ExEcutivE summary

BUSINESS CASE TO DELIVER BETTER, SOONER, MORE CONVENIENT HEALTH CARE

GREATER AUCKLAND INTEGRATED HEALTH NETWORK (GAIHN)

Summary Paper

1 March 2010

THROUGH GAIHN...
Patients will experience
Care that focuses on your whole family/whnau Better access to after-hours care Clinicians know more about you less duplication of tests and questions Better management and support for chronic disease Phone help and navigation support so you can access the right services Faster access to radiology services Better care for the elderly where they live More health promotion from your GP, especially for children More services available locally through Enhanced General Practice and Community Health Hubs Better care outside the hospital when you are acutely ill

Clinicians will experience

More time spent caring for patients, less time spent filling out forms More direct access to diagnostic tests when you need them More services available to treat your patients in the community Phone help so you can access the right services Electronically shared care plans to support multidisciplinary care teams Evidence-based clinical care pathways to support high quality care Networks of clinicians across clinical disciplines and organisations Active involvement in determining where health resources are used

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GAIHN Business Case Summary

At a Glance
Through a network of 1050 general practitioners working in primary care teams, 11 PHOs and 3 DHBs, we will deliver Better, Sooner, More Convenient health care to 1.25 million Aucklanders. The Greater Auckland Integrated Health Network (GAIHN) is a commitment by DHBs and PHOs in the region to share the risk and responsibility to deliver: Better health outcomes Better patient experience and Better use of money. GAIHN will sustainably achieve zero increase in hospital acute demand in three years through more effective community-based health services. GAIHN will also deliver on measurable goals for reducing inequalities, chronic conditions, elective services and prevention. GAIHN will do this within the current funding environment. GAIHNs goals can only be achieved by impacting on decisions made by thousands of clinicians every minute of every hour of every day. GAIHN will be empowering clinicians with new skills, community networks and access to clinical resources to meet the needs of Mori, Pacific and high needs communities. Clinicians have advised that the best ways of achieving the goals are to: improve the patient journey through consistent best practice models of care for all GAIHN partners, focusing on long term conditions, acute care and prevention give clinicians tools to work together and make better decisions, including access to diagnostics, IT and training build a new locality focus by establishing six Local Health Networks (in collaboration with PHOs), and new multiservice Community Health Hubs that will support the shift of services from hospitals into the community. Three major Community Health Hubs will be developed during 2010/11, with others to follow. GAIHN will also support a market-led response to general practice amalgamation and co-location of services to deliver Better, Sooner, More Convenient care.

To deliver these outcomes, GAIHN will simplify and transform the health environment, with joined-up organisational and clinical leadership, and an aligned and simplified funding and contracting environment. GAIHNs new infrastructure will support multidisciplinary teams and new opportunities for efficient use of the workforce. Preliminary financial analysis has shown that there are substantial savings to be made by improving the impact of community services on hospital demand. More detailed financial analysis is required. GAIHN believes that the new clinical and management structures will lead to significant efficiencies and direct cost savings. GAIHN acknowledges the need to continue to evaluate management structures, to ensure that form follows function, and that the environment it has put in place will rationalise structures over time. The GAIHN partners agree to achieving organisational efficiencies, including consolidation, over the next two years. GAIHN will remove barriers and implement changes by improving regional coordination and building from the strengths of the GAIHN partners. GAIHN will systematically implement its plans over three years, with regional and local clinical leadership.

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GAIHN Business Case Summary

The GAIHN business case story

1. Make health Better, Sooner and More Convenient for patients and clinicians
Better access to care outside the hospital when you are acutely ill Access to your own medical records for you and people you trust Care models that focus on your whole whanau

Better support for people with chronic disease Faster access to radiology services

Better access to after hours care

Clinicians know about you less duplication of tests and questions Whats better for patients in GAIHN 2010/11

More health promotion at your GP

Greater range of services available locally through Community Health Hubs

Education designed to support you to take control of decisions about your health

Better care for the elderly

Phone help so you can access the right services

GAIHN will deliver real, visible changes that deliver Better, Sooner, More Convenient health care for patients. It will also make the heath environment one where clinicians are empowered to deliver high quality care for their patients. Improvements will start in mid 2010 and will continue to expand in scale and scope over the three years of the business case. GAIHN will improve personal health and population health.

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GAIHN Business Case Summary

GAIHN recognises, trusts and values all clinicians by redesigning our health system to increase clinical leadership and empower clinicians to have more access to resources in caring for patients. These changes carry with them an increased responsibility for clinicians to ensure the health system works well for all Aucklanders, including those not specifically cared for by their services. Our new health system is based on cooperation, networks and alliances across the sector. It moves away from them and us towards together we; looking to break down barriers between clinicians and management, primary and secondary, clinicians and communities and across health disciplines.

Improved services for the whole family across age groups and levels of ability. Skilled experienced health professionals, applying contemporary evidence informed practice, using innovative models of care that are patient and family centred rather than health professional centred. Opportunity for patients and families to have their say about their own health care with the provision of all relevant information.
The quotes in these boxes are from the on-line survey of frontline clinicians GAIHN commissioned to inform the Business Case development

2.

Set ourselves real measurable goals for the whole health system

The core business case proposition for GAIHN is that it will sustainably reduce hospital acute demand through high performing communitybased services. By leveraging the efficiencies of community-based services, GAIHN will deliver improved whole system outcomes at a lower cost. Improvements will be achieved through better use of existing resources and predicted future funding streams.

GAIHN believes that in order to achieve a sustainable high quality health service within the economic constraints of the New Zealand environment, GAIHN must focus on the parallel achievement of: Better health outcomes, Better patient experience and Better use of money.

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GAIHN is committed to reducing inequalities and aims to halve the current measurable inequalities over the next three years, wherever it intervenes in the health system. GAIHN is driven by four measurable goals that align with the New Zealand Health Targets. GAIHNs Outcomes and Goals will lead to a voluntary alignment of strategic approaches across the GAIHN partners, including incorporation of the features of the GAIHN Regional Annual Plan in DHB District Annual Plans and in PHO contracts. GAIHNs progress towards its goals will be measured through a set of whole system performance indicators.

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3.

GAIHN is committed to new solutions for reducing inequalities

GAIHN provides new opportunities for addressing the issue of health inequalities. GAIHNS states its commitment to: An unequivocal priority for reducing health inequalities Measurement of existing inequalities and of the impact of interventions Incorporating reducing inequalities as an important element of all initiatives at all levels

GAIHN will focus on reducing inequalities through four strategic planks:

1. Targeting the clinician-patient interaction: Real change to inequalities happens at the hundreds of thousands of interactions every day at the front line. GAIHN believes that reducing inequalities is best addressed by providing front line health professionals with the motivation, tools, resources and skills to provide services that better meets the needs of Mori, Pacific and other high needs groups.

2. Aligning regional effort to reduce inequalities across the whole system: GAIHN will
embed new regionally-consistent best-practice models of care that will emphasise inequalities and whnau focused care.

3. Achieving new whnau and localities focus

(partnerships with communities): GAIHN will develop

new locality-based health infrastructure through Local Health Networks and Community Health Hubs. The locality infrastructure will better meet the needs of local communities. The new infrastructure includes Whnau Ora Centres and Networks.

Holistic care of the family unit, not just an individual within that unit. Ability to address a need when it is recognised. Health professionals considering the family/whnau's own resources, strengths, commitments, health beliefs and practices.

4. Support service innovations and rapid diffusion of

good ideas that work: Many excellent services already exist that support high needs
individuals and communities. GAIHN will rapidly spread good ideas to reduce inequalities across the network. GAIHN will work constructively with the Alliance Health+ and Mori PHO Coalition to support new models of care, such as Whnau Ora.

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GAIHN Business Case Summary

4.

Simplifying and transforming the health environment

GAIHN proposes a new, simpler health environment, (shown above) in which PHO, DHB and Iwi partners link with clinical leaders to produce a GAIHN Regional Annual Plan. This plan will inform a new resourcing environment: New aligned DHB funding, planning and contracting for community-based services across Greater Auckland. New focus on locality-based resourcing through aligned Local Health Networks, led by PHOs. New - scope for general practice to commission services on behalf of their patients.

Clinical initiatives, focused on the GAIHN goals, will be implemented in a coordinated fashion across Greater Auckland. Implementation will be supported by clarity of direction and performance expectations, outlined in the annual regional plan, but accompanied by local flexibility on how to deliver improvements. GAIHN expects impacts to include better strategic decisions, more responsive local services, greater operational efficiency and faster change through reducing both clinical and organisational bureaucratic log jams. GAIHN aims to lift whole system performance across its three outcome areas of Better Health outcomes, Better patient experience and Better use of money.

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GAIHN Business Case Summary

5.

Improving clinical practice across the patient journey

GAIHN realises that it will only achieve its goals by influencing the many decisions that thousands of clinicians make every minute, of every hour of every day. Change at the periphery will not suffice. In developing this business plan, GAIHNs clinical leaders have spent considerable time looking at how the new joined-up approach can deliver the biggest benefit for front line clinical practice and patients. The core clinical focus for the next three years is to achieve more consistent best practice clinical decisions in priority areas. GAIHN will focus on achieving best practice models of care across prevention (with a focus on whnau health), long term conditions (including frail elderly and end of life care) and acute care (including adults and child/youth).

Long term conditions (including frail elderly)

GAIHN will develop and implement a comprehensive, proactively planned approach to long term condition management across the network. The LTC model of care will be progressively implemented by identification and transfer of existing best practice models. This approach will maximise effort on implementation, not invention. The aim is improved prevention and community based management of disease and of complications. This will include management of the frail elderly and end of life care. The 2010/11 work plan will focus on developing and piloting a regionally consistent long term conditions programme incorporating: Self management programmes Developing an annual interdisciplinary review Standardised and consistent pulmonary and cardiac rehabilitation Services that can be accessed according to patient and family/whnau need Establishing Health Navigators (Patient and Practice).
I would like to see Primary Care teams focus on how can we make the patient less dependent on the healthcare system by enhancing the role of the expert, empowered patient who can safely and effectively self-manage their acute and chronic health conditions.

Acute care (Adults and child/youth)

GAIHN will implement initiatives across the network that target the drivers of acute demand (ED presentations and acute hospital admissions). The 2010/11 work plan will focus on: Extending and strengthening the Primary Options for Acute Care programme regionally

Developing a regional quality pre-contact telephone triage service Developing regionally consistent Integrated Care Pathways Improving accident and medical and after hours care via: o o co-ordination across all providers of acute care walk-in nurse assessment clinics.

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GAIHN Business Case Summary

Prevention (focus on whnau)

GAIHN will implement best practice preventive health that encompasses health promotion and primary prevention. The initiative will improve health promotion and self management of chronic conditions, with a focus on family-centred interventions. It will also improve capability to deliver child and youth health, immunisation, screening and smoking cessation interventions. The 2010/11 work plan will focus on: Implementing the Health Promoting Practices Quality Framework across at least 10% of practices Optimising general practice systems for immunisation, screening, counselling and support.

6.

Improving tools and enablers for quality clinical practice

Community-based clinicians need better access to clinical tools and information if they are to take on greater responsibility for managing patients with complex conditions.

Access to diagnostics
GAIHN will introduce direct access to diagnostics for GPs, based on agreed clinical pathways. GPs will be able to directly order diagnostic tests, including CT, MRI, Ultrasound, Plain X-Ray, according to guidelines, without the need for the current specialist review and authorisation. This process will provide earlier diagnosis, faster access for patients and more appropriate use of specialist time. General practice will order diagnostic tests within a framework in which they are fully aware of the cost and of their responsibility to work within a constrained resource environment. The methods used here are expected to expand or scale to cover direct access to many other services in the future.

Health Information technology

There is an existing regional information systems strategic plan (RIS10-20) for Greater Auckland that outlines a pathway for information systems technology development. GAIHN supports this plan and aims to work through the plan to ensure that the IT needs for the specific GAIHN initiatives are prioritised, including:
Ability to order ultrasounds and x-rays and mammograms and CT's through the community (publically funded), without having to refer to a specialist, without actually having to budget-hold.

Knowledge Management: Making sure that relevant information is available to providers and patients when required. This includes non patient-centric data such as referral processes, care pathways and general health information for patient care. Population Health Information: Structured clinical information about the population, gathered from different areas but stored in a single repository and available for both anonymised research and reporting and to drive behaviour change at the point of care. Shared clinical information: Rather than exchanging information between providers who may need access to it, a Regional Health Management Information System is established, and all providers and patients can access that resource using appropriate security and privacy mechanisms. Starting with shared electronic care plans in year 1.

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GAIHN Business Case Summary

Resource Management: Information systems support frontline clinician decision making and provide timely and accurate information to health funders and planners to determine the quality and quantity of health resources being utilised.

7.

Developing new locality-based infrastructure and accountabilities for health

A fundamental step for providing Better, Sooner, More Convenient services for patients is the development of new locality-based health infrastructure. GAIHN believes this is the key to achieving the full potential of the NZ Primary Healthcare Strategy. Locality-based infrastructure will be more responsive to local needs, improve coordination of care for patients, increase access to support services, provide integration between health and social services, ensure efficiency within community-based services and to enable the shift of hospital services into the community.

Local Health Networks

GAIHN will develop six new Local Health Networks (LHNs). The LHN is a locality-based network of clinical professionals, health organisations and social services. PHOs will establish and support he networks. LHNs are a new concept for New Zealand, therefore GAIHN is proposing pilots in the first year that are based around a variety of dimensions e.g. size, population need, scope, and are supported by a learning framework so success factors are identified to inform future development. It is likely the pilots will involve scale differences, from LHNs responsible for 100,000 down to 10,000 people.

Enhanced general practice

I do not believe that you can sustain long term devolution of services unless there are better primary care delivery units. Patients are not virtual they need to be physically seen and larger medical centres will provide efficiencies of service and economy.

GAIHN will support the amalgamation and development of general practice to support a greater range of health services. This process will occur by the clearly describing incentives and benefits for Enhanced General Practice. GAIHN will support an entrepreneurial, market-led response by general practice and accident and medical clinics.

Community Health Hubs

In order to support the shift of services from hospital to community, scale is necessary for many services. Community Health Hubs are larger centres for health support services and social services. Community Health Hubs will help general practice, as the patients medical home, to better manage patient care outside the hospital. They will support Better, Sooner, More Convenient access to health services. Community Health Hubs are likely to service populations of about 100,000 people. DHB planning is essential for an orderly and safe shift of services into the new hubs. GAIHN will establish at least three new hubs in 2010/11, one in each DHB district.

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GAIHN Business Case Summary

Whnau Ora Centres

Two GAIHN PHO partners, Te Kupenga o Hoturoa Charitable Trust and Tamaki Healthcare Ltd, are also members of the National Mori PHO Coalition. Both PHOs have indicated that they wish to develop a number of Whnau Ora Centres. GAIHN is supportive of this approach. Initial models for Whnau Ora Centres have been developed and include: Mori owned and governed Enabling families to improve their wellbeing Holistic approach to promoting wellness and addressing causes of ill-health, not only providing clinical services Targeting Mori and high need populations, but open to all Engaging with other providers to improve health outcomes for Mori and high need populations

The Whnau Ora Centres will be developed to have a synergy with the GAIHN Community Health Hubs. The first graphic below shows the relationships between a Local Health Network, a Community Health Hub and other health services. The second shows a Whnau Ora Centre and its potential relationship with a Community Health Hub. 1

Acknowledge Tamaki Healthcare, Te Kupenga o Hoturoa Charitable Trust and Francis Group for the Whnau Ora plans

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GAIHN Business Case Summary

Appropriate direct GP relationship with hospital, clinicians and private specialist services

General Practice registered patient

bLocal Health Network hN GPs Hu supports PHO from any alt d He an ealth l ca yH Lo nit u mm Co
Health consumers
Examples of GP referrals Diagnostics Chronic conditions support team Acute episode support/ observation After hours care Devolved secondary care services Community support services Discharge care

o etw

rk

General Practice is Medical Home

Supports GP manage patient needs in the community Appropriate care and interventions in collaboration with GP Real time medical notes Training and development opportunities for general practice staff

Reduces ED admissions and acute demand on hospitals Improves mgt of acutes, electives and discharge

Hospital and DHB community services

Community Health Hub

Patients remain registered with their family medical practice Multidisciplinary, multiservice centre Local Health Network supports care integration A&M services

Credentialed services and network of clinicians from hub, hospital, community and local general practice

Provide scale to enable shift of services Improved care and continuity for patients Integrated care Devolved secondary services Devolved community services

Improved local access to serivces

Improved clinical management of acutes, electives, discharge and long term conditions Self referral walk in and after hours

Other social agencies

Appropriate referrals

DHB strategic health programmes

Private medical specialist services

Tertiary Education
(incl. School of Population Health)

Marae

Rnanga

After Hours

GP Practices

Mori Health Providers

GAIHN CHH Whnau Ora Centre

Primary Services GPs, Nurses, Others (Other complementary localities)

Social Services Clinical Networks

Secondary Services Mm, Pp & Tamariki, LTC, Others

Shared Services

Other Services

Economic & Social Development

DHB Services

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GAIHN Business Case Summary

Examples of impact on acute demand management from GAIHN actions 2010/11 GAIHN actions 2010/11 Speed outflow from hospital and reduce readmission Reduce inflow to hospital (short term - 1 minute to 1 week) Reduce inflow to hospital (medium term - 1 week to 1 year) Reduce inflow to hospital long term (long term - 1 year to a lifetime)

Models of care
Long term conditions Health Navigators Self Management Education Pulmonary & Cardiac Rehabilitation End of Life Care Health Navigators Clinical Care Pathways End of Life Care Health Navigators Multidisciplinary Annual Review for Complex Patients Self Management Education Clinical Care Pathways Health Navigators Multidisciplinary Annual Review for Complex Patients Self Management Education

Acute Care

Enhanced Primary Options Improved After Hours Coordination Telephone Triage Walk In Clinics Smoking Cessation CVD Risk Assessment Immunisation Health Promoting Practices

Prevention

Clinical enablers
Access to diagnostics Direct Access to XRay, CT, MRI & Ultrasound Shared Electronic Care Plans Shared Electronic Care Plans Direct Access to XRay, CT, MRI & Ultrasound Shared Electronic Care Plans Direct Access to XRay, CT, MRI & Ultrasound Shared Electronic Care Plans Population Health Tools

IT

Locality-based infrastructure
Local health networks Enhanced General Practice Community Health Hubs Whnau ora centres Community Based Beds Links to social services Improved Communication Improved Communication Walk In Clinics After hours Specialist Advice After hours Outreach services Improved Communication Multidisciplinary Teams Specialist Clinics Multidisciplinary Teams Multidisciplinary Teams Improved Communication Multidisciplinary Teams

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GAIHN Business Case Summary

8.

Improving the capability and productivity of our workforce

GAIHN understands that workforce is both a key constraint and enabler of sector performance. Our workforce is also mobile and GAIHN sees a huge opportunity in developing a strategic response across Greater Auckland. New locality infrastructure of Local Health Networks, Enhanced General Practice and Community Health Hubs and Whnau Ora Centres establish multidisciplinary ways of working and new responsibilities across teams and across the hospital/community divide. There is also greater opportunity for professionals to learn together and break down barriers that currently inhibit the delegation of tasks whether from specialist to GP or from GP to nurses. GAIHN not only provides opportunities for new models of care, but to prove that those models are scalable. GAIHN will identify workforce models and skills that are required to provide whnau-centric care and develop these at a scale required to make a real difference to reducing inequalities.

GAIHN will increase the rate of learning in the health system as this is the key to continuous quality improvement. The Active Clinical Network will lead clinical learning, based on data and improved information about what is working across the GAIHN network. The Active Clinical Network will link to the Local Clinical Networks to support local level and regional learning.

Professionals working together as a team and not doing their own thing. We need to agree that we all can together improve the health outcomes of our patients. Better sharing of information, resources and the acceptance by all parties that we should be working together would improve the care to our patients.

9.

Creating regional leadership that brings organisations and clinicians together

In signing this business case the GAIHN partners agree to: Participate in a formal network Support the charter and principles (e.g. information sharing) Participate in developing a Regional Annual Plan (including outcomes/performance measures) Commit to implementing the plan which may require resource reorientation DHBs will incorporate the Regional Plan in their DAPS PHOs will incorporate the Regional Plan in contracting.

GAIHN is a network; it does not supplant the governance of any of the partner organisations. It improves collective leadership for community based health services.

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GAIHN Business Case Summary

GAIHN will be developing two key leadership structures for Greater Auckland, the GAIHN Partner Group and the GAIHN Active Clinical Network. The Partner Group will build from the current GAIHN Steering Group. The Partner Group represents the collective interests of GAIHN and is a leadership forum charged with developing the GAIHN Regional Annual Plan and supporting its implementation and measurement of GAIHN-wide performance. GAIHN will not develop new bureaucratic layers it is an integrator. The Active Clinical Network will include leading clinicians from across the GAIHN partners and from key professions. The ACN will provide leadership across clinical priorities, programmes and infrastructure and will link to the emerging Local Health Networks. It is expected that once the Partner Group and ACN are established a number of existing bureaucratic and clinical committees will be disestablished, leading to a more streamlined leadership process.

10. An efficient and practical approach to resourcing and contracting across health
GAIHN plans to simplify the whole approach to health planning, funding and contracting in primary care. Resourcing decisions will be guided by the GAIHN Regional Plan. GAIHN believes that having one plan for communitybased health that all partners agree to will lead to a large reduction in process complexity and bureaucracy, with much clearer understanding of roles and goals. GAIHN will pilot innovative new contracting approaches that provide incentives for organisations to work together. This alliancing approach is being developed by the Ministry of Health and GAIHN sees opportunities in new contracting mechanisms to drive service integration and service level alliances across organisations.
Develop explicit inter disciplinary approaches that promote recognition of the core knowledge and skills of the disciplines working in the community. Recognise where there are overlaps and focus teams on best possible outcomes for individuals with difficulties achieving optimal independence and quality of life with most efficient use of resources.

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PHOs will be aligning their many funding streams to create Flexible Funding Pools, which improve responsiveness and targeting of resources for Mori, Pacific and other high needs groups. The locality approach will lead to PHOs developing consortia to support locality-based networks. As these networks mature, GAIHN believes there is opportunity for new and innovative locality-based resourcing, to reflect local needs and capabilities. General practice will take on a greater role in commissioning clinical resources directly for patients.

11. Achieving efficiencies in bureaucracy, infrastructure and clinical practice

The 11 PHO GAIHN partners, along with the three Auckland DHBs are committed to working together to create efficiencies. These include eliminating the need for duplication of process and contracting that is present under the historic structures. Functioning at a regional level also offers fewer border-driven constraints to efficiencies and consolidation. GAIHN will achieve efficiencies across: clinical infrastructure organisational efficiencies investment efficiencies
Create provision of alternatives to hospital admission. Respite services. Often people don't require admission to hospital but do so as there are not enough services in the community to enable safety and reduction of risk.

Examples include regionally consistent care pathways, one plan (not 3 flowing into 14), and alliancing meaning fewer contracts, better coordination, and leveraging rare skills and capabilities across the whole network. GAIHN acknowledges the need to continue evaluating PHO structures in terms of form following function, and believes that the environment it has put in place will lead to a rationalisation of PHO structures over time. GAIHN will work towards achieving organisational efficiencies over the next two years. GAIHN is aware that all but one of its PHOs serves an enrolled population above the median PHO size in NZ. GAIHN will support further work to identify the optimal size of a PHO and to ensure that consolidation processes are based on a clear logic around outcomes. GAIHN notes that PHOs and DHBs retain valuable skill sets and relationships and that any efficiency and transformation processes should be seeking to retain and leverage that capability within new structures.

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GAIHN Business Case Summary

12. Creating financial systems that improve productive investment

GAIHN resources
GAIHN has identified a series of existing funding streams and other resources it expects to utilise to deliver BSMC as outlined in this business case. These include: Flexible funding pools from existing PHO contracts comprising health promotion, services to improve access, care plus and management fee streams and valued at $40.6m per annum Other DHB / PHO existing contracts that provide resources in the areas relevant to achieving GAINs objectives are currently valued at $21.2m per annum NGO contracts with DHBs to provide services in support of objectives aligned with GAIHN DHB owned services which contribute to achieving objectives aligned with GAIHN.

GAIHN will align the goals and objectives of the matrix of existing resources and does not intend significant redistribution of resources. Instead, GAIHN partners have committed to utilising the resources they currently have in support of common goals and objectives as laid out in the GAIHN Regional Plan.

Efficiencies and improvements

GAIHN has identified areas where significant cost savings could be achieved whilst simultaneously improving the quality of health care. GAIHN has not been able to undertake financial modelling around all these opportunities. However, two are outlined below as examples. These are aligned with the year one priorities of GAIHN: Long Term Condition Management where Ambulatory Sensitive Hospitalisation (ASH) rates are our main chosen indicator. ASH accounts for around $112m of healthcare expenditure per annum in the GAIHN region. In theory all of these events are avoidable, however based on the assumption that 15% of these are actually avoided over the first three years we could estimate a net saving after the costs of alternative programmes in primary care of around $20m. Reducing Acute Demand Of the approximately $500m per annum spent on triage and direct hospitalisation costs following ED attendances, approximately $100m is spent on patients triaged as being categories 4 or 5. Conservative estimates suggest that around 76,000 attendances at ED, which cost around $25m per annum, are amenable to management in primary care. Using an uptake curve of 25% in year one, 50% in year 2 and 70% in year three of these 77,000 potentially primary care managed cases, we estimate that after costs we would produce a net cost saving of around $10m over the first three year period.

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GAIHN Business Case Summary

Implementation of GAIHN business case

The GAIHN business case sets out high level priorities for changes to our health system and also provides some analysis of the size of the opportunities and the broadly anticipated costs. Despite this, there remains a requirement for much more detailed costing analyses as each of the priority areas is worked into implementable projects and programmes. In order for the GAIHN partners to have confidence to progress together, GAIHN has adopted a stage-gate approach through which concepts develop into proposals and projects (discussed under the risk section). As the stages progress so more detailed financial information is required. GAIHN believes the financial components of these projects needs to include: Whole of system perspective, especially looking at the incentives for different stakeholders to take different actions and also looking at the risks of unintended consequences causing cost overruns elsewhere in the system Accurate and detailed costing of the proposed new services, including projections of numbers of patients that could be affected, proposed uptake modelling and transition costs Projections of the future if the status quo was preserved Analysis of the strength of the evidence that supports the size of the projected improvement in health outcomes or cost efficiencies, including analysis of the relevance of the evidence to our specific environment Explicit understanding of the risks associated with changes and exactly who is responsible for managing them and how they plan to undertake that management.

Looking forward whole system financial thinking

In the current resourcing system, funding for community interventions and for hospital services are delinked savings made in hospitals through improved community services are not reinvested in the community. Also, where community services create increased pressure on acute demand they are not held accountable. GAIHN believes that key to a sustainable health system is a much improved whole system resourcing and incentive frameworks.

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GAIHN Business Case Summary

Saving GAIHN defines best investment areas GAIHN makes decision will freed up resource go to efficiency bottom line or for re-investment Communitybased intervention Assess the resultant impact on hospital demand If benefit - define efficiency and extract freed up resource

Improved impact measures

If loss or ineffective modify or stop. Improved linkage of community activity and ED/outpatients trends etc Enable informed decision making about best use of sector resource Develop ability to extract freed up resource

New system and culture requirements

The graphic describes a new type of system in which there is an explicit attempt to understand the impact of community services, extract efficiency gains in real dollars and make a clear prioritisation decision about reinvestment. Achieving this approach will require a new thinking, new financial support systems and a new culture.

13. Remove barriers and build from strengths to implement change fast

Approx 10 - 30% impact

High needs innovations: Begin to grow innovative models e.g.whanau centred models and whare oranga initiatives

Approx 20 70% impact

Evaluate and expand successful models

Focus for service and infrastructure improvements

Resourcing environment: Establish new resourcing and contracting environment pilot alliancing approaches

Evolutionary transition from old to new resourcing environment

Clinical infrastructure: Establish and pilot LHNs, EGP and CHHs

Clinical Enablers: Establish regional enablers to support quality clinical practice access to diagnostics, POAC, HPP, Optimising general practice, telephone triage etc

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Approx 60-90% impact

Expand scope of services and coverage across Greater Auckland

Expand scope of enablers and % of practices

Models of care: Develop consistent regional models of care for LTC, prevention and acute.

Acute /COPD focus in year 1 expand to cover new conditions and greater % of practices

Year 1

Year 2 Phasing of change

Year 3

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GAIHN Business Case Summary

The graphic above identifies the key action domains for GAIHN over the next three years. The aim is that by year three, the cumulative impact across the programmes is such that it achieves the goal of sustainably reducing hospital acute demand to zero. The implementation challenge is substantial in terms of technical, process and relationship complexity. GAIHN sees the key to this is to build from the strengths of existing organisations, encourage entrepreneurial market-led solutions and empower clinical leadership. Through its regional plan, GAIHN will set out high-level outcomes and directions. GAIHN will also identify key indicators and performance measures, including some elements of consistent infrastructure and clinical protocols, but it strongly supports existing organisations to flexibly deliver the changes, and for DHBs to retain the rights of lead planners across their districts. GAIHN expects that partner organisations will take the lead on various projects for the whole network, thus reducing duplication. PHOs/LHNs and DHBs will be encouraged to stagger the implementation of the GAIHN initiatives in a manner that best meets the needs of their localities, for example a focus on children versus a focus on frail elderly.

Im all in favour of new models of care, and of clinical networks, but Id like to know that it was going to work before throwing too many eggs in this basket. Im unconvinced that there is sufficient untapped clinical leadership (with time available) in primary or secondary care, project expertise or the money required, to make the IHCF work in totality, certainly in the next few years happy to be convinced otherwise.

GAIHN believes the new structures will reduce significant bureaucratic logjams and create a point of dialogue around significant issues impacting on implementation. Clinical communications and leadership are at the core of the implementation approach.

14. Build efficient risk management into our implementation process

GAIHN understands the business case involves risks and that many of the initiatives require more work before they can be agreed all partners. However, there is a need to embrace both prudent risk management and change at a faster pace. GAIHN believes the solution is to introduce an explicit stage-gate process for all major projects. The stage-gate approach is used in managing inherently complex and risky projects. The stagegate aims to enable rapid development and implementation of projects, and to do so in an environment where risk is constantly managed. The concept is to clearly identify a pathway for development and critical decision points in advance of a project progressing. The criterion for decision at the stage-gates is clearly defined in advance to meet the project objectives and risk management concerns associated with the project. For GAIHN, it is intended to use the stage-gate approach for the major initiatives. This forces a process whereby the GAIHN partners outline their objectives and risk requirements early in the process and agree to development pathways, timelines and stop/go criteria for projects. If projects do not meet the stop/go criteria they do not proceed, or are reworked until they meet the criteria. GAIHN will be developing stage-gate criteria during the implementation phase.

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15. Next steps to build our business plan

Following submission of this business case, GAIHN will establish its Partner Group and Active Clinical Network and continue to develop the details of the business case, whilst working on the Regional Annual Plan for 2010/11.

Challenge in GAIHN short term work plan

n Pla al on nt gi Re pme IHN evelo GA d e as sC es iled sin a Bu det nt HN oing pme I GA ong velo de

GAIHN workplan and stage of readiness

1 March 2010 Time

As the graphic above shows, the aim is to have more details to support the fundamental business case and a signed off GAIHN regional plan for 2010/11 by 30 June 2010. Key outcomes for 30 June 2010 include: Functional governance structures partners signed up with Charter Further Business Case details agreed and signed off Regional Annual Plan developed and agreed Ownership across stakeholders Accountabilities clear Engaged sector Ministry of Health sign off.

The new GAIHN structures will build from the existing GAIHN organisational and clinical leadership. Workstreams will continue to develop the detailed clinical, organisation and financial requirements for implementation.

Business Case

30 June 2010

Board sign off

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The process outcomes for the implementation stage include: Clinical ownership Informed sector Informed debate around the hard issues Informed decision making Keep partnership together Improved community and consumer input into process Greater understanding across DHB clinical and support workforce Public communications accurate information and expectations.

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16. GAIHN response to MOH criteria

Business case assessment criteria GAIHN response

1 The nature and expected magnitude of benefits that will flow from the proposed service improvement initiatives, including how the proposal expects to:
1.1 Support the delivery of the Governments key health targets; GAIHN is committed to achieving the Governments health targets (see GAIHN outcomes and measurable goals) The primary focus is on acute demand management (sustainable zero absolute acute demand growth), designed in such a manner as to support the Government health targets of: shorter stays in Emergency Departments (and improved access to after hours) shorter waits for cancer treatment reduction in tobacco consumption through more help for smokers to quit integrated multidisciplinary diabetes and cardiovascular services increasing immunisation GAIHN is focusing on acute demand management strategies in 2010/11 and will address elective services from 2012/13. This pathway was chosen to create a more manageable set of initiatives for 2010 and to create relief for hospitals from acute demand pressures. GAIHN is addressing the health targets directly through its models of care, clinical enablers and locality infrastructure initiatives. GAIHN aims to systematically implement the initiatives over three years. GAIHN is aiming for broad influence across all clinicians as well as niched programmes for high needs communities. The magnitude of impact will be across more than 1000 GPs and associated primary health teams. Approximately 300,000 health consumers will be impacted by the establishment of six Local Health Network and three Community Health Hubs from 2010/11. These initiatives, including Enhanced General Practice and Whanau ora centres will continue roll out across the regional over the three years of the business case. The aim is to have coverage of the whole GAIHN catchment by 2013/14

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1.2

Contribute to health sector productivity and quality improvement;

GAIHN will improve productivity and quality:

Regionally consistent best practice models of care and integration pathways Change based on rapid transfer of existing best practice across the network proven quality/low risk Regional clinical leadership through the Active Clinical Network to inform clinical quality, performance indicators and a learning/ quality framework. Improved efficiency through greater clinician direct access to resources to manage patients in the community Improved problem solving and care coordination in localities through LHNs General practice amalgamation and service collocation Changes roles and relationships within multidisciplinary teams (see workforce discussion) to support more cost effective care models Shift of services to lower cost environments Alignment of DHB planning/funding/contracting to become more regionally focused Reduction in duplication and reinvention across planning, clinical programme design and implementation More shared services and pathways towards consolidation of PHOs Alliancing and reduction in cost of contracting overheads Logjams to change are addressed at the GAIHN Partner Group and Active Clinical Network, where key stakeholder have a voice. Create an environment where collaborative action is easier and barriers lower. Development of environment across Greater Auckland to support market-led response to amalgamate general practice and develop collocated services. Seeking market-led response from general practice and A&Ms.

1.3 Lead to the rapid establishment of Integrated Family Health Centres in appropriate locations;

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Three Community Health Hubs developed during 2010/11, to support improved access to services, better capability for general practice to manage patients in the community and shift of hospital services into the community. Further Community Health Hubs will follow. (see scope and magnitude in discussion above)

1.4 Support the shift of services from secondary care to primary care;

Whanau Ora Centres and Networks will be established. Local Health Networks provide a clinical network to support the effective functioning of locality infrastructure. DHBs are still working on appropriate locations for Community Health Hubs. Locations were proposed during business case process but need for engagement response meant further dialogue is required. Community Health Hubs are being explicitly developed to support the shift of services from hospital to community, as many services require scale and cannot be devolved to smaller sites. Three CHHs (one in each DHB) will be established in 2010/11 to pilot shift of services. The three initial CHHs may service up to 300,000 people, depending on final location.

Where hospital services can be devolved to Enhanced General Practice and Whanau Ora Centres, they will be.

Shift of services will be strategically managed to ensure the GAIHN outcomes of Better health outcome, Better patient experience and Better use of money are achieved.

The regional Active Clinical Network and Local Health Networks will have a role in ensuring the shift of services leads to improved team-based healthcare. Note links to workforce development, GAIHN performance indicators and learning environment to support shift of service.

1.5

Reduce acute demand on publicly funded hospital services;

GAIHN key performance target is to sustainably achieve zero acute demand growth.

Acute demand will be reduced through the systematic implementation of strategies across the regional focusing on:

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Model of care long term conditions (and frail elderly), acute (adult/child) prevention (whanau focused)

Clinical enablers improved access to diagnostics and IT

Locality infrastructure Community Health Hubs (x3) initially Enhanced General Practice Whanau ora Centres Local Health Networks (x6) initially Workforce development and the focus on high needs populations

The package creates a new health environment within the community where clinicians have the skills, tools, relationships, teams and resources to prevent and manage disease in a community setting. Initial financial modelling shows significant positive impact from a quite achievable impact on ASH rates and ED admissions (see financial chapter) 1.6 Ensure a wider range of health services are delivered including but not limited to extended hours, walk-in access, telephone and email Walk in access will be provided at Enhanced General Practice and Community health Hubs.

A regional telephone triage system is being rolled out, scaled from existing models.

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consultations, laboratory specimen collection and some on-site processing, day-stay surgical procedures and observation beds

On site laboratory testing is proposed for the Community Health Hubs and will be a component and Enhanced General Practice. The CHHS will delivery a very wide range of services, including integration with existing district nursing. The Optimising General Practice approach is supporting txt reminders and improved use of technology for communication with patients and whanau. The CHHs will support many services such as day stay surgery and observation beds (see details in locality infrastructure and workforce chapters) The new Locality Infrastructure will lead to team based care models and use of technology to support patients out of hospital. Including on-line access to their own records.

1.7

Support better management of patients with chronic conditions to slow disease progression;

GAIHN will implement a comprehensive, planned and proactive approach to long-term conditions management across the Network (1.25 million people). This will include management of the frail elderly and end of life care. In Year 1 GAIHN will: pilot a regionally consistent long-term conditions programme incorporating: self management annual interdisciplinary review standardized and consistent pulmonary and cardiac rehabilitation (services will be accessed according to patient and family/whnau need) establish Patient and Practice Health Navigators expand the CMDHB Chronic Care Management Depression programme, targeting people with long-term physical health conditions.

GAIHN will implement best practice preventive health care that encompasses health promotion and primary prevention. In Year One, GAIHN will: implement the Health Promoting Practices Quality Framework across at least 10% of practices - including CHHs

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optimise General Practice systems for immunisation, screening, counselling and support.

GAIHN believes its focus on Maori, Pacific and high needs families, through improving access to skills, tools and relationships will improve long term conditions management.

In the longer term the locality infrastructure is key to local health services and health teams better meeting the prevention and disease management needs of local communities.

The Whanau Ora Centres and networks will focus on the long term health needs of Maori. 1.8 Increase the use of the wider primary health care workforce and support multidisciplinary teams; The development of new locality infrastructure (Local Health Networks, Enhanced General Practice, Community Health Hubs and Whanau Ora Centres) is designed to bring about a new health environment, which supports multidisciplinary teams within the new centres, and as virtual teams across the local networks.

The GAIHN workforce strategy points to changing roles and relationships across medical, nursing, pharmacy and allied health workforce. Workforce development to support these changes will be integrated with the development of the new infrastructure. Whanau Ora Centres will develop multidisciplinary teams and support new roles, such as health navigators.

IT solutions are being designed to enable multidisciplinary teams, along with new approaches to alliance contracting.

1.9

Provide for workforce development, training and innovation in the primary care setting;

The locality infrastructure supports teams that link into social services. GAIHNs workforce development approach is across four areas (details in workforce chapter): Leveraging the new regional approach to support strategic workforce development at scale to enable new health roles (such as health navigators) and skills to support moves to multidisciplinary teams. Also to support scaling of existing best of class workforce programmes to be implemented across PHOs and DHBs

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GAIHN Business Case Summary

Supporting the LHN establishment especially with the skills required to support improved resourcing and commissioning at a locality level.

Workforce development as a tool to enable multidisciplinary teams this will include training multidisciplinary teams together as new centres are established

Addressing inequalities providing new skills through the Health Promoting Practice programme across multiple practices to improve the clinician patient interaction in terms of the way Maori, Pacific and other high needs people live their lives. The establishment of the regional Active Clinical Network, provides for a new leadership centre for clinical programme design and quality. The ACN will also have responsibility for regional clinical performance measures and all GAIHN partners have committed to new transparency in terms of their performance measures. Local Health Networks reflect these functions at a locality level.

1.10

Achieve the above objectives in a way that is cost effective and assures quality and safety for users of services.

GAIHN is proposing new performance measures that will allow for much improved analysis of business performance and clinical performance.

Alliance contracts aim to lock in performance measures across multiple providers involved in delivering to common outcomes.

The fundamental approach to GAIHN performance improvement is to build from what works well now, make it scalable and roll best practice out across the network servicing 1.25 million people. GAIHN believes this approach is low risk, does not involve reinvention and will deliver proven benefits to a very large number of patients.

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2
2.1

The capability and capacity of the respondent to deliver major service improvement initiatives in support of these benefits, including:
Ownership and governance arrangements; GAIHN is a formal network, in signing this Business Case the partners commit themselves to: participate in a formal network GAIHNs charter and principles (e.g. Information sharing) participate in development of GAIHN Regional Annual Plan (outcomes/measures) commit to implementation of plan which may require resource re-orientation DHBs GAIHN Regional Plan in DAPS PHOs GAIHN Regional Plan in contracts.

GAIHN is not an extra level of bureaucracy, but aligns and integrates existing capabilities.

GAIHNs core structure is the Partner Group and Active Clinical Network, and a small support office. The strength of GAIHN to implement its initiatives is via the strength of the partner organisations e.g. three large DHBs and seven of the 14 largest PHOs in NZ. GAIHNs partner organisations will individually and collectively take responsibility to deliver on the GAIHN goals and expect these actions to be reflected in formal performance accountability documents. GAIHN will be supporting alignment across DHB funding/planning/contracting and across PHO services especially in consortia to support LHN establishment. GAIHN believes consolidation of PHO structures will occur in an evolutionary manner as a progression of formfollows-function as the GAIHN agenda unfolds. GAIHN draws on some of New Zealands most experienced clinical leaders from both a clinical and clinical/managerial perspective. Clinicians have guided many of the aspects of this business case.

2.2

Strength and experience of the clinical leadership;

The ACN and the locality networks will create new structures in which clinical leadership is more explicit, embedded in key sector decisions and accountable.

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GAIHN also points to the depth of clinical leadership within the PHO structures, in terms of experience with designing and implementing clinical change programmes at the workforce. Two Maori-led PHOs within GAIHN provide strengths in addressing the clinical needs of Maori and high needs communities. 2.3 Financial strength and viability; The Network includes a number of large and sustainable health management service organisations and PHOs with considerable resources. The Network also includes three large DHBs

The approach of the GAIHN is to make existing structures work better, not develop new structures

The clinical and business improvement models proposed by GAIHN are mostly focused around reorientation of existing resources. GAIHN has undertaken initial modelling to show that it can achieve considerable savings in the hospital environment. GAIHN acknowledges that it will need to undertake more detailed financial analysis for each of its key initiatives this has been flagged as a priority action between 1 March and 30 June, 2010.

GAIHN is proposing a new approach to whole system financing that improves the linkage between community activity and hospital outcomes to better manage downside risk and upside savings and reinvestment potential. GAIHN believes that this whole system financing approach is the key to a long term sustainable system.

The one GAIHN regional plan and approach to alliancing will improve alignment of resources and financial transparency and meaning performance reporting. The Network includes some of New Zealands largest and most experienced organisations with regard to change management within primary care, including change across models of care, quality accreditation, budget holding, IM design and implementation, clinical governance, learning systems, integration pathways, practice capability development, ancillary and allied services and clinical guideline implementation

2.4

Change management ability and experience in the health sector across the primary and secondary sector;

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There is significant PHO experience with population specific services such as those for Mori and Pacific peoples

GAIHN brings together DHBs and PHOs into the same consortium, leading to new opportunities for integrated change management that is not bound by cumbersome single-focus contracts and divergent strategies.

GAIHN will implement change through a Tight-Loose-Tight approach with key directions and performance measures in the GAIHN Regional Plan, with implementation being undertaken by existing capable and experienced organisations.

GAIHN has explicitly proposed a stage-gate process to change management to embrace the need to simultaneously manage risk and the need for rapid change. The proposal describes the stage gate process sin detail. The GAIHN organisations include some of New Zealands largest and most experienced primary health organisations with regard to information management design and deployment in the primary care environment

2.5

Information management that enables new models of care, and improves quality and efficiently deliver services.

GAIHN is working from existing platform for the Auckland regional IS strategic plan, that is driving the long term IT infrastructure investment.

GAIHN is seeking to modify RIS10-20 to focus on key infrastructure for the proposed models of care and locality infrastructure and clinician-based commissioning, including: Population health tools in general practice Electronic shared care plans Online resource management tools By working within the framework of the RIS10-20 GAIHN is minimising risk and tapping into existing funding streams to support IT development.

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3
3.1

The strength of relationships between the various parties, and partnership arrangements with key stakeholders, including;
The degree of engagement and/or support from DHBs, specialist clinicians, practitioners from a range of disciplines; The Business Plan outlines the significant effort GAIHN has put into engaging with the health workforce and health leaders (including on-line surveys, summits, well attended clinical workstreams, NGO forums, minisummits at hospitals and normal PHO and DHB communication channels).

There has been robust clinical dialogue around many of the GAIHN initiatives. For example the detailed discussion around IHFCs led to a change from the approach proposed in the original EOI. Clinicians have designed the details of the clinical initiatives in GAIHN. GAIHN is very aware of the very large number of clinical stakeholders and that as the initiatives develop, ongoing clinical communication, leadership and ownership are critical. The three Auckland DHBs are GAIHN partners. They have been involved in all aspects of the Business Case development and DHB senior staff have led several of the workstreams that have informed this business case. DHBs are providing support with qualifications around the need to undertake further detailed work across many of the initiatives which is a qualification all partners share.

3.2

Experience in meaningful engagement with consumers and the community.

PHOs participating in the Network are committed to consumer engagement and many include consumer representation within their governance structures.

Network members have dedicated community services which link with local communities, iwi, and community organisations. These relationships will be supported and strengthened through GAIHN.

Consumer representatives have attended the GAIHN summits and direct consumer involvement will increase as the more detailed planning of GAIHN initiatives proceeds. GAIHN believes that developing Local Health Networks and the reorientation of PHOs to support LHNs will lead a far greater linkage between health services and local communities. Establishing LHNs will involve creating clinical and community networks. The evolving role of LHNs to potentially take on a locality resourcing/commissioning role will empower the relationship with local communities.

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Whanau Ora Centres and networks will create a new infrastructure in which to engage Maori communities and health consumers.

Iwi have been invited to join the GAIHN partner group. There are opportunities for manawhenua involvement in local health networks.

Community Health Hubs will provide the infrastructure for more meaningful engagement around health services and local social and regional determinants of health, including the integration of social agencies such as MSD, Housing New Zealand, Justice, ACC and others

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