing private providers continue to operate as semi-autonomous businesses within
IFHCs, but will enter into a collective agreement (possibly an alliance style contract)
that involves shared corporate and facility based services, and collective vision, and
alignment of clinical processes, policies and pathways.
Other services within IFHCs will be provided by the IFHS.
In addition, the PHO will play a role as a facilitator of integration within each IFHC.
Business case EoI V38 AC 25Feb10 Page 57

9 Financial sustainability
9.1 Status quo financial situation
As noted in section 1, the WCDHB is projecting a sizeable deficit. The table below shows the
DHB and PHO forecast annual profit and loss for 2009/10 based on the six months actuals to
December 2009, using the proposed new service groupings 18 .
Overhead &
Annual forecast Revenue Expenditure Profit / loss
revenue
allocation
Profit / loss
after Oheads
Buller IFHC - 6,916,966 10,971,593 -4,054,627 311,079 -4,365,706
Grey IFHC - 4,786,998 5,501,697 -714,698 - 377,934 -336,764
Westland IFHC - 2,251,108 2,644,070 -392,962 125,677 -518,639
IFHC distict wide - 2,623,900 2,957,122 -333,222 207,653 -540,875
WCPHO - 5,186,089 4,666,855 519,234 - 519,234
Total primary & community - 21,765,061 26,741,337 -4,976,276 266,474 -5,242,750
Mental Health - 12,503,600 10,665,960 1,837,640 1,644,881 192,759
DHB secondary - 36,143,984 43,823,541 -7,679,557 640,689 -8,320,246
DHB corporate - 7,911,042 11,246,868 -3,335,826 - 3,335,826
0
DHB Funder - 51,726,777 46,304,029 5,422,748 783,782 4,638,966
Total DHB services - 108,285,403 112,040,398 -3,754,995 - 266,474 -3,488,521
Total West Coast - 130,050,464 138,781,735 -8,731,271 0 -8,731,271
Based on status quo revenue and expenditure, each of the IFHCs, plus the district wide service
would make a sizeable deficit. Overall, the estimated deficit for primary and community
services is $5.25 million, approximately 20% of current revenue. The PHO is forecasting a
surplus of around $0.5 million for the year, resulting from lower than anticipated uptake of
some of the LTC and other fee for service programmes – hence the status quo DHB loss on
these services is in the order of $5.75 million for 2009/10. At the same time, the DHB
secondary care services core deficit is about $8 million, partially offset by a DHB funder
surplus.
The reader should note that this projection is based on a 6 month snapshot, updated to
incorporate WCDHB finance team forecast as at end January 2010. Year end actuals for 2010
may vary from those projected. This table also does not incorporate any adjustments for the
expected DAP budget 2010/11 changes.
Overheads and internal revenue have been allocated using the 08/09 national pricing project
West Coast submission with minor adjustments.
If the business case is approved, the DHB and PHO will undertake a more detailed allocation of
direct and indirect revenue and expenditure to fully validate the new service groupings and
refine the P&L forecast.
18 Note that known duplicates in the DHB funder arm and PHO have been eliminated, but some may persist resulting in
double counting of both revenue and expenditure – this does not affect the profit/loss calculation.
Business case EoI V38 AC 25Feb10 Page 58

Of note, a large proportion of the current loss in community and primary care services is driven
from service provision in the Buller/Reefton Territorial Local Authority (TLA). This reflects
losses at both the medical centres and from the provision of hospital and residential care
services.
9.2 Addressing affordability
Clearly the projected losses are unsustainable. The DHB has indicated a target reduction in the
deficit of 50% at the end of three years, and 100% within 5 years. We have adopted a target
reduction of 65% of the primary/community deficit within 3 years, with full deficit eradication
within 5 years.
This will require tough decisions to be taken, and will inevitably involve reductions in services in
some areas, as well as efficiency and effectiveness gains.
The options for achieving these savings are still under discussion, and will be subject to
consultation, but the table below outlines the size of the possible gains that can be made over
three years based on a preliminary assessment.
The financial sustainability initiatives include:
$0.5m estimated to be able to be saved by reducing administration and management
FTEs through primary and community co-location and service integration.
$1.5m estimated to be able to be saved by service reconfigurations, relocations and
reductions.
$1.1m savings through adopting a team based model of general practice care and moving
to a 1:2000 GP ratio, partly offset by costs of $0.6m associated with moving to a 1:900
practice nurse ratio.
$0.23m estimated to be saved through reduced use of secondary care follow ups.
$0.1m from reductions in ASH admissions.
$0.25m from referred services management initiatives.
$0.5m gain to the community provider from a realistic price for rural inpatient bed
services.
Each of the possible initiatives has been scoped at a conceptual level, but will require further
work and some will require consultation and clinical validation before they can be confirmed.
Some savings could be made quite quickly, while others savings will not be realised until new
facilities are in place.
Transitional arrangements
The intention is that the DHB will provide transitional funding on an abating basis to cover the
deficit over the first five years of operation – at the end of which the operations will be
breakeven or better. The transitional funding reduces from $4.6m in year 1 to $1.3m in year 3.
Business case EoI V38 AC 25Feb10 Page 59

In early years, the IFHS community provider is likely to continue to purchase some corporate
services from the DHB, though it may need to assess the viability of doing so beyond the first
year, in order to continue its momentum towards breakeven.
The transitional funding, and resulting forecast revenue and expenditure are set out in the
table below:
Integrated primary & community revenue and expenditure forecast
IFHC + DHB wide community Start point year 1 year 2 year 3
Base revenue - 21,765,061 - 21,765,061 - 21,765,061 - 21,765,061
Service changes - 547,500 - 690,000 - 690,000
Transitional funding - 4,600,000 - 2,100,000 - 1,300,000
Total revenue - 21,765,061 - 26,912,561 - 24,555,061 - 23,755,061
Base expenditure 27,007,811 27,007,811 27,007,811 27,007,811
service changes - 142,500 - 2,479,992 - 3,316,420
Net expenditure 27,007,811 26,865,311 24,527,819 23,691,392
Profit / loss -5,242,750 47,250 27,242 63,669
9.3 Impact on the DHB
The DHB provider arm is currently incurring a loss of some $5.75 million on its primary and
community services. This loss would reduce to nil in year one as both the revenue and
expenditure are transferred to the PHO.
The DHB funder would incur new costs associated with paying the transitional funding amount
(starting at $4.6 million in year 1 and abating to $1.3 million in year 3) and a proposed higher
price for rural inpatient bed services to reflect the actual cost of provision.
Overall, in year 1 there is a net financial gain to the DHB of $0.5 million (representing the PHO
surplus contribution defraying current losses), while by year three the net fiscal gain for the
DHB increases to $3.95 million (ie. the difference between the current loss of $5.75m and the
forecast transitional funding of $1.3m plus about 0.5m in higher bed day prices). This equates
to around a 68% improvement in the fiscal impact on the DHB bottom line for these services.
Over the following two years the transitional funding amount would reduce to zero.
Critical assumptions
Important assumptions in this business case include:
Transitional funding support is made available from the DHB on an abating basis over 5
years.
Funding flexibility – to allow savings in one area to offset losses in others.
Savings on referred services and secondary care derived from changes to primary care
are passed back to the PHO/community provider to offset losses.
Business case EoI V38 AC 25Feb10 Page 60

The DHB delegates decision making on the service change/reduction proposals to the
PHO/community provider to expedite decision making (or takes financial responsibility
for any delays in approval).
The DHB will bear the cost of any redundancies of community based staff over the
initial 3 year period. From that point, responsibility will shift to the PHO/community
provider.
The DHB will retain ownership of major capital items such as hospital facilities, and the
PHO will pay for use of the same
Current revenue and expenditure associated with the provision of the identified
community service will transfer from the DHB to the PHO.
Decisions will be taken by 31 July 2010 on those service changes/reductions that will
require community/staff consultation before finalizing – so that changes can be
implemented before the beginning of year two.
Business case EoI V38 AC 25Feb10 Page 61

•
10 Implementation plan
10.1 Project governance and management
If either of Options C (devolution to PHO) or D (new joint entity) are chosen the two boards will
establish a subcommittee led by the two chairs to oversee the change. The subcommittee will
appoint an individual to take over the current PHO CEO and DHB community GM roles and will
oversee the development and implementation of a change plan.
The subcommittee will also establish a Project Office under the direction of the newly
established combined PHO CEO/GM community role to ensure best practice project
management of the intended changes, including:
task sequencing and critical path development
reporting
communications planning
financial monitoring
HR and legal input.
The advisory group that helped to create this business case will be maintained to advice on
aspects of the change programme.
The change programme will be governed using project alliancing principles, including:
transparent information sharing
shared risk/gain
integrated operational management of the change
alignment around a set of mutually agreed goals
agreed decision making processes
shared project values.
These principles will be agreed in a heads of agreement or alliance contract between the PHO
and the DHB.
10.2 Change management
The key drivers for change are:
Clinical sustainability: the current model of care in most health centres requires GP
numbers we have not been able to achieve consistently on the Coast for at least five
years, and leads to long waiting times for appointments (often > three weeks) and lack of
continuity and consistency of care.
Business case EoI V38 AC 25Feb10 Page 62

Limited integration of community services with primary care leading to lack of coordination
and consistency of care and some duplication of services.
Financial: primary care medical practices and community services owned by the DHB
contribute significantly to the DHB overspend each financial year. Hospitals in Reefton
and Buller together also contribute significantly to the DHB overspend each financial
year.
The barriers to change include:
Some primary care providers are overworked and lack energy for change.
GPs not having time to participate in planning workshops.
Some health providers are comfortable working within the current model of care and do
not see the need for change.
There are concerns that changes in the current model of care may lead to a decrease in
the quality of care.
Some staff may be concerned about erosion of current terms and conditions of
employment, and/or reduced support for professional development.
Recruitment on the coast is difficult, whereas health professionals generally find it easy
to get jobs elsewhere if they are not successful engaged in the new models of care.
The key change management task is to communicate to the community and health providers the
vision of Integrated Family Centres that provide better, quicker, more convenient health care.
The Toolkit for Change produced by the primary health care strategy implementation work
programme 19 , promotes the following steps when introducing change:
“Building the case for change, establishing a sense of urgency and using emergent
opportunities as a catalyst for change.
Confirming the vision for the future desired state and achieving widespread ownership
of the change / new vision.
Early engagement with key stakeholders, particularly those likely to be opposed to
change. It will be important to understand the perspectives of key stakeholders and
reframe the message accordingly.
Developing plans with short-term achievable objectives and also longer term objectives.
The short term goals are a stepping stone to the larger vision and create momentum.
Emphasising the win-win nature of the change, but also being transparent with regard to
uncertainties.
We note that the Toolkit for Change provides a very useful guide for change management in
health, and that it will be used as a guide in implementing the change programme, particularly:
Lewin‟s forcefield analysis, pg 17.
Nilakant‟s change framework, pg 19.
19 Primary health care strategy implementation work programme. Toolkit for Change. MoH, DHBNZ. April 2009
Business case EoI V38 AC 25Feb10 Page 63

Kotter‟s change framework, pg 25.
Dealing with the human aspects of change, pg 46.
What‟s in it for me framework, pg 48.
Change checklist, pg 49.
Roadmap for transformational change, pg 52.
10.3 Investing in change
West Coast PHO has agreed to make $750,000 available from its conserved resources to
facilitate change management associated with achieving the changes proposed. Further
resources may be provided if required.
Estimated change management costs are set out in the table below:
2009/10 2010/11 2011/12 2012/13
Project office 20,000 90,000 90,000
HR/organisation redesign 20,000 30,000
Facilitating new models of care 20,000 94,000 70,000 60,000
Implementing service
strategies (particularly
workforce & improved access
to diagnostics work streams)
93,000 100,000 90,000
Analysis of pharms and labs
30,000
spend & strategy development
Information systems
30,000 170,000
development
Other costs (legal, service
40,000 50,000 50,000 0
development, financial
modeling)
Total 130,000 557,000 310,000 150,000
Total over three years $1,147,000
The Ministry of Health is requested to provide funding of $130,000 in 2009/10, and $167,000
in 2010/11 and $100,000 in 2011/12 to facilitate the next steps in the business case.
No capital development costs are included in this business case as yet. Private capital options
to fund facilities development are being explored in the first instance.
Business case EoI V38 AC 25Feb10 Page 64

10.4 Key milestones
The table below shows the important milestones associated with the integration of primary and
community services.
Element Year 1 Year 2 Year 3
Integrating Primary
and community
services
Team based primary
care
Integrated management
and delivery of primary and
community services
through a single
management structure and
IFHC teams
Refinement of team based
primary care at Buller –
move to 1:2000 GP ratio
and 1:900 practice nurse
ratio
Cross DHB standardisation
of standing orders, use of
HML triage and service
pathways
Affordability Implementation of year 1
savings initiatives,
transitional funding of
$5.5m. Consultation on
service relocations and
reductions and decisions
taken
Facilities and colocation
Information systems Move allied health and
district nurses to
MedTech.
Allow access to primary
and hospital records to all
authorized DHB and PHO
practitioners
Implement privacy audit
arrangements.
Bedding in of new IFHC
teams. Implement new
policies and procedures
across
primary/community
Introduction of team
based care at Grey
practices
Implementation of year
1 savings initiatives –
transitional funding of
$3.5m
Co-location of services
at Buller
Full implementation of
InteRai.
Review possibilities for
integrated health
record in conjunction
with Canterbury.
Integration of mental
health services with
primary and community
health services
Refinement of team
based care at Grey
practices - move to
1:2000 GP ratio and
1:900 practice nurse
ratio
Implementation of year
1 savings initiatives –
transitional funding of
$1.5m
Co-location of services
at Greymouth
Pre- establishment milestones
Prior to 30 June 2010, the following milestones will be achieved:
agreement on organisation/governance option
agreement on project charter/alliance contract
agreement on final list of phase 1 services
agreement on revenue and expenditure to be contracted to the PHO/community provider
agreement on payment to DHB for corporate overheads/services
agreement on transition funding and abatement regime
Business case EoI V38 AC 25Feb10 Page 65

appointment of GM/PHO CEO to oversee the changes
establishment of project office and commencement of detailed project planning
agreement on year one Annual Health Services Plan (including funding, reporting, etc).
10.5 Objectives, key activities and workplans
The tables below map the objectives, key activities and associated workplans to each of the
eight major goals for Better Sooner More Convenient health care in the West Coast. This
provides an overall implementation roadmap for the interlinked series of projects.
Goal 1. Partnership with the community
Objectives Key activities Associated work plans
Community focus on wellness
and prevention
More self care skills leading
to decreased acute demand
Information campaign about after
hours arrangements
Information campaign about how to
access care at your general practice –
role of nurses etc
Collaborative approach to health
promotion
Focus on smokefree, immunisation and
health living
More health promotion in the
workplace
Health promoters based in IFHCs
Enhanced screening programmes
Community education about self care
for common conditions
Access to web based information
Coaching for frequent flyers
Self management support for those
with long term conditions
Core general practice
redesign
Acute Care
Keeping people healthy
Mental health
Long term conditions
Core general practice
redesign
Keeping people healthy
Long term conditions
Mental health
Frail older people
Goal 2 Sooner for patients: improving access to primary care
Objectives Key activities Associated projects
More flexible appointment
systems in general practices
Expanded nurse roles
Facilitated workshops with practices
to develop more flexible appointment
systems eg. triage of appointments,
phone appointments, email
appointments, varying appointment
length, extended hours clinics
Nurse triage
Nurses as first contact
Implementation of standing orders
Core general practice
redesign
Core general practice
redesign
Acute care
Business case EoI V38 AC 25Feb10 Page 66

Expanded pharmacy roles
Improving access for Māori
Improved after hours care
Nurse LTC clinics
After hours care
Development of team based
partnership model of care
Treatment of minor ailments
Medication utilisation reviews
Pharmacy facilitation
Māori nurse roles
Kaiawhina support
Lay navigators
HML Triage
Shared nurse and GP rosters
ED sends Triage 5 to GP
Work more closely with St John
Long term conditions
Workforce
Core general practice
redesign
Long term conditions
Workforce
Referred services
Core general practice
redesign
Long term conditions
Workforce
Acute care
Goal 3. Better for patients: improving continuity of primary care
Objectives Key activities Associated projects
Patient usually sees same
nurse and GP
Facilitated workshops with practices
to develop systems to enhance
continuity
Core general practice
redesign
Increase number of
permanent GPs on the Coast
and decrease number of short
term locums
Increase retention of staff
Coast wide system for recruiting GPs
and locums for all practices
Rural academic training centre
Support programmes for staff and
families of health providers
Workforce
Workforce
Goal 4. Better: Improving consistency of care
Objectives Key activities Associated projects
GPs and nurses support each
other to provide consistent
care
Provide consistent care for
those with LTCs
Care provided is consistent
across primary and secondary
care
Processes established in each
practice for dedicated time to
discuss care of individual patients
Expansion of LTC programme
Canterbury Health pathways adapted
for local situation and implemented
Dual staff appointments
Core general practice
redesign
Long term conditions
Health pathways
Business case EoI V38 AC 25Feb10 Page 67

Goal 5. Better: Improving co-ordination of care between general practices, hospitals and
community providers
Objectives Key activities Associated projects
More co-ordinated care
from the wider
multidisciplinary team
Co-ordinated support for
high needs patients with
LTCs
Integrated mental health
Better access to the range
of services for frail older
people
Closer links with Māori
providers
Closer links with NGOs
Closer links with pharmacy
Shared information
MDT clinically focused meetings in
each IFHC and satellite clinic
Lay navigators
Clinical nurse specialists based in or
linked with IFHC
Allied health providers based in or
linked with IFHC
One entry point to primary and
secondary care
Establishment of co-ordinator roles
Primary care involvement in discharge
planning, shared care arrangements
Community mental health workers and
psychiatrists see patients in IFHCs
Free primary care checkups and flu
vaccinations
Care link in IFHCs
Pathways of care
Case management with key clinical
workers and heath navigators
Processes for referrals to and from
Shared approach to LTC – CVD
screening
Regular monthly forum at each IFHC
Newsletters
Locum prescribing guide
Medication reviews
Written My Shared Health Record
for patients with LTCs
Web based patient record, eg.
MedTech Manage My Health portal
ED access to general practice notes
General practice access to Health
Views
Improved referral and discharge
information
Shared electronic clinical notes across
all providers based in IFHCs
Integration: DHB
community based
services
Integration: DHB
community based
services
Mental health
Frail older people
Long term conditions
Long term conditions
Integration: DHB
community based
services
IFHC facilities
Goal 6. More convenient: community based care in integrated family health care
Objectives Key activities Associated projects
IFHC established
All community based services located
in 3 integrated family health centres,
IFHCs facilities
Business case EoI V38 AC 25Feb10 Page 68

Devolved community based
services
with satellite clinics for more remote
areas
Community nursing, allied health, Care
Link devolved to primary care
Integration: DHB
community based
services
Devolved specialist
services
Direct access to secondary
services
Move some First Specialist
Assessments (FSAs) follow-ups to
IFHC when workforce issues solved
Expand direct access to radiological
investigations
Health pathways
Improved access to
diagnostics
Remote clinical support Telemedicine Acute care
Goal 7: Greater clinical leadership
Objectives Key activities Associated projects
Clinical engagement in
leading change
Shared training
Ensuring staff spread
across IFHCs maintain
professional relationships
Clinical leaders planning workshops
Enhanced practice Quality
Improvement (QI) teams
Training centre for rural excellence
providing multidisciplinary education
Peer support and development for
each professional group
Core general practice
redesign
Integration: DHB
community based
services
Workforce
Integration: DHB
community based
services
Goal 8: Living within available funding
Objectives Key activities Associated projects
Return DHB owned and
operated practices to
profitability
Return other DHB owned &
operated services to
profitability
Engage clinicians within practices in
identifying the problems & owning the
solutions
Reduce unnecessary and/or duplicated
management layers
Transfer practices to NGO (PHO)
ownership(?), and apply private sector
disciplines
Engage clinicians within services in
owning the problem and identifying
the solutions
Reduce unnecessary and/or duplicated
management layers
Transfer services to NGO (PHO)
ownership(?), and apply private sector
disciplines
Governance, ownership,
management
Governance, ownership,
management
Cost effective prescribing Analyse current spend for laboratory Referred services
Business case EoI V38 AC 25Feb10 Page 69

and laboratory testing
and pharmacies
Identify potential areas of saving
Implement programmes to align
clinical and financial drivers
10.6 Work in progress items
While this entire business case is a work in progress, we note that the following, in particular
require further work and consideration:
The linkages between Reefton and Buller /Greymouth based services.
The linkages between South Westland and Hokitika / Greymouth based services.
The nature of the future assessment and care co-ordination role/function at each IFHC
relative to LTC management, frail elderly service co-ordination and mental health.
The size and timing of service related savings.
The organisational structure and governance arrangements.
The activity based FTE model.
10.7 Risks and Mitigations
The following risks and mitigations strategies have been identified.
Risk description
Mitigation
Service continuity
If clinical staff do not support the proposed
changes then they may move elsewhere,
jeopardizing service continuity.
Keep staff informed and apply best practice
change management techniques. Programme
adequate funding and time to achieve shifts in
models of care.
Workforce
Workforce may be unprepared to take on new
clinical tasks or to work in new ways.
Invest in workforce competency development.
Decreased integration between
primary/community and secondary care
Devolution of community services to a primary
care organisation may result in decreased
integration with secondary care.
DHB Financial impact
DHB may retain fixed costs in the form of
overheads and facilities and corporate
services, but with reducing revenue.
PHO Financial impact
PHO may inherit services that run at large
deficit, without ability to manage costs down.
Invest in purposeful development of clinical
pathways across primary and secondary care
using an engagement approach. Contract
SMOs to visit IFHCs and to deliver outpatient
services from IFHCs.
Allocate overhead costs to community services
and require PHO to purchase back from the
DHB those services for the initial 3 year
period.
Ensure change programme agreed prior to
transfer. Agree transitional funds to cover
deficit for the first 3 years.
Business case EoI V38 AC 25Feb10 Page 70

Appendices
Appendix One: Health Equity Assessment Tool - Integrated Family Health Centres ....................... 2
Appendix Two: Core general practice redesign ............................................................................................... 6
Appendix Three: Acute care................................................................................................................................ 18
Appendix Four: Keeping people healthy ......................................................................................................... 26
Appendix Five: Long term conditions ............................................................................................................... 38
Appendix Six: Integration - DHB community based services .................................................................. 52
Appendix Seven: Integration - HealthPathways .......................................................................................... 63
Appendix Eight: Improved access to diagnostics ......................................................................................... 71
Appendix Nine: Referred services.................................................................................................................... 79
Appendix Ten: Mental health.............................................................................................................................. 88
Appendix Eleven: Frail older people ................................................................................................................ 101
Appendix Twelve: Workforce ............................................................................................................................ 110
Appendix Thirteen: IFHCs - Facilities ........................................................................................................... 119
Appendix Fourteen: IFHCs – Information technology.............................................................................. 130
Appendix Fifteen: Project advisory and reference groups..................................................................... 139
Business case appendices V12 AC 25Feb2010 Page 1

Appendix One: Health Equity Assessment Tool -
Integrated Family Health Centres
1. What health issue is the programme addressing?
Access to better sooner more convenient primary health services.
Quality of service/care pathways through primary – community - secondary health
services.
2. What inequalities exist in this health area?
Despite year on year increases in PHO enrolments occurring at faster rate for Māori,
enrolment in primary care remains lower than for non Māori.
Māori enrolment in primary care is lowest in the Grey District.
Māori enrolled in primary care access GP/nurse appointments at a lower rate than
non Māori.
Māori are under enrolled and have lower utilization rates in some primary care
programs (eg. care plus, CVD annual reviews, immunisation) but not all (cancer
navigation services, diabetes annual review, youth sexual health, primary mental health,
green prescription).
Māori have poorer health outcomes in the majority of health outcomes monitored.
3. Who is the most advantaged and how?
Data would indicate that non Māori are the most advantaged, with higher enrolments and
higher access rates than Māori, they receive the benefits associated with primary
practice enrolment including:
VLCA fees
lower after hours fees
recall for screening, annual reviews and immunisations
access to programs including, smoking cessation, green prescriptions, brief intervention
counselling and self management education programs.
4. How did the inequality occur? (What are the mechanisms, by which this inequality was
created, is maintained or increased?)
The inequality was created, and is maintained through a variety of mechanisms including:
long term impact of colonization and the resulting education and economic disparities
lower enrolments in primary care
mainstream service effectiveness
Business case appendices V12 AC 25Feb2010 Page 2

ongoing GP shortage creating an environment where:
- it can take up to 20 days for a routine appointment, disadvantaging those with
more difficulty using the system
- a number of medical practices have had closed books, including at one stage all
practices in Greymouth (now only one of three), meaning those who were
unregistered could not register, compounding the inequalities as Māori are
disproportionately represented in the unregistered population
- consults can be rushed, which is not conducive for providing holistic whanau ora
services.
5. What are the determinants of this inequality?
Socio-economic, culture, living conditions, geographic location, social and community
influences and behavioural determinants all impact on the development and maintenance of
inequalities in primary care access, utilization and health outcomes.
6. How has the Treaty of Waitangi in the context of the New Zealand Public Health and
Disability Act 2000 been addressed?
Māori are entitled to the same health status as other West Coasters, and addressing the
existence of inequalities in enrolments, access and outcomes for Māori, requires a specific
and dedicated focus.
The Integrated Family Health Centre (IFHC) Model is a more holistic model of service
delivery, utilizing a greater range of health practitioners, including kaiawhina/navigators
within multi-disciplinary teams that are in turn more integrated with community and
secondary health services.
Ensuring Māori benefit more than non Māori, from the implementation of Integrated
Family Health Centres will contribute to reducing the existing inequalities in enrolments
and access to services and health outcomes. Employing specific Māori nursing positions
within each integrated family health centre, employing a kaiawhina to focus on improving
enrolments, developing Māori workforce, and increasing mainstream service effectiveness
by increasing cultural competencies among non-Māori staff are identified as the dedicated
focus to achieve.
7. Where/how will you intervene to tackle this issue? (use the Ministry of Health
Intervention Framework to guide your thinking).
The proposal intervenes at the Health and Disability Services level of the Intervention
Framework to improve health and reduce inequalities. Specifically:
Business case appendices V12 AC 25Feb2010 Page 3

Improving Access:
increasing co-location of a range of primary, community and secondary services
increasing multi-disciplinary working
implementing navigator/Kaiawhina positions to provide practical assistance to access
services
implementing Māori nursing positions within each integrated family health centre
increasing mainstream service effectiveness by increasing cultural competencies among
non-Māori staff
changing models of care to increasing nurse/allied health led services, including
advancing development of nurse practitioners and working understanding orders.
Improving pathways through care:
reviewing pathways across through primary, community, secondary services across a
number of disease states
navigator/kaiawhina positions implemented to „navigate‟ patients through care.
Take a population health approach:
matching services to identified health needs, including Māori health needs
increasing self-management education.
8. How will the intervention affect health inequalities?
Inequalities in enrolments and utilization of services will reduce with the interventions,
particularly with the focus on enrolment and access of the kaiawhina position, and the
increasing responsiveness of mainstream services with specific Māori nursing positions
within each Integrated Family Health Centre, and increasing cultural competencies among
non Māori staff.
Implementation of these initiatives will also reduce inequalities in health outcomes over
time.
9. Who will benefit the most?
Those enrolled in primary practice and utilizing primary health services will benefit the
most from access to better sooner more convenient primary health services and improved
quality of service and care pathways through primary-community-secondary health
services
Business case appendices V12 AC 25Feb2010 Page 4

10. What are the unintended consequences?
There is the potential that improving access to better sooner more convenient primary
health services and improved care pathways through primary, community and secondary
health services will increase inequalities if Māori continue to have lower enrolments, and
lower access rates to primary services.
11. What will you do to make sure it does reduce/eliminate inequalities?
To ensure that implementation of Integrated Family Health Services reduce inequalities in
enrolment, access and health outcomes for Māori, the following initiatives are included in
the business case:
Māori nursing positions will be established within each IFHC
a kaiawhina with a focus on increasing Māori enrollments and access to primary
services, including by providing practical assistance will be appointed in Greymouth
Māori workforce development
increasing cultural competencies among non Māori staff to improve mainstream service
effectiveness
increasing integration with kaupapa Māori health services
matching services to identified Māori health needs
increasing provision of culturally based self-management education
continuing to measure access to services and health outcomes with ethnic comparisons
so as to monitor improvements and make further changes as required.
The Steering Committee overseeing the development of the business case has included the
West Coast DHB (WCDHB) GM Māori Health and the CEO of Rata Te Awhina Trust,
kaupapa Māori health service. A review of the work of all 15 work-streams has been
undertaken by the WCDHB Māori health service staff.
12. How will you know if inequalities been reduced/eliminated?
The following measures will be monitored to measure if inequalities have been reduced or
eliminated:
Māori enrolment in West Coast PHO (WCPHO)
% of Māori not enrolled in the PHO
utilization of GP/nurse appointments
immunisation coverage rates: childhood and flu
cancer screening: breast and cervix
mental health assessments and brief intervention counselling
Long Term Conditions Programme enrollments and outcome indicators for
cardiovascular, respiratory and diabetes.
Business case appendices V12 AC 25Feb2010 Page 5

Appendix Two: Core general practice redesign
1 Aspirational statement
West Coasters will be able to access appropriate primary health care in a timely manner.
2 Project overview
This project addresses the important issue of access to core general practice care by
redesigning general practitioner, nurse and health assistant roles and medical centre delivery
systems, including appointment systems. The IHI Breakthrough Series PDSA quality
improvement model will be used as the change management tool.
This project also includes improving access to appropriate primary health care for Māori
through developing roles for Māori nurses and kaiawhina.
An expanded first contact role for community pharmacists is proposed.
This project does not include integration of general practice with other community based
nursing, allied health or NGOs, after hours care or recruitment and retention since these
aspects are covered in other plans.
3 Problem definition
In every consultation meeting with health providers from primary or secondary care, and with
community representatives, the following two problems were seen as the most important to
solve as part of this EoI process:
long waiting times to be seen
difficult for new arrivals to the West Coast to enrol in a health centre.
Other related issues commonly raised were:
lack of extended hours clinics to improve access for those with full time jobs
lack of continuity of care, ie. seeing a different GP or nurse each time
limited co-ordination/communication between GPs and nurses, sometimes resulting in
inconsistency of care
lack of community understanding of nursing roles and abilities.
Business case appendices V12 AC 25Feb2010 Page 6

It is common for people with an acute health problem wanting an appointment to be seen by a
GP, to wait three weeks to get an appointment in either Buller or in Greymouth (very urgent
adult presentations and sick children are seen sooner).
The perceived reasons for difficulties in accessing appointments are:
lack of permanent GPs on the Coast
heavy dependence on locums and difficulties at times attracting locums
GPs in DHB owned health centres are on MECA contracts and so have three half days
each week as non contact time
variable development of nursing roles.
General practice team roles
To counter the GP shortage a number of initiatives have already been implemented:
staffing remoter rural clinics with rural nurses as first line carers
increased role for nurses in providing long term condition management, carrying out
reviews and assessments and providing repeat prescriptions signed by the GP
nurses seeing acute patients and then slotting in to see a GP or asking GP to sign a script
as required
nurses seeing patients and providing medications under standing orders
GPs and nurses doing quick retrospective case note reviews of patients managed by
nurses
dividing the health centre enrolled population into subgroups with teams of one to two
GPs (one permanent, one locum) and two nurses per subgroup
phone triage of appointments to nurse or GP by either receptionist or by a nurse.
Currently in many places on the West Coast nurses are providing a significant proportion of the
kind of consultations that would elsewhere be done by GPs. While in some practices nurses with
advanced qualifications have been employed, there has been extensive nurse training and/or
standing orders have been implemented according to Ministry of Health guidelines, in others
practices nurses are taking on an expanded role in order to meet patient needs, without
adequate training, support or supervision.
Currently while there are no nurse practitioners with prescribing rights on the West Coast,
some nurses are working towards this qualification.
Community Pharmacy
The West Coast is well served by four community pharmacies who have assisted when GPs are
not available by:
managing minor ailments with over the counter (OTC) preparations
providing up to two weeks medication as a pharmacy-generated interim prescription
when a prescription for long term medications is required but the patient cannot get an
appointment
Business case appendices V12 AC 25Feb2010 Page 7

dispensing nurse generated, unsigned scripts with a formal agreement that a GP will take
full responsibility and sign within one week.
Māori access
Māori access to care, as shown by the percentage of the census population enrolled in a health
centre, has also been an issue, previously in the Buller region and now in Greymouth. For two
years a kaiawhina was employed by the PHO in the Buller region to enhance relationships
between the health centres and the Māori community.
4 Objectives:
The objectives of this plan are:
to improve access to first contact core general practice team care (access to long term
condition management is addressed in the Long Term Conditions project)
to reduce waiting times for general practice appointments
to improve continuity of care
to improve co-ordination of care
to develop a team approach with patients seen by GP or nurse according to health need
to implement the above through providing a facilitated learning environment for health
centres in each region to redesign their delivery systems to improve access and
continuity of care
to improve access to care through expansion of the role of community pharmacist
to improve access for Māori through health centres working closely with local kaiawhina.
5 Benefits and gains
Output measures
Indicator Baseline Target – Year 2 Year 3
Yr 1
Facilitated regional planning sessions 0 6 4 2
% of health centres with extended
0% 25% 50% 60%
hours clinics
% of health centres with drop in nurse 37% 50% 50% 50%
clinics for acute problems
% of health centres with weekly clinical 88% 100% 100% 100%
review meetings between GPs and
nurses
Number pharmacists dispensing using 0 0 4 6
„standing orders‟
Number of Māori nurses employed 4 5 6 7
Number of Kaiawhina employed 1 1 2 2
Business case appendices V12 AC 25Feb2010 Page 8

Outcome measures
Indicator Baseline Target –
Yr 1
Year 2 Year 3
Nurse:GP consultation ratio 0.78:1 1:1 1.2:1 1.5:1
Waiting time for adult with acute Same day Same day Same day Same day
problem, eg. short of breath, to be
seen
Average waiting time for adult needing
3 monthly check and script
Winter
10 days 7 days 4 days 2 days
Summer
5 days 4 days 3 days 2 days
% of health centres enrolling new
patients
88% 100% 100% 100%
Measure of continuity of care – to be
developed
% of Māori enrolled in PHO Buller: 95%
Gymth: 76%
Wstlnd: 95%
Number of triage 5 seen at Greymouth
ED 07.00-15.30hrs Mon - Fri
TBC TBC TBC TBC
Buller: 95%
Gymth: 85%
Wstlnd: 95%
Buller: 95%
Gymth: 95%
Wstlnd: 95%
43/week 40 35 30
Community satisfaction survey results TBC TBC TBC TBC
6 Deliverables / activities
The business case modeling around the financial sustainability of general practice assumes a
move to a strategy whereby experienced practice and rural nurses see most general patients
(including dispensing under standing orders), and GPs provide back-up support, supervision and
are available to see complex patients whose diagnosis and care plan is less clear. Currently a
version of this model of care is in place at some practices, but often in an unplanned way – as an
ad hoc response to a shortage of GPs. This model of care accepts that the West Coast
generally has ratios of 1 GP to 2000 patients, and provides the necessary supports in the form
of additional practice nurses and consistent policies and processes to make this model safe and
rewarding for patients and staff. However this model is not yet set in stone and if alternatives
are proposed that have as good or better outcomes in terms of access, safety of care and
financial viability, they will be considered.
This plan uses the IHI Breakthrough Series PDSA methodology to develop and implement plans
within each health centre, with sharing of ideas, progress and outcomes between health centres.
This methodology harnesses clinical leadership to develop and trial new initiatives using PDSA
cycles to Plan (a potential solution), Do (implement), Study (review the effectiveness of the
solution) and Act on the outcome (either try a new solution or imbed the trialed one so that it
Business case appendices V12 AC 25Feb2010 Page 9

ecomes business-as-usual). Input is also provided by expert speakers and reports of
successful initiatives in other places.
Implementation plan: to June 30
A. IHI PDSA cycles methodology to improve health centre delivery systems:
identify team(s) in each health centre to work on this project with at least one nurse,
one GP and the practice manager in each team
facilitate one workshop for health centre teams in both Greymouth and Westport
facilitate two team workshops with each health centre
identify the current patient pathway for common types of presentation to general
practice as per the Stratified Levels of Care model in the Primary Health Care Advisory
Council report 20 (see Appendix A)
reach consensus on the desired patient pathways (see Appendix B for potential change in
patient pathway for acutely unwell adult)
implementation of at least two PDSA cycles in each health centre that may include the
following initiatives to improve the patient pathway:
- increased role for nurses as first contact;
- triage systems for deciding who patient needs to see and length of appointment;
- GPs providing back up for a nurse team (patients make appointments with nurses,
GP provides input and advice at the end of nurse consultations);
- implementation of standing orders (see Acute Care plan);
- longer booked consultations with GPs for complex patients;
- GP and nurses divided into smaller teams within the health centre, each with its
own designated population;
- development of the nurse practitioner role within practice teams;
- regular clinical meetings of GP and nurse teams;
- shared review of clinical notes for high needs patients;
- e-mail and phone consultations;
- extended hours clinics during the week;
- drop in nurse clinics;
- development of a health assistant role;
- using Dr Info for recall letters;
- provide focused education for frequent flyers
development of data definitions and collection mechanisms for measuring continuity of
care and community satisfaction with services
identification of training needs of nurses and arrange for Nursing Post Graduate
Certificate Health Assessment paper to be delivered on the Coast in 2010 (see Acute
Care paper)
20 Primary Health Care Advisory Council. Progress Report of the Council‟s work to provide advice to the
Ministry of Health and District Health Boards on Primary Health Care Service Models. Nov 2009
Business case appendices V12 AC 25Feb2010 Page 10

determine ratio of nurses and GPs to patient population (see Workforce project)
address recruitment and retention issues (see Workforce Project).
B. Improving access and outcomes for Māori:
implement a time-limited Greymouth based version of the kaiawhina project that was
successful in engaging Māori in Buller with the medical centre there:
- ascertain roles of various players (health centres, Māori health provider, PHO);
- implement kaiawhina role to address Grey district enrolment of Māori;
- provide appropriate training and support
identify/recruit one Māori nurse in each practice. Develop part of her/his role to focus
on improving access and health outcomes for meeting the needs of Māori patients,
providing a whanau ora approach and improving Māori engagement in services and clinical
programmes
link health navigators in each health centre with Māori nurses so that they can provide
community based support for hard to reach patients.
C. Extended role for pharmacists
Formalise arrangements between practices and pharmacies for pharmacists to provide
interim prescriptions when GPs not available to sign prescriptions.
Year one:
A. IHI PDSA cycle to improve health centre delivery systems
Task
Four facilitated workshops in each health centre to review PDSA cycles
and implement new ones
Review progress on outcome measures and feed back into quarterly
planning sessions
Monthly meetings with health centre delivery systems redesign teams
to provide support
Three regional workshops to share ideas across health centres
Health centre newsletters to explain new systems
Develop community education programmes about care of common minor
ailments
By when
Quarterly
Quarterly
Monthly
August, Nov, Feb
August
April
B. Māori access
Task
Roles of Māori nurses defined
Kaiawhina commences
Review level of Māori enrolment
By when
July
July
Quarterly
Business case appendices V12 AC 25Feb2010 Page 11

C. Extended role for pharmacists
Task
Investigate pharmacy access to MedTech
Extend the Standing Orders aspect of the Improving Access to Acute
Care project to include pharmacists as follows:
In consultation with GPs select two conditions from the current
Westland Medical Centre Standing Orders documentation that
are appropriate for pharmacists.
Formalise process for pharmacists to assess patients, document
consultation, send copy of consultation note (formal GP referral
forms are currently in use at some pharmacies) and
prescription for retrospective signing to GP, review by GP and
further education provided as required.
Formalise a process for pharmacists to be remunerated.
Provide half day training session for first two conditions.
By when
March
May
Year two
A. IHI PDSA cycle to improve health centre delivery systems:
evaluate success of this project to date
identify remaining problem areas
continue facilitated health centre workshops where outcome targets are not being met.
B. Māori access:
continue to monitor increases in Māori enrolments each quarter
refine roles of Māori nurses, kaiawhina and health navigators.
C. Extended role for pharmacists:
evaluate success of standing orders pilot
identify whether more conditions should be added
provide further training as required.
Year three
A. IHI PDSA cycle to improve health centre delivery systems:
continue to report on outcomes
address any problem areas with more workshops.
B. Māori access:
evaluate impact; review & revise role/project as necessary.
Business case appendices V12 AC 25Feb2010 Page 12

C. Extended role for pharmacists:
identify whether more conditions should be added
provide further training as required.
7 Capability and capacity
This project will require dedicated time from health centre staff, particularly their Quality
Improvement (QI) teams. Currently they have limited time to engage so where possible their
time on this project will be back filled with locum cover. A skilled facilitator will be contracted
to assist with this project.
Capacity issues and desired numbers of GPs and nurses are addressed in the Workforce project.
Support and training will be provided for the kaiawhina.
Dedicated time from pharmacists will be required in order to provide greater first contact care.
8 Effect on inequalities
The development of Māori nurse and kaiawhina positions will improve access for Māori to
primary health care (see section on addressing inequalities).
9 Evidence for this initiative
The IHI Breakthrough Series is an evidence based quality improvement approach 21 . It has been
used in a number of settings with good results 22 and was successfully used on the West Coast in
2009 to implement the PHO Long Term Conditions Framework 23 .
Different models of nursing care and enhanced roles for nurses have been implemented
successfully internationally 24 , and in New Zealand 25 .
21 Wagner - find Wagner E, Austin B, Davis C, Bonomi A., Provost L, McCulloch D, Carver P, Sixta C. Quality Improvement
in Chronic Illness care: a Collaborative approach. J Q Improvement 2001; 27(2):63-80.
22 Daniel D. Norman J. Davis C. Lee H. Hindmarsh M. McCulloch D. Wagner E. Sugarman J. A state-level application of
the chronic illness breakthrough series. Joint Commission Journal on Quality and Safety. 2004; 30(2):69-79.
23 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010.
24 Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can
provide equivalent care to doctors. BMJ 2002; 324: 819-23.
Business case appendices V12 AC 25Feb2010 Page 13

Pharmacist minor ailments services have operated successfully in the UK (Scotland) for a
number of years.
The effectiveness of the kaiawhina role in improving Māori enrolments has already been proven
in the Buller region 26 .
10 Risk analysis
Risk Probability Impact Contingency plan
Staff do not have
time to engage
Medium High Arrange workshops in locations and at
times that suit practices.
Health centres
unable to implement
new systems
Medium High Health centre teams take lead in
developing plans.
Project manager visits each health
centre monthly to provide support and
identify early barriers.
Changes made do not
improve access
Low High Monitor results of PDSA cycles
quarterly and adapt plans as required.
Insufficient training
and support provided
to nurses
Medium High Provision of training in Health
Assessment and Standing Orders (see
Acute Care project).
Ongoing general professional
development provided (see Workforce
project).
At least weekly shared clinical
meetings.
Monitoring by clinical nurse leader.
Difficult to attract
Māori nurses
Low High Develop a whanau ora, holistic model of
care in health centres.
Provide Tiriti o Waitangi workshops to
other staff.
Pharmacists do not
have time to expand
their role
Medium Medium Assist pharmacists with recruitment
and retention.
25 McKinlay E. Thinking beyond Care Plus: The work primary health care nurses in chronic conditions programmes NZ Fam
Phys 2007;34(5):322- 7.
26 Cooke A. Evaluation: Improving Māori Access in Kawatiri. Jul 2009.
Business case appendices V12 AC 25Feb2010 Page 14

11 Engagement
Working group who developed this plan: Dr Greville Wood, Dr Anna Dyzel, Nigel Ogilvie RN, Dr
JD Naidoo, Hecta Williams, Marie West, Dr Paul Cooper, Pauline Ansley, Helen Reriti, Karyn
Kelly, Julie Kilkelly, and Kerri Miedema.
Other clinicians involved: Workshops were initially held in Greymouth and Westport, with all
nurses, GPs and practice managers invited. Follow-up meetings were held in each health centre
to refine the content of this proposal.
12 Organisational accountabilities
The change management process will be managed by the PHO in consultation with health centre
owners of all health centres; private and DHB.
13 Budget considerations
Costs from this plan include:
practice, district and regional change management support and facilitation
modeling and analysis of changes in model of care on practice viability
development/ adaptation and annual administration of community survey
kaiawhina employment (SIA).
Year one Year Two Year Three
Change management facilitation and
$74,000 $50,000 $40,000
support
Analysis of effects of changes on
$10,000 $10,000 $10,000
practice viability
Community survey $10,000 $10,000 $10,000
Kaiawhina ($60,000 from SIA Budget)
Total $94,000 $70,000 $60,000
These costs are included in the Investing in Change budget, Section 11.1 in the business case.
Estimated savings to health centres from changing the model of care are included in Section 9.2
of the business case.
Business case appendices V12 AC 25Feb2010 Page 15

Appendix A: Models of care from Primary Health Care Advisory Council report
Business case appendices V12 AC 25Feb2010 Page 16

Appendix B: Acutely unwell adult patient journey
Unwell adult: current situation
Makes appt
to see
nurse
• May wait several days for
appt
•Nurse may manage
consult
•May also need review by
GP – then or later
Unwell adult rings
for appointment –
3+ week wait for GP
Given
phone
advice by
nurse
Goes to
ED
•May be managed with
phone advice
•May need rptd ph calls
•May need to make appt
or end up at ED
•Seen at ED
•May be for problem
better managed in GP
•May have LTC and ED
may not know current
Rx
Waits 3
weeks for
GP
•My deteriorate while
waiting and be admitted
•May suffer from delayed
treatment
•May get better and not
need appt
Unwell adult: future scenario
Given appt
to see
nurse
within 24
hours
•Seen within 2 days
•Nurse may manage
consult under SO
•May also need review by
GP at the time
Unwell adult rings
for appointment –
triaged over phone
Given
phone
advice by
nurse
Advised to
see
pharmacist
•May be managed with
phone advice
•IF not improving within
24 hours seen by nurse or
GP
•Seen by pharmacist and
treated under ‘SO’ with GP
reviewing consult note
and signing script later
Given appt
to see GP
within 48
hrs
•Different appt lengths
available according to
nature of problem – 10 /
15/ 20 / 30 min (e.g.
exacerbation of complex
LTC)
Business case appendices V12 AC 25Feb2010 Page 17

Appendix Three: Acute care
1. Aspirational statement
All West Coasters will know how to appropriately access acute and after hours care and will be
satisfied with the service received.
2 Project overview
This project has three main aspects: introducing HML nurse phone triage after hours, increasing
community knowledge of how to access after hours care appropriately, and upskilling nurses to
provide more acute care after hours and within office hours.
It builds on the West Coast After Hours Plan which is available for review.
If patients who are acutely unwell are unable to be seen during the day by their usual GP/nurse
team, then this increases the demand for after hours care and inappropriate use of emergency
departments. The project on the redesign of core general practice care addresses this issue.
3 Problem definition
Key problems in the provision of both after hours care and acute care within office hours are:
the burden of after hours call
lack of community understanding of how to access after hours services
high rates of triage 5 attendances at Greymouth ED, both during office hours and after
hours
variation in training and skills of nurses providing after hours and acute care.
For greater detail on the current situation see Appendix One.
Recruitment and retention and decreasing the waiting time to be seen in general practice are
important contributors to after hours issues; they are covered in other project plans.
Business case appendices V12 AC 25Feb2010 Page 18

4 Objectives
to implement nurse phone triage throughout the West Coast after hours
to provide advanced training for nurses doing after hours call
to implement the use of standing orders in all practices
to increase community understanding of how to use after hours services
to decrease inappropriate attendances at ED
to increase coordination of care between practices and ED.
5 Benefits and gains
Output measures
Indicator Baseline Target – Yr
1
HML triage in place By June 10
Community education campaign
implemented
Number of nurses with PG Cert in
Assessment and Pharmacology or
equivalent
ED and hospital pharmacy able to
access patient MedTech notes
Year 2 Year 3
By August Rptd in April Rptd in April
2010
11 20 25 30
No
In place
Outcome measures
Indicator
Number of triage 5 seen at
Greymouth ED 07.00-15.30 Mon -
Fri
Number of triage 5 seen at
Greymouth ED 15.30-22.40 Mon -
Fri
Number of triage 5 seen 22.40-
08.00 Mon - Sun
Numbers of triage 5 seen at
weekends 08.00-22.40
Numbers triaged and
redirected/wk
Baseline
YTD to
Dec 09
Target – Yr 1 Year 2 Year 3
43/week 40 35 30
11/week 9 8 7
1.75/week 1.7 1.6 1.5
15/week 13 12 11
0 7 14 21
Business case appendices V12 AC 25Feb2010 Page 19

% pts discharged of transferred
from ED within 6 hours
% ringing HML who need local
GP/nurse assessment
100% >95% >95% >95%
TBC
6 Deliverables / activities
Implementation plan: to June 30
HML Triage:
Draw up contract with HML Triage to provide after hours nurse phone triage for every
practice.
HML visits every practice and Greymouth ED to gather information on local systems and
capability.
Ensure practices have good systems in place to care for patients who need follow-up
care the next day, eg. phone consultations, acute appointment slots, walk in clinics.
Ensure all practices receive regular reports from HML and all systems are working
appropriately.
Community education campaign – four to six weeks later:
Content: if you are unwell after hours ring your general practice and you will receive
advice from an experienced nurse regarding what you should do. Do not go straight to
the emergency department unless it is an emergency.
Involve St John in campaign.
Design campaign methodology: newspaper articles, pamphlets, radio messages, practice
newsletters.
Campaign also tailored towards Māori and Pacific Island communities.
Implement campaign.
Redesign Greymouth after hours arrangements:
Practices will see their own urgent patients during the day instead of these patients
being seen at the duty practice. There will be a duty practice but it will see only urgent
out of town or non-enrolled patients (often re-directed from ED).
The newly established academic practice will be on-call in the evenings (Mon, Tues, Wed)
with GP registrars seeing patients under the supervision of Dr Willet or Dr Wood.
Town practices will roster Thursday evening call.
Weekends will be covered by all practices allocated on the basis of capitation population.
This should result in a more equitable allocation of on-call and reduce the number of GP
patients presenting at ED because urgent appointments will be available at each
practice.
Business case appendices V12 AC 25Feb2010 Page 20

Review Buller after hours arrangements:
The practice closes at 5 pm and any urgent presentations from about 4:30 to 5:00 are
directed to Buller Health ED.
Buller Health ED is staffed by a GP until 5:30 and may stay on duty until 10:00 pm if
required.
An after hours co-ordinator supervises a mix of RNs and ENs who staff ED.
GPs are on call for Triage 1 and Triage 2 patients. The decision to call the GP for other
triage levels is made by the team leader on duty.
Weekend emergency clinics operate on Saturday, Sunday and Public Holidays from 10:00
to 11:00 am and again at 5:00 to 6:00 pm.
x-ray services are provided 24/7 on an on call basis between 4:30 pm and 8:30 am.
Nurse education:
Identification of training needs of the nurses providing after hours and acute primary
care (24 practice nurses and 12 rural nurses).
Arrange for Nursing Post Graduate Certificate Health Assessment paper to be
delivered on West Coast in 2010, with funding from after hours budget if required.
Arrange access to further PRIME training for new staff on PRIME call out roster as
required, with support for travel and accommodation costs.
Standing orders:
Develop standard processes for the use of standing orders in practices.
Adopt content of the Westland Medical Centre standing orders for Coast-wide use.
Select which standing orders.
Establish subcommittee to oversee development of standing orders training.
Develop a curriculum to provide training on each standing orders over 2010/11.
Develop the lesson plan for the first training session.
Run the first two training sessions for 6-8 standing orders in both Westport and
Greymouth.
Fund nurses to attend training sessions.
Visit each practice to discuss the use of standing orders and obtain written agreement
to use the standard processes and content from all GPs.
Plan and run second training session in both regions.
Co-ordination with ED:
Install a copy of MedTech in a computer in ED.
Change patient registration form/casualty sheet on arrival to include consent for access
to their MedTech notes for that hospital visit.
Ensure privacy considerations are met.
Obtain agreement from practices.
Create link into DHB practice server.
Evaluate community cellulitis management project and extend to all practices.
Business case appendices V12 AC 25Feb2010 Page 21

Year one:
HML triage:
review use and acceptability – Dec.
Community education:
agree on processes to be used by ED to redirect patients who would be better seen by
general practice (triage 5) – by August
implement processes, along with voucher system for those in financial hardship – by
September
repeat community education campaign in April.
Nurse education:
providing funding for more nurses to do PG Cert papers and PRIME.
Standing orders:
provide 5 more day long training sessions in Greymouth and Westport
review and update content of standing orders - May
review use in each practice and adapt standard processes as required – October.
Co-ordination with ED:
create link into other MedTech practices
enable hospital pharmacy to link into MedTech.
Review after hours arrangements in South Westland:
include St John – enhancing conditions for volunteers, including ability to sleep over.
Telemedicine:
implement proof of concept plan for telemedicine links from IFHCs.
Year two
Community education campaign:
repeat in April.
Nurse education:
providing funding for more nurses to do post graduate certificate papers and PRIME.
Standing orders:
provide 4 more day long training sessions in each of Greymouth and Westport
review and update content of standing orders - May
review use in each practice and adapt standard processes as required – October.
Evaluate and update after hours plan and develop other initiatives as required.
Business case appendices V12 AC 25Feb2010 Page 22

Year three
Community education campaign
repeat in April.
Nurse education
providing funding for more nurses to do PG Cert papers and PRIME.
Standing orders
provide 4 more day long training sessions in each of Greymouth and Westport
review and update content of standing orders - May
review use in each practice and adapt standard processes as required – October.
7 Capability and capacity
This project is about increasing capacity by using HML to triage all after hours phone calls, with
an expected drop in GP/nurse call outs of 50%.
It also builds on the models of care developments in that it promotes an increased role for
nurses, and so provides extra postgraduate training and training in standing orders to increase
nurse capability.
The plan also provides extra capability through use of new technology, ie. Cisco in Buller.
8 Effect on inequalities
It is well documented that the inequalities in health exist between Māori and non Māori on the
West Coast.
The after hours primary health care services proposed in this plan will ensure that all West
Coast residents, and particularly those with the greatest need, will have access to free and
consistent telephone triage services, through the diversion of phone calls from general practice
to HML triage. For those who have no phone and go directly to an emergency department there
will be vouchers available if they are referred to afterhours services and cannot pay the fee.
Business case appendices V12 AC 25Feb2010 Page 23

9 Evidence for this initiative
HML Triage has been successfully implemented throughout New Zealand, now covering over one
million people each night.
Standing orders have been successfully implemented in Westland Medical Centre resulting in
the majority of acute care and after hours care being provided by skilled nurses.
10 Risk analysis
Risk Probability Impact Contingency plan
Practices select not to Low Moderate Fund out of After Hours funding
use HML triage
Nurses unable to take
time off to do standing
Moderate High Provide courses at weekends and pay
for attendance
orders training
Nurses unable to take Moderate Moderate Deliver papers on the West Coast
time off to do PG Cert
papers
Triage 5 patients still go
to ED
Redirection to IFHCs
Use vouchers for low socioeconomic
Adapt community education campaign
11 Engagement
Working group who developed this plan: Hecta Williams, Dr JD Naidoo, Nigel Ogilvie RN,
Dr Martin Smith, Julie Lucas RN, Dr Rodger Mills, Karyn Kelly RN, Wayne Turp, Shona McLeod,
Dr Vicki Robertson, Barbara Smith RN, Dr Greville Wood, Dr Carol Atmore, Dr Jocelyn Tracey.
Other clinicians involved: Copy sent to every general practice for input by nurses and GPs.
12 Organisational accountabilities
Shared DHB and PHO accountability in the after hours steering group.
Business case appendices V12 AC 25Feb2010 Page 24

13 Costs
Budget considerations:
The DHB received $80,000 for implementing the after hours plan in 2009/10. It is
expected that the same amount will be received in 2010/11.
Postgraduate university fees for advanced nursing papers are covered by Clinical
Training Agency funding.
Note that separate funding is available from MoH for proof of concept of the benefit
of telemedicine in remote sites.
To June 10
Year one
Income
MoH after hours fund 80,000 80,000
Expenditure
HML 18,000 36,000
Standing orders training sessions 24,400 30,500
PRIME support 2,000 3,000
Communication 10,000 5,000
ED vouchers 500 1000
Project management 25,000 4500
Total expenditure 79,900 80,000
Profit $100 $0
Business case appendices V12 AC 25Feb2010 Page 25

Appendix Four: Keeping people healthy
1. Aspirational statement:
All West Coasters will live healthy lives.
2 Project overview
Many of the public health and health promotion activities delivered on the West Coast by the
West Coast DHB (WCDHB), West Coast PHO (WCPHO) and Community & Public Health (CPH)
address the same health outcomes. Some degree of joint planning and implementation of health
promotion activities take place at present however there is a need to shift the focus from the
sharing of information and co-operation to effective and meaningful „collaboration‟. It has been
determined that each of the three organisations focuses on the following areas that will serve
as the basis of joint planning and collaboration for „keeping West Coast people healthy‟:
tobacco control/smokefree
improving immunisation coverage
increasing physical activity and nutrition.
This initiative is designed to further enhance public health and health promotional activities in
the above three areas through the production of a joint health promotion plan and
implementation strategy that will be shared between the organisations. The first year of this
plan describes common areas of delivery in detail and indicates the breadth of activity that will
be planned jointly at the end of three years.
There are other areas of health promotion delivery that do not cross over between
organisations and are not incorporated as part of this plan. The details of PHO specific
activities are however detailed in the deliverables section.
3 Problem definition
For the last three years the West Coast District Health Board (DHB), West Coast Primary
Health Organisation (PHO) and Community & Public Health (CPH) have carried out some degree
of joint planning around health promotion activities. This joint planning was designed to bring
the three organisations together and to identify areas of commonality where each could
complement others work. This often focused on the sharing of information and the
implementation of joint initiatives where all three organisations contributed to a project. To
enhance this joint planning and initiate more effective collaboration the Healthy West Coast
Governance Group, with management level membership across the three organisations was
Business case appendices V12 AC 25Feb2010 Page 26

established. This group now oversees health promotion projects/activities developed by each
organisation.
Up until recently each of the three organisations continued to develop their own public health
and health promotion plans, and there was the potential for a large amount of cross over and
duplication of effort and resourcing. The imperative to reduce this duplication was augmented
by the limited health promotion funding and qualified public health workforce on the West
Coast. By carrying out joint planning and avoiding potential cross over means that any funding
and workforce we do have is maximized to it best potential.
Keeping people healthy and reducing the burden of chronic disease through public health and
health promotion initiatives is integral to the primary care business case. The emphasis of
keeping people healthy is on preventing West Coasters from becoming unwell and improving the
health of those with existing chronic conditions. The three key priorities, tobacco
control/smokefree, increasing immunisation and physical activity and nutrition coverage have
been selected due to the impact that these interventions areas have on preventing or minimizing
chronic disease and infirmity.
Tobacco Control/Smokefree
Smoking is one of the leading causes or mortality and morbidity for the West Coast population,
with 25.7% of all West Coasters reporting they are regular smokers compared to 20.7% of the
national population 27 . Māori smoking rates are considerably higher on the West Coast (by
comparison with non Māori), particularly for Māori girls at Year 10 28 . Of concern is the high
rate of smoking amongst 20-24 year olds, with 40.9% of West Coast youth compared with
29.8% nationally smoking on a regular basis. Lifestyle changes such as not smoking will have a
positive impact on the health status of West Coasters and lead to a reduction in chronic illness,
notably respiratory, cardiac and vascular conditions, cancer rates and diabetes.
Increasing Immunisation Coverage
Increasing immunisation coverage at 24 months of age continues as a focus for improving child
health on the West Coast. In 2008/09 80% of children were immunised at 24 months of age,
below the national target of 85%. More recently the Immunisation Advisory Group has
extended its brief to focus on seasonal influenza and HPV vaccinations. In 2008/09 55% of
the total West Coast population and 60% of the high needs West Coast population were
vaccinated for seasonal influenza.
Physical Activity & Nutrition
Sedentary lifestyles, poor nutrition and overweight and obesity are a major and increasing cause
of preventable disease, disability and death in New Zealand 29 . The New Zealand Health Survey
2002/03 indicates that West Coasters have particularly high levels of excess adiposity, with
27 Statistics New Zealand. (2006). Census of Population and Dwellings. Wellington: Statistics New Zealand.
28 Beg A. West Coast Tai Poutini Maori Health Profile, August 2008.
29 Ministry of Health. (2000). The New Zealand Health Strategy. Wellington: Ministry of Health.
Business case appendices V12 AC 25Feb2010 Page 27

61% of residents identifying as overweight or obese. Of particular concern are the high levels
of obesity among West Coast Māori (32%) 30 . Furthermore, over half of West Coasters do not
consume at least two pieces of fruit per day.
4 Objectives
To enhance the health and well being of West Coasters and reducing the burden of
chronic disease through a reduction in smoking initiation and increase in cessation;
increasing immunisation coverage; increased physical activity, improved nutrition and
reduced rates of obesity throughout the district.
To improve immunisation coverage for West Coast residents, particularly relating to
childhood immunisations, HPV vaccination and seasonal influenza vaccine.
To improve the health and wellbeing of West Coast residents through the creation of
environments that support physical activity, healthy eating (including breastfeeding) and
weight reduction.
To reduce harm caused by tobacco with the overall objective of reducing the number of
West Coasters who smoke on a regular basis to be no greater than the national average.
To create and maintain social and physical environments that support smokefree.
To empower West Coast communities to take action around „keeping people healthy‟.
Establish a virtual single entity where the WCPHO, WCDHB and CPH plan and implement
the health promotion strategy collaborative to „keep West Coasters healthy‟.
To maximize resources (funding and personal) available to the West Coast by ensuring
that projects are provided efficiently and are designed to meet the needs of the
community and are evidence based.
5 Benefits and gains
Increased immunisation:
85 percent of two year olds will be fully immunised by July 2010; 90 percent by July 2011; and
95 percent by July 2012.
Better help for smokers to quit:
80 percent of hospitalised smokers will be provided with advice and help to quit by July 2010;
90 percent by July 2011; and 95 percent by July 2012. The measures for primary care that will
be introduced from July 2010, through the PHO Performance Programme are the percentage of
the enrolled population for whom smoking status has been recorded and the percentage of the
enrolled population who are current smokers.
30 Ministry of Health. (2004). A portrait of health: Key results of the 2002/03 New Zealand Health Survey. Wellington:
Ministry of Health
Business case appendices V12 AC 25Feb2010 Page 28

Output measures
Tobacco control / smokefree
Indicator Baseline Target – Yr 1 Year 2 Year 3
% total population who have ever
had a smoking status recorded –
Total (PPP)
% total population who have ever
had a smoking status recorded –
High needs (PPP)
% of current smokers who been
given brief advice in the last 12
months July 2011. (PPP)
% of current smokers who been
given or referred to cessation
support services in the last 12
months July 2011. (PPP)
% of hospitalised smokers will be
provided with advice and help to
quit by July 2010
Total West Coast-wide population
accessing smoking cessation
services (AKP, Coast Quit, Quitline,
WCDHB)
33% 36% 40% 44%
35% 38% 42% 46%
TBC TBC TBC TBC
TBC TBC TBC TBC
19% 80% 90% 95%
969 979 989 1000
Outcome measures
Tobacco control / smokefree
Indicator Baseline Target – Yr 1 Year 2 Year 3
Year 10 students who smoke on a 3.2% 3% 2.8% 2.6%
daily basis (ASH)
Year 10 students living in a
smokefree home (ASH)
55% 60% 65% 70%
Immunisation
Indicator Baseline Target – Yr 1 Year 2 Year 3
% Childhood Immunisation
Coverage at 24 months – Māori
(NIR*)
70% 75% 80% 85%
% Childhood Immunisation
Coverage at 24 months – Total
(NIR*)
% seasonal influenza coverage –
Total (PPP)
% seasonal influenza coverage –
High needs (PPP)
80% 83% 86% 89%
55% 56% 57% 58%
60% 61% 62% 63%
Business case appendices V12 AC 25Feb2010 Page 29

Physical Activity and Nutrition
Indicator Baseline Target – Yr 1 Year 2 Year 3
Full and exclusive breastfeeding at 75% 75% 76% 77%
6 weeks – total (Plunket)
Full and exclusive breastfeeding at 66% 68% 70% 72%
6 weeks – Māori (Plunket)
Full and exclusive breastfeeding at
6 months – total (Plunket)
35% 35% 36% 37%
Full and exclusive breastfeeding at
6 months – Māori (Plunket)
25% 27% 29% 31%
* figures are adjusted for WCDHB „eligible‟ population as Gloriavale Christian Community does not immunise.
6 Deliverables / activities
Implementation phase
Alignment of the three organisations planning processes and joint planning in three
priority areas (tobacco control/smokefree, immunisation, physical activity and nutrition).
Year one
Tobacco control/Smokefree:
Implementing the ABC strategy –joint implementation of the ABC strategy to ensure
patients across community, primary and secondary care are provided with advice and
support to quit.
Smoking cessation services – including training of primary and secondary staff on brief
advice (additional training will be provided to mental health workers, Māori providers,
midwives and those working with youth), utilization of NRT and referrals onto specialist
cessation services, a media campaign to promote smokefree lifestyles and cessation
services and provision of a range of cessation services (including Coast Quit, ABC & NRT
dispensing, Aukati kai Paipa, WCDHB Specialist Smoking Cessation Services, Quitline).
Smokefree pregnancy – smoking cessation training will be provided to midwives
throughout the district. A joint plan will be established to provide services specifically
for this key target group (including a key focus on Aukati kai Paipa for Māori women).
Māori Smokefree Initiatives – implementation of smokefree initiatives and health
promotion through Aukati kai Paipa and Rata Te Awhina Trust. This will include other
health promotion activities. Māori smokefree health promotion roopu continues to work
together to reduce unacceptable Māori smoking rates on Tai Poutini.
Reducing smoking initiation – joint health promotion initiatives will focus on increasing
the percentage of year 10 students living in a smokefree home. The HPS programme will
continue to support smokefree environments and strategies in West Coast schools.
Smokefree Policies - training and support will be offered to WCDHB providers and
selected workplaces.
Business case appendices V12 AC 25Feb2010 Page 30

Improving immunisation coverage – health promotion strategies:
Co-ordination of the Immunisation Advisory Group - continue to co-ordinate an
Immunisation Advisory Group (includes Māori representation) to work strategically to
increase immunisation coverage and work collaboratively to achieve this outcome.
Seasonal Influenza – facilitation of a range of seasonal influenza health promotion
activities such as primary care clinics, promotions in practices, promotional campaigns
targeting the chronically ill and those aged 65 years and over, supermarket promotions
and linking into the national campaign through radio advertisement, aquatic centre
promotion and pharmacy flu bug themed promotions.
Staff Seasonal Influenza Vaccination Programme – facilitation of the WCDHB and
WCPHO staff seasonal influenza promotion (encouraging and educating staff on getting
immunised). Supporting workplace staff to become immunised throughout the West
Coast (for larger organisations such as Pike River Coal).
Childhood Immunisations (including HPV):
Improvement of the practice process for immunisation, particularly relating to providing
timely recall information (using the long term conditions model of engagement and
collaboration) and offering flexibility around clinic times.
Ongoing promotion and implementation of the HPV programme in schools throughout the
West Coast with a focus on promotion and uptake for Māori girls.
Provision of immunisation education in antenatal classes.
Health promoting schools framework used to promote immunisation services.
Outreach Immunisation Services – continued provision of Outreach Immunisation
Services with a focus on reducing inequalities in coverage for tamariki Māori and
children in NZ Dep 9 and 10 areas (including by use of Māori staff).
Training & Education – the ongoing provision of practice nurse training by the
Immunisation Co-ordinator.
Increase physical activity and improve nutrition:
Breastfeeding Action - implement the Breastfeeding Action Plan (focus on
implementation of the Mum4Mum Peer Support programme, education of primary care
and social service providers, antenatal education, creating and maintaining environments
that support breastfeeding and professional development for maternity and well child
staff).
Māori Community Action - implement the Māori Community Action Plan that focuses on
Māori communities being supported and assisted to devise and implement programmes
that improve nutrition, increase physical activity and reduce chronic disease.
Healthy Ageing Programme - this programme targets adults aged 65 years and over (and
Māori aged 55 years and over) and focuses on improving nutrition, increasing physical
activity and decreasing falls.
Building Community Capability – implement programmes such as the Cooking Skills to Life
Skills, Senior Chef, workplace wellness interventions and relevant physical activity
programmes that use a skill-based model to build capability of community volunteers and
at risk populations.
Business case appendices V12 AC 25Feb2010 Page 31

Prevention & Early Intervention – co-ordination and facilitation of early intervention
programmes (such as Green Prescription, Cooking Skills to Life Skills), information
dissemination and education, creating social environments that support healthy eating
and physical activity and provision of the Health Promoting Schools programme in West
Coast schools.
PHO specific deliverables – health promotion
Men‟s health forums - focused on men‟s health issues including cardiovascular, mental
health and urology issues. Men‟s engagement with the practices to reach „hard-to-reach‟
males is a key focus of this campaign.
Whanau Ora Pai /Living Well Hui - targeted for West Coast Māori and focused on all
aspects of healthy living in a culturally appropriate environment.
Awareness week promotions - targeted on cervical screening, diabetes, mental health,
breastfeeding, prostate cancer and men‟s health, cancer.
Breastfeeding support - peer support programme, community promotions, breastfeeding
friendly workplaces and cafés.
As well as working on the above priority areas we also intend to:
work together to reduce health inequalities
operate as a virtual single entity for the three key priority areas
work under a common banner for health promotion 'Healthy West Coast'
produce a common community health needs assessment
have transparent funding streams for public health for the three key priority areas
work to develop a common approach to evaluation and review the effectiveness of
different types of programme
share training across all workers within the three organisations.
Year two:
One joint plan covering all health promotion services that each organisation implements
in addition to tobacco control, immunisation coverage, physical activity and nutrition.
This will further enhance the virtual single entity and ensure the needs of the West
Coast community are met.
Review and revise outputs and outcomes for the tobacco control/smokefree,
immunisation coverage and physical activity and nutrition plans.
Re-allocate funding to programmes/activities which have been shown to be more
effective by appropriate evaluation.
Transfer responsibility for programmes/activities to those organisation best placed to
deliver them.
Business case appendices V12 AC 25Feb2010 Page 32

Year three
Continued joint planning by each organisation with one plan covering all health promotion
services.
Enhanced collaboration between the three organisations.
Fully functional virtual single operating entity where each organisation WCPHO, WCDHB
and CPH work together to create a “Healthy West Coast”.
7 Capability and capacity
Between the three organisations, the West Coast has a small but strong health promotion
workforce. This workforce is strongly supported by a range of clinicians including general
practice teams, pharmacies, rural nurse specialists, practice nurses and so on. General practices
and pharmacies are actively engaged in health promotion campaigns and provision of health
promotion resources.
West Coast PHO
The West Coast PHO has a small but strong health promotion workforce with 0.5 Full Time
Equivalent (FTE) Health Promoter and 1 FTE Active Communities Co-ordinator that are
supported by the Clinical Manager. The Coast Quit programme is implemented by GP‟s, practice
nurses, rural nurse specialists and three pharmacies.
West Coast DHB
Tobacco Control/Smokefree - the 1 FTE Regional Smokefree Co-ordinator is based within the
Planning & Funding team and smoking cessation services and clinical training a delivered within
the hospital setting by the Smoking Cessation practitioners (1 FTE total).
Physical Activity and Nutrition - the Healthy Eating Healthy Action (HEHA) team is based
within Planning & Funding and consists of 2.5 FTE of HEHA co-ordinators that work across the
nutrition and physical activity areas and 1 FTE HEHA manager that works across the West
Coast and Canterbury DHBs.
Immunuisation - Outreach Immunisation co-ordinators (1 FTE total – 0.4 clinical, 0.6 Māori coordination),
HPV co-ordinator (0.4 FTE), Public Health Nurses, Immunisation co-ordinator (0.6
FTE).
Community & Public Health
Tobacco Control/Smokefree - Aukati Kai Paipa 1.0 FTE, Māori Smoking Health Promoter 0.4
FTE, Smokefree Health Promoter 0.5 FTE, Smokefree Environment Compliance 0.2 FTE.
Immunuisation - Youth Health Promoter 0.2 FTE, Health Protection Officer 0.2 FTE, Public
Health Specialist 0.1 FTE.
Business case appendices V12 AC 25Feb2010 Page 33

Physical Activity and Nutrition - Community Dietician 0.5 FTE, Health Promoting Schools 0.2
FTE, Health Promoter Physical Activity 0.3 FTE.
This team is managed and supported by the Medical Officer of Health, Regional Manager and
Team Leader. Support is also provided through Canterbury-based staff particularly around
research and evaluation
8 Effect on inequalities
All projects implemented by the three organisations are based around the Ministry of Health
key target areas, as well as areas identified in a West Coast Health Needs Assessment and
Māori Health Needs Profile 2008, which identified areas of concern. At the core of this work
is our belief that health inequity is unacceptable and all West Coasters are entitled to be as
healthy as they can be regardless of ethnicity or socio-economic status.
Projects worked on are evidenced based to show their effectiveness, or developed with a strong
evaluative component to measure effectiveness. They are also designed with community input
taking into account the principles of the Treaty of Waitangi and the requirements of involving
Māori in all aspects of planning and implementation processes. West Coast Māori experience
inequalities in their health status and as such each of the three components of this initiative
has a key focus on improving the health of Māori and „keeping whanau well‟. The General
Manager of Māori Health is a key member of the Healthy West Coast Governance Group. In
addition it is anticipated that the Healthy West Coast Governance group will receive advice
from Māori involved in the health sector regarding appropriate ways to engage Māori with
health education and health promotion messages
9 Evidence for this initiative
The three organisations have been working closely in planning and delivery for the last three
years. It is our understanding that this joint planning and sharing of information does not take
place in other areas and in fact there is often competition and conflict between District Health
Boards, Primary Health Organisations and Public Health Units. This initiative is unique in its
approach to collaborative planning and implementation of strategies between the three
organisations and provides value for money.
We consider this project to be a pilot and evidence of its effectiveness will be gathered over
the course of the implementation.
The following PHO programmes have been evaluated over the last three years (evaluations have
all been positive and suggested continuation or expansions of the programmes with suggestions
for improvement 31 ): and full version are available on request:
31 Copies of the full evaluation reports are available on request
Business case appendices V12 AC 25Feb2010 Page 34

extending health promotion activities into medical centres and pharmacies
smoking cessation
Mum4Mum breastfeeding peer support programme
men‟s health events.
An evaluation into the effectiveness of school-based edible gardens in achieving HEHA
outcomes is currently underway. The final results of this evaluation will be available in May
2011.
An evaluation of the Appetite for Life programme was also completed in 2008 which
demonstrated positive outcomes for participants (copy available on request).
An evaluation of the Rata Ahuahi Kore project is also underway and evaluation of the
implementation of the first phase will be completed in March 2010. A further report on
progress and impacts of the second phase will be available by the end of 2010.
10 Risk analysis
Risk Probability Impact Contingency plan
Further reduction in
public health and
health promotion
funding
Workforce –
recruitment and
retention of
appropriately
qualified staff
Shifting government
priorities
Mainstream
approaches are
ineffective in
reaching Māori
Medium High Review of health promotion focus
areas (potential reduction in key
priorities and areas of
implementation).
High High Refer to the recruitment and
retention workstream of this business
case.
Medium High As above, the health promotion focus
areas will be reviewed and potentially
reduced depending on government
priorities.
Low to
medium
High
Ensure Māori are involved from the
beginning and that Māori health
inequalities are addressed through a
strong cooperative commitment to
improving Māori health .
11 Engagement
Working group who developed this plan: Healthy West Coast Governance Group (comprised of
representatives from the West Coast PHO, West Coast DHB and Community & Public Health).
Other clinicians involved: The West Coast Medical Officer of Health is a member of the
Healthy West Coast Governance Group.
Business case appendices V12 AC 25Feb2010 Page 35

Networks/Groups: Active West Coast Network (Network of health promotion staff from a
range of government departments and NGOs), Immunisation Advisory Group.
12 Organisational accountabilities
The accountability for this initiative is with the members of the Healthy West Coast
Governance Group that includes:
• Wayne Turp, General Manager - Planning & Funding, West Coast DHB
• Gary Coghlan, General Manager - Māori Health, West Coast DHB
• Cheryl Brunton, Medical Officer of Health/Public Health Specialist
• Jocelyn Tracey, Acting CEO, West Coast PHO
• Helen Reriti, Clinical Manager, West Coast PHO
• Kim Sinclair, HEHA Manager, West Coast DHB
• Derek Benfield, Regional Manager, Community & Public Health
• Jem Pupich, Team Leader, Community & Public Health
• Heather Muir, Regional Smokefree Co-ordinator
This Governance Group will continue to oversee and retain the accountabilities for this project
in the short and long term. As specified in the Terms of Reference for the Healthy West Coast
Governance Group will act in a joint advisory capacity to the organisations represented, but will
not have final decision making capacity except when mutually agreed by all of the agencies
represented.
13 Costs
The following tables indicate the funders and providers of health promotion services in the
tobacco control/smokefree, immunisation and physical activity and nutrition areas.
Tobacco Control / Smokefree
Funder
Provider
Activity
WCDHB MOH (via CDHB) WCDHB WCPHO CPH
Smokefree DHB regional co-ordination $85,000 $85,000
Smoking cessation $89,500 $81,000 $8,500
NRT $100,197 $100,197
Aukati Kai Paipa $65,000 $65,000
Māori Smokefree $25,000 $25,000
Smokefree Compliance $11,000 $11,000
Smokefree Projects $6,000 $6,000
Business case appendices V12 AC 25Feb2010 Page 36

Immunisation Coverage
Funder
Provider
Activity
WCDHB MOH (via CDHB) WCDHB WCPHO CPH
Immunisation Co-ordination $78,666 $78,666
HPV $169,527 $169,527
NIR Administration $65,780 $65,780
Health Protection $13,000 $13,000
Public Health Specialist $18,000 $18,000
Youth Health Promotion $12,000 $12,000
Health Promotion Infrastructure $10,000 $10,000
Physical Activity & Nutrition
Funder
Provider
Activity
WCDHB MOH (via CDHB) WCDHB WCPHO CPH NGO
HEHA Leadership and
$142,160 $142,160
Co-ordination
HEHA Breastfeeding $113,174 $26,674 $86,500
Māori Community Action $128,000 $45,000 $83,000
HEHA Information
$12,000 $5,000 $5,000
dissemination
Older Persons HEHA & Falls $85,000 $85,000
Prevention
Cooking Skills to Life Skills $10,000 $10,000
Green Prescription $16,728 $16,728 *
Health Promotion
$41,000 $41,000
Infrastructure
Community Dietetics $36,000 $36,000
Health Promoting Schools $12,000 $12,000
Health Promoter – Physical
$18,000 $18,000
Activity
Project Funding $5,000 $5,000
*Plus an additional SPARC contract of $14,440.
Business case appendices V12 AC 25Feb2010 Page 37

Appendix Five: Long term conditions
1. Aspirational statement:
Every patient with a long term condition will have the clinical care and support they need to
achieve good health outcomes.
2 Project overview
The West Coast Long Term Conditions (LTC) Management Strategy was developed in 2006 by
the West Coast District Health Board i(WCDHB) in collaboration with the West Coast Primary
Health Organisation (WCPHO), Community & Public Health (CPH) (the local public health
provider), NGOs and Māori and consumer representation. This strategy is underpinned by
Wagner‟s Chronic Care Model 32 and the Continuum of Care approach. The LTC Steering Group
continues to meet regularly and oversees the implementation of the various aspects of the
framework by each of the contributing organisations.
As part of that strategy the PHO redesigned all its LTC programmes (Care Plus, Diabetes
Annual Review, Cardiovascular Annual Reviews, Diabetes Self Management Education groups,
Coast Quit smoking cessation) into one overall LTC management programme in 2008.
Implementation of this programme began in 2009, assisted by Ministry of Health funding to use
the Institute for Healthcare Improvement (IHI) Breakthrough Series 33 approach to quality
improvement.
This project builds on the work already done, particularly in regards to enhancing the
integration of care for those with high complexity LTCs and to providing extra health navigation
support services.
3 Background and Problem definition
DHB wide strategy
The DHB strategy contains a framework that incorporates all DHB, primary care and NGO
activity around LTCs and is updated on an annual basis to ensure that all groups are working
32 Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical
Practice. 1998;1:2-4
33 Wagner - find Wagner E, Austin B, Davis C, Bonomi A., Provost L, McCulloch D, Carver P, Sixta C. Quality
Improvement in Chronic Illness care: a Collaborative approach. J Q Improvement 2001; 27(2):63-80. 33
Business case appendices V12 AC 25Feb2010 Page 38

The
Community
Health
System
Delivery System
Design
Clinical
Information
Systems
Equity in
Health
together to meet the health needs of the population. While full version of this runs to many
pages, the key aspects are summarises in the following diagram:
Chronic conditions management – the WCDHB
framework,
The Patient’s Journey
Environment
Healthy
At Risk
Acute
Event
Initial
management
Long term
clinical and
Self
management
End of Life
Care
Healthy public
policy and
creation of
supportive
environments
Non-italics=
existing service
Italics= proposed
service
Healthy
Schools;
Smoke free;
HEHA:
Community
events;
Breast feeding;
Men‟s health;
Green Rx;
Health
promoting
practices
CVD and
diabetes
screening,
follow up
for those at
highest risk
Smoking
cessation
Diagnosis,
hospital
admission
Pre-hospital
fibrinolysis
Diabetes
Pulmonary
rehabilitation,
Cardiac
rehabilitation,
Arthritis and
diabetes
education/
support
groups
PHO LTC: Focus on,
CVD, diabetes ,
COPD: clinical and self
management support
CareLink and AT&R
assessments and MDT
review for more
complex
Cancer
navigators
Palliative
care
funding in
primary
care
UNDERPINNED BY THE WEST COAST‟S 7 PILLARS OF CHRONIC CONDITIONS MANAGEMENT
The PHO Long Term Conditions programme (as it is now)
The programme is both based on the Wagner Chronic Care model 1 (self-management support,
community support, delivery system redesign, clinical information systems and decision support)
and the Kaiser Triangle stratified care approach 34 . The programme meets the National Health
Committee‟s objectives 35 of providing effective chronic care management and co-ordination
through using a population health approach to care delivery, based on level of need, both clinical
need and need for self management support. There is a focus on those with conditions that are
frequent or severe, and these are addressed by national evidence based clinical guidelines and
are responsive to enhanced primary care management, and have outcomes that can be tracked
over time to measure improvement (Cardiovascular Disease (CVD), Diabetes, and Chronic
Obstructive Pulmonary Disease (COPD)).
34 World Health Organisation Innovative Care for Chronic Conditions: Building Blocks for Action: Global Report 2002
WHO document no. WHO/NMC/CCH/02.01.
35 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee
Wellington May 2005
Business case appendices V12 AC 25Feb2010 Page 39

The DHB and the Ministry of Health both approved the content of the LTC management
programme in late 2008, including giving permission to allocate all LTC funds (Diabetes Annual
Review, Care Plus, some Section J contract lines and some SIA funding) into a global budget for
this programme.
The programme is based on all patients with diabetes, CVD or COPD having an annual review
from the time of diagnosis, and then based on their clinical condition and ability to self manage,
a decision is made as to the level of care they require for the following year as shown in the
diagram below:
Patient enters system
Package of care
discussed
with patient,
package provided
for following year
Annual assessment
carried out of
patient's clinical
condition & ability
to self manage
Decision made as to
which level of
care is most
suitable for patient
Patient may
exit following
annual
assessment of
care
There are three packages of care, with increasing intensity and support as shown in the
following three tables:
Level One Care: Annual Reviews
Patient LTC Diabetes ±
Cardiovascular Disease
(CVD)
Target group
Only CVD or
Diabetes or
COPD patients:
Meets diagnostic
criteria for diabetes.
Assessed to be self
managing well –
informally or formally
Cardiovascular
Disease
(If risk only, use CV
Screening
programme)
Established
cardiovascular
disease
Assessed to be self
managing well
Chronic Obstructive
Pulmonary Disease
(COPD)
Confirmed diagnosis of
COPD: Spirometry
showing FEV 1 /FVC

Clinical care
Practice self
management
support
PHO/Community
self care support
Electronic clinical
decision support
Targets
Annual review of clinical management by GP team according to national
guidelines
Recall for annual review and annual flu vaccination
Plus ongoing usual clinical care
Refer to CNSs and allied health as required
My Shared Health Record 36 provided or updated at annual review, used
at all consultations, smoking cessation (Coast Quit programme) if
required
Referral to Diabetes self management group, cooking skills for life,
Living a Healthy Life, Kaiawhina, community support groups, green
prescription, pharmacist support
Diabetes advanced EDGE CVD form COPD Advanced form
form (this includes
CVD)
National Practice Performance Programme (PMP) targets for Diabetes
and CVD
15% current smokers and 85% flu recall for COPD
Numbers Enroll all COPD, CV Disease and Diabetes pts – estimated number 2000
Level Two Care: Annual reviews and quarterly follow-up to support self management
LTC Diabetes CVD COPD Other
Patient will benefit from extra level of care
Patient gives consent
Capped numbers for each practice
Target group
New diagnosis of
diabetes OR
HbA1c> 8
AND/ OR
Flinders PIH
assessment shows
person is not self
managing well
New diagnosis of
CVD OR
BP>150/90
TC >6mmol/l
Worsening
symptoms
AND/OR
high Flinders
Score
New diagnosis OR
FVC 1 < 60%
(moderate –
severe COPD)
Smoker
AND/OR high
Flinders score
Two or more
long term
conditions
(but not
COPD, CVD or
Diabetes)
AND
High Flinders
score
Clinical care
Practice Self
Management
Support
Quarterly half hour reviews by GP Team of clinical management according
to national guidelines
Recall for quarterly appointments and annual influenza vaccination
Timing to coincide with need for regular script
Focus on continuity of care – same provider for regular visits
Other care as required
Refer to clinical nurse specialist and allied health as required
My Shared Health Record developed at annual review, used at all
consultations, Full Flinders assessment, smoking cessation (Coast Quit
programme),
referral as required to PHO Mental Health Programme
36 This includes goal setting, medication card, list of health problems, educational material
Business case appendices V12 AC 25Feb2010 Page 41

PHO/Community
self care
support
Electronic
clinical decision
support
Targets
Referral to Diabetes SME group, cooking skills for life, Living a Health
Life, Kaiawhina, community support groups, green prescription, pulmonary
or cardiac rehabilitation, pharmacist support
Diabetes form
Flinders
Questionnaire
National PMP
targets
EDGE CVD form
Flinders
Questionnaire
National PMP
targets
COPD Advanced
form
Flinders
Questionnaire
15 % smokers
85% flu
vaccination
Flinders
Questionnaire
Decrease in
Flinders
score
Capped numbers Capped at 950 across whole PHO Cap of 25%
of 950
Level Three Care: Integration (level two care, plus the following)
Patient with long term conditions – not managing, clinical Patient with long term
problems (+/- social problems)
conditions – not managing
well due to social problems
Assessed by GP: Needs level 3 Long Term Conditions Care
Refer for inpatient AT&R
assessment
Referred to Care link
asking for AT&R
assessment
Referred to Care link asking
for NASC assessment
Has AT&R assessment – inpatient or outpatient
Has NASC assessment by
needs assessor
Plan written
Referrals to allied health, mental health, secondary care (physicians, nurse specialists),
pharmacy medication utilization reviews, home care, community support groups, as required
Copy of plan to GP
Followed up by AT&R nurse in community
Followed by Care Link
service co-ordinator
3 monthly reports to GP, until discharge from ongoing co-ordination
Practice puts patient onto level 3 LTC care
Receives funding for extra hour of GP time and extra hour of nurse time for either
quarterly 30 minute GP assessments or quarterly 15 minute assessments plus home visit
Full Flinders assessment with quarterly follow up by nurse and My Shared Health Record
Funding available for GP or nurse to participate in case conference with AT&R nurse or Care
Link service coordinator or clinical nurse specialist
At one year GP reassesses and decides whether :
- Goes back to Level 2 care
- Or continues on Level 3 with ongoing service integration/AT&R nurse
- Or continues on Level 3 and referred for another AT&R or NASC assessment
Capped at 190 patients each year for the whole PHO
Implementation of the programme has gone well in 2009 using the IHI Breakthrough Series
methodology. A recent evaluation 37 of the implementation showed high acceptance by practices
37 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010.
Business case appendices V12 AC 25Feb2010 Page 42

and increases in the numbers of patients with LTCs managed in a proactive and planned manner
as shown in the following table:
Enrolment Comparisons
December 2008 December 2009
Care Plus enrolments 51% 80%
Level 1 enrolments 0 1061
Level 2 enrolments 0 300
Level 3 enrolments 0 27
COPD enrolments 0 74
CVD annual reviews 558 675
Diabetes annual reviews 55 Māori reviewed
35% Māori smoking
61 Māori reviewed
26% Māori smoking
Cardiovascular risk and diabetes screening
Active screening is in place for both cardiovascular risk and for diabetes, with follow-up
management and support. The programme can profile and monitor cardiovascular risk
assessments where people have a greater than 15% risk of having a cardiovascular event within
the next 5 years. These identified patients are closely followed up with interventions to reduce
their risk, and provide patients with the individual supports they require for self management
and risk reduction.
Cancer navigators
The PHO has had pilot funding from the Ministry of Health to provide a Cancer Lay Navigator
service for three years, finishing in June 2010. Programme evaluation reports have shown that
the navigators have developed excellent skills in supporting predominantly low socio-economic
and Māori people to access the health care and social support systems they need in order for
their condition to be appropriately managed. There is growing international support for the use
of lay navigators to support patients with LTCs 38 and opportunity to expand the role of this
workforce to include LTCM.
Clinical nurse specialists and allied health
The clinical nurse specialist‟s are experienced clinicians in their respective fields of cardiac,
respiratory, diabetes, oncology, urology, palliative care and AT&R. This specialised group of
nurses provide clinical management to people with sometimes very complex needs. Some nurses
work across two specialty areas like cardiac and respiratory which proves as a great advantage
to continuity of care and management of these patients.
38 Improving access to cardiac care report: http://www.libin.ucalgary.ca/documents/news/Libin-2008-07-23.pdf . accessed 14
Jan 2010
Business case appendices V12 AC 25Feb2010 Page 43

Each provides support and education to clinicians within primary and secondary settings, as well
as education and self management support to patients within the hospital and home settings,
some examples are:
Breathe easy groups have been happening sporadically according to staff resourcing cardiac
rehabilitation have two formal programmes:
phase 2 cardiac rehabilitation, a six week outpatient programme based at the DHB
physio gym in Greymouth and a modified programme at Buller hospitals
Heart Guide Aotearoa, a home based programme designed to improve access to
rehabilitation for West Coasters.
Allied health comprises physiotherapy, occupational therapy, social work, dietician, speech
language therapy, all with work components crossing secondary and primary care. These
services are utilized within all levels of care as required, preferably sooner than later within the
patient journey, this will ensure patient and family supports are put in place earlier before crisis
point is hit.
Pharmacist support
This is related to levels of care, people would tend to move to more „intensive‟ care over time.
Patients managing well – prescription dispensing, brief counseling/education as medicines
added or adjusted, eg. take with food, side effects to watch for, inhaler/spacer
technique, self care cards, adherence support, referral onto other team members as
required.
Supporting self management – as above but likely to be seen more often as receiving
more medicines and more presentations to pharmacy, increased likelihood of
medicines-related problems, medication reviews, compliance aid provision as necessary.
Integration – as above, likely weekly compliance packaging – picked up or delivered to
home or sometimes district nursing, reminders to visit GP for 3 monthly prescription,
liaison with hospital and GP practice at discharge, follow-up if (blister-packed)
medications not collected. Scope for comprehensive medication review at this level.
General support – pharmacists are involved with various support groups, eg. cardiac and
respiratory as speakers and are accessible to those with questions, presenting for Over
The Counter (OTC) products or wanting their weight or blood pressure measured.
Smoking cessation services are offered. People are referred as necessary, eg. to
diabetes nurse specialist or general practice team.
Ambulatory sensitive hospitalisations for those aged 45–64 are helpful in indicating whether
LTC management is keeping people out of hospital. 39
39 Included are angina, MI, CHF, pneumonia, asthma, diabetes, stroke, epilepsy
Business case appendices V12 AC 25Feb2010 Page 44

Ambulatory Sensitive Hospitalisation ISDR - ages 45 to 64 years (12 months to 30 Sep 2009)
Indirectly Standardised Discharge Rate per 1,000
Māori Pacific peoples Other
West Coast Actual ASH rate 8 n/a 152
ISDR value for Year to Date 35.1 n/a 90.4
West Coast DHB overall total discharge rates per 1000 for ambulatory sensitive
hospitalisations, while below the average of 100, does not vary significantly from the overall
national rates at the 99% confidence interval.
Current issues
Areas where there is still room for improvement include:
total numbers of patients enrolled in LTC
percentage of patients meeting clinical KPIs, e.. target lipid, BP, HbA1c levels
closing of inequality gaps, eg. smoking levels
integration of care for Level 3 patients (who have high hospitalisation rates), with a
focus on preventing acute exacerbations and avoiding hospital admissions
more support for those Level 3 patients who have difficulty accessing the health and
social systems and would benefit from kaiawhina and/or health navigator assistance
closer co-ordination and greater consistency of care between clinical nurse specialists
(CNS) and medical centres and allied health and medical centres
more support for patients self care is required .
4 Objectives
To increase implementation of the programme so that over 70% of all patients with
COPD, CVD and/or diabetes have an annual review followed by a timely package of care
appropriate for their level of need.
Development of a Māori team within each Integrated Family Health Centre (IFHC) who
will focus on improving access and health outcomes for Māori.
To review the management of Level 3 patients and enhance the integration between
general practice care and AT&R, Care Link and nurse specialist care and allied heath.
To enable and empower people in the community to obtain process and understand health
information and services needed to make appropriate decisions about their health.
To develop health navigator support services for Level 3 patients who have difficulty
accessing health care and social services.
Business case appendices V12 AC 25Feb2010 Page 45

To better integrate the support provided to patients by CNSs, allied health and medical
centres, eg. through better communication and information sharing.
To link with the activities described in the health promotion workstream.
5 Benefits and gains
Output measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
% Care Plus enrolments 80% 83% 85% 88%
Numbers in level 1, 2, 3
All
Māori
1061/300/27
35/24/2
% estimated CVD coded* All 21.5%
Māori 25%
% estimated diabetes coded* All 69%
Māori 72%
1410/500/80
75/45/6
70%
70%
73%
74%
1880/750/120
100/65/12
80%
80%
77%
77%
2000/950/190
150/75/15
90%
90%
80%
80%
% diabetes (coded) annual reviews* All 57% 65% 75% 80%
% of diabetes reviews with retinal All 73% >85% >85% >85%
screening
Māori 67%
Number CVD annual reviews YTD All 577
Māori 28
Number COPD annual reviews All 75
Māori 4
% eligible popn screened for CV
risk/diabetes*
All 33%
Māori 31%
627
35
200
30
51%
51%
677
40
300
45
65%
65%
720
45
400
60
80%
80%
No. pharmacy medication reviews 0 100 200 300
% of those hospitalised with angina 49% 55% 62% 70%
or MI receiving cardiac
rehabilitation 79 YTD to Sept 09
% of those hospitalised with COPD 0 20% 30% 40%
receiving pulmonary rehabilitation
% patients admitted who are
offered smoking cessation
support*
70% 75% 80% 85%
Outcome measures – for all and for Māori
Indicator Baseline Target – Yr 1 Year 2 Year 3
% diabetes HbA1c80%
80%
70%
70%
% CVD LDL

% CVD on lipid lowering drugs,
beta blockers
ACE
aspirin*
% diabetes with microalbuminuria
on ACE*
Māori 67% 70% 75% 80%
73%
49%
49%
73%
All 84%
Māori 89%
80%
55%
55%
80%
86%
89%
85%
65%
65%
85%
88%
90%
90%
70%
70%
90%
90%
90%
% COPD on flu recall All 84% 86% 88% 90%
% COPD not smoking All 73% 77% 81% 85%
Average number exacerbations in 2.6 2.4 2.2 2
last year/patient
% decrease in Flinders score TBC
LTC ASH rates: ISDR (aged 45-
64yrs) includes: Diabetes, MI/angina,
Pneumonia, CHF, Stroke
90.4 89 87.5 85
*Current or proposed PHO Performance Programme indicators and National Health targets
6 Deliverables / activities
Implementation plan: to June 30
Increase participation:
continue to employ a practice nurse facilitator to support practices to identify and enrol
new patients into LTCM
assist practices to adopt texting or use of Dr Info IT package for recalls.
Level 3:
review the implementation of level 3 care to date
work with AT&R and Care Link, specialist nurses and allied health to develop processes
to increase co-ordination and integration with primary care in a case management style
approach within the IFHC environment, (overlap with workstream on community based
nursing and allied health integration)
implementation of regular meetings with cardiac, respiratory, diabetes nurse specialists
within practice teams to plan level 3 patient care/management.
Discharge planning:
This is a stand-alone project being managed by the DHB Patient Journey Improvement
Co-ordinator that aims to provide advice around service changes and identify opportunities to
enhance discharge planning processes at WCDHB. It will be completed by June 2010 and
encompasses the following objectives:
Provide advice on clinical service and business process changes related to discharge
planning to enhance outcomes and efficiencies.
Business case appendices V12 AC 25Feb2010 Page 47

Participate in the development and review of change proposals to improve discharge
planning across the continuum of care, including examination of models of good practice
which exist elsewhere, and support implementation of changes.
Undertake consultation with staff groups being represented by members to ensure that
all those involved in the discharge planning process are adequately engaged in the
development and implementation of service changes.
Promote internal and external multi disciplinary team working and communication.
Promote continuous improvement of discharge planning activities to all staff.
Self management/health literacy support:
group diabetes self management programme: 4 sessions per year
continue support for and referrals to Arthritis Foundation group self management
support programme
develop data analysis and reporting systems for measuring changes in Flinders self
management score, produce first reports
training session for health providers on health literacy
publicise health navigator patient self management website – for providers and
community, eg. pamphlet in prescription bags
create link to Community & Public Health website on PHO website
restart pulmonary rehabilitation programme, and create referral pathways from Green
prescription
increase referrals to other NGOs providing educational support
support pharmacist to complete accreditation for medication utilization reviews
develop a whanau focused approach to health literacy and self management.
Year one
Link PHO LTCM programme in with relevant HealthPathways
Implement IT support for integration:
create health views link from all practice and outpatients, wards and hospital pharmacy
link into MedTech
investigate use of shared electronic record.
Medication reviews:
develop funding stream for medications utilization reviews done by hospital and
community pharmacies.
Māori health team:
develop a dedicated team that includes a Māori nurse and kaiawhina to build and
strengthen relationships across the health care sector and with a key focus on the
disengaged and hard to reach Māori within the West Coast community.
Business case appendices V12 AC 25Feb2010 Page 48

Health navigators/ kaiawhina:
change cancer navigator processes and criteria to include helping those with LTCs
provide training in LTCs for health navigators and kaiawhina
health literacy training for kaiawhina/navigators
align health navigators and kaiawhina with IFHCs
refine patient pathways between navigators/kaiawhina, in close relationship with Māori
nurses within the IFHCs
develop and implement pathway to follow-up frequent LTC emergency department (ED)
attendees/admissions so that they understand how to access and navigate the primary
care system.
Self management/health literacy support:
scope MedTech Manage my Health portal as a tool to improve self management
review transport issues and develop plan to address these.
Integrated community nursing and allied health in IFHCs:
regular multidisciplinary meetings with clinical nurse specialist and allied health
placing of CNS and allied health in IFHCs
investigate use of shared electronic record.
Decreasing repeat attendances at ED for LTC patients:
work with ED to create a pathway to refer these people to either CNSs, health
navigators or core general practice team.
Care Link integration (see Appendix Eleven: Frail older people for more information)
InterRAI assessments done in IFHCs/practices
include Care Link in MDT meetings in IFHCs
align LTC and frail elderly pathways.
Data and reporting:
review prevalence estimates and Read coding for West Coast, particularly for COPD
review appropriateness of reports provided to IFHCs
Year two
more integrated community nursing and allied health working in IFHCs, (see EOI
community and allied workstream plan)
packages of care for patients with deteriorating medical condition/social situation,
enabling faster access to a greater range of home/community support services.
Year three
review outputs, outcomes and the implementation of this plan, revise this plan as
required.
Business case appendices V12 AC 25Feb2010 Page 49

7 Capability and capacity
The PHO currently has strong capability to design and implement LTC programmes: the clinical
advisor teaches the LTC Management Postgraduate Certificate at the University of Otago, the
Nurse Clinical Manager has a strong focus on LTCs and the LTCM practice facilitator is an
experienced practice nurse.
The current cancer navigators have highly developed skills in their role, and as of late 2010 will
broaden their focus from cancer alone to cancer and LTCs. This will require both extra training
and a stronger focus on the high needs population of the West Coast.
Hospital based community nurses key focus is care of people within the community, with closer
integration and co-ordination with practice teams this can only improve services and care to
patients and families.
8 Effect on inequalities
Already the focus on LTCM has made considerable difference to inequalities in management and
health outcomes for diabetes (see 2008 Diabetes Annual Review report).
By reporting on differences by ethnicity at the practice level there is encouragement to work
towards further reduction in inequalities.
A dedicated Māori health team, addressing inequalities through better links and communication
with all health care providers whilst helping Māori people on their health care journey. This is
about engagement (face to face) at the right time from the right people, fostering relationships
and promoting trust.
The PHO is working with Rata Te Awhina in regards to support a whanau ora approach that will
co-ordinate screening for cardiovascular risk and ensure patients with high CV risk, CVD,
Diabetes or COPD are given free vouchers for annual reviews with their GP.
9 Evidence for this initiative
The programme is both based on the Wagner Chronic Care Model 1 (self management support,
community support, delivery system redesign, clinical information systems and decision support)
and the Kaiser Triangle stratified care approach 40 . The Programme meets the National Health
40 World Health Organisation Innovative Care for Chronic Conditions: Building Blocks for Action: Global Report 2002
WHO document no. WHO/NMC/CCH/02.01.
Business case appendices V12 AC 25Feb2010 Page 50

Committee‟s objectives 41 of providing effective chronic care management and co-ordination
through using a population health approach to care delivery, based on level of need, both clinical
need and need for self-management support.
10 Risk analysis
Risk Probability Impact Contingency plan
Potential reduction in funding
for LTC programme
Medium High Clear communication with key
stakeholders regarding necessity
for ongoing funding
Enrolments in LTC do not
increase as expected
Medium High Address workforce issues; see
plans for Core General Practice
Redesign and Workforce
When community services
move into IFHCs demand is
too great
Develop patient pathways and
target criteria
11 Engagement
Working group who developed this plan: WCDHB LTC steering group: Helen Reriti RN, Peter
McIntosh (Funding and Planning, DHB), Jem Pupich (Community and Public Health), Dr Cheryl
Brunton, Lisa Smith CNS, Maureen Frankpitt RN, Kim Sinclair (HEHA), Barbara Beckford
(Consumer rep), Gary Coghlan (GM Māori), Dr Jocelyn Tracey
Plus Robyn McLachlan (Care Link), Danielle Smith (Cancer navigator), Janette Anderson (DHB
Physio), Dr Carol Atmore, Community pharmacists.
This plan has been reviewed and amended by PHO Clinical Governance Group and DHB Primary
secondary liaison group.
12 Organisational accountabilities
The DHB LTC steering group will continue to oversee the implementation of this plan. Changes
in organisational accountability are covered in the Service Delivery design aspect of the
business case.
13 Budget considerations
The PHO LTC budget has been modified to include cancer navigators.
Secondary care budgets are assumed unchanged at this stage.
41 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee
Wellington May 2005
Business case appendices V12 AC 25Feb2010 Page 51

Appendix Six: Integration - DHB community based services
1. Aspirational statement:
West Coasters with complex health needs will receive co-ordinated and consistent care from
their health providers working together as an integrated health team.
2 Project overview
This project establishes integrated health teams inclusive of general practice based primary
health practitioners and non general practice based community health nurses 42 and allied health
staff, to ensure the provision of integrated and co-ordinated multi disciplinary care and a
holistic approach to meeting the populations' needs.
3 Problem definition
Traditional medical centres, or general practices, care for their enrolled populations. Some of
those same patients are cared for by district nurses, and other community based nursing and
allied health professionals, both as hospital inpatients and post discharge, sometime for an
extended time period. But the two systems of care are not routinely or systematically well
connected together. They operate to a large extent as parallel systems of care. When the two
systems do intersect, it may be purposeful, eg. a GP refers a patient to district nursing, or it
may occur by accident, eg. one individual is employed as both a practice nurse and a clinical nurse
specialist, or a district nurse and a GP happen to know each other and have a working
relationship. This work stream aims to better connect these two significant health care
workforces, and to do so systematically and fundamentally, to ensure patients will benefit from
co-ordinated and consistent care.
Key issues identified as a result are:
Lack of co-ordination of care across the different systems of care and difficulties for
the patient navigating through the system:
- communication gaps between primary and secondary health providers (referral,
discharge, treatment)
- duplication of care, and consequent unnecessary costs
42 "community health nurses" is defined broadly; it is taken to include: district nurses, public health nurses, rural nurse
specialists, neighbourhood nurses, immunisation coordination & outreach nurses, Well Child & Plunket nurses and clinical
nurse specialists (cardiology, respiratory, oncology, palliative, diabetes etc)
Business case appendices V12 AC 25Feb2010 Page 52

- lack of consistency of care between providers; inconsistent information given to
patients by different providers
Inequalities in health outcomes:
- poorer health status for Māori and deprived populations through lower access
rates to services
Lack of continuity of care:
- seeing a different health provider each visit
- lack of a single patient record system across health care providers
- providers working in silos and not „joining up‟ episodes of care.
Problems in accessing services:
- services not co-located in some areas, making it particularly difficult for the
frail elderly or those without transport who need to see several health care
providers
- referral system for care outside core primary health team inefficient and
unwieldy.
Workforce shortages.
The patient numbers and, in particular, the patient demand on the health system, relevant to
the possible intersection of these two workforces, are significant.
An analysis of West Coast PHO enrolled patients and visit numbers for 2009 shows the
following:
Business case appendices V12 AC 25Feb2010 Page 53

It is significant that the 9% of the 30,000+ enrolled population who attended medical centres
most frequently, accounted for 35% of the 120,000+ visits to medical centres, ie. those sickest
9% patients attended their medical centre an average 16 times during 2009.
In addition, district and rural health nurses received 2,351 referrals in 2009 and saw patients
on average 12 times, clinical nurse specialists received 782 referrals and saw patients on
average 6 times, while allied health received 4,613 referrals and saw patients on average 4
times. All in all, the community nursing and allied health workforces conducted some 50,000
patient contacts, in addition to the 120,000+ visits to medical centres.
4 Objectives
The overarching aim is to provide better co-ordinated care for patients across medical centres,
community nursing and allied health services, by including the community nursing and allied
health workforces as members of Integrated Family Health Centres (IFHC)teams. This is likely
to be of particular benefit for high complexity patients with Long Term Conditions (LTCs) and
high numbers of admissions (see also LTC Project plan).
A multi disciplinary team (MDT) approach to care (for that subset of patients who will benefit
from it), including MDT clinical review, will be developed. Patient pathways for common and
complex conditions, which integrate home based and clinic based care, and that align the
activities of health professionals providing that care will be developed (see also the LTC Project
plan and the Health Pathways Project plan).
We will therefore work towards achieving a unified management and clinical leadership
structure which respects and promotes the professional contribution of all staff within the
IFHC, and makes the most efficient use of the nursing and allied health resources available on
the West Coast. This structure will recognise the particular ownership characteristics and
needs of participating health providers in the integrated setting.
Where particular roles or professions need to contribute to more than one IFHC, we will define
how such specialist roles can best be organised across the region. It will be important to
maintain linkages between professional groups, who are working in a variety of settings, and to
review and develop professional roles so that they contain both generalist and special interest
components. Health professionals will retain their professional identity and have access to
robust professional development processes to ensure the delivery of evidence based best
practice, especially in the context of delivery of rural/remote services with practitioners often
working in isolation.
We intend to develop health assistant roles within the IFHCs and so ensure health professionals
are working to their maximum capacity in delivering care to patients commensurate with their
Business case appendices V12 AC 25Feb2010 Page 54

qualifications and skills. Where care can be delegated to a health assistant, this should happen,
provided the health assistant receives adequate support, supervision and training. This will then
free the health professional to provide the more complex care.
We will also design and implement common infrastructure systems and service specifications to
support a more integrated way of working.
Patients will benefit from GPs and practice/rural nurses being made aware immediately when one
of their patients is admitted to hospital (for example), and the district nurse and allied health
professionals can work with the GP & practice nurse on the plan for the patient's discharge
from the time of their admission to hospital. Patients will benefit when these two workforces
are utilizing the same clinical information system to record their interactions with, and care for,
the patient, and when all the health professionals involved in their care are giving them
consistent advice.
Patients will benefit when clinical nurse specialists and allied health professionals are available
to intervene earlier with patients with long term conditions, rather than being called in to
address the patient's needs only after a patient has been admitted to hospital.
Currently well child service provision is fragmented between Plunket, primary care, Māori health
NGO providers, midwives and community nursing services. The advent of IFHCs creates the
opportunity to bring these carers together, so that care is streamlined, information is shared
and families get the right level of follow-up. Initial discussions with NGO service providers
indicate a willingness to collaborate in order to achieve better health outcomes and better use
of resources. More detailed discussions and project planning will occur in year one of the
implementation phase.
Objectives:
to improve the care of patients with the greatest need on the health system
to make the most efficient use of the nursing and allied health resources available on
the Coast
to design and implement common infrastructure systems and service specifications to
support a more integrated way of working
provide leadership that is able to respond to the flexing/changing needs, and provides all
staff with feedback on performance
include staff in planning the delivery of services, complete a gap analysis asking staff
what is working/not working and implement these ideas in to working smarter/better use
of resources
review and develop nursing roles into a more holistic primary health nurse role aimed at
blurring existing boundaries between specific nurse functions, but one that contains
both generalist and special interest components.
Business case appendices V12 AC 25Feb2010 Page 55

5 Benefits and gains
Output measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
Percentage of health centres with
monthly (or more frequent) regular
clinical full MDT meetings
25% 67% 100% 100%
Development of single health
assessment
Shared electronic health record
Patient timeframe to move through
system - average time from new
routine service request to patient
being seen:
- district nurses
- rural health nurses
- clinical nurse specialists
- allied health
Not in
place
Not in
place
TBC
In place
Partially in
place
In place
Outcome measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
ASH rates
See LTC
paper
% people with LTCs meeting
clinical targets, eg. HbA1c, lipids
and BP
See LTC
paper
Annual No. re-admissions per year 8.21%
(2009)
No. patients with more than 6 ED TBC
attendances per year
No. patients with more 2 or more 199
admissions for 5 or more bed days (2009)
per year 43
8% 7% 6%
190 180 170
43 Definition borrowed from the Counties Manukau project: Roseman, P. (2003). "Frequent Adult Medical Admissions
Final Report." Retrieved 15 December 2008, 2008, from http://www.cmdhb.org.nz/Funded-
Services/CCM/documents.htm.
Business case appendices V12 AC 25Feb2010 Page 56

6 Deliverables / activities
Implementation plan: to June 30
Establish MDT meetings: allied health, district nursing and clinical nurse specialists will
meet with core health centre staff in each health centre to plan the care of specific
high complexity patients. More sharing of information about patient needs for care will
ensure more effective management of these patients. Guidelines for conducting these
meetings will be developed.
Identify extent and nature of overlap between medical centre frequent attenders
cohort and community nursing/allied health clients; conduct review of care provided to
patients common to both cohorts; examine systems and/or performance issues
identified by this review and rectify/optimize.
Review nature and type of home based nurse assessments with a view to developing
standardised assessment procedure.
Plan for assignment of community nursing and allied health clinicians to practice
populations.
Identify a professional grouping/team(s) and locations to be the first centre for
implementation of the integrated model. Pilot, refine, spread.
Develop common, integrated service specifications (break down barriers created by the
existing specs). Consolidate and reduce reporting requirements where possible. To
achieve this outcome, communication with the Ministry of Health needs to commence
this year.
Year one:
Develop and implement a pathway for nurse care for different patients groupings, eg.
post surgery, long term condition, frail elderly, palliative (covering the various nursing
groups/specialties) and for wound care, across clinic and home settings.
Examine better linking of home based care with district nursing.
Develop IT and administration systems that enable closer integration, including those
that enable data capture in the home/at the bedside.
Review current referral systems, considering potential role of Care Link, and change to
'within-system-request-for-assistance/booking'. Monitor workload and waiting times
and develop new priority and entry criteria as required.
Identify the requirements for sharing clinical notes on MedTech in a single clinical file
used by all health providers in the IFHC. Develop specifications for new system and
fund implementation. Work with the current health centre that does not currently use
MedTech to determine the barriers and facilitators for change.
Develop a plan for better integration of well child services.
Business case appendices V12 AC 25Feb2010 Page 57

Year two:
Maintain deliverable/activities from year one. Monitor & audit progress & changes.
Extend MedTech across all health centres and for all community nursing and allied
health.
Develop a client load aligned with practice populations, eg. each physiotherapist, social
worker or specialist nurse relates to one (or more) health centres and may see patients
there. They will be members of the multi disciplinary team.
Review the location of sexual health services, with a view to them being located in IFHCs
Year three
Build on and maintain previous years work.
7 Capability and capacity
Capability and capacity are core aspects of this plan and are therefore covered in the above
sections.
8 Effect on inequalities
This work stream focuses on those who are current frequent users of the health system,
including the frail elderly, and aims to improve their care. While focusing on optimizing care for
those who do frequently interact with the health system, it will be important to ensure that
those who typically don't benefit, and are disconnected, from the health system (but who could
benefit from better care) are not forgotten. It is intended that achieving better (as distinct
from more) care for those patients currently utilizing the health system frequently, will free
resources that can then be focused onto meeting the needs of Māori and Pacific peoples.
9 Evidence for this initiative
The need for new models of integrated care for the aging population and those with long term
conditions has been well described by Rosen and Ham 44 :
44 Rosen R, Ham C. Integrated Care: lessons from evidence and experience. Report of the 2008 Sir Roger Bannister
Annual Health Seminar by R Rosen, Nuffield Trust , C Ham, University of Birmingham
Business case appendices V12 AC 25Feb2010 Page 58

“With an aging population and an increasing prevalence of chronic disease, ever more
people require care and support services from organisations that cross the boundaries
of health, social care, housing and voluntary organisations. A wealth of studies report
that people with chronic, complex health problems – particularly older people – are often
confused by the array of services they are faced with, receive duplicate interventions,
and find it hard to understand where to turn with specific problems. They value
initiatives to coordinate care and simplify their journey through the health and social
care systems.
Equally, with pressure to deliver elective care in community settings and prevent
avoidable ill health, integration and collaboration between generalists and specialists –
GPs, consultants, specialist nurses and other clinicians – is increasingly important.”
They advise that any project involving integration of services:
makes improved patient care the main objective of every proposal
develops clearly articulated and shares goals
involves local primary care networks and clinicians in developing the strategy
takes time and effort to build the relationships, trust and clinical leadership required in
integrated teams
measures clinical and social outcomes so that the effect of changes can be reviewed and
programmes modified
is careful to unbundle the true costs of any services before devolution occurs
develops robust governance arrangements from the start
establishes the right incentives for services and clinicians to want to be involved.
Similarly Glendenning 45 observes that integration is more likely when the following are present:
joint goals
tight knit highly connected professional networks
high degree of mutual trust
joint arrangements which are part of „core business‟ rather than marginal integration at
the edges
joint arrangements covering operational and strategic issues and shared or single
management arrangements,
Nick Goodwin, Kings Fund 46 , in his recent presentation to the Ministry of Health concluded from
the international literature that:
“There is a lack of rigorous evaluations of polyclinics in other countries. Contextual
differences are important.
Co-location of professionals is not sufficient to guarantee integrated care - in the
same polyclinic, and between polyclinics and hospitals.
45 Glendenning, C (2002) „Breaking down barriers: integrating health and care services for older people in England‟,
Health Policy 65: 139–151.
46 Nick Goodwin. Powerpoint presentation to Ministry of Health, Wellington. 15 March 2010
Business case appendices V12 AC 25Feb2010 Page 59

Risks to professional development and motivation.
Issues of patient choice and continuity of care, and how these are to be
safeguarded within a polyclinic-based system
Caution needs to be exercised in basing policy on international experience. “
His advice for successful integration was:
“Strong clinical leadership – quality focus
Team working
Cluster services & diagnostics around patient needs
Investment in change management & process redesign
Maximise benefit of new technologies and IT”
10 Risk analysis
Risk Probability Impact Contingency plan
Co-location of community
nursing and allied health
with medical centres is
achieved, but does not lead
to better integration
Re-orientation and
re-focusing of community
nursing/allied health
workforces towards
primary end leads to
overload for staff
("something added, but
nothing dropped")
Re-orientation and
re-focusing of community
nursing/allied health
workforces towards
primary care, worsens
connection with secondary
care
High High Recognise this key risk (as identified from
overseas experience/published literature).
Understand the limitations of co-location
back-up co-location with electronic
records integration
back up co-location with common
organisational/management structures
where possible
back up co-location with development and
implementation of an Integration Charter
that is linked to lease/tenancy
arrangements.
High High Identify early opportunities for improving
outcomes (rather than just responding to
service demands) for patients with high
demands on the system with view to reducing
the current level of demand/service utilization.
Target services to those most in need/most
able to benefit; refine entry/exit &
prioritisation criteria.
Medium High Recognise this key possibility and address from
the outset.
Ensure inpatient workload is fully understood
and necessary availability to the wards etc is
protected.
Business case appendices V12 AC 25Feb2010 Page 60

Differences between
revenue generating
imperatives faced by
medical centres and free
service ethos of
community nursing/allied
health causes professional
disconnects and/or
confusion for the public
Management of change
process handled
ineffectively.
Physical co-location of
community nursing and
allied health with medical
centres cannot be achieved
Community nursing/allied
health workforce being
allocated to medical
centres leads to
fragmentation and loss of
support within the
professional groupings
Sub-specialisation becomes
impossible and/or is not
supported (in any move to
generalist roles)
High Medium Carefully examine & understand public policy
implications & possibilities; engage with MoH
early.
Ensure all workforces are aware of financial
imperatives & requirements.
Ensure clear boundaries, entry/exit criteria
etc.
Ensure clear communication with
patients/public.
Medium High Have a transition pathway.
Introduce a change manager to lead this.
Ensure patients/family/whanau and the
Community walk alongside the developments/
Consumer input and involvement.
Have clear guidelines and timeframes.
Have plan for management of staff resistance
and monitor.
Medium Medium Ensure clinical notes integration.
Implement common organisational/management
links.
Medium Medium Recognise this key possibility and address from
the outset.
Ensure professional support and communication
needs are understood and addressed in
implementation plan.
Ensure new business/organisational model
contains necessary support, mentoring,
professional development infrastructure for all
professional groups.
Low Medium Recognise this possibility and address from the
outset.
Identify and plan out the skills required, set
education around this plan and review.
11 Engagement
Working group who developed this plan: Hecta Williams, Raewyn McKnight, Maureen Frankpitt,
Janette Anderson, Hecta Williams, Helen Reriti, Pauline Ansley, Barbara Smith, Jenny
Robertson, Jane O‟Malley, Cheryl Hutchison, Jenny Woods, Dr Jocelyn Tracey, Anthony Cooke.
Other clinicians involved: Dee Dolby, Dr Carol Atmore, PHO Clinical Governance Committee.
Business case appendices V12 AC 25Feb2010 Page 61

12 Organisational accountabilities
There are two levels of change proposed.
Within each IFHC, co-located services will sign up to an Integration Charter that sits alongside
their tenancy/lease agreement. This Charter will commit those services that co-locate to the
service integration objectives of the IFHC and to involvement in the 'service integration
management team' that is likely to operate in each facility.
Subject to decisions made in relation to the overall ownership and operation of various services
(see the Ownership, Governance & Management work stream) it may be that services currently
operated by the DHB will come under the auspices of the PHO. The PHO, suitably revised or
replaced, would then become the operator of a larger proportion of the community and primary
health care service infrastructure, with service integration, management and development of
the whole primary and community health service, its core role and responsibility.
13 Costs
No change to ownership of services is proposed initially. Each service owner will continue to be
responsible for their services own revenue & costs.
Achieving the early goal of change to, and integration of, clinical services will, however, require
dedicated project & change management resource as described in the Business Case.
Business case appendices V12 AC 25Feb2010 Page 62

Appendix Seven: Integration - HealthPathways
1. Aspirational statement:
Patients will receive care that is consistent, co-ordinated and in accordance with best practice
guidelines across their health care journey.
2 Project overview
HealthPathways is a web-based information system developed by Canterbury DHB Planning and
Funding in conjunction with local clinicians. GPs and hospital clinicians identified the importance
of current information in securing the best care for patients within existing constraints
(workforce and fiscal) and developed HealthPathways to provide this information, with a primary
focus on general practice care, as part of the Canterbury Initiative (see www.canterbury
initiative.org.nz.).
This project describes the adaptation and implementation of HealthPathways for the West
Coast.
3 Problem definition
Description of HealthPathways
HealthPathways:
Uses the skills of other clinicians including nursing, allied health, and health scientists.
Provides local information about local services.
Is based on and referenced to Best Practice NZ guidelines if available, or international
guidelines.
Provides information on assessment, management, hospital departments, and referral;
and also patient information, reference material, and educational resources.
Covers the most frequent reasons for referral to a hospital department, acute and
non acute.
Is complementary to the planned electronic referral management system.
Keeps clinicians up-to-date with which services are available, which are funded, and how
to access them.
Business case appendices V12 AC 25Feb2010 Page 63

HealthPathways is not:
decision support software (no patient information is entered)
evidence-based guidelines
designed for patients
comprehensive – many departments and clinical areas have not been started.
Development of pathways:
Pathways are initiated by the clinical work groups within the Canterbury Initiative and
then progressed by clinical editors. T he relationships developed in the work groups
provide the foundation to develop the pathways. Additional pathways are continually
being added to HealthPathways as additional work groups are created.
While one of the key drivers in Canterbury for the development of HealthPathways was to
decrease waiting times for first specialist appointments (FSAs), the drivers for the West Coast
are somewhat different. Currently, the primary care system on the West Coast is not in a good
position to take on clinical tasks currently performed in secondary care settings. Similarly, Grey
Base Hospital services are generally staffed on a capacity model – in which staff costs do not
vary with reductions in activity. However, in the medium term, with the strengthening of the
primary care sector, and the development of more activity based staffing for some services,
associated with a closer working relationship with Canterbury DHB 47 , there may be an
opportunity to move some clinical work from the hospital setting into Integrated Family Health
Centres (IFHCs).
West Coast issues to be addressed by this programme:
The care provided is not always consistent across primary and secondary providers.
There is a heavy dependence on locums, often from overseas, to provide GP care and
they do not always know what can be done in general practice, and when to refer to
secondary care.
Nurses are taking an increasing role in first line care in general practice and will find
locally adapted HealthPathways valuable to guide the care they provide.
While waiting times for FSAs are not a major issue currently given the relative high
specialist:population ratio, as the Sustainability Project effects the numbers and types
of secondary care clinicians on the West Coast it will become important to have
pathways that describe what is expected to take place in primary care prior to referral
for an FSA.
An increasingly amount of secondary care is provided by clinicians jointly employed by
Canterbury and West Coast DHBs; it is therefore important that care and access to
FSAs is consistent across the regions.
47 See LECG report: Analysis of options: models of care for West Coast DHB. Nov 2009
Business case appendices V12 AC 25Feb2010 Page 64

It is expected that HealthPathways will provide:
Better care – in line with Best Practice guidelines, and consistent between providers,
including primary, secondary and Māori providers.
Sooner care – patients will be able to access some investigations and treatment options
earlier directly from their general practice, and waiting times for FSAs may decrease.
More convenient care –more care will be provided at IFHCs rather than hospital based.
Nurses and doctors working in general practice have expressed interest and support for this
development, as have those in community nursing, allied health and secondary care.
4 Objectives
To enhance the patient journey for patients presenting with common health problems,
including the incorporation of a whanau ora approach.
To increase the consistency and co-ordination of care between primary and secondary
care.
To increase the appropriateness of FSAs.
5 Benefits and gains
Output measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
Number of topic areas
HealthPathways sections adapted
for the WC
0 8 6 6
Referral quality audit TBC 20%
improvement
Number of hits on West Coast HP
web site per month
Further 10%
improvement
Further 10%
improvement
0 500 1000 2000
Outcome measures
Indicator
FSA rates (numbers actually seen)
Paediatrics
Gynaecology
Baseline
2009 year
177
371
Target – Yr 1 Year 2 Year 3
No change 10%
decrease
Further 10%
decrease
Business case appendices V12 AC 25Feb2010 Page 65

6 Deliverables / activities
Implementation plan: to June 30
Trial a process for adapting the HealthPathways:
Decide on the first two areas – areas where HealthPathways have already been
developed in Canterbury, where there are keen local clinicians, and where there are no
major barriers to progress.
Identify local hospital specialists, GPs, hospital and community based nurses who are
willing to participate.
Set up two workshops with local clinicians, plus experienced clinicians and IT support
from Canterbury for the first two pathways.
At the workshops begin with copies of the Canterbury pathways and work through each,
identifying what changes need to be made and where there are access or resource
issues that will need to be solved outside the workshops.
Write up the results of the workshops and circulate back to members.
Work with management to resolve access and resource issues as possible.
Meet in person (or e-mail) to finalise the West Coast adaptation.
Hold professional development meetings with primary and secondary care to educate
regarding the HealthPathways.
Evaluation:
Review how well the above process went, adapt and refine.
Develop a process to adapt future pathways locally without requiring facilitation from
Canterbury.
Select next areas for developing the West Coast adaptation.
Referral quality audit:
develop audit tool
use to gather baseline data.
Year one:
implement the process to adapt another 8 groups of Health Pathways groupings
refine processes
provide further educational sessions
review results of
develop referral quality audit and work on addition of Health Pathways (will depend on
cost and available resources).
Business case appendices V12 AC 25Feb2010 Page 66

Year two
implement the process to adapt another 6 groups of Health Pathways groupings
refine processes
provide further educational sessions
evaluate usage and progress, adapt plan as required.
Year three
implement the process to adapt another 6 groups of Health Pathways groupings
refine processes
provide further educational sessions.
7 Capability and capacity
Capability: This project is an adaptation of the successful Canterbury Initiative project and will
be supported by Canterbury and hence benefit from their expertise.
The project is supported by key West Coast clinicians (Chief Medical Officer, Director of
Nursing and Midwifery, Primary Secondary GP Liaison) and the Patient Journey Improvement
Co-ordinator. They will manage the implementation of the project.
The project depends on the involvement of other local clinicians in working groups. Given the
demands on local clinicians the project has been adapted so as to use their time as efficiently as
possible.
8 Effect on inequalities
It is important that the patient journeys take into account a whanau ora approach and provide a
holistic approach to care. Māori will be included in developmental working groups.
9 Evidence for this initiative
The following evidence from the Canterbury initiative suggests that this programme is likely to
be successful:
Proven implementation team from Canterbury to work with WCDHB.
Proven track record in Canterbury - over 180 pathways in just over a year many
adaptable for the West Coast.
Business case appendices V12 AC 25Feb2010 Page 67

Rapid rise in figures on use of the website containing the HealthPathways. Statistics
show average pages per day per month accessed for February 09, was 405 pages, June
09, 647 pages and November 09, 1404 pages.
Participation by hundreds of clinicians in Canterbury means the site is designed by the
users for their needs. Regular and frequent feedback from participants in the
Canterbury Initiative process has enhanced the content.
A high participation rate by specialists and general practitioners was achieved in
Canterbury in education sessions with positive feedback indicates the programme fulfills
a need for information.
Multiple changes in clinical service provision were achieved with gradually increasing
uptake such as subsidised skin cancer surgery, gynaecology procedures and respiratory
investigations.
West Coast general practice is already accessing the Canterbury HealthPathways site
for reference material and sees the value in customising it to fit the West Coast.
Canterbury Initiative are evaluating effectiveness using a number of methods including an online
questionnaire repeated over time to general practitioners and specialists, monitoring changes in
service utilization with many sets of usually collected DHB data. As well, research programmes
have been initiated for significant changes in service delivery including prioritisation of
colorectal symptoms and the community management of post-menopausal bleeding.
Canterbury clinicians have noted that the use of the pathways:
Provide better outcomes for patients.
Can provide alternatives to a referral from general practice to hospital for an FSA.
Have improved the quality of information being provided by general practice enabling
more effective and consistent triage.
Allow hospital clinicians to discharge patients back to general practice for follow-up
care.
10 Risk analysis
Risk Probability Impact Minimisation plan
Low clinician
engagement in
High High Personal approach, pay for their time,
share the load.
workshops
Relationship with
CDHB deteriorates
Low High Regular meetings and shared decision
making.
Business case appendices V12 AC 25Feb2010 Page 68

Low uptake by
primary and
secondary care
clinicians
Local adaptation
process not
effective
Low -
moderate
High Educational sessions, assist clinicians
to put in „favourites‟ in their web
browser, multiple reminders about the
pathways, link on PHO and DHB
websites.
Low High Will need to revert to joint workshops,
if necessary.
11 Engagement
Working group who developed this plan:
West Coast:
Vicki Robertson, Chief Medical Officer
Jane O‟Malley, Director of Nursing and Midwifery for West Coast District Health
Dr Jocelyn Tracey, West Coast Primary Secondary Liaison Officer
Alison McDougall, Patient Journey Improvement Coordinator
Canterbury:
Graham McGeoch – Canterbury Initiative Clinical Leader and Clinical Editor for HP
Juanita Gibson – Technical Writer – Streamliners.
Emma Harding Streamliners
Ian Anderson – Streamliners, also working on CDHB EOI project.
Bronwyn Petrie – Project Manager – Canterbury Initiative team.
Other clinicians involved: Dr Greville Wood, Dr Carol Atmore, Dr John Garret, Alison Lobb (RN),
Liz Burns (RN).
12 Organisational accountabilities
Canterbury will retain ownership of the Health Pathways.
13 Costs
The Canterbury Initiative is supporting and funding the West Coast adaption of the pathways as
follows:
access to HealthPathways web site
Business case appendices V12 AC 25Feb2010 Page 69

time involvement of clinical editors will be funded in accordance with the package agreed
with
cost of technical support from Streamliners.
Changes to HealthPathways that require input from WCDHB administration, clinician,
management personnel will be provide from within current resources with the exception of
general practitioner/nurse specialist input to workshops which will be remunerated at agreed
Canterbury DHB rates. Reviewers and those who provide wider feedback are not remunerated.
Given the small number of GPs and nurses on the West Coast, the burden of involvement may fall
on a few individuals. The PHO will budget $5,000 each year in the workforce budget for extra
payments for local primary care involvement.
Business case appendices V12 AC 25Feb2010 Page 70

Appendix Eight: Improved access to diagnostics
1. Aspirational statement:
The people of the West Coast will be able to access radiological diagnostic investigations in a
convenient and timely manner.
2 Project overview
Currently there is direct access from primary care to Grey Hospital for plain film x-ray and
ultrasound (except musculoskeletal) in a timely manner.
Direct access to selected CT imaging using referral guidelines will provide sooner and more
convenient care for patients and will be implemented by July 2010.
Direct access to musculoskeletal ultrasound will require capacity issues to be addressed;
planning will commence in July 2010, with access using referral guidelines possible by January
2011 if current barriers can be overcome.
3 Problem definition
A full range of plain x-ray, CT scans and ultrasounds is available at Grey Base Hospital. The
digital PACS system is used and images sent digitally to Christchurch for reporting by
Christchurch Radiology Group radiologists. Buller Hospital has plain x-ray.
There is no private radiology service on the West Coast; to access private services patients
travel to Christchurch or Nelson.
Plain film radiology
Currently there is open access from primary care to plain film radiology in Greymouth and
Westport during office hours.
For urgent x-rays in Greymouth the practice rings for an appointment and then faxes in the
request form or sends it in with the patient; either same day, or within 24 hour access is
available. For less urgent requests the form is posted and waiting times are a maximum of one
week. This service is highly regarded by general practitioners.
Business case appendices V12 AC 25Feb2010 Page 71

The service views the great majority of requests as being appropriate. There are times when
locums and nurses (with GP sign off) appear to be quicker to x-ray rather than using time as a
diagnostic tool to determine whether an x-ray is necessary.
Current volumes of primary care ordered plain films and ultrasounds: 5000 per annum,
increasing by about 200 per year. No national comparative data is available from the Ministry
of Heath 48 .
Ultrasound
Open access is available from primary care for all ultrasound examinations except
musculoskeletal. Current capacity is full and further sonographers and ultrasound machines
would be required if access was made available for musculoskeletal investigations, which
generally take longer, (eg. a shoulder ultrasound takes twice as long as an abdominal ultrasound).
GP ordering of ultrasound is viewed by the service as being generally appropriate.
There is no access to ultrasound in Westport currently, although this has been possible in the
past.
There are plans to introduce generalist medical ultrasound in ED in Greymouth, for use by
clinicians in caring for patients acutely. This may have a small effect on the number of
diagnostic ultrasounds ordered (generalist medical ultrasound is useful to aid doctors in ED
management, however it lacks the sensitivity and specificity of a diagnostic ultrasound done by a
trained sonographer, and is not reviewed and reported on by a radiologist).
If a GP thinks a musculoskeletal ultrasound is required then a referral for an orthopaedic First
Specialist Appointment (FSA) can be made, potentially adding to the cost of care if the
ultrasound result proves the FSA unnecessary. Alternatively, a number of patients, either with
injuries covered by ACC or with medical insurance, travel to Christchurch to access
musculoskeletal ultrasound. On occasions this is linked in with private specialist appointments in
Christchurch and subsequent procedures that might otherwise have been carried out at Grey
Base Hospital and paid for by ACC.
CT scans
Currently the only access for primary care to CT scanning is for CT urogram for renal colic.
However GPs can on occasions phone a Senior Medical Officer (SMO) and obtain verbal consent
for the ordering of CT scans (this is more likely to happen if the GP knows the SMO, and is able
48 Personal communication, Andrew Downes, Portfolio Manager, Elective Services
Business case appendices V12 AC 25Feb2010 Page 72

to easily access by telephone). Otherwise the patient is referred for an FSA and may have the
investigation done prior to, or after, their FSA.
There is potentially spare capacity which does allow for increasing direct access for those
conditions where:
CT is the appropriate first line investigation,
GPs are often able to provide the management indicated by the CT scan diagnosis
without needing an FSA
guidelines can be implemented that will manage demand.
CTs currently seen by both general practitioners and the radiology department as being
appropriate for direct access are:
CT head for head injury
CT scan for painless haematuria
CT urogram for renal colic
CT colonography instead of barium enemas.
As the Health Pathways are adapted for West Coast, it may be that other kinds of CT scan are
identified for development of direct access pathways.
Remote access
If patients are coming from remote rural areas, such as Fox Glacier, and are likely to need a
FSA along with their radiological investigation, where possible the Central Booking Unit
organises for both to happen on the same visit to Greymouth.
There are difficulties for low socio-economic families in rural areas with the cost of transport
to Greymouth for radiological procedures and the difficulty accessing travel assistance.
Radiology in Integrated Family Health Centres (IFHC)
The equipment and resources required for radiology services are expensive. Currently at 5000
community ordered radiology investigations a year, this equates to approximately 1700 per year
per IFHC, approximately 7 investigations per day per centre. While it would be desirable to
have plain radiology and portable ultrasound in each IFHC, and this is achievable in Buller, in
Hokitika/Westland (thirty minutes from Greymouth) this would not be cost effective. In
Greymouth while it would be convenient to have the radiology department within the IFHC, use
is greater by the hospital and having two radiology centres would not be cost effective;
therefore the radiology department should remain close to ED, and medical and surgical wards.
Proximity of the IFHC to the hospital could advantage those 7 patients a day who need
radiology, but only if their investigation was able to be provided at the same visit.
Business case appendices V12 AC 25Feb2010 Page 73

4 Objectives
to continue with direct access from primary care to plain film radiology
to develop direct access by primary care to CT scans for health problems that meet the
criteria
to develop access to musculoskeletal ultrasound without significantly increasing the
waiting list for other types of ultrasound
to enhance the skills of those requesting radiological investigations and interpreting the
reports.
5 Benefits and gains
Output measures - track quarterly
Indicator Baseline Target – Yr 1 Year 2 Year 3
Number of plain film and US 5000 pa 5200 5400 5700
Total number of CT scans 3500 3750 4000 4250
Numbers CTs ordered by GPs Est. 10 300 320 340
Number of musculoskeletal 0 0 40 60
ultrasounds
Orthopaedic FSAs 873 870 830 810
Number of educational sessions
held per annum
1 1 1 1
6 Deliverables / activities
Implementation phase: to June 30, 2010
Develop guidelines for general practitioners to access:
CT head for head injury
CT scan for painless haematuria
CT urogram for renal colic
CT colonography instead of barium enemas.
Task
Gather copies of guidelines used in other regions
Establish multidisciplinary groups to review guidelines and adapt for
local use (include Māori participation)
Develop referral template based
Provide educational session for referrers in the use of the guidelines
Establish system for tracking volumes
By when
March
March – April
May
May
Business case appendices V12 AC 25Feb2010 Page 74

Year One – July 2010 to June 2011
Task
Continue open access to plain x-rays
Provide a generic Coast-wide educational session plus regular updates in
newsletters and reminders of websites that provide guidance for both
ordering and interpreting investigations, eg. CRG
Review use of plain x-rays: audit use by practice according to size of
enrolled population
Put in place educational intervention for any practices that have
significantly greater than average usage.
If necessary develop notional budget holding
Report on numbers of CTs requested
Audit of CT requests against the guidelines
Review existing CT referral templates, modify and develop an
electronic version
Review need for increased access to other radiology investigations as
part of Health Pathways project
Ensure HealthPathways contain helpful advice for those ordering
investigations
Review travel assistance arrangements and develop plan for Buller
region (include Māori participation)
By when
July
Annually
August
October
June
Quarterly
April
June
Ongoing
February
Year Two – July 2011 to June 2012
Investigate ability to provide direct access for musculoskeletal ultra sound (US)
possibly increase capacity in Greymouth through starting regular fortnightly or monthly
US service in Buller
possibly establish notional budgeting for primary care US services and enable
musculoskeletal US though tighter management of other US capacity.
Expand direct access to other diagnostics as part of Health Pathways project.
Annual educational session.
Year three
Consolidation and review.
7 Capability and capacity
Current capacity and capability exists to allow access to CT scans as along as volumes are
controlled by the use and audit of referral guidelines.
Business case appendices V12 AC 25Feb2010 Page 75

There is no current capacity to increase numbers of ultrasounds usage and therefore this is
dependent wither on a decrease in current requests or the establishment of a service in Buller.
There are concerns regarding the capability of some of those ordering and interpreting
investigations. With an increase in primary care consultations managed by nurses there is a
need for increasing educational support as described in the plan above.
8 Effect on inequalities
There is already very good direct access to radiology services which benefits low
socio-economic families. Direct access to some CT investigations will remove the need for FSAs
which will benefit those who have difficulty accessing extra appointments.
The need for travel assistance for those living in Buller and travelling to Greymouth for
diagnostic investigations is an important barrier for some and will be addressed as part of this
plan.
9 Evidence for this initiative
A number of other regions in NZ have piloted direct access to CT and to musculoskeletal
ultrasound as shown in the following table 49 :
Location
Details
General ultrasound Northland
Whanganui
Range of US – developed referral guidelines (GL)
Used Australian radiology GL – too many referred
Abdomen, pelvic, renal
US
Auckland
Canterbury
Referral GL developed
Also pelvic for 5 conditions
Soft tissue US Canterbury Triage GL and education
Shoulder US Canterbury New pathway and education
CT abdomen, liver, Canterbury Triage GL and education
pancreas
CT for headache BoP
Nelson
GL and education
GL developed
CT colonoscopy
Whanganui
Nelson
Developed referral GL
For those where colonoscopy not so important
CT and MRI Wairarapa For TIA, breathlessness and atrial fib
CT renal colic Nelson Freed up ED time, decreased FSAs
49
Summarised from MoH report: A summary of improving patient pathways – diagnostic pilots. 2009
Business case appendices V12 AC 25Feb2010 Page 76

LECG 50 evaluated whether “the improvement processes implemented in these pilots were cost
effective and provided value for money”. They concluded that “redesign of pathways for
patients referred by GPs for diagnostic tests do offer opportunities for cost effective
improvements”. They also identified that “opportunities for improvement are location specific
and need to be identified with care” and provided helpful guidance for the development and
implementation of direct access pathways.
LECG anlaysed in depth a number of pilots that have direct relevance to this project:
Northland DHB musculoskeletal ultrasound, Nelson Marlborough CT urograms, Whanganui
general ultrasound.
The information from these analyses will be very useful in guiding the implementation of direct
access on the West Coast.
10 Risk analysis
Risk Probability Impact Contingency plan
Too many CTs ordered –
(significant amount of
radiation per CT)
Low High Develop referral guidelines and audit
regularly.
Only general practitioners order CTs.
Unable to free up
capacity for
Low High Work closely with all those involved
using a variety of approaches.
musculoskeletal US
Increase in numbers of x-
rays ordered resulting
from changed primary
care delivery models
Medium Medium Educational sessions and audits as
described above.
11 Engagement
Working group who developed this plan: Raewyn McKnight, Jason Lister, Wayne Champion,
Jocelyn Tracey, Helen Reriti, Anthony Cooke.
Other clinicians involved: Vicki Robertson, Martin Smith, Dr Martin London, Dr Andy Backhouse,
Tony Young (Canterbury Radiology Group) .
50 Moore D, Black M, van Essen E. Evaluation of 13 diagnostic pilots. Report from LECG for MoH, Nov 2009.
Business case appendices V12 AC 25Feb2010 Page 77

12 Organisational accountabilities
No change in current accountabilities until, and if, notional budget holding for investigations (in
particular ultrasounds) is developed.
13 Costs
The changes in service delivery proposed for the implementation phase and year one, can be
done within current budgets and resources. Currently $321,400 allocated for primary referred
radiology. At approx 5000 investigations p.a., that is $64.28 per investigation.
There will be some development costs (included in the „Implementing Service Strategies‟ aspect
of the Investing in Change budget, Section 11.1 in the Business Case) as follows:
Implementation Year one
phase
Project management, support for
$10,000 $10,000
guideline developments, education
sessions, audits etc
Multidisciplinary team members time to
$1,600
develop guidelines: locum cover
Development of electronic referral
$2,000
templates
Cost of educational activities $100 $100
TOTAL $11,700 $12,100
In years two and three the following costs will be calculated:
cost savings due to decreased FSAs for CTs
cost of any overall increase in CT volumes
volumes and costs of current community ultrasounds, with a view to moving to devolved
budget holding and opening access to shoulder ultrasounds
any savings from decreased volumes in plain films resulting auditing practice volumes and
providing educational initiatives.
Business case appendices V12 AC 25Feb2010 Page 78

Appendix Nine: Referred services
1. Aspirational statement:
Better alignment of clinical and financial decision making for referred services within an
integrated system will improve the effectiveness and efficiency of service provision both from
a clinical and financial perspective.
2 Project overview
This project begins in year one with a detailed analysis of current laboratory and
pharmaceutical expenditure so as to better understand current patterns of use and unexplained
variation. Current expenditure on both laboratory investigations (labs) and pharmaceuticals
(pharms) is below the national average. If the analysis shows potential for savings if financial
and clinical incentives were better aligned, then a number of change management activities will
be implemented.
3 Problem definition
General
Poor access and/or delays in receiving appropriate treatment can result in increased utilization
of emergency services and an increase in avoidable hospital admissions.
Currently there is poor linkage and co-ordination between the different parties involved in the
funding, commissioning, provision and monitoring of referred services.
The general increase in demand for services is placing increasing pressure on scarce health
resources. As both laboratory and pharmacy services are essentially demand-led services it
would generally be inappropriate or counterproductive to cap or otherwise limit expenditure or
funding. However it may be appropriate to establish better mechanisms and procedures to
increase the effectiveness and efficiency of referred service utilization and the prescribing of
pharmaceuticals to achieve better resource management and health outcome within an
integrated model.
Business case appendices V12 AC 25Feb2010 Page 79

Laboratory
There is anecdotal evidence to suggest that GPs and primary care nurses are referring some
patients that may be able to be safely managed within primary care without referral for
investigations.
While there has been relative stability in year on year cost for laboratory services, there is an
overall (small) increase. Despite this, there is evidence to show that some laboratory
procedures and tests are duplicated unnecessarily leading us to believe that further efficiency
can be gained.
.
Annual variance in laboratory costs – total DHB
Year Laboratory $ Increase
(decrease) for year
% increase
(decrease) for year
2005/2006 $1,148m - -
2006/2007 $1.336m $218k 19%
2007/2008 $1.186m ($150k) (11.2%)
2008/2009 $1.193m $130k 10.9%
Change over 3 yrs $45k 3.9%
Annual variance in laboratory costs – PHO only (from PPP)
Year Laboratory $ Increase
(decrease) for year
% increase
(decrease) for year
2005/2006 $678k
2006/2007 $680k $2k 0.3%
2007/2008 $732k $52k 7.7%
2008/2009 $650k ($82k) (11.2%)
On the basis of preliminary investigations it is believed that there are opportunities for process
improvement through the streamlining of referral systems, achieving a reduction in the type and
quality of referral procedures and avoiding unnecessary or wasted expenditure on repeat
laboratory testing.
PHO Performance programme data on the West Coast PHO share of the national expenditure
using a needs-based population formula, based on the enrolled population, for the period ending
30 September 2010, was significantly lower than the national average at 46.76 (performance
target

them by technical errors or lack of detail in prescription details being brought to them by
patients.
PHO Performance programme data on the West Coast PHO share of the national expenditure
using a needs-based population formula, based on the enrolled population, for the period ending
30 September 2010, was 83.57 for pharms (performance target

5 Benefits and gains
Output and outcome measures
These will be developed on completion of the analysis phase.
6 Deliverables / activities
Implementation plan
It is proposed to address the year one process in two phases as follows:
Year one – phase one July 2010 to December 2010:
Investigate the opportunities and benefits of implementing a comprehensive programme of
process improvement for referred services (for labs and pharms).
Subject to satisfactory conclusion and outcome of phase one, we will proceed to the next phase
as follows:
Year one – phase two January 2011 to June 2011:
From this list of potential strategies those most likely to result in cost effective utilization of
referred services will be implemented:
Establish effective information sharing between clinicians, managers, funders and other
staff who plan, fund, purchase, refer for and deliver diagnostic and pharmaceutical
services.
Use PHO Performance Programme cube tool to identify high cost medication usage and
laboratory use, both generally across the region and also to identify outliers.
Identify the greatest opportunities for cost saving without adversely effecting quality
of care.
Develop more detailed performance indicators for use of referred services and use as a
process improvement motivator with providers.
Develop better guidance on prescribing and test ordering as part of the HealthPathways
initiative.
Expansion of the pharmacy newsletter for GPs, to support the above.
Establishment of a “pharmacist advisor” function to the GP practices to look at trends in
pharmaceutical usage, provide updates on latest evidence and deliver clinical education
sessions common to practice staff and pharmacists – community and hospital.
Business case appendices V12 AC 25Feb2010 Page 82

Identify patients that would benefit from medication use reviews.
Establish a test order mechanism (both at a GP level and within the Hospital) that will
allow recommended repeat intervals to be applied to each type of test. (This would alert
a requestor that a test has been performed and result available within the stated
repeat interval).
Improvement of diagnostic service quality, through reviews and improvements in
administration, GP and nurse referral processes, and data management.
Year two - July 2011 to June 2012
Establish mechanisms that will better alignment of clinical and financial decision making
processes for pharmaceuticals, laboratory services and radiology:
Identify opportunities for delegated funding mechanism for some or all referred
services.
Audit and evaluate effectiveness of improved administration, GP and nurse referral
processes.
Improve the systems that lead to clinical decision making as other aspects of the
integrated family health system come into play, such as greater delegation of clinical
decision making to nurses.
Year three - July 2012 to June 2013
Potential delegation of funding and decision making in agreed areas of referred services:
Conclude evaluation and monitoring of improvement in processes(s).
Establishment of devolved funding and decisions making mechanism (refer alliance
contracting model.
7 Capability and capacity
There are no changes in the staffing against current number overall but it is anticipated that
role and function will change to incorporate combined decision making processes, the
undertaking of medicine use reviews (MUR) and allow for the introduction of the “pharmacist
advisor” function.
The data analysis phase will require the identification of skilled resource who can be contracted
to provide this support.
Business case appendices V12 AC 25Feb2010 Page 83

8 Effect on inequalities
It is anticipated that more effective and efficient clinical pathways in both laboratory referred
services and pharmacy services will lead to a reduction in resource wastage (both time and
money) enabling more attention and resources to identify and target those most in need in order
meet their health needs in a better sooner more convenient way.
9 Evidence for this initiative
In 2009 West Coast Primary Health Organisation commissioned a report 51 to investigate ways in
which the PHO could, and community pharmacies would, work together more closely to advance
its goal of achieving better health for people on the West Coast. This report identified the
following from evidence in the literature:
“Medication has the ability to enhance the quality of life and reduce the manifestations
of diseases that would normally lead to suffering and premature death. There is also a
growing awareness of the potential for these same drugs to cause a significant amount
of morbidity and mortality.
Underpinning nearly all innovative, cognitive services that might be provided by
pharmacists is the issue of drug-related morbidity and mortality. Drug-related
morbidity and mortality represents a serious medical problem that requires expert
interdisciplinary attention. Unrecognised and unresolved drug therapy problems may
result in extra primary care visits, hospitalisations, long term care facility admissions
and premature death. The literature suggests that a large proportion of drug-related
morbidity is preventable. Potentially pharmacists have the skills to ameliorate this
problem by identifying existing and potential drug therapy problems likely to cause
harm, a reduction in the quality of life, or death. “
It went on to say that:
“Clinical advisory pharmacists are recognised as having the qualifications, skills and
abilities to work in a variety of specialist roles. The services provided focus on
optimising medicines-related health outcomes for individual patients and working to
reduce existing and potential drug therapy problems from a population based health
perspective,
These roles may include:
• Pharmacist facilitation
• Comprehensive medication management (clinical medication reviews)
• Medicines therapy assessment (eg. in rest homes, residential care)
51 Linda Bryant and John Dunlop. Opening the Door on Community Pharmacy, , June 2009)
Business case appendices V12 AC 25Feb2010 Page 84

• Provision of patient specific medicines information
• Undertaking clinical audits at practice level
• Working with community pharmacists
• Review of medicines for high-risk people discharged from hospital
• PHO Performance Management
• Undertaking or assisting with research initiatives
• Collaborative Prescribing”
In 2007 DHBNZ published the “New Zealand National Pharmacists Framework” 52 . The
executive summary of this document reads as follows:
“Ministerial strategic documents highlight an opportunity for pharmacists to add value in the
primary health care sector. The final framework describes existing dispensing services and five
new services in two main themes:
1. Information services comprised of:
Health Education to patients.
Medicines and Clinical Information Support to practitioners (this includes Clinical
Advisory Pharmacist and Pharmacist Facilitation roles).
2. Medicines review services.
Medicines Use Review and Adherence Support (MUR), a four part review assessing
the patient‟s use, understanding and adherence to their medication regimen. This
service has been aligned with the NZ Pharmacy Council competency standards and
titles.
Medicines Therapy Assessment (MTA), a comprehensive clinical review of an
individual patient‟s medication as part of a multidisciplinary team.
Comprehensive Medicines Management (CMM), case based active management of
changes and (future) pharmacist prescribing activities, as part of a multidisciplinary
team.
These new services aim to:
Enable flexible implementation, eg. via District Health Boards (DHBs), or Primary
Health Organisations (PHOs), in line with available resources
Promote optimal medicine related outcomes from medicines.
Encourage multidisciplinary work practices, primary-primary and primary-secondary
integration.
Provide the prime tools in managing and ensuring value from pharmaceutical
expenditure apart from PHARMAC supply and demand initiatives.
Utilise the opportunity for enhanced access that community pharmacy offers for
the promotion of public health and well-being and the encouragement of self-care.
52 Elizabeth Plant & Ruth Rhodes. New Zealand National Pharmacist Services Framework, DHBNZ Pharmacy Advisory
Group, 2007
Business case appendices V12 AC 25Feb2010 Page 85

Enable the optimisation of health by evaluating and addressing where possible, the
medication management needs of local populations and individual patients.
Enable the development of medication management services that enhance patient
choice, access and convenience and provide a positive experience for patients and
other providers of healthcare.
Enable the provision of a range of clinically effective and cost-effective medication
management services that build on the strengths of community pharmacy teams and
that are provided within a multidisciplinary environment.
Enable the development of an integrated approach to planning and commissioning of
innovative medication management services that contribute to the development of
primary health care and the optimisation of health outcomes regionally and
nationally.
10 Risk analysis
Risk Probability Impact Contingency plan
Inability to “realise” savings
made through more efficient
and effective practice
medium high Effective and ongoing monitoring and
review to identify and attribute
changes in volumes of referred
services.
Growth in patient need
outstripping effectiveness
and efficiency measures
medium high See above.
Linkages with other monitoring
processes to determine improvement in
wider health outcomes, (eg. avoidable
hospital admissions).
Increasing emphasis on long
term condition management
could lead to an increase in
diagnostic testing and
prescribing
medium
Close monitoring and evaluation of
diagnostic testing and prescribing to
determine the „desirability‟ of any
specific increases or decreases in
volumes.
11 Engagement
Working group who developed this plan:
Dr. Tim Bolter (GP), Dr. Jocelyn Tracey (GP, Primary/Secondary Liaison), Phil Clark (Laboratory
Manager), Nick Leach (Hospital Pharmacist), Wayne Champion (Corporate Services Manager,
Acting Secondary Service Manager), Peter McIntosh (Senior Planning and Funding Analyst),
Kerri Miedema, July Kilkelly and Lindy Mason (Community Pharmacists), Wayne Turp (GM
Planning and Funding).
Business case appendices V12 AC 25Feb2010 Page 86

12 Organisational accountabilities
A shared DHB, PHO steering group will oversee the implementation of this plan.
13 Costs
A full cost analysis of the implementation of this workstream will be developed after phase one,
year one. However $30,000 for further data analysis has been included in the Investing in
Change budget, Section 11.1 in the Business Case.
Business case appendices V12 AC 25Feb2010 Page 87

Appendix Ten: Mental health
This plan was written on the basis of funding being available to employ a Mental Health
Co-ordinator in each (Integrated Family health Centre) IFHC. It became apparent on 23
February that this funding was not going to be available. While aspects of this plan may
still be able to be implemented within existing resources and funding, this will require
discussion with, and support from, clinicians from community mental health services,
primary mental heath services and primary care. Given the time available a revision to this
plan was therefore not attempted; this will done by June 30, 2010.
1. Aspirational statement:
Every West Coaster will be able to access the care and support they need to enjoy positive
mental health and well being.
2 Project overview
This project aims to integrate mental health services and primary health care on the West
Coast in a way that will result in better, sooner and more convenient services for patients,
delivered from IFHCs.
Changes in current service configurations include more seamless entry points for patients who
require care and support for mental health issues, packages of care for those currently falling
between primary and secondary services, shared care arrangements, improved discharge
planning processes and delivery of secondary mental health and addiction service within IFHCs.
A kaupapa Māori approach is incorporated into the plan. This will include enhanced information
sharing and mental well being resources for both mental health professionals and service users.
3 Current Situation and problem definition
The Primary Mental Health Program, targeted at enrolled patients with mild to moderate
mental health issues, has been operational on the West Coast for the past four years,
with very good results and good integration with general practices. A strength of the
program is that it does not purport to be a separate service but is an integral part of
the general practice teams – „in the practice, of the practice, for the practice‟. Patients
Business case appendices V12 AC 25Feb2010 Page 88

emain under the care and management of their general practices, thus allowing a more
holistic approach to well being with no stigma attached.
Secondary mental health services on the West Coast currently provide services to more
than 3% of the population. Services are mainly community based and include adult,
psychiatric emergency, child and adolescent, alcohol and drug, and Māori mental health
teams, with a small inpatient unit and family and consumer advisory services. There are
close linkages with Canterbury regional specialty services (youth inpatient, mother and
baby, eating disorders, detoxification services) and service users are able to access a
range of NGO provided residential and support services.
The Māori mental health team work alongside mental health service case managers to
provide cultural support to clients of mental health service and support clinical
processes to ensure they are delivered in a culturally appropriate manner.
“Recognising the integral relationship between cultural identity as Māori and Māori
wellbeing is a core element of a kaupapa Māori model of care. The term “Kaupapa Māori”
refers to the culturally derived philosophy that underlies and is woven into all aspects of
service delivery, with wellness for tangata whaiora Māori as the desired outcome 53 .”
To date there has been limited integration of primary and secondary care mental health
services on the West Coast because of the following reasons:
- they have been established, funded and operated in very different ways in order
to adhere to two distinct sets of criteria;
- shortages of psychiatrists to help develop shared care systems, shortages of
GPs with consequent lack of resource to take on a greater role;
- primary mental health co-ordinator role has focused on assessments and not had
capacity to take on a wider role;
- the current patient pathway is only established as a one way track i.e. primary
mental health team to secondary, no pathway back to primary mental health for
brief intervention counselling;
- current primary/secondary contracts add to the fragmentation of services due
to their distinction between mild and moderate/severe.
In terms of volumes, currently the adult community mental health services carry out 736
community adult assessments and admit to their service 636 new patients per year. This
excludes TACT team (449 assessments), inpatient (63), Alcohol & Drug Services and Child &
Adolescent Mental Health Services (382). The PHO Mental Health team assessed 414 patients
(aged 14 and above: 37 Māori) in 08/09 of whom 180 received Brief Intervention Counselling
(BIC) of up to six sessions per person.
Issues of current concern that may be able to be addressed as part of an initiative to better
integrate mental health services are:
lack of seamless entry for patients into the most appropriate pathways via a stepped
care approach
53 Te Haererenga mo te Whakaoranga 1996-2006. The Journey of Recovery for the New Zealand Mental Health Sector.
Mental Health Commission. Pg 157
Business case appendices V12 AC 25Feb2010 Page 89

lack of clarity in regard to roles of Primary Mental Health Co-ordinator has led to
duplicate assessment processes provided by both primary and secondary mental health
services
lack of assistance for patients who need ongoing psychosocial support for a period of
time but neither qualify for secondary services, nor are suitable for brief intervention
counselling
Māori in primary care do not have access to Māori mental health support workers; Māori
in secondary services do not receive the option of having a Māori Psychologist
lack of primary care involvement in discharge planning
lack of information for GPs from secondary mental care on the patient‟s mental health
management plan and medications, eg. difficulties arise when GPs are asked to provide
repeat prescriptions
lack of information for GPs from secondary mental care on the patient‟s management
plan and medications eg difficulties arise when GPs are asked to provide repeat scripts
no processes in place for shared care between primary and secondary care prior to
discharge from secondary care (except for methadone programme)
limited promotion of self care activities, eg. web based support programmes.
The recently released guidance paper, Towards optimal primary mental health care in the new
primary care environment 54 , provides a helpful guide for the further development of primary
mental health services. It makes a case for the importance of integrating mental health into
primary care:
“The World Health Organisation (WHO) and World Organisation of Family Doctors (Wonca) list seven
central reasons for integrating mental health into primary care (WHO and Wonca 2008). These
include:
1. Th e b urd en o f m en t al d isord ers is gr eat
2. Men t al an d p h ysical h ealt h p r ob lem s are int er w o ven
3. Th e t r eat m ent gap f o r m ent al d isord er s is en or m o us
4. Pr im ar y care f or m ent al healt h en h an ces access
5. Pr im ar y care f or m ent al healt h p r o m ot es resp ect of h um an r ight s
6. Pr im ar y care f or m ent al healt h is af f o rd ab le and cost ef f ect ive
7. Pr im ar y care f or m ent al healt h generat es good h ealt h o ut co m es”
This paper describes an optimal service user pathway in primary care as follows:
54 Ministry of Health. Towards optimal primary mental health care in the new primary care environment. MoH,
Wellington, 2009.
Business case appendices V12 AC 25Feb2010 Page 90

Service user pathways in an optimal primary mental health initiative (Dowell et al 2009)
The role of the coordinator is further described:
“Role of primary mental health coordinators
The PMHC role involves a combination of service development, screening and assessment, referral,
brief intervention, and mentoring existing primary care staff. Coordinators with clinical skills often
carry a caseload and use a variety of psychological and other therapeutic techniques.
An important role for PMHCs is care coordination for patients who have complex social needs and for
whom multiple agencies might be involved. Related to the care coordination role, it is also important
that PMHCs are good „connectors‟. They assess people referred from GPs or other primary care
providers, identify clinical and social needs, and find appropriate services to meet those needs.
Other key roles of PMHCs are:
facilitating better working relationships and integration between primary and secondary mental
health and AOD services
visiting or liaising with key NGOs and social services to obtain up-to-date information on the
services they offer and their referral criteria
organising training for practice staff
advocacy for service users with complex social needs – a key focus of intervention may be to
assist patients with obtaining benefits and entitlements, or with obtaining transport services, or
providing advice about the support available for victims of domestic violence
project management – developing policies and procedures, designing referral and other forms,
recruiting staff, etc.
It is recommended that the primary health care sector move towards employing PMHCs with the
clinical skills to conduct assessments, triaging, and brief mental health and/or substance use
interventions. This is consistent with a stepped care approach because it enables the patient to
Business case appendices V12 AC 25Feb2010 Page 91

eceive a brief intervention from the PMHC rather than (or prior to) a more expensive package of care.
The clinical positions require some administrative support (eg., project management, paperwork
involved in referring patients to different non-government organisations, scoring questionnaires,
monitoring). Therefore there is also a need for non-clinical roles to provide this support.”
This provides an appropriate blue print for the West Coast for further development and
integration of mental health services.
4 Objectives
To improve patient care by better integration between community mental health
services and primary health care and more collaboration amongst primary mental health,
secondary mental health, NGOs and social services.
To continue to support general practice teams to provide screening, initial assessments,
and extended consultations.
To develop a common set of assessment processes.
To develop a primary care based assessment service for all new adult patients (except
those referred acutely to the TACT team) .
To develop the primary mental health co-ordinator role.
to develop stepped care pathways and packages of care for patients with different
levels of severity and complexity, including shared care arrangements.
To re-design discharge planning processes to include primary care.
To extend the Kaupapa Māori mental health service to include tangata whai ora in both
primary and secondary mental health care settings.
To improve the patient pathway for Māori by establishing a whanau ora approach to the
delivery of services.
To develop a population health approach for all mental health services with service
delivery focused on the enrolled population in each IFHC.
to increase mental health promotional activities and support for self care.
5 Benefits and gains
Output measures
Indicator
Number of primary mental health
co-ordinators appointed
Single point of entry to mental
health services
Number of Multi Disciplinary Team
meetings within practices / IFHCs
Baseline
09 year
Target – End
Yr 1
Year 2 Year 3
1 3 3 3
Not in
place
Established
Continued
and revised
Continued
1/mth 3/mth 6/mth 6/mth
Business case appendices V12 AC 25Feb2010 Page 92

Model for shared care pathways
developed
Shared discharge planning
processes in place
Number of adult community
referrals processed
Number of adult assessments done
by MH co-ordinator
Number of adult assessments done
by Community MH
Number of patients receiving BIC
in primary care
Number of patients receiving
extended primary care consults
Number of patients receiving
other community based packages
of care
Number of patients admitted to
specialist services
Not in
place
Not in
place
Established
Established
Continued
and revised
Continued
and revised
Continued
Continued
1150 1150 1100 1050
414
814 950 1050
Māori: 37
736 436 150 0
180
180 150 150
Māori: 10%
79 100 120 140
0 50
Māori: 8
636
Māori:TBC
Number of patients in shared care 10
Māori: 2
Numbers of tangata whai ora
TBD
accessing Kaupapa Māori mental
health services
100
Māori: 15
100
Māori: 15
610 580 540
100
Māori: 15
150
Māori:22
300
Māori:45
Outcome measures
Indicator
% improvement in GHQ12 pre and
post BIC
HoNOS T10/12 scores %
improvement entry to discharge
Knowing the people planning (KPP)
targets:
Increase in the number of KPP
clients in a shared care
arrangement with mental health
services and GP
Increased number of KPP clients
participating in metabolic
monitoring
Baseline
at Dec 09
Target – Yr 1 Year 2 Year 3
78% >75% >75% >75%
80% > 90% > 90% > 90%
5%
0%
15%
15%
30%
30%
50 %
50%
Business case appendices V12 AC 25Feb2010 Page 93

6 Deliverables / activities
Following the WHO model 55 , patients in primary health care with mental health problems will
have their health needs identified and assessed and will be offered effective treatments,
including referral to specialist services for further assessment, treatment and care, if they
require it.
To achieve this standard, each primary care group will need to work with the support of
specialised mental health services to:
develop the resources within each practice to assess mental health needs
develop the resources to work with diverse groups in the population
develop the skills and competencies to manage common mental health problems
agree the arrangements for referral for assessment, advice or treatment and care
have the skills and necessary organisational systems to provide the physical healthcare
and other primary care support needed, as agreed in their care plan, for people with
severe mental illness.
This plan works towards a model of care that includes in the short term:
single point of entry for those referred to mental health services 56
primary mental health co-ordinators review all adult community referrals, and make the
decision as to whether the initial assessment is best carried out by themselves or the
specialist MH team
an increase overtime in the assessments done in primary care until all are done by the
coordinators
provision of different packages of care available depending on need and ethnicity,
ranging from community support to psychiatric assessment
increased access by tangata whaiora to Kaupapa Māori mental health services
development of processes for shared care
review of discharge planning processes with the IFHC teams
all mental health workers seeing patients within IFHCs.
Integration of primary and secondary mental health services within IFHCs will be explored in
year two.
55 DoH (1999) „A National Service Framework for Mental Health: Modern Standards and Service Models‟. London
accessed on 16/2/2010 at
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4077209.pdf
56 Patients assessed by General Practice Teams as needing only Brief Intervention Counselling (BIC), and meeting
specified entry criteria, will go directly to BIC providers
Business case appendices V12 AC 25Feb2010 Page 94

Implementation plan: to June 30
Development of the Mental Health Co-ordinator role
develop job descriptions and competencies required based on the role expectations
outlined in the guidance paper
identify FTEs required in Greymouth, Buller and Hokitika
identify potential funding stream and transition of human resource
develop assessment procedures: screening for anxiety and mood disorders, screening
for substance use disorders, detailed comprehensive assessment when clinically
indicated
develop patient pathways for all new referrals to mental health services
identify resource requirements for extending maupapa Māori Mental Health service to
include tangata whai ora in primary settings
develop a range of „packages of care‟, eg. brief intervention counselling provided by the
co-ordinator, ongoing psychosocial support provided by the co-ordinator, client referred
to community based support with or without ongoing review by co-ordinator, brief
intervention counselling provided by primary mental health psychologist/ counsellor,
client is referred for management to secondary mental health services, „shared care‟
arrangements are supported by the co-ordinator.
Enhance general practice team roles
develop a pathway for selected patients who require only brief intervention counselling
from psychologist/counsellor to be assessed by the general practice team and to access
this counselling directly
provide further training in screening and assessment to general practice teams
up-skill nursing team in management of anxiety/panic/depression.
Greater integration between secondary services and general practice teams
enhance the psychiatric consultant liaison role to support GPs, providing phone support,
educational sessions, medication reviews
implement primary/secondary Multi Disciplinary Team meetings.
Support for patient self care
widely distribute PHO developed self help materials in a variety of formats
promote approved mental well being resources supplied by CPH and available for patients
and health professionals at IFHCs.
create link to Community & Public Health website on PHO website
enhance access to web based patient support programmes via publicity campaign eg.
www.healthnavigator.org.nz, access to Monkey See DVDs
develop links between primary mental health professionals and mental health promoters
develop closer linkages with community agencies eg. PACT, Richmond Fellowship, Te Ara
Mahi, Homebuilders and Focus Trust etc.
Business case appendices V12 AC 25Feb2010 Page 95

Year one:
Co-ordinator role:
three co-ordinators appointed and based in Buller, Greymouth and Westland
two monthly review steering group sessions to review and refine processes and roles.
Discharge planning process:
set up mental health discharge planning process, levering off the generic project
develop a plan for change
consult widely among primary and secondary care providers and consumers
revise plan
put new processes in place
review six months later.
Shared care:
establish a planning group that includes consumer, whanau and Māori representation
review current contracts and funding models
develop model and processes for shared care, ie. reviews; agreed role boundaries; clinical
accountability and responsibilities
consult widely among primary and secondary care providers and consumers
revise plan
pilot processes in one region
review and revise
pilot processes
transition of support workers to primary care.
Brief intervention:
review age group covered by primary care youth counsellor (14 – 18).
Improving integration:
allocate a secondary mental health team member liaison person for each practice/IFHC
where facilities allow co-locate secondary mental health team in IFHCs.
Addressing physical health needs:
develop and implement annual health checks for long term mental health patients at
their IFHC
fund and encourage flu vaccinations for long term mental health patients.
Extending kaupapa Māori Mental Health service:
kaupapa Māori mental health services include service provision for Māori clients in
primary health settings.
Business case appendices V12 AC 25Feb2010 Page 96

Year two
Review progress, outcome measures and adapt plan
Alcohol and Drug:
review the patient pathway for alcohol, drug and other addictions.
Integration:
develop shared patient record systems
review the ownership, management and organisational accountabilities for primary and
secondary mental health services to consider whether both should be merged with
IFHCs (some service will need to be district wide, eg. Child and AdolescentMental
Health Services).
Professional development activities:
integrate activities across the services.
Shared care:
review pilot processes and refine process for shared care
roll out across the region.
Support for patient self care:
further up-skilling of staff in self management education
review availability of self management education and support and consider establishment
of group self management education.
Year three
Review progress, outcome measures and adapt plan.
7 Capability and capacity
Current configuration of adult secondary care community mental health into three teams will
align well with the IFHC model and provide the capability and capacity required to deliver
services to each of the three IFHCs.
Current primary mental health services are delivered within general practices, and will in the
future be delivered from IFHCs.
Greater involvement of GPs and primary care nurses in shared care and discharge planning are
dependent on current workforce issues being addressed.
Business case appendices V12 AC 25Feb2010 Page 97

Further professional development for core general practice teams will be required.
Increase in the Māori workforce will be required to effectively deliver kaupapa Māori services.
8 Effect on inequalities
Māori and low socio-economic people are over represented in mental health clientele.
The Māori mental health team will work alongside the primary and secondary mental health
services to ensure that clients receive a culturally appropriate service.
Locating mental health services in IFHCs will help reduce the stigma and marginalisation of
those presenting with mental health problems, particularly those with addictions. It will also
help them to access the physical care they need from their primary health care team.
9 Evidence for this initiative
Aspects of this plan follow the recently released guidance paper, Towards optimal primary
mental health care in the new primary care environment 57 .
Placement of mental health workers within primary care has been the subject of a significant
body of research. A recent Cochrane review of 42 studies 58 concluded:
“This review investigated whether having mental health workers on-site to work with physicians
at their offices would change the care that physicians provide. Forty-two studies were reviewed
in which on-site mental health workers, such as counsellors or psychiatrists, worked alongside
physicians to provide therapy to patients. The review found that when there were mental health
workers on-site, patients may reduce the number of visits to their doctors; doctors may reduce
how often they refer patients to off-site mental health specialists; doctors may reduce the
number of drugs they prescribe to the patients who see the mental health workers; and the
costs related to those drugs may be lower. However, these reductions were small and not found
consistently in all the studies.”
57 Ministry of Health. Towards optimal primary mental health care in the new primary care environment. MoH,
Wellington, 2009.
58 Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial
interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane
Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000532. DOI: 10.1002/14651858.CD000532.pub2.
Business case appendices V12 AC 25Feb2010 Page 98

10 Risk analysis
Risk Probability Impact Contingency plan
Lack of clear clinical
accountability for
High High Establish robust guidelines re shared
care arrangements.
treatment
Coordinator role
loses focus
Moderate High Ensure sufficient resource is available
for role function.
No capacity for GPs
and nurses to take on
wider role
Moderate High See workforce plan.
11 Engagement
Working group who developed this plan: Hecta Williams, Anne Tacon, Shona McLeod, Bev Barron,
Lois Scott, David Stoner, Jocelyn Tracey, Bryan Geer.
Other clinicians involved: Paul Cooper.
12 Organisational accountabilities
The shared steering group continues to further develop and oversee the implementation of this
project plan. In the short term organisational accountabilities remain the same, however after
the review in year two this might change, depending on the results of the review.
13 Budget
2009/10 2010/11
Primary Mental Health
MH BIC $186,878 $186,878
Child & Adolescent $90,000 $90,000
Liaison/ Coordination $96,878 $290,634
Discharge Planning Meetings
-
$5,000
(50 patients with 1 meeting
$100/meetings)
Business case appendices V12 AC 25Feb2010 Page 99

Shared Care MDT‟s
-
Long Term MHS users –
Physical Health
$40,000
(100 patients with 4 meetings/pa
@$100 per 50meetings)
$ 25,000
(350 annual checks @ $65 & seasonal
influenza vaccinations)
Community Providers $ 2,164,717 $3,007,422
Secondary Mental Health $9,358,288 $7,863,577
Secondary IDFs $788,675 $788,675
TOTAL $12,619,960 $12,199,960
Business case appendices V12 AC 25Feb2010 Page 100

Appendix Eleven: Frail older people
1. Aspirational statement:
Frail older people and others with long term disabling conditions will be able to access support
services that are timely, flexible and appropriate to their individual needs and those of their
carers.
The pathway of care among primary, secondary and community based services for older people
and those with long term disabling conditions will operate smoothly with excellent informationsharing
among all services and with people and their families.
All health and support service workers will be proactive in helping the person and their carers
maintain and regain their functional abilities and prevent further illness or injury.
2 Problem definition
Lack of clarity/agreement on appropriate pathway of care for frail older people, within
Grey Hospital as well as between hospital and primary health services and home based
and residential care services.
Stroke patients not transferred to specialist care soon enough and sometimes not at all,
and national stroke guidelines have not yet been adopted.
Opportunities missed for keeping frail older people fit and well and preventing admission
to the acute hospital and to long term residential care – lack of a pro-active approach to
reducing the risks of avoidable hospital admission or rest home entry.
Frail older patients admitted to the acute medical and surgical wards or presenting at
ED are not always appropriately referred to specialist Health of Older Peoples services.
Lack of a shared client information system even among DHB services, let alone primary
care, home support or residential care.
Lack of step down beds for convalescence and slow stream rehabilitation, and continued
inappropriate use of long term respite care and carer support budgets for this purpose.
Over use of long term residential care (particularly rest home level) due to under
development of home based alternatives, (eg. flexible homecare packages, planned
respite, dementia day care, support for carers).
Under development of home support services – most carers are untrained and casual,
with limited supervision or linkage to district nursing, community allied health, Care Link
or primary health services. Home support agencies cannot always provide staff for
high/complex packages
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Underdevelopment of support for carers – local voluntary agencies are barely
sustainable as the Coast population is not large enough to support services that would be
available in bigger centres, (eg. age concern befriending, continence education, dementia
support). Carer burnout contributes to the relatively high rate of rest home entry.
Many health and support workers and many clients still hold to a traditional dependency
and entitlement model for rest home and home support services and there is limited
implementation of a restorative model as yet.
Very limited availability of allied health staff for community based work, (eg. supervising
home carers in home based rehabilitation programmes, responding to GP referrals),
reflected in high rate of inpatient admission to AT&R ward.
Residential aged care facilities (in Greymouth) have had limited access to general
practitioner services, reflected in a relatively high rate of referrals to the acute
services. Primary health care received by residential care residents is sometimes suboptimal
and would benefit from greater input from medical staff with specialist
knowledge of older peoples health, including dementia.
A number of residential aged care facilities have had a continued shortage of registered
nurses, which has repeatedly compromised quality of care.
3 OBJECTIVES
Set up a clear pathway for accessing primary and community services. This would include:
A hub of shared client information available to all health and support services – GPs,
practice nurses, district nurses, Care Link, ward staff, allied health, residential care,
home care agencies etc. This includes InterRAI and other assessments.
A triage function for logging all cases and sending simple routine cases directly to the
appropriate service while ensuring complex cases receive multidisciplinary assessment,
case management through Chronic Conditions Programme and/or Care Link, and/or
referral to specialist services
Clear, agreed protocols for accessing services
Co-locate Care Link with the Integrated Family Health Centres (IFHC), and link staff to
specific primary health teams, thereby giving those teams easy access to expert assessment
(InterRAI), community-based support packages and a case management function for people with
long-term disabling conditions.
Set up a restorative home-based support service based on need, accessed through Care Link and
closely linked to primary and community health services:
Home care workers having close connection to primary health services, community
nursing and allied health, in some cases working under supervision to help clients do the
Business case appendices V12 AC 25Feb2010 Page 102

ehab and treatment programmes that occupational therapists, physios, GPs etc have
prescribed.
All relevant health and support workers (in primary, hospital, community and residential
services) trained in a restorative goal based model of care that focuses on the client
being helped to regain and maintain their function and on proactively preventing illness
and injury (eg. falls prevention, flu immunisation, timely equipment, active continence
management and other ways of preventing carer burnout).
Include a strong focus on supporting carers to prevent/reduce care burnout – Care Link
will use long term funding for carer support more flexibly to support carers and
voluntary patient support agencies.
Make best use of specialist Health of Older People (AT&R) resources:
Set up clear pathways to ensure timely transfer to specialist services for frail older
people and anyone with a stroke.
Set up step-down/admission avoidance beds in the main centres
A greater proportion of AT&R staff time available for consultation and support for
primary health services, home care services and residential care.
4 Benefits and gains
Output measures
Indicator Baseline Target – Yr Year 2 Year 3
1
Percentage of stroke patients Nil 25% 100% 100%
transferred to specialist stroke
team
Pathways implemented for the
appropriate care of frail older
people admitted to
medical/surgical wards
No Yes Yes Yes
Number of people with high falls
risk receiving ACC-funded falls
prevention programmes (55+ years
Māori, 65+ years non-Māori)
Shared client record can be
accessed by all appropriate staff
working in primary health,
community, hospital and residential
care services
Percentage of people receiving
NASC assessment within the
appropriate timeframe
Single point of entry and clear
pathway exists for access to all
community services
30 in
Greymouth
& Hokitika
in 2009-10
75
throughout
Coast
100
throughout
Coast
No Partially Partially Fully
90% 100% 100% 100%
No Partially Partially Fully
100
throughout
Coast
Business case appendices V12 AC 25Feb2010 Page 103

Outcome measures
Indicator Baseline Target – Yr
1
Rate of admission for falls-related
fracture, for people aged 75+
years, over 3 year rolling period
Average length of stay in specialist
Health of Older People (AT&R)
service
Rates of re-admission to acute
hospital care over a 6-month
period for people aged 75+
Rate of „frequent fliers‟ (6+ acute
hospital admissions per year) for
people aged 75+
Rate of admission to permanent
rest home level care per capita of
people aged 75+ years
Rate of ambulatory sensitive
admissions 45-74 years
Carer stress as measured by
average years duration of
employment for carers
TBC
TBC
TBC
TBC
5.98%
(July-Dec
2009)
TBC
Not yet
measured.
Same as
baseline
Same as
baseline
Same as
baseline
Same as
baseline
Year 2 Year 3
5% reduction
on baseline
5% reduction
on baseline
5% reduction
on baseline
5% reduction
on baseline
5.75% 5.5% 5.0%
Same as
baseline
5% reduction
on baseline
5%
reduction on
baseline
10%
reduction on
baseline
10%
reduction on
baseline
10%
reduction on
baseline
5%
reduction on
baseline
Baseline Baseline 5%
reduction on
baseline
5 Deliverable / activities
Implementation plan:
To June 30
Identify the process, timeframe, resources and accountabilities for establishing a
single shared patient record that is available to all appropriate primary, community,
hospital and residential care staff.
Introduce clinical protocols whereby stroke patients and frail older people admitted to
Grey Hospital are routinely referred to the specialist Health of Older People Service
(AT&R), with their primary health teams and case managers being alerted electronically
Progress the planned changes to a restorative model of homecare that have already
started, aligning with similar work by Nelson Marlborough and Canterbury DHBs
Complete implementation of InterRAI at Care Link and ensure read-only access to at
least other DHB services
Set up a robust budget management system for the long-term support services
accessed through Care Link, and a plan for linking InterRAI data to volumes and
expenditure data
Business case appendices V12 AC 25Feb2010 Page 104

Year one:
Maintain and continue the initiatives up to June 30 and also:
Identify patient pathways for older people, especially those disabled by frailty and
medical conditions. Create a simple, easy-to-use process for all health and support
workers to access community and primary services, including primary health services,
community nursing and allied health, palliative care, clinical nurse and allied health
specialists, and needs assessment/service coordination for short term and long term
support services, including mental health support services.
Extend InterRAI read-only access to non DHB health and support services, including
primary health teams, home support agencies and residential care facilities.
Set up a case management function for complex older clients by linking Care Link NASC
staff more closely to each primary care team to provide expert multidisciplinary needs
assessment and to ensure each client has a key worker to coordinate the treatment,
rehabilitation and support provided at home. This would work closely with the Chronic
Conditions Programme – „frail complex older people‟ treated as one more Chronic
Condition.
Set up a medical and geriatric nurse specialist rotation among primary health teams,
Care Link and specialist Health of Older People service (AT&R)
Reconfigure AT&R service to enable greater input to primary health teams, community
services and residential care facilities
Set tight criteria for access to long term support services, based on reliable data and
ongoing consultation with all stakeholders
Change relevant protocols and contractual arrangements to allow greater allied health
and nurse specialists input to home support agencies and residential care facilities
Explore the best way of providing step-down beds in the main centres for admission
avoidance, convalescence and slow stream rehabilitation (in the light of the experience
at Waikato and Wairarapa DHBs).
Prepare a Carer Support Strategy and Action Plan that identifies needs, proposes
service changes and allocates funding for services to support carers.
Pharmacist support:
- for patients managing well – prescription dispensing, brief counseling/education
as medicines added or adjusted;
- supporting self management – Medication Utilization reviews and compliance aid
provision as necessary;
- for those requiring integrated services: compliance packaging – picked up or
delivered to home or sometimes District Nursing, reminders to visit GP for three
monthly prescription, liaison with hospital and GP practice at discharge, follow-up
if (blister-packed) medications not collected. Scope for comprehensive
medication review at this level;
- General support – pharmacist involvement with various support groups, eg.
cardiac and respiratory, answering patient questions, providing smoking cessation
services, referral of patients to other providers, eg. diabetes nurse educator or
general practice.
Business case appendices V12 AC 25Feb2010 Page 105

Year two
Maintain and continue the initiatives from year one and also:
implement the Single Shared Patient record
implement a restorative model of homecare, with greater allied health and nursing
input, stronger connection to the primary health team, more skilled carers and services
tailored flexibly to the needs of clients and their carers
set up training in the restorative goal-based approach for all people working in health
and support services for older people, linked to what Canterbury and Nelson are doing
reconfigure allied health services to enable greater input to primary health teams,
community services and residential care facilities
establish step-down beds
implement the Carer Support Action Plan
extend medical an specialist nurse rotation to residential care facilities.
Year three
Maintain and continue the initiatives from year one and also:
co-locate Care Link with the other primary and community services in the IFHC
plan to move to a case-mix model of funding long term support services, based on work
done by Canterbury and Auckland DHBs.
6 Capability and capacity
These changes are more to do with how people work and changes of treatment model than actual
increase in numbers.
There is a need for further upskilling of the home care workforce.
7 Effect on inequalities
West Coast older people will gain access to home-based and specialist health of older people
services that are more similar to that available in most other areas of NZ.
These changes are based on a proactive and preventive model of care for older people and their
families/carers. This is highly likely to reduce the rate of illness, injury and disability, thereby
reducing the rate of hospital admission and long term residential care. West Coast older
people, like the rest of the West Coast population, have a higher rate of illness and injury than
the NZ average, so any improvement will reduce inequalities.
Business case appendices V12 AC 25Feb2010 Page 106

Māori have a higher incidence of most chronic health conditions and a higher need for long term
support from a lower age, and so will benefit most from a more proactive and preventive
approach to older people‟s care. The number of older Māori on the West Coast is increasing.
The proposals described above will help develop services that are acceptable to Māori and
effective in helping them maintain their health and fitness.
8 Evidence for this initiative
Evidence of the cost-effectiveness of integrating primary, community and hospital/specialist
and residential care services, using a single point of entry, multidisciplinary assessment and case
management to ensure that older people experience a smooth pathway among services, can be
found in:
The research underpinning the NZ Ministry of Health‟s Health of Older People Strategy and
integrated continuum of care concept (2002 – www.moh.govt.nz/publications/hops), such as
the Aged Care Literature Review on the Coordination and Integration of Services (2001
www.moh.govt.nz/moh.nsf/pagesmh/6127/$File/aged-care-literature-review.pdf )
UK NHS standards for older persons services, and UK evaluation of the NHS intermediate
care initiative - see www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/
DH_4073597
A major Canadian literature review: MacAdam M (2008) Frameworks of Integrated Care for
the Elderly – a systematic review. See www.cprn.com/documents/49813_FR.pdf
Much other overseas literature – see Wainwright T (2003), Home Thoughts from Abroad - a
literature review of the cost-effectiveness of home care - see
http://nzhta.chmeds.ac.nz/publications/home_care.pdf
Evidence for the importance of a goal-based restorative model of home/community-based care,
can be found in:
A number of reports from Auckland University‟s multi-DHB study of the implementation of a
restorative approach in older people‟s health and long-term support services – see
www.fmhs.auckland.ac.nz/son/research/default.aspx
Much overseas work on the value of community-based rehabilitation and on goal setting – see
for example Kroemer DJ et al (2004). Acute transitional alliance – rehabilitation at the
acute/aged care interface. Aust Health Review 28(3) 266-274 www.aushealthreview.com.au/
publications/articles/issues/ahr_28_3_131204/ahr_28_3_266-274.html
The rationale for moving to a community-focused specialist Health of Older Peoples (AT&R)
service can be found in the NZ Guideline for Specialist Health Services for Older people – see
www.moh.govt.nz/moh.nsf/pagesmh/3474
The rationale for adopting the NZ national stroke guidelines (2003) may be found in the
guideline at www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineID=37
Business case appendices V12 AC 25Feb2010 Page 107

The rationale for implementing InterRAI may be found in the many reports on interRAI and
assessment tools produced by the Ministry of Health and other organisations since 2003 - see
www.moh.govt.nz/moh.nsf/indexmh/hop-projects-assessmentandservicecoordination
9 Risk analysis
Risk Probability Impact Contingency plan
Lack of strong management
or clinical champions for a
new model of Older Peoples
High Medium Discuss within EOI process.
Consider basing HOP service in the
community, working into the hospital.
Health services
Service changes span
several management/
funding silos, making DHB
High High Discuss within EOI process.
Consider basing HOP service in the
community, working into the hospital.
decisions difficult
Many clinical staff work to
a traditional model of care
for older people
Medium Medium Use Care Link and InterRAI to drive
changes on a case by case clinical
basis.
Involve sector in restorative training
scheme eg SMART.
Difficulty in moving funding
because of deficit
Medium Medium Discuss in EOI process and get DHB
commitment.
constraints
Lack of connection between
PHO and its primary health
care programmes and what
Care Link and DHB has
been doing in HOP
Medium Medium Use EOI process to get greater
involvement and buy-in among
stakeholders.
10 Engagement
Working group who developed this plan: Hecta Williams, Robyn McLachlan, Diane Brockbank,
Helen Rzepecky, Torfrida Wainwright
Other clinicians involved: Tim Bolter, Jocelyn Tracey
Business case appendices V12 AC 25Feb2010 Page 108

11 Organisational accountabilities
West Coast DHB GM Primary and Community Services is accountable for:
changes to Care Link location, working methods, and implementation of InterRAI
changes to do with community based nurses and clinical nurse specialists (?)
establishment of step-down beds at Westport and Reefton.
West Coast DHB GM Planning & Funding is accountable for:
the change to a restorative home support service
budget management processes for long-term support services
initiating a Carer Support Strategy and Action Plan.
West Coast DHB GM Secondary Services is accountable for:
changes to AT&R services
establishment of step-down beds in Greymouth (if hospital-based)
changes to do with allied health staff.
12 Costs
An increase in community allied health FTEs has been budgeted within the Care Link and long
term home support budgets as part of the change to a restorative model of home care.
Business case appendices V12 AC 25Feb2010 Page 109

Appendix Twelve: Workforce
1. Aspirational statement
The Integrated Family Health Centres (IFHCs) will be centres of rural excellence that have the
capacity and capability to meet the health care needs of the people of the West Coast, and are
attractive and rewarding work environments both the current and future workforce.
2 Project overview
Because of the current difficulties recruiting and retaining core general practice staff, with
consequent major access difficulties for patients to primary care, the first year of this plan
focuses on detailed workforce planning for the core general practice team workforce.
During 2010/11 detailed planning will take place to extend the project to include other members
of the multi disciplinary team (MDT) within the Integrated Family Health Services.
The plan covers activities to enhance retention, recruitment, professional development and
quality improvement, including the need to develop a centre of excellence for health provider
training, in part to support recruitment and retention.
3 Problem definition
Current issues that need to be addressed are:
The number of permanent GPs is low: currently there is one GP per 2000 people,
including locums.
There is currently one nurse per 1180 people, a low ratio considering the extent of
remote rural areas covered by rural nurses.
There are continuing difficulty getting GP and nurse locum cover and making new
appointments.
There is a high dependence on GP locums with subsequent lack of continuity and
consistency of care.
Long waiting times often exist for appointments.
This adds to the workload of other primary care providers, eg. pharmacists.
In many areas there is a dependence on nurses for first line care, without always
providing adequate training and support.
Business case appendices V12 AC 25Feb2010 Page 110

There are often vacancies for allied health and community nursing roles, with disruptions
in service delivery as a result.
Under representation of Māori working within the West Coast Health & Disability
workforce.
Currently there are 8 vacant positions for GPs, 4.7 for nurses and none for practice managers or
admin/receptionists, as shown in the following table:
General practice full time equivalent (FTE) positions on the West Coast
Current
FTEs
Vacant
FTEs
Total
Patients
per staff
member now
Patients per staff
member if all positions
filled
GPs 15.35 8 23.35 2020 1328
Nurses 26.3 4.7 31 1179 1000
Practice Manager 5.35 0 5.35 5794 5794
Admin/
Receptionist 22 0 22 1409 1409
When these numbers were collected in February, a time of relatively low patient demand for
appointments, the average waiting time for a routine appointment was five days.
The desirable ratio of GPs and nurses per head of population is difficult to determine and
depends on a number of factors such as models of care, rurality, skill sets, level of support from
secondary care, and available funding. The RNZCGP suggested a ratio of 1: 990 59 , on the basis
of a traditional model of care with GPs doing the majority of first contact care. Pinnacle
carried out a workforce survey of staff in general practices in Waikato, Lakes, Taranaki,
Eastern Bay of Plenty and Gisborne regions in 2007 60 which found a GP to patient ratio of
1:1,794 and Practice nurse to patient ratio 1:1927.
Activity based modeling was carried out based on a model of care where the majority of first
contact care and long term condition care is done by skilled nurses, with readily available back
up support from GPS, shared consultations as needed and longer review consultations with GPs
for complex patients. This resulted in a ratio of one GP per 2000 patients and 1 nurse per 900
patients. This was considered appropriate by the working group who produced this plan as long
as extra FTEs are allocated for remoteness, travel and teaching time. Having a stable nurse and
GP workforce based on these ratios has advantages over a workforce that has more GPs, but
with many of them being short term locums who have a limited understanding of the local health
care system.
59 Fretter J, Pande M. How many general practitioners are enough? Forecasting GP workforce capacity in New Zealand.
NZ Family Physician 2008; 35: 232-44.
60 http://www.nzdoctor.co.nz/news?article=81145179-bd90-40cf-a249-fc1b4a719ec9
Business case appendices V12 AC 25Feb2010 Page 111

Nurse practitioner positions have been added to the output targets below but not yet included
in the modeling; while there is a commitment to move to including nurse practitioners in IFHCs,
our ability to attract nurse practitioners to the Coast, and their roles and responsibilities within
the core general practice team have yet to be determined.
4 Objectives:
To recruit sufficient GPs and nurses to provide better, sooner, more convenient care.
To retain GPs and nurses so as to provide continuity and consistency of care.
To provide a professionally fulfilling work environment.
To provide or assist access to the professional development activities required to
maintain competence.
To support quality improvement activities.
To develop the multidisciplinary team.
To broaden the above activities to support all members of the multidisciplinary team.
5 Benefits and gains
Output measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
No. patients per practice/rural 1140 1000 900 900
nurse*
No. patients per permanent GP* 2000 2000 2000 2000
No. primary care nurse
practitioners
Number Māori practice team
members
0 1 2 3
3 nurses, 1
manager
5 6 7
Shared recruitment agency est. No Yes Yes Yes
*These ratios depend on a full complement of postgraduate students, and locum cover for holidays. They
do not include teaching time. Remote areas need higher Dr/nurse: patient ratios.
Outcome measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
% of PHO Performance Programme
targets met
Number of practices cornerstone
accredited
79% >80% >90% >90%
3 6 7 7
Business case appendices V12 AC 25Feb2010 Page 112

6 Deliverables / activities
Programme to be in place by June 2011
Attract students and new graduates to primary care on the Coast:
Stimulate interest among intermediate and high school students in careers in health by
offering workplace experience attachments.
Greater participation in career expos at the local high schools.
Greater utilization of the incubator project, designed to encourage year 12 and 13 high
school students to consider a career in health.
Provide 24 third year nursing student placements, each 6 weeks duration.
Work in partnership with schools of nursing to include a dedicated rural component in
the undergraduate training, including participation in guest speaking opportunities.
Continue to utilize road shows to nursing schools for recruitment purposes and greater
exposure to rural opportunities.
Provide 3 rural immersion medical student 5 th year placements per year.
Provide twelve 5 th year medical student placements per year.
Provide 6 th year placements as possible.
Develop opportunities for contact between house surgeons and general practitioners, eg.
take them on a general practice tour as part of their orientation, invite to GP
professional development activities and PHO activities, encourage GPs to participate in
educational sessions at Grey Base Hospital, eg. radiology sessions.
Develop a package to be given to all those applying to the RNZCGP to be GP registrars
encouraging them to come to the West Coast for their training.
Provide two full year Rural Hospital Medicine registrar placements per year and three
placements for GP registrars per year, with scholarships available.
Attract four GPEP2 (second and third year registrars) to the West Coast each year,
for a full year placement.
Provide four nurses with scholarships to complete the NETP Expansion programme in
primary care.
Provide one placement per year for newly graduated primary care nurse practitioners.
Provide centrally co-ordinated teaching from the Rural Learning Centre in Greymouth,
with local teachers in each IFHC. Utilise Buller Hospital for work experience for
advanced Rural Hospital Medicine registrars and Reefton as a placement for nurse
practitioners towards the end of their training.
Continue to work with the Clinical Training Agency to develop rural training opportunities
for doctors and nurses on the West Coast.
Promote West Coast health scholarships uptake by Māori.
Increase the number of Māori utilizing CTA funding.
Providing opportunities for Māori intermediate and high school students and Māori
second chance learners by utilizing national initiatives, eg. nursing and midwifery for
Māori and Hauora as a career.
Develop programme and support so that the West Coast becomes the most desirable
centre for rural primary care training in New Zealand.
Business case appendices V12 AC 25Feb2010 Page 113

Recruitment:
Establish a Coast-wide recruitment agency for primary care to support all
practices/IFHCs, recruiting in the first instance all new permanent and locum primary
care nurses and GPs for the West Coast.
Work with practice owners to define what will be done by central agency, what
processes they will need to manage, (eg. contracting).
Develop a relationship with NZ locums to avoid duplication: subcontract what they do
best.
Establish fair processes for allocating available locums or new staff to IFHCs
(distribute according to where recruits want to go and where the patient:GP/nurse ratio
is highest).
Plan, co-ordinate and support the orientation of all new doctors/nurses, working closely
with the IFHC managers.
Support recruitment for new pharmacists as required, and develop joint appointments
between DHB and private pharmacies.
Obtain feedback from all locums and new staff that can be used to improve recruitment
processes.
Develop a plan to increase the Māori health workforce.
Create an atmosphere where Māori want to come and work because there is an
organisational commitment to support the Māori workforce, ie. “Māori Friendly”.
Retention:
Provide central co-ordination to ensure all new recruits and their families receive the
support they need to integrate into the community.
Provide peer mentoring of new recruits by a peer in a different IFHC as required.
Assist the mentors of GPs who are under Medical Council supervision.
Support collegial relationships by providing an annual weekend getaway that combines
educational and fun activities for clinical staff and their families. Invite house
surgeons.
As part of the development of new models of care, work with each practice/ IFHC to
evaluate current job content and job satisfaction for each current staff member.
Review job descriptions with regard to who is the most appropriative person to do each
task.
Provide practice workshops that facilitate the development of a team approach.
Provide comprehensive career planning and education to support this.
Ensure nurses feel supported in their clinical environment and receive training to meet
role specific competency requirements.
Retain Māori workforce by providing a culturally appropriate working environment thus
showing a clear demonstration of organizational commitment to the Māori workforce,
development.
Business case appendices V12 AC 25Feb2010 Page 114

Professional development:
Provide monthly professional development evening meetings for GPs, nurses, practice
managers, pharmacist and other members of the multi disciplinary team (MDT), with
videoconference links.
Provide annual PHO workshops: PHO day, practice management workshops, practice
nurse workshops.
Link in educational activities with those of the Rural Learning Centre.
Provide training in the use of standing orders, (see Acute Care plan).
Develop guidelines for direct CT access and provide educational sessions to implement
them, (see Direct Access to Diagnostics plan.)
Adapt Canterbury HealthPathways for Coast use and provide educational sessions to
implement them, (see HealthPathways plan).
Provide education about health literacy, (see Long Term Conditions plan).
Link with DHB Māori health team to provide cultural competence and health inequalities
training annually.
Actively engage Manawhenua to give guidance and support regarding Tikanga Māori
protocol appropriate to Te Tai O Poutini rohe.
Ongoing implementation and utilization of CTA funded cultural supervision for relevant
staff.
Fund conference/course leave for all members of team.
Continued and increasing utilization of PG Nursing CTA funded education.
Refinement of cohort learning between medical and nursing teams.
Career planning and educational support for nurses, including pathways leading to nurse
practitioner.
Quality initiatives:
Develop quality improvement and clinical governance systems in every IFHC.
Provide Cornerstone support and co-ordination support practice quality improvement
teams .
Support practice improvement activities for GPs (MOPS) and nurses (accreditation and
expert endorsement).
Produce practice level PHO Performance Programme reports with peer comparisons.
Provide practice visits by GP and nurse facilitators to review PHO Performance
Programme reports and assist in the development of quality improvement plans.
Provide PHO Performance Programme incentive payments according to the percentage of
targets met by each practice.
Support pharmacists to provide feedback to GPs on cost effective prescribing.
Develop active feedback loops so that any concerns about the quality of patient care will
be fed back to the health providers concerned in a constructive, educational
environment.
Business case appendices V12 AC 25Feb2010 Page 115

Seek feedback from Māori community to ascertain their view about the quality of
patient care for Māori.
Develop/adopt a patient survey to measure patient satisfaction with the care they
receive at their IFHC.
See also the Quality section of the business plan for an overview of the quality
framework.
Year two
Multidisciplinary focus:
Extend programme to include clinical support and educational opportunities for
pharmacists, the wider nursing team (includes community nurses and practice nurses),
and allied health within the IFHC.
Provide integrated professional development for all mental health workers.
Extend recruitment and retention programme to cover all staff.
Year three
Consolidate and review.
Evaluate strategies pertaining to Māori patients and staff.
7 Capability and capacity
This plan picks up the capability and capacity requirements of the other work streams and
collates them into one document.
Considerable progress has made in the last few years in regards to opportunities for training,
professional development activities and quality programmes. This plan extends the work already
done in these areas.
The formation of IFHCs provides the opportunity and resources to enable this plan to support
the wider multidisciplinary workforce.
8 Effect on inequalities
Cultural competency training improves access for Māori and Cornerstone accreditation requires
practices to meet a number of indicators that measure cultural appropriateness. Increasing the
Māori workforce improves access for Māori to heath care.
Business case appendices V12 AC 25Feb2010 Page 116

Mainstream arguments are concerned with projected excess health and disability workforce
demand, overall, and recognition that increasing and strengthening the Māori workforce is part
of a sustainable long-term solution to addressing the shortfall. Equitable health outcomes for
Māori are, however, a fundamental rationale for Māori health and disability workforce
development, through this does not imply a „one size fits all‟ approach. 61
9 Evidence for this initiative
The activities in the plan follow the Health Workforce Advisory Committee guidance in the
following documents:
2005 Strategic Principles for Workforce Development In New Zealand
2006 Report of the Health Workforce Advisory Committee on Encouraging Māori to
Work in the Health Professions
2006 National Guidelines for the Promotion of Healthy Working Environments
2007 Rauringa Raupa, Recruitment and Retention of Māori within the Health and
Disability Workforce.
10 Risk analysis
Risk Probability Impact Contingency plan
No increase in
permanent staff
recruited
Medium High Continue reliance on locums, with an
increase in support and training for
provided.
Staff come and move
on
Low Medium Exit interviews for all departing staff,
so that current activities can be
altered if necessary.
High number of
complaints to H&DC
Low Medium Review content of professional
development programme.
11 Engagement
Working group who developed this plan: Dr Paul Cooper, Mary Crooks, DrMartin London, Kathy
Hines, DrAnna Dyzel, Joanne Shaw, Rosalie Sampson, Helen Rereti, Jocelyn Tracey, Karyn Kelly,
Kerri Miedema, Gary Coghlan.
61 Rauringa Raupa Recruitment and Retention of Maori within the Health and Disability Workforce Ministry of Health
2007 Page 12
Business case appendices V12 AC 25Feb2010 Page 117

12 Organisational accountabilities
Organisational accountability lies with the PHO for the first year, and with the IFHS
thereafter.
13 Costs
Draft budget
Income
Recruitment and retention fund - 30% 75,000
Payment from practices to recruitment agency 80,000
Professional development (PHO contract) 65,000
PHO Performance programme 120,000
Expenditure
Total 340,000
Project management 40,000
GP registrar scholarships 15,000
New grad nurse scholarships 12,000
Teaching - funded by CTA 0
Recruitment agency 100,000
Recruitment agency advertising costs 80,000
Peer mentoring 1,000
Professional development activities 25000
Health pathways editors 5,000
Course/ conference leave support 35,000
Support for Cornerstone and practice quality
activities 10,000
PHO Performance programme facilitation 24,000
Support for Practice QI teams 20,000
Pharmacy support for PPP 4,000
Practice PPP incentive payments 50,000
Total expenditure 421,000
Surplus/deficit ($91,000)
The deficit in this budget has been included in the „Implementing Service Strategies‟ aspect of
the Investing in Change budget, Section 11.1 in the Business Case.
Business case appendices V12 AC 25Feb2010 Page 118

Appendix Thirteen: IFHCs - Facilities
1. Aspirational statement:
Facilities are renovated and/or created that best progress and support the new models of care,
so as to improve the health of West Coasters.
2 Problem definition
Primary care facilities across the Coast vary enormously. In Greymouth and Westport, in
particular, the location and/or nature of the buildings that house the primary services and
workforce are problematic for delivering the desired model of care. In Greymouth, the three
medical centres and other private providers including pharmacies are in different parts of town
(and none is connected to the hospital). No medical centres have on-site or adjacent diagnostics
or pharmacy. In Westport, the medical centre is located in old hospital buildings, with other
community based services on the same campus, but widely separated by long corridors - the
layout/location of services is a barrier to communication between services. Some individual
centres are cramped for space. A number of facilties are old and don't comply with seismic
regulations (Westport in particular).
3 Objectives:
To integrate a variety of services alongside traditional general practice service, in line
with the revised model of care and other workstreams
To adapt facilities to best fit with the new ways of working, where this is feasible
To purpose-build future-proofed facilities optimised for the new model of care where
this is the best option and/or necessary
4 Benefits and gains
Output measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
No. of IFHCs 0 Embryonic 1 2
Business case appendices V12 AC 25Feb2010 Page 119

5 Grey/Greymouth IFHC
An interim step towards the development of the Greymouth IFHC, is the construction of an
academic/rural training practice (an outpost of one of the three existing medical centres in
Greymouth), in a re-locatable building, on the Grey Hospital site, adjacent to the Emergency
Department. The floor plan is below, and opening date is scheduled for 1 Jul 2010.
Work has begun on bringing the three medical centres in Greymouth together into a single
facility, that might also contain other private providers (e.g., physiotherapy) and pharmacy, and
that would allow the community nursing and allied health workforces currently operated by the
DHB to work in an integrated way with the medical centres.
The PHO led a process of engagement during Feb '10 with private provider in Greymouth around
the possibility of a one-stop shop for primary care services. All three practices have indicated
a significant level of interest, including providing detailed information around their current and
likely future level of service delivery and space requirements. Private pharmacists have asked
for space in the IFHC, though there are some limitations on their ability to relocate entirely in
the short term, given their current investment in, & commitment to, existing retail premises.
Physiotherapists, dentists, opticians, chiropractors, massage therapists and acupuncturists in
town were all also invited to participate, as were various NGO/disability support providers. It is
from this process that the following facilities proposals and options have arisen.
Specifically, the proposal is that the facility be constructed such that the non-hospital, nondomiciliary,
clinic-based patient contact work of the community nursing and allied health
workforce, be conducted in the clinic rooms of the co-located medical centres. Whether, the
facility might also contain the office bases of the community nursing and allied health
workforce is being explored.
Business case appendices V12 AC 25Feb2010 Page 120

A key possibility is that land at the north end of the Grey Base Hospital site is vacant and
available for such a facility. It is possible that the construction of the Greymouth IFHC could
be integrated with, and even physically connected to, Grey Base Hospital (in a way which colocates
services initially but allows for full integration when the hospital is eventually
refurbished). This option is one that is likely to deliver cost savings for both the IFHC facility
development, and for the Grey Hospital redevelopment, particularly if both projects were done
together.
This site, however, is not the only one being considered. A key limitation of the Grey Hospital
site is its Crown ownership, which reduces its attractiveness to private investors, who have
expressed greater interest in options that involve freehold land.
Three separate options for the Greymouth IFHC have been developed.
Option 1 - greenfield IFHC
The first is a greenfield option that is agnostic about location; it describes a stand alone facility
that could be constructed on either a freehold site elsewhere in Greymouth, or on the vacant
north end of the Grey Hospital campus. This option provides a stand-alone primary care facility
with some community and allied health services relocated and/or duplicated from existing
hospital facilities. Separation from hospital-based services means that this option is the least
supportive of integrated multi-disciplinary health service delivery across the primary-secondary
continuum, but it does deliver an integrated primary & community IFHC. The gross floor area is
4,200 m 2 .and the estimated costs in the region of $14.8m, excluding land.
Business case appendices V12 AC 25Feb2010 Page 121

Option 2 - IFHC integrated with Grey Hospital master plan
The second option integrates with the staged development proposed in the Grey Hospital
masterplan. It proposes a 3,385m2 gross floor area for the IFHC component, 1,395m2 of which
is refurbishment to existing hospital buildings and 1,990m2 is new building.
This option tightly integrates with the proposed new hospital, such that the strategic aims of
both IFHC and hospital developments can be most effectively achieved. This option is the only
one of the three that allows optimum integration of primary care, hospital-based care and
community services in one location and fully supports an integrated, multi-disciplinary model of
health service delivery in Greymouth across the primary-secondary continuum. It also makes
most effective use of existing buildings, thereby reducing the amount of new building required,
avoiding duplication of services and facilities. The combined cost estimate is $76.545m, with
the IFHC component being $10.1m and the hospital component being $66.445m. The IFHC could
be built as the first stage of this project.
Option 3 - IFHC located adjacent to existing Grey Hospital
The third option is also on the Grey Base Hospital site. However, it assumes that no funds are
made available for the Grey Base Hospital rebuild, locates the IFHC adjacent to the existing
hospital without connecting the two, and assumes that both allied health services and the office
bases of the likes of community nurses and mental health services would remain in existing
hospital buildings, even though their clinical contact with patients would occur within the IFHC.
Business case appendices V12 AC 25Feb2010 Page 122

This option is effectively a Greenfield part-IFHC adjacent to the existing hospital and, as such,
goes some way towards integrating health service delivery, but does not support fully integrated
multi-disciplinary service models to the extent of option 2. The new build area of the IFHC is
less than the other options because allied health and community services remain in existing
hospital buildings, some distance away from primary services. The area of this smaller option is
2,863m 2 , 2,213m2 of which is new building and 650m2 is refurbishment of the existing
Corporate Building. This option requires relocation of DHB Administration to another, as yet
undefined location, most likely rental accommodation off site. The cost of this option is in the
region of $10.785m and includes an allowance for fitout of new DHB Admin offices elsewhere,
but excludes both relocation and lease costs (though these costs should be considered as part
of the overall cost of option 3). The resulting site plan is as follows:
Financing
Private financing of the capital cost of the IFHC is being explored; initial discussions have
indicated strong potential for a private funding syndicate. A key conversation has been with
Development West Coast, which has expressed its interest in the project, particularly if a
freehold option is chosen, and indicated that the likely scale of the project is one that is
manageable for, and attractive to, them. Mawhera Incorporation is a major Maori land owner in
central Greymouth, which has also expressed interest in a financing and/or development role.
Business case appendices V12 AC 25Feb2010 Page 123

It may even be possible to pull together a private funding syndicate to fund both projects - a
completely integrated Family Health Centre and the eventual refurbishment of the Greymouth
Base Hospital facility - if there is political interest in such an arrangement.
6 Buller/Westport IFHC
The West Coast DHB currently owns and operates the medical centre, Buller Medical Centre,
and Buller Hospital, in the town of Westport. Westport is 107kms from Greymouth (at least an
hour and a quarter by road). There is no public transport connection between the two centres.
Earlier work has explored options for revamping the facilities on the Buller Hospital site. The
future status and size of Buller Hospital is unclear, with discussion currently occurring in
relation to the DHB contracting out aged residential care, and the impact for other services of
this proposed change still somewhat unclear.
A greenfields IFHC in Westport, probably on the Buller Hospital site (there is sufficient land),
is a distinct possibility. A revision of the earlier proposed facility is likely to be required to
match the revised model of care envisaged in this EoI business case, and to fit with any
decisions regarding the future shape of secondary services.
One proposed floor plan for a greenfields construction on the Buller Hospital site is as follows:
This and other options are being explored. This option had a $16.3m price tag in Aug 2008.
Revisions will be required to reduce the capital spend to more manageable proportions. Private
financing for this facility has not yet been explored, as further work is required to understand
the likely final size and scale of the project.
Business case appendices V12 AC 25Feb2010 Page 124

7 Westland IFHC
Facilities options are not top of the list for the Westland District.
Hokitika's sole medical centre, the Westland Medical Centre, and the DHB's community nursing
& mental health services at the Hokitika Health Centre, are in separate buildings across the
road from each other. But the two services work well together, and a facilities revamp is
thought unlikely to offer significantly greater benefits, such that the required capital spend
could be justified. Both building are relatively modern and comply with health centre facility
standards.
In South Westland, the population is scattered over vast distances. General practice and
community nursing services are currently delivered from five clinic locations.
This business case does not envisage further changes to the facilities aspects of service
delivery in South Westland, apart from a separate facilities development already planned in that
area . This proposed development will contribute in a physical sense to the development of an
otherwise virtual Integrated Family Health Centre. The project is the joint development of a
combined rural health centre / ambulance station in Franz Josef, which will act as the
centerpiece for the DHB's remote South Westland practice (covering Hari Hari, Whataroa,
Franz Josef, Fox Glacier and Haast). Both St John and the West Coast DHB have already
committed to this project, which will be built on St John owned land.
An artist impression of the proposed Franz Josef Health Centre / Ambulance Station
Business case appendices V12 AC 25Feb2010 Page 125

8 Deliverables / activities
Implementation plan: to June 30
Proto-IFHC in Greymouth
Plan and build primary care academic practice on Grey Base Hospital site
incorporates teaching component to support rural workforce retention &
development
co-located with Grey Base Hospital, with GP registrars doing work in both facilities
contribution to resolving after hours cover issues
Substantive-IFHC in Greymouth
Plan primary and community care components of Grey IFHC
relationship map completed by Feb '10
understand links to and implications (both ways) of possible link with Grey Hospital
site & business case by Mar '10
explore site options by Apr '10
explore financing options by May '10
concept design by June 2010
Westport
Review plans for Westport
assess fit with revised model of care; adapt & revise designs as necessary
Year one:
Proto-IFHC in Greymouth
Academic practice on Grey Base Hospital site opens 1 Jul '10
Substantive-IFHC in Greymouth
Build substantial primary/community care facility (on Grey Base Hospital site?)
preliminary design by August 2010
capital funding in place by end Aug '10
developed design by October 2010
resource consents received by end Oct '10
detailed plans completed by Feb 2011
building consents received by Mar 2011
building commences April 2011
Westport
revise designs, timelines, decanting etc by end Dec '10
finalise plans and submit resource & building consent applications by end Mar '11
capital funding in place by Mar '11
Reefton
Explore and document Reefton's facility requirements
Business case appendices V12 AC 25Feb2010 Page 126

Year two
Substantive-IFHC in Greymouth
Substantial primary/community care facility on Grey Base Hospital site in operation
building completed Feb 2012
building opens 1 March 2012
various tenants move in during Mar '12
building fully operational from 1 Apr '12
Westport
first stage of building commences 1 Apr '12
Reefton
progress options developed
Year three
Westport
all stages of building completed 30 Sep '12
Changes to current staffing:
Well configured facilities will assist in achieving optimised, efficient staffing levels.
9 Risk analysis
Risk Probability Impact Contingency plan
Capital costs of, and
therefore operating High High
Revise plans to be reduce capital costs /be
affordable
costs in, new facilities
too high
Connection of Grey
IFHC with Grey
Hospital rebuild
High High
Explore options for Grey IFHC to not be
dependent on Grey Hospital obtaining
Crown funding for its rebuild
causes delays and/or
derails project
Co-location does not
lead to integration of
services
High Medium
Develop Charter to sit alongside leases
(Charter commits tenants to integrated
way of working)
PHO provides facilitation/overall
management function to drive integration
Community opposition
to Buller IFHC, if seen
as a downgrade for/of
Buller Hospital
High Medium
Engage community leaders early
Engage with community re service delivery
options for Buller, and facilities
implications
Articulate reasons for service & facility
options once chosen
Business case appendices V12 AC 25Feb2010 Page 127

Private providers
decide not to locate to
new IFHC facility
Medium
High
Engage early & continuously
Articulate increased foot traffic/business
benefits of all health providers being colocated
Private financing for
capital cannot be
secured
Medium
High
Ensure business case stacks up/is viable
Crown land makes
facilities business case
unattractive to private
investors
Medium
Medium
Research financing options used in other
jurisdictions
Explore with MoH how to make proposition
attractive for private investors
Community/provider
opposition to hospital
location for Grey IFHC
Medium
Low
Explore all site options with community
Articulate pros & cons of different
options
Articulate reasons for final site selection
10 Engagement
Working group who developed this plan:
Wayne Champion, Hecta Williams, Anthony Cooke, Darryl Haines and Darryl Carey (architects -
Chow Hill and Warren & Mahoney), Neil O'Donnell (quantity surveyor - Rider Levett Bucknall)
Other clinicians involved: Julie Kilkelly, Kerri Miedema, Maureen Frankpitt, Dr JD Naidoo,
Barbara Smith, Jenny Robertson, Dr Jocelyn Tracey, Marie West,
11 Organisational accountabilities
Participants will include multiple organisations at the commencement, e.g., three separate
general practices in Greymouth. There will be an over-arching organisational structure to
facilitate the ongoing operation of co-located and aligned, though still separate,
organisations/businesses. This facilitation function may be performed by the PHO.
Tenants will sign a facility Charter as well as the lease - committing them to the revised model
of care that will operate in the facility, and to integration with the expanded primary care team.
Business case appendices V12 AC 25Feb2010 Page 128

12 Costs
Capital costs
Greymouth IFHC
Westport IFHC
Year 1 Year 2 Year 3
$10.11-14.8m
Est. $8m
Assumptions:
Private sources fund the capital requirements
DHB/Crown land is made available on a long-term basis that is attractive to private
investors.
Business case appendices V12 AC 25Feb2010 Page 129

Appendix Fourteen: IFHCs – Information Technology
1. Aspirational statement:
Appropriate information and communication technology is in place that best progresses and
supports the new models of care for West Coasters.
2 Project overview
One of the key elements of the West Coast Integrated Family Health Centre (IFHC) project is
the electronic integration of health services, supporting an integrated model of service delivery
across a range of geographically isolated service delivery locations.
This plan proposes the development of an integrated health information strategy for all health
providers on the West Coast, with the aim of ensuring that the right level of access to clinical
information is available at each point of care encountered by patients, and that all appropriate
clinical information follows the patient from carer to carer as they travel through a patient
centred network of care, all in a way that minimises waste and duplication and whist
safeguarding patient privacy.
This plan will put the West Coast in a good position to adopt national initiatives as they become
available, eg. a core set of personal health information available electronically to New
Zealanders and their treatment providers, and electronic prescribing.
3 Current situation / Problem definition
Within primary/community care
All but one of the West Coast‟s General Practices use the same patient management system
(PMS) MedTech 32. Those practices that are owned by the West Coast District Health Board
use the West Coast DHB PrISM system, which provides a single shared patient administration
system but which has been configured in a way that restricts integration because of patient
privacy concerns. A number of other services are available over the PrISM system (access to
hospital health information systems on Health Views [such as discharge summaries, PACS
radiology images, laboratory results], access to the DHB‟s library resources and online clinical
databases, secure email, DHB intranet access). Two of the privately owned GP practices also
Business case appendices V12 AC 25Feb2010 Page 130

utilize MedTech, but via their own separate installations, whilst the other privately owned
practice uses a product called Profile.
Most other primary health and community service organisations maintain their own independent
systems, with the exception of Rata Te Awhina Trust (a Māori Health NGO), which uses the
DHBs PrISM system and MedTech. The majority of non general practice services that are
currently owned by the DHB, such as community nursing and allied health, use DHB‟s iSOFT
patient information system, but aren‟t using its electronic patient notes capacity.
Therefore, while GPs, rural and practice nurses use MedTech for their consultation notes, most
other community based nurses and allied health providers who are caring simultaneously for the
same patients keep paper based clinical records: this can lead to duplication and lack of coordination
and consistency of care, with resulting confusion for patients. In the Buller region a
recent change to all these providers using MedTech has proved very successful.
Information flows between primary and secondary care
Two of the key integration points between primary/community and secondary services are the
referral and discharge processes. The objective is to ensure that all relevant information is
made available to the receiving provider when there is a transfer of a patient‟s care (either a
referral to a provider or a discharge back to the original referrer). Currently while referrals
from the general practices are written in their practice management system, they are then
printed out and faxed to the hospital rather than electronically transmitted. Discharge letters
are sent and received electronically.
DHB owned practices can use PrISM to access HealthViews for patient information as
described above.
Many patients arrive at the Emergency Department (ED) without a referral from their general
practice: care would be safer if ED and admitting senior medical officers (SMOs) could access
the patient's general practice records, particularly their problem list, regular medication list
and allergies. Currently ED clinical notes are hand written and not always easy to read, which
may lead to lack of appropriate follow-up by GPs/nurses or even an inpatient ward if the patient
is admitted into hospital from their ED visit.
Laboratory and radiology
All West Coast radiological images and reports are accessible via the central iSOFT system at
the DHB. All except one of the current general practices uses the hospital laboratory for lab
investigations, and all results are stored in iSOFT. This means that all radiological
investigations and most laboratory results are all stored in a central system, accessible by those
who can access HealthViews in iSoft.
Business case appendices V12 AC 25Feb2010 Page 131

Community pharmacy
Community pharmacies face problems at times when dispensing prescriptions for newly
discharged patients, as they try to reconcile the information on the prescription with previous
medications dispensed, and without the benefit of a discharge summary providing information on
what changes to regular medication have been made and why.
Given the importance of a strong retail trade for the viability of pharmacy businesses, it may be
that there is no pharmacy within some IFHCs. Developing the ability to send electronic
prescriptions from primary care, with the ability to home deliver to frail elderly and those with
transport issues, would provide more convenient care.
Communications Technologies
With its vast distances, small population and geographic isolation, the West Coast is ideally
placed to benefit from investment in improved telecommunications technologies. The availability
of telecommunications network capability (bandwidth) along the West Coast has historically
limited the ability to benefit from some technologies, however this has recently been overcome
with the availability of a direct fibre optic link between Hokitika, Greymouth and Westport and
potentially Reefton in the future (one of the first business to business uses of this service is an
upgrade of West Coast DHBs wide area network, interconnecting Buller Health with Grey Base
Hospital from December 2009).
The current Telepaeds network links videoconferencing between Greymouth, Westport,
Hokitika, Reefton, Christchurch and over 100 other locations in New Zealand. It is currently
mainly used for clinical conferences, educational sessions, and management meetings and to a
lesser extent for remote patient consultations, eg. methadone clinics, surgical follow-up clinics.
The new fibre optic link will enhance its usefulness, particularly in regards to linking into
aspects of the hospital IT system such as PACS to review radiology images.
Medical telemetry can support remote clinical support, remote consultations and remote
diagnosis, potentially integrated with videoconferencing. An example of this is the CISCO
Health Presence System, which is being trialed as a standalone medical telemetry and video
conferencing unit linking Buller Health (ED and Outpatients) with Grey Base Hospital for remote
diagnosis and outpatient consultations. This system is large, fixed, not well linked in with other
DHB IT and telemedicine systems.
As part of the Canterbury initiative, Dr Mike Sullivan and Bronwyn Petrie are reviewing the
current clinical telemedicine capability on the West Coast, the range of potential clinical
applications, and potential linkages with Canterbury. Of particular interest will be the ability to
„store and forward‟ patient information, (eg. photos, ECG, spirometry etc) so that this can be
reviewed at a later time by both the original clinician and a remote specialist. Their report is
due in March 2010 and will inform development of the Telemedicine aspects of this plan.
Business case appendices V12 AC 25Feb2010 Page 132

4 Objectives:
To implement communications and information technology that facilitates integrated
care for patients.
To improve information flow between primary care, community nursing and allied health
clinicians by all using the same electronic patient medical record.
To improve information flows between primary and secondary care by establishing
mechanisms for primary/community clinicians to view the hospital based electronic
clinical medical record and vice versa.
Adopt electronic prescribing.
To increase the use of telemedicine for both outpatient appointments, and for seeking
management advice from a distance (either real time or „store and forward‟).
To enable and empower people in the community to obtain, process and understand the
health information they need to make appropriate decisions about their health.
To prepare local IT systems so that the West Coast in a good position to adopt national
initiatives as they become available, eg. a core set of personal health information
available electronically to New Zealanders and their treatment providers, and electronic
prescribing
5 Benefits and gains
Output measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
High Definition Videoconferencing
interconnects all West Coast
IFHCs
Shared Medical Telemetry System
Medical Practices move to a shared
Med Tech 32 Database system
Standard
Definition
only
CISCO
Health
Presence
being
trialled in
Buller
All West
Coast DHB
Practices
share same
system but
independent
practices
maintain
their own
All
videoconferenc
e-ing equipment
replaced with
high definition
equipment
Options for an
integrated
medical
telemetry
network
explored
Move to shared
Med Tech
database
explored in
detail.
Logistics of
moving iSOFT
Community
Nursing
Addition
Videoconferencing
equipment
deployed in
IFHCs
Move to
shared
Medical
Telemetry
system.
Move to
shared Med
Tech
database and
move iSOFT
Community
Nursing
functions to
Med Tech
Business case appendices V12 AC 25Feb2010 Page 133

separate
databases.
functions to
Med Tech
delineated.
Outcome measures
Indicator Baseline Target – Yr 1 Year 2 Year 3
Numbers of remote outpatient TBC
consultations per quarter/year
Number of times medical
telemetry system used to share
diagnostic information with
Greymouth Hospital , per
quarter/year
TBC
6 Deliverables / activities
One of the aims of the IFHC is to provide an integrated health information system that allows
clinical information to be available at each point of care that a patient connects with, so that
patient specific information relevant to an episode of care follows the patient from carer to
carer across the entire network of integrated health services. The aim is to support an
integrated model of care, whilst minimizing waste and duplication, and whist safeguarding
patient privacy.
One way of achieving this involves moving services that are similar in nature to the same shared
information system. A logical choice for this would be MedTech 32 for all providers working in
IFHCs, probably provided over the West Coast DHB developed PrISM system, as it is already
well established on the West Coast. The system needn‟t be owned and hosted by the DHB; it
has been developed in a way that allows it to be transferred to another provider such as the
PHO or an IFHC in the future.
Complete Population
To be of the greatest benefit, an electronic health record needs to include all health activity
provided by all health providers. With this in mind, plans have been developed to make the
West Coast DHB PrISM system available to other providers, so that all relevant health
information can be available when and where it is required for patient care.
Self Service Access
A logical next step beyond developing an integrated electronic health record is to provide
access for people to see their own health information and so that they can provide updates for
changes of address or provide any new health information, (such as diabetes patients entering
home blood tests).
Business case appendices V12 AC 25Feb2010 Page 134

Security
An individual‟s health information is a taonga – it has great value and is sacred to them. It is
therefore essential to ensure that health information is secure and that a patient's wishes are
adhered to regarding its availability.
Resilient
Health Information Systems need to be resilient to external factors such as a localised
disaster, so that critical information is available to those who legitimately need it wherever and
whenever it is required, regardless of the challenges involved in ensuring its availability.
Improving Data Quality
Health information systems are large complex IT systems with numerous users and complex
information flows. Data needs to be accurate and reliable as incorrect data can dramatically
impact on a patients wellbeing. Continuous quality improvement philosophies need to be applied
in order to ensure that the risk of error is minimized.
Implementation plan: to June 30
Within primary/community care
Begin the process of identifying the requirements for sharing clinical notes on
MedTech in a single clinical file used by all health providers in the IFHC.
Understand and, as necessary, re-negotiate reporting requirements for community
nursing & allied health.
Between primary and secondary
Establish access for all medical centres to HealthViews, through the DHB's PRiSM
system.
Co-ordination with ED acute care
install a copy of MedTech on a computer in ED
change patient registration form/casualty sheet on arrival to include consent for
access to their MedTech notes for that hospital visit
ensure privacy considerations are met
obtain agreement from practices
create link into DHB practice server.
Patient access to information
Publicise Health Navigator patient self management website – for providers and
community, eg. pamphlet in prescription bags for (see also LTC workstream)
Create link to Community & Public Health website on PHO website, (see also Keeping
people healthy workstream).
Business case appendices V12 AC 25Feb2010 Page 135

Year one
Primary secondary
create link to Heath Views for community pharmacies
develop link into MedTech for outpatients, wards and hospital pharmacy.
Within IFHC
Develop specifications for new system and fund implementation. Work with the
current health centre that does not currently use MedTech to determine the
barriers and facilitators for change.
Review current referral systems, considering potential role of Care Link, and change
to within system request for assistance/booking. Monitor workload and waiting
times and develop new priority and entry criteria as required.
Telemedicine
Review the Canterbury Initiative Telemedicine plan and implement proof of concept
plan for telemedicine links from IFHCs, likely to include:
o Increased number of outpatient clinics done at a distance using telemedicine
(reducing patient travel and so making services availability better, sooner
and more convenient)
o Increase in the use of the medical telemetry system to share diagnostic
information with Greymouth Hospital reducing patient travel and so making
services availability better, sooner and more convenient
Web based support for providers
(see health pathways work plan).
Year two
extend MedTech across all health centers and for all community nursing and allied
health
develop link into MedTech for community pharmacy
work with the private practice on Profile to overcome barriers to the use of
MedTech, and assist with migration to MedTech
ensure all Coast lab results are in the same database.
Year three
(to be developed)
7 Capability and capacity
There will be training requirements for new providers to use MedTech32 for consultations.
Training in the use of telemedicine will also be required to ensure this methodology is used
safely and appropriately.
Business case appendices V12 AC 25Feb2010 Page 136

8 Effect on inequalities
The increased use of telemedicine will benefit those who have difficulties with the expense of
traveling from rural areas to Greymouth.
9 Evidence for this initiative
This plan follows the Better, Sooner, More Convenient Primary Health Care Business Case
Development Process Information Pack principles:
• Prioritisation and access to services (shared scheduling of primary care,
community nursing and allied health appointments)
• Information sharing (shared electronic clinical record, sharing electonricni
information with pharmacy and between primary and secondary care)
• Quality and performance (HealthPathways, patient access to web support, i.e.
Health Navigator)
The changes proposed will result in a more patent/whanau centred approach since with all
primary and community health providers using the same electronic medical record there will be
less need to repeat their same story to multiple providers and for unnecessary repeated
assessments.
10 Risk analysis
Risk Probability Impact Contingency plan
Increased risk of privacy
breaches with move to more
providers using the same
electronic health record
Low High Ensure patients understand how
their information is stored and
shared. Ensure all health providers
understand privacy requirements
Provide training in how to hide
sensitive consultation notes.
New users find MedTech32
difficult
Moderate Moderate Provide adequate training.
Use enthusiastic peers to support
and motivate.
Larger numbers of providers
using the same electronic
medical record making it
difficult for different types
of providers to follow the
flow of their consultations
Moderate Moderate Review how other places have
dealt with this situation, such as
coding consultations according to
types of provider
Business case appendices V12 AC 25Feb2010 Page 137

11 Engagement
Working group who develop this plan: Wayne Champion, Dr Jocelyn Tracey, Anthony Cooke.
12 Organisational accountabilities
The Integrated Family Health Service will be responsible for working closely with the West
Coast DHB to implement the IT requirements described in this section.
13 Costs
Implement High Definition
Videoconferencing
Implement Integrated
Medical Telemetry system (if
practical)
Migrate to shared Med Tech
database (hardware and
software)
Year 1 Year 2 Year 3
$30,000 $20,000
$30,000
$120,000
Assumptions:
Some of these costs would be borne by West Coast DHB regardless of the IFHC proposal.
West Coast DHB will provide IT staff, expertise and network bandwidth at marginal cost. The
cost of this contribution will be defined when each stage of the plan is investigated in detail. In
the interim the above costs have been included in the Investing in Change budget, Section 11.1 in
the Business Case.
Business case appendices V12 AC 25Feb2010 Page 138

Appendix Fifteen: Project advisory and reference groups
Principal authors of
the business case
Anthony Cooke, PHOcus on Heath
Dr Jocelyn Tracey, PHOcus on Health
Martin Hefford, LECG
Also:
Kim Sinclair
Torfrida Wainwright
Helen Reriti
Wayne Champion
Wayne Turp
Project advisory
group
Dr Greville Wood, GP, Chair PHO clinical governance
committee
Dr Vicki Robertson, Chief Medical Officer
Jane O‟Malley, PhD, DoN Nursing & Midwifery
Hecta Williams, GM Primary & MH Services
Wayne Champion, GM Hospital and Corporate Services
Gary Coghlan, GM Māori, WCDHB
Julie Kilkelly, pharmacy
Kerri Miedema, pharmacy
Lindy Mason, pharmacy
Elinor Stratford, Manager, Disability Information Network
Barbara Greer, CEO, Rata Te Awhina Trust
Val Henry, Rata Te Awhina Trust
Ann Donovan, Rata Te Awhina Trust
Jem Pupich, Community & Public Health
Maureen Frankpitt, Nurse leader community and primary care
WCDHB
Raewyn McKnight, Allied Health, WCDHB
Janette Anderson, physiotherapy, WCDHB
Karyn Kelly, Assistant DON, WCDHB
Yvonne Anisy, RN, WCDHB
Marie West, Greymouth Family Health
Jenny Robertson, Manager Buller Health
Barbara Smith, Clinical Services manager, Reefton
Colin Weeks, GM Finances WCDHB
Shona McLeod, Planning & Funding, WCDHB
Project reference
group
Dr Anna Dyzel, GP, Hokitika, and Trustee WCPHO
Dr JD Naidoo, GP, Greymouth
Dr Martin London, GP, South Westland
Dr Tim Bolter, Greymouth Medical Centre
Dr Paul Cooper, GP Buller Health
Business case appendices V12 AC 25Feb2010 Page 139