Pro-equity and systemic models of care
Elements we are building from
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What we need to achieve
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Successful modern health systems are built around developing a clear and proactive approach to a patient’s journey for various conditions or situations. This systematic approach should include the key steps, activities at each step of the patient journey and roles of various organisations and professional groups.
Clear systems of care improve equity, efficiency, patient experience and quality.
They also allow the system to be far more efficient. Ideally, a system of care involves population, primary, specialist hospital and rehabilitation services. Systems of care are the core ‘software’ for a connected health system.
Clear systems of care improve equity, efficiency, patient experience and quality.
They also allow the system to be far more efficient. Ideally, a system of care involves population, primary, specialist hospital and rehabilitation services. Systems of care are the core ‘software’ for a connected health system.
Current systems of care in the South lead to inequity. Statistics show inequities for Māori across many parts of our care systems and, ultimately, in morbidity and mortality. On average, Māori in the South die younger than non-Māori, mostly due to the higher rate of childhood deaths. Another key reason is that the majority of Māori (55%) die before 70 years of age, compared to only 23% of Non-Māori who die before the age of 70. The Southern system urgently needs to develop systems of care that explicitly address equity, and create a pro-equity response, at every step of the journey. |
One of the challenges with actions to address inequity is to understand where to focus effort.
Data from the National Mortality Data Collection was used to calculate amenable mortality (premature deaths under age 75 that could potentially be avoided, given effective and timely healthcare) from 2014-2018. This showed that the rate of amenable mortality deaths for Māori is higher than that of non Māori from 25 years of age, and in the 60-74yr age bracket is 2.2 times higher. |
The graph below presents the number of Māori deaths due to amenable mortality by condition. The biggest contributors in the Southern region are cardiovascular disease and neurological disease (mostly stroke), linked through similar pathophysiology and contributing factors (including risk factors and lifestyle contributors). Additionally, suicide is a large contributor to amenable mortality in the Southern region, and this is also known to disproportionately affect Māori.
To inform this strategic briefing, a group of clinical and cultural sector leaders came together to explore how these inequities in life outcomes could be reversed. They explored the care pathway of a person with cardiovascular disease or stroke through the Southern Health system and identified issues that led to inequities at each step of the journey. |
The group identified a number of areas within cardiovascular and stroke care that should be further investigated with good quality data to understand if there are equity concerns within the patient journey (Figure below). The group identified a number of population factors that contribute to inequities in outcomes for these conditions that need to be better understood through analysing the data and accessing population health expertise.
It is important to improve identification and appropriate early treatment in primary care, including access and quality of primary care and the information people receive to enable them to manage their long term conditions. Early identification through the use of lab tests, diagnostics and screening tools in a range of settings is particularly important. Access to secondary care through urgent care, ED and then hospitalisation need to be further understood as there appear to be inequities to access to secondary care. Once there is engagement with secondary care, there needs to be clear ways to ensure follow up that ensure equity. Finally, understanding poor outcomes is absolutely necessary, especially those that result in early death.
It is proposed that this analysis is used to inform a second stage of work to develop a pro-equity system of care for cardiovascular disease and neurological conditions, this work would involve:
Learning from this process should then inform the development in other pro-equity systems of care in key areas that data identifies impact on the gap in health outcomes between Māori and non Māori. Key areas include suicide prevention, respiratory conditions and cancers.
- Leadership: A stewardship group that will develop pro-equity systems of care, oversee their implementation and monitor results. Stewardship groups should include the Iwi Māori Partnership Board, clinical governance and managerial representation from across the system.
- Action: The immediate focus should be on the development of pro-equity system of care for cardiovascular disease and neurological conditions. This work could build from the initial analysis undertaken during the strategic briefing, with a plan of action being developed in a matter of months.
- Resourcing: Implementation of a pro-equity system of care may require the reframing of current resources to address issues such as barriers to access that have been identified in in the pathway plan. New services models may need to be implemented that are designed with and for Māori.
- Data and feedback: There needs to be a system for monitoring progress using data extracted from various parts of the system of care to identify whether progress is being made to improve equity and ultimately differences in quality of life and mortality. Regular data should be made available to the Iwi Māori Partnership Board.
Learning from this process should then inform the development in other pro-equity systems of care in key areas that data identifies impact on the gap in health outcomes between Māori and non Māori. Key areas include suicide prevention, respiratory conditions and cancers.
Proposed leadership for actions in this area: Build out from existing working group that informed this strategic briefing. Stewardship via Iwi Māori and extended (whole system) Clinical Council. Enabled by Southern DHB/MHA/Health NZ
Building integrated clinical leadershiP
Elements we are building from
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What we need to achieve
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Clinical Leadership is vitally important in a healthcare system, particularly when there is a dramatic transformation – as is the case with the current NZ Health reforms – when managerial leadership will be subject to significant change.
Clinicians respect clinical leadership. Clinicians are more engaged in their work, patient care improves and clinical staff are more satisfied when services and service redesign are led by clinical staff. The public also trusts clinical leadership and public trust in the healthcare system will be vital as our health system responds to Covid-19 outbreaks.
The health reforms propose a more integrated healthcare system, with a ‘rebalancing’ towards population health and primary care. Clinical leadership should reflect this with the establishment of whole system integrated clinical governance. Current clinical governance structures in the South are not fit-for-purpose for the integrated healthcare system of the future.
The DHB Clinical Council is primarily focused on specialist services. There is not a formal clinical leadership forum that collectively represents primary care, rural hospitals, population health and other community providers. Other parts of New Zealand have a variety of mature and functional structures that bring clinicians together from across the system to provide analysis, advice and leadership.
The transition period provides an opportunity for the Southern system to reframe clinical leadership to have a stronger role across the system, with a clear mandate, roles and responsibilities. It is likely that the new Health NZ southern regional office will want to create some form of regional clinical leadership, however, this should not stop the Southern system from thinking through and actioning what will work best for the South.
It is proposed the current Clinical Council be tasked with developing a model for whole system clinical governance, and that this must occur in co-design with community-based clinicians and organisations. One of the key roles for clinical governance in the region should be reviewing the agreed national system indicators and monitor areas for similarities and differences with other regions and advise health leaders on improvement actions.
Clinicians respect clinical leadership. Clinicians are more engaged in their work, patient care improves and clinical staff are more satisfied when services and service redesign are led by clinical staff. The public also trusts clinical leadership and public trust in the healthcare system will be vital as our health system responds to Covid-19 outbreaks.
The health reforms propose a more integrated healthcare system, with a ‘rebalancing’ towards population health and primary care. Clinical leadership should reflect this with the establishment of whole system integrated clinical governance. Current clinical governance structures in the South are not fit-for-purpose for the integrated healthcare system of the future.
The DHB Clinical Council is primarily focused on specialist services. There is not a formal clinical leadership forum that collectively represents primary care, rural hospitals, population health and other community providers. Other parts of New Zealand have a variety of mature and functional structures that bring clinicians together from across the system to provide analysis, advice and leadership.
The transition period provides an opportunity for the Southern system to reframe clinical leadership to have a stronger role across the system, with a clear mandate, roles and responsibilities. It is likely that the new Health NZ southern regional office will want to create some form of regional clinical leadership, however, this should not stop the Southern system from thinking through and actioning what will work best for the South.
It is proposed the current Clinical Council be tasked with developing a model for whole system clinical governance, and that this must occur in co-design with community-based clinicians and organisations. One of the key roles for clinical governance in the region should be reviewing the agreed national system indicators and monitor areas for similarities and differences with other regions and advise health leaders on improvement actions.
An example of an area that could be monitored by the Clinical Council is ASH rates for the region.
One of the system level indicators for the whole healthcare system is ASH rates in the 45-64 year old age bracket. In the Southern District, Māori adults have significantly higher ASH rates than for non-Māori over the past 5 years, and higher than the national average. The conditions contributing to this difference have been cardiovascular conditions, respiratory and skin conditions. |
Further areas where integrated clinical governance would add value include:
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Leadership groups that don’t have real responsibility tend to diminish over time.
Groups that do real work together grow stronger. Clinical governance should have a clear mandate to lead and be supported with staff from the DHB, with access to a project office and data analysts. Community based provider organisations should also be prepared to proactively support the role of joined up clinical leadership and oversight.
The Clinical Council should actively begin working with clinical colleagues from across the system to expand its brief and mandate and to identify a pathway to evolve into a new role.
As with other recommendations in this strategic briefing, it is suggested that less time is spent on theoretical discussions and structures and instead real projects are taken on and structures are evolved to deliver on that work.
Get going and get better.
Groups that do real work together grow stronger. Clinical governance should have a clear mandate to lead and be supported with staff from the DHB, with access to a project office and data analysts. Community based provider organisations should also be prepared to proactively support the role of joined up clinical leadership and oversight.
The Clinical Council should actively begin working with clinical colleagues from across the system to expand its brief and mandate and to identify a pathway to evolve into a new role.
As with other recommendations in this strategic briefing, it is suggested that less time is spent on theoretical discussions and structures and instead real projects are taken on and structures are evolved to deliver on that work.
Get going and get better.
Proposed Leadership for actions in this area: Clinical Council – engaging with clinical leaders across the system
Create data-driven health intelligence function
Elements we are building from
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What we need to achieve
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A connected health system simply cannot function intelligently without connected data.
Linking existing data to understand a patient journey through the health system and inform how a system is functioning is a core enabler of integrated care.
There are two levels to data integration. One is information for managing a patient, such as detailed and identifiable patient information, which is part of a diagnostic or referral processes. This integration of patient notes is optimal, but complex and reliant on progress with national and regional infrastructure.
The other type of data integration is the aggregation of anonymised person-event level data that can be extracted from multiple and diverse Patient Management Systems and linked up to provide intelligence about how the whole system is performing. Achieving aggregation and integration of person-event level data is simpler, more affordable, and much more achievable (than a shared care record as described above) in the short and medium term.
Integrating person-event level data is a key enabler of locality networks, understanding equity, ensuring care is delivered close to home and monitoring pro-equity care pathways. It is also an invaluable tool to enable whole system clinical governance to be informed by whole system data.
The Southern system should be moving to join up person-event level data. The first step is establish agreements between organisations about sharing data and how that data will be used to inform system improvement. Other parts of the country already have systems to integrate data. For example, there are more than 130 diverse datasets within the Auckland Regional Healthsafe data infrastructure.
The technologies and methodologies existing for safely extracting, storing, linking and analysing data are not a barrier and the costs of person-event data integration is not prohibitive.
Linking existing data to understand a patient journey through the health system and inform how a system is functioning is a core enabler of integrated care.
There are two levels to data integration. One is information for managing a patient, such as detailed and identifiable patient information, which is part of a diagnostic or referral processes. This integration of patient notes is optimal, but complex and reliant on progress with national and regional infrastructure.
The other type of data integration is the aggregation of anonymised person-event level data that can be extracted from multiple and diverse Patient Management Systems and linked up to provide intelligence about how the whole system is performing. Achieving aggregation and integration of person-event level data is simpler, more affordable, and much more achievable (than a shared care record as described above) in the short and medium term.
Integrating person-event level data is a key enabler of locality networks, understanding equity, ensuring care is delivered close to home and monitoring pro-equity care pathways. It is also an invaluable tool to enable whole system clinical governance to be informed by whole system data.
The Southern system should be moving to join up person-event level data. The first step is establish agreements between organisations about sharing data and how that data will be used to inform system improvement. Other parts of the country already have systems to integrate data. For example, there are more than 130 diverse datasets within the Auckland Regional Healthsafe data infrastructure.
The technologies and methodologies existing for safely extracting, storing, linking and analysing data are not a barrier and the costs of person-event data integration is not prohibitive.
The key issues to work through are the relationship and process issues such as:
Many of these issues have also been worked through in other health districts, where integrated data is commonplace. |
To enable the trusting and transparent relationships vital for locality networks, integrated data systems should be established on ‘democratic’ principles.
This means that all organisations that contribute data also contribute to data governance and have a say in how the data is managed and used. A commitment to a transparent and democratic integrated data infrastructure provides the basis for organisations to feel safe when contributing their data to a common pool. It also forms a foundation for enabling Māori data sovereignty.
Actions should begin right away. The Southern DHB and WellSouth PHO are well advanced in a data sharing agreement and this could form the foundation for an open and democratic approach to governing integrated data. Clinical governance should work with this linked data infrastructure to identify system level quality indicators, for issues such as access, equity, efficiency and effectiveness of care.
As this system is established, there are opportunities to expand membership. The Southern Mental Health review recommended that MHAIDs data be included, and the expansion to include data from mental health providers, NASC (disability), NGOs and hospices should occur as it becomes available. (All these providers are part of the Health and Disability Systems Review roadmap, and essential parts to any locality.)
Other organisations that should be part of integrated data sharing include:
WellSouth is already using data intelligence and has created a sophisticated dashboard at a system and practice level. With the data organised at a provider level, the PHO can identify variation and use this to drive improvement programmes.
This type of capability should be available at a system level.
Dashboarding system-level data allows leadership to answer questions quickly that would previously have led to a lengthy analysis period and delays to discussion and actions.
Developing integrated data reports and dashboards will enable the Iwi Māori Partnership Board to monitor system performance for Māori and to identify inequities and understand if pro-equity initiatives are working.
Linked data is an essential tool for driving improvements for Māori.
Experience from other parts of the country shows it may be useful to establish data governance groups at two levels: organisational and technical. The organisational level deals with wider issues such as goals, principles, Iwi Māori data sovereignty, privacy issues, access and funding. The technical group deals with issues such as technical specifications, data schemas, security protocols, details of data analysis and permissions. Both are critical areas where there is transparency and all organisations who are part of the data collective can contribute and have confidence in the safety and use of their data.
Iwi Māori should be engaged early in this process to develop a positive approach to protecting Māori data sovereignty.
Initial work could meaningfully be led by a combination of DHB and PHO representatives with reporting lines to the Clinical Council (and future whole system clinical governance group).
Work should proceed to getting a proof of concept up and running as soon as possible to show use cases and value. If there are sensitivities with which organisation holds and manages the data (as there has been in other districts) then it may be that an independent third party be engaged to facilitate the process of data acquisition, storage, analysis and visualisation.
This means that all organisations that contribute data also contribute to data governance and have a say in how the data is managed and used. A commitment to a transparent and democratic integrated data infrastructure provides the basis for organisations to feel safe when contributing their data to a common pool. It also forms a foundation for enabling Māori data sovereignty.
Actions should begin right away. The Southern DHB and WellSouth PHO are well advanced in a data sharing agreement and this could form the foundation for an open and democratic approach to governing integrated data. Clinical governance should work with this linked data infrastructure to identify system level quality indicators, for issues such as access, equity, efficiency and effectiveness of care.
As this system is established, there are opportunities to expand membership. The Southern Mental Health review recommended that MHAIDs data be included, and the expansion to include data from mental health providers, NASC (disability), NGOs and hospices should occur as it becomes available. (All these providers are part of the Health and Disability Systems Review roadmap, and essential parts to any locality.)
Other organisations that should be part of integrated data sharing include:
- Rural hospital trusts
- Maternity providers
- Kaupapa Māori providers
- Social sector providers
WellSouth is already using data intelligence and has created a sophisticated dashboard at a system and practice level. With the data organised at a provider level, the PHO can identify variation and use this to drive improvement programmes.
This type of capability should be available at a system level.
Dashboarding system-level data allows leadership to answer questions quickly that would previously have led to a lengthy analysis period and delays to discussion and actions.
Developing integrated data reports and dashboards will enable the Iwi Māori Partnership Board to monitor system performance for Māori and to identify inequities and understand if pro-equity initiatives are working.
Linked data is an essential tool for driving improvements for Māori.
Experience from other parts of the country shows it may be useful to establish data governance groups at two levels: organisational and technical. The organisational level deals with wider issues such as goals, principles, Iwi Māori data sovereignty, privacy issues, access and funding. The technical group deals with issues such as technical specifications, data schemas, security protocols, details of data analysis and permissions. Both are critical areas where there is transparency and all organisations who are part of the data collective can contribute and have confidence in the safety and use of their data.
Iwi Māori should be engaged early in this process to develop a positive approach to protecting Māori data sovereignty.
Initial work could meaningfully be led by a combination of DHB and PHO representatives with reporting lines to the Clinical Council (and future whole system clinical governance group).
Work should proceed to getting a proof of concept up and running as soon as possible to show use cases and value. If there are sensitivities with which organisation holds and manages the data (as there has been in other districts) then it may be that an independent third party be engaged to facilitate the process of data acquisition, storage, analysis and visualisation.
Auckland Patient After Hours and Urgent Access (PAUA) initiative as a case study The Auckland Patient After Hours and Urgent Access (PAUA) integrated data system has been evolving and improving since its inception 10 years ago The PAUA system links patient-event level data from five EDs, seven PHOs (the ASR/PHO register), 20 Urgent Care Clinics and St John Ambulance, via an encrypted NHI. The information is uploaded quarterly into the regional HealthSafe data system and provides a whole system view of the regional after hours system, which includes information such as demographics, eligibility for funding, time of presentation, diagnosis code and outcome. A whole system set of quality indicators was designed by a group of cross-system clinical leaders. The data is used to inform system-level improvement actions overseen by an alliance of managerial and clinical leaders from across the network and implemented via projects with collaborative leadership. The overall governance for the data sits with Metro Auckland Data Stewardship Group, which PAUA regularly reports progress and findings to. Proposed leadership for actions in this area: Southern DHB, WellSouth PHO and Iwi Māori initially. Engage others as systems in place. |