Community and consumer voice
Elements we are building from
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What we need to achieve
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The Government has highlighted the importance of the voice of communities and consumers in the design, development and delivery of health services, under the reformed health system. Understanding community perspectives and issues is particularly important in isolated rural areas as people in these areas often do not have a choice of services or providers and issues of access or service scope can quickly drive inequalities and safety issues.
The Cabinet Minute on establishing the new health system states ‘Prioritising the consumer voice is a key enabler of people and whanau-centred care … we should embed consumer voice more explicitly and consistently in the future; moving beyond a norm of ‘consultation’ to one in which there is more active engagement and involvement’. The Cabinet Minute also talks of ensuring that ‘… mechanisms to ensure the voice of disadvantaged and minority populations influences service design and delivery. This would include, among others: disabled people, Pacific peoples, those with mental health issues, young people, refugees and migrants, and the rainbow community. The role of consumer voice in service design is vital in understanding the drivers of inequity and for service models that improve outcomes for Māori. Consumer voice is also important for people whose situation or condition means they have a close and long-term association with a service, for example for people with disabilities, mental health challenges and long term conditions. The health reforms, and the changes they envisage, provide an opportunity for reframing how the health system engages with Māori, consumer and communities. The Southern Health system should work the Iwi Māori Partnership Board and with the Community Health Council to ensure communities and consumers can be engaged into the locality establishment process and into the development of pro-equity pathways of care. The establishment of localities and the rebalancing of the health system towards primary and community care and population health, provides an opportunity for the ‘more active engagement and involvement’ of community and consumer voice in how our health system works. |
If communities and consumers are engaged in key transformation processes, it creates a platform for their continued engagement and influence as new networks and services take shape.
Actions to embed community and consumer engagement:
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Proposed leadership for action in this area: Iwi Māori and the Consumer Council
Reframe funding
Elements we are building from
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What we need to achieve
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The health reforms are set to change the way that many health services are commissioned. The signals are that Health NZ will have regional commissioning teams and will commission at a locality level. The MHA will influence the Health NZ commissioning approach and directly commission some services. The Iwi Māori Partnership Boards will influence how services are commissioned locally.
Commissioning is complex and it will take time for new commissioning policies and programmes to be put in place. However, some signals are clear, such as wanting to commission more integrated primary and community services.
Details plans for a future commissioning environment may not be settled until Health NZ is established, but there are things the Southern system and the Southern DHB can do to proactively prepare.
The localities establishment work should encompass creative local ideas about how different funding approaches could overcome silos and support improved service integration. A good outcome would be for a newly established Health NZ to be met with strong recommendations from the South about the best ways to fund service networks.
DHB funding should be reframed to support the recommendations in this strategic brief. Many of the recommendations do not require significant resources. They are about the power of mobilising leadership and building connections to improve how services are led and delivered. The Southern DHB has a key role as the catalyst for this activity, which will require some seed funding to facilitate action and some ongoing funding to drive high quality change processes (see section on change).
The table below provides further details as to the application of funding and relative priorities for resources:
Proposed leadership for action in this area: Southern DHB with appropriate contributions from other major health providers.
Virtual healthcare and digital systems
Virtual healthcare – reorient to telehealth
Elements we are building from
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What we need to achieve
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Connect our digital systems to enable localities
Elements we are building from
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What we need to achieve
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Telehealth
Telehealth provides an opportunity for a revolution in how the health system is connected and how clinicians connect to patients. Done well, telehealth offers care closer to home, values patient’s time, can improve access and equity and deliver efficiency.
The infrastructure for telehealth is generally in place. Clinicians can quickly and easily videoconference. The extremely rapid uptake of telehealth during the COVID-19 lockdowns shows that clinicians and patients can and will take up telehealth consults. (Uptake of telehealth under COVID-19 restrictions include between 30 to 330 GPs offering telehealth across the DHBs nationally, from 3,300 to 34,500 DHB appointments per week nationally.)
Outside of the COVID-19 lockdowns, telehealth use has been slow. Given its geography, sparse population and travel times, the South is well suited to make gains from the deployment of telehealth. Telehealth uptake is primarily not a technology problem, it is one of clinical and patient cultures, the organisation of clinical systems and communications. Implementing telehealth should be a priority.
It is estimated that up to 30% (NZ Telehealth forum) of outpatient appointments can be done by telehealth, especially those from the specialties that have less of a requirement for examination or intervention, especially for follow up consults. At a national level, there is already a high level of specialist care delivered via telemedicine in cardiology, psychiatry and radiology, however more recent examples were in surgery and endocrinology / diabetology. In other remote settings, follow-up was successfully performed with a health aide to navigate IT issues.
Across the country, primary care has adopted telehealth significantly, both in the healthcare home model, during COVID-19 (90% of primary care consults were telehealth in the Level 4 lockdowns) and the advent of App-based services, of which there are a number of large providers throughout the country.
Telehealth also suits many priority groups including most disabilities, because of the cost and extra time it takes to attend an appointment. Early research out of Australia also seems to suggest that it is more palatable for elderly and indigenous people than previously thought, but there needs to be an assessment of the skill with technology and those in whom English is not their first language may struggle without support.
Data from the Southern system identifies opportunities for telehealth:
There is ample opportunity to increase and improve the telehealth service delivery in the Southern region, supporting healthcare to be more accessible, acceptable, convenient and efficient.
- In 2021 there were only 31,000 consults coded as telehealth from Southern hospitals, which was <1% of all events.
- In 2019 there were over 56,000 medical outpatient appointments at Dunedin and Southland for patients who did not live in Dunedin City or Invercargill. There were also a further 16,000 nursing and allied health outpatients. 6,900 of these were oncology, 2,000 cardiology, 1,300 rheumatology, 1,100 haematology, 1060 endocrinology outpatient appointments – being five specialties which the literature and specialists have identified as being potentially amenable to telehealth.
- These specialties account for one quarter of all outpatient appointments at these major hospitals from those that do not live in the urban centres.
- If two thirds of these are follow ups, then around 10,000 events could potentially be delivered over telehealth, if the patients were supported by their GP and the system.
- If a proportion of patients were supported by their GP to have nursing care closer to home through telehealth, up to 10,000 more events could be delivered through the primary care.
- In 2019 there were 3,200 DNAs from people who lived out of Dunedin and Invercargill, which was 4.3% of all Outpatient events. 2,200 of those DNAs were to Dunedin hospital at a rate of 4.5% and a further 1,000 to Southland. (At a rate of 3.8%).
- DNA rates were higher in younger patients with rates for 15-24 approaching 10%.
- There were over 10,000 DNAs from those under 39 years of age – in which the infrastructure and capability to use telehealth should be more available and intuitive.
- The DNA rate at Dunedin hospital was a further 2% higher for the 0-39 year old age brackets, including those that lived in Dunedin - indicating that although telehealth may be most beneficial for those that live geographically isolated from their appointment facility access is not always the issue.
There is ample opportunity to increase and improve the telehealth service delivery in the Southern region, supporting healthcare to be more accessible, acceptable, convenient and efficient.
Clear guidelines will provide clinicians with clarity and confidence to use telehealth technologies and give administrators the direction to book patient appointments accordingly and organise acceptable equipment when needed. The proposed whole system clinical governance group should have oversight of a programme to significantly increase the uptake and value delivered by telehealth – as dialogue and clinical leadership will be essential to influence clinicians to support telehealth uptake across the system. Elements to a programme to increase the uptake of telehealth may include:
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Proposed leadership for action in this area: Telehealth uptake should be a work programme led by the DHB and WellSouth that has oversight from an extended Clinical Council.
Digital opportunities to create one system
The vision for a digital future sees a fully connected health system, where different technologies are connected within hospitals, hospitals can easily share patient data between each other, GPs and specialist services share important patient information and GPs can refer easily to NGOs and to other community-based social services and Kaupapa Māori services.
There are also opportunities for patients and whānau themselves to be connected to their care through better digital information and advice and through technologies such as ‘wearables’ that allow for remote monitoring.
We are a long way from this point now. Digital infrastructure will be a priority of Health New Zealand and the Ministry of Health is making progress with systems and standards to improve interoperability of healthcare technologies in the future.
The health technology ecosystem is complex and change often occurs slowly. There are national, regional and district digital strategic plans and actions under way. It would be expected that Health NZ will provide a degree of rationalisation and consistency across digital strategies for the sector and these issues fall outside this strategic briefing.
From a southern perspective, a key issue is to successfully implement the vision for the new Dunedin ‘digital hospital’, which will place Dunedin as national leaders in digital systems and be an enabler across specialist services connectivity and the entire system.
In the shorter term, digital technologies have a key role in actioning priority areas outlined in this strategic briefing, including, connected care in localities, pro-equity pathways, and developing the capacity of Māori health providers.
Building digital infrastructure for Māori health providers
There needs to be a strategic effort to improve and enable the digital capability of Māori health networks. The service models of the future envisage improved connectivity and care coordination between Māori health and social service providers and improved connection between Māori providers and general services, and improved information availability for whanau.
There should be a review of the current digital infrastructure available to Māori providers and a plan developed to invest in and develop the digital capability. This may require a focus on both technology and workforce capacity.
There should be a review of the current digital infrastructure available to Māori providers and a plan developed to invest in and develop the digital capability. This may require a focus on both technology and workforce capacity.
Localities
The future connected care models being envisaged for localities will be difficult to realise without appropriate digital systems. There is a risk that coordinated care prototypes are tried and fail without digital support. There needs to be engagement between leaders in the digital health ecosystem and those devising how connected care could operate in localities in the south. Local digital capability should be leveraged in the development and delivery of service prototypes that will create learnings for wider implementation of connected care.
The DHB should facilitate active engagement and co-design between digital experts, technology providers and health service designers to create innovative ideas that can be presented to commissioners at Health NZ and the MHA.
The DHB should facilitate active engagement and co-design between digital experts, technology providers and health service designers to create innovative ideas that can be presented to commissioners at Health NZ and the MHA.
Pro-equity pathways
Digital enablers should also be explored as part of the development of pro-equity pathways in the south. Technology can support improved access, remote monitoring, new care models, and improved integration with Kaupapa Māori providers. Digital leaders should join clinical and cultural leaders to explore digital enablement of equity actions.
Proposed leadership for action in this area: Southern DHB, WellSouth, Health One