Mah

itahi

Hau

ora

Feed

back

on

Plan

Con

sult

atio

n an

d ne

w G

P St

ruct

ure

May

201

9

1

1

Acknowledgement I would like to take the opportunity to thank the PHO teams, primary care providers, including Māori providers who have supported, challenged and advised me over the last three months. I was greatly encouraged that there was overwhelming support and widespread recognition that there is a need for a new organisation, and a way of working to deliver on commitments made in the Tiriti o Waitangi to improve health outcomes for Māori. There was also acknowledgment that if we are to close the Māori health equity gap, and improve the overall health and wellbeing for those living in Northland, we need to work more effectively with a broader agenda and stronger more effective partnerships. I would also like to acknowledge the detailed consideration given to the planning documents provided and the high calibre feedback provided which was very helpful in shaping future direction and in deciding on the optimal organisational structure to deliver this strategy. I would also like to acknowledge the ambition of the existing PHO Boards, Manaia Health and Te Tai Tokerau PHOs, Northland DHB, Māori Health providers, general practice teams, and Northland Iwi leaders in determining that the current status quo is not acceptable and a transformation agenda is required. There has been openness to taking bold steps to address many of the challenges we face in improving primary care services, and to strengthen the valuable partnerships that exist between the wider health and social care team. There has also been support to develop a new model of care based on what matters to whānau, hapu and Iwi in which the community has a stronger role in setting and achieving priorities. I would also like to thank the Mahitahi Hauora Board who have been constantly available for advice, guidance and direction. This support extends to defining clearly the approach to be taken to develop a new model of care and a new way of planning and funding health services. This focus will be to ensure Mahitahi Hauora provides an equitable health spend driven through localities based on priorities determined by whānau need and aspiration. The goal is to also develop healthier communities across Northland, with improved long term outcomes. To deliver this change the Board have supported the new structure within Mahitahi Hauora to lead the transformation agenda. It is anticipated that this change, will close the equity gap for Māori, make Northland a great place to work for Primary care Providers, and make the health system more sustainable and more effective in the future. The input from primary care providers and wise counsel has been invaluable throughout the planning process. I would like to meet with practice teams to outline the direction for 2019/20, the locality planning and associated priorities for growing the network of care providers around primary and community care. Without this clarity of thinking the planning process would have been much more difficult.

2

2

Introduction The question for Mahitahi Hauora and for Northland DHB to grapple with is whether we have achieved the goals of the 1938 social securities act entitling “All New Zealanders to have equal access to the same standard of treatment.” and whether this in itself would be doing enough. One of the ways we can assess the effectiveness of the current model is to compare the impact on the wider population. What is clear is that there are significant differences in outcomes for Māori, for those living in more rural communities and/or those from lower socioeconomic groups. This gap is described in the first document developed called Te Whakaritenga, https://community.northlanddhb.org.nz/mahitahi-hauora/ Part of the reason for a difference in outcomes as outlined in Te Whakaritenga is attributable to barriers to access such as cost, time and distance. However, it is very clear from this report that if only 20% of the health outcomes are determined by the health system itself and the remainder come from a broader range of health and social determinants, a wider focus is required. To achieve a broader population health strategy for all in Northland, and to close the equity for Māori it is important to recognise that change is required on not just one but multiple levels within the health and social system if we are to impact social determinants of health. Only by working with partners in other sectors and communities themselves will progress be made. How all this is reflected in measuring progress in the delivery of the Mahitahi Hauora strategy will be important in respecting and strengthening those partnerships. Attribution at health outcome level will always be challenging but a shared outcomes framework where all are working in an aligned way is critical to our success. One of the barriers as identified by the HQSC national patient experience survey shows cost barriers disproportionately stop Māori people from seeing GPs and getting medications. Approximately a third of Māori (28.7%) patients responded that cost stopped them visiting primary care, compared with 18.5% of European patients, and almost a quarter of Māori said cost prevented them picking up a prescription, compared with only 7% of Europeans. Māori adults were also less likely to answer yes to the question “Was the purpose of the medication properly explained to you?” The result is less people attend a GP, pick up their prescription, or understand what their medication is for if they pick it up. The historical barriers to healthcare due to these financial barriers within the Northland community means that many whānau simply have no tradition of attending a family doctor but rather putting up with their condition as long as possible until they arrive in the emergency department often in a dire condition. The current reality with public hospitals and primary care providers funded quite differently it has made it more difficult to strengthen integration between primary and secondary providers within the health system. DHBs and their hospitals largely receive a fixed income based on population out of which they pay staff salaries. Primary care and general practice are privately provided, with around half of their income from a mix of government sources, and patient co-payments though this can vary. This complexity means patients and providers are often involved in complex series of transactions and gate keeping with variations in access also impacted. The Waitangi Tribunal WAI 2575 Health Services and Outcomes Kaupapa Inquiry indicated that the current situation does not meet the commitments made under the Tiriti o Waitangi to improve Māori health outcomes. The health minister’s health system review, led by chair Heather Simpson, is working to identify ways the system can be improved. To reduce some of the anomalies and inequities in our system should the funding in primary care be increased to remove financial barriers to access. Northland DHB and the Northern region recognise that we need to proactively develop a new model of care which is delivered through a collaborative, patient-centred web of primary, community, Iwi and hospital-based healthcare settings. It also recognises the importance of investment to realise Māori health equity.

3

3

Manaia Health and Te Tai Tokerau PHOs, Northland DHB, Māori Health providers, general practice teams, and Northland iwi leaders recognised that there needed to be a transformation in the way primary care services including Māori Providers were structured and funded in Northland. They agreed to the establishment of Mahitahi Hauora, a new primary health entity (PHE) to take over the work of the existing primary health organisations from July 1 2019. Mahitahi Hauora Is not a merger of two PHOs but rather an entirely new organisation with a new strategy and plan to deliver on the aspirations of the Board called Te Rautaki, Te Whakamahere (The strategy and the plan) https://community.northlanddhb.org.nz/wp-content/uploads/Mahitahi-Hauora-The-Planv12.pdf . The establishment of Mahitahi Hauora marks a big mind-set change, to deliver on commitments made in the Tiriti o Waitangi including improving Māori health outcomes. The significant change also includes a broader focus on addressing the wider determinants of wellbeing including social, economic, and environmental factors. Mahitahi Hauora cannot do this by itself, but instead needs to work with other partners to deliver what is needed including communities, primary and secondary care, and other social service providers. This will require a more collaborative approach in planning and tailoring services to what matters to individuals, whānau, hāpu, iwi, and the general population. The best way to link to “what matters to whānau’ is to work more at a local level. The Mahitahi Hauora ‘locality’ focus will include five to six localities, or areas, defined around the region. Mahitahi Hauora teams will work with the communities within the localities and with other services located within them. This allows for services to be more easily planned for the needs of each community, and for a more integrated approach to improving the health of Northlanders. Mahitahi Hauora’s plan and approach is summarised in the conceptual diagram on page 5, with the goal to achieve equitable self-determined wellbeing through making health equity a priority for all, fostering multi-sectoral collaboration, and growing community’s capacity to achieve outcomes that matter to them. The outcomes or community driven solution are aligned with the whānau ora framework and include the broader social determinants of wellbeing. To achieve this, plan we need to develop a new model of care: 1. that designs services around the requirements of our populations and their expressed local

needs. 2. where all service providers, DHB owned or otherwise, are working as a more integrated

regional health system irrespective of who the employer is; 3. that increases collaboration and coordination between all nodes of the health and social

care delivery system such as patient self-care, primary, community and Iwi care, private and NGO services and DHB hospital, public health and community services and other intersectoral agencies;

4. that reduces the boundaries between care settings, with the focus on providing care in the most appropriate setting and wherever possible closer to home;

5. that improves coordination of services, centralising where required and where not strengthening coordination at a local level to improve quality, safety and outcomes of care.

4

4

Te Whakamahere/ The plan of Mahitahi Hauora is summarised in a conceptual model shown below This approach is depicted in our locality planning model shown below. Unlike a logic model, which is linear and progresses neatly from inputs to outputs and outcomes, the model is circular to reflect the complexity of achieving equitable self-determined well-being for the Northland community. The model is best read starting from the outside in and includes the following focus areas: • inputs shown in the outer circle depicting the context of structural inequities, socioeconomic

and political drivers that still need to be addressed, • community-driven solutions that will be supported in order to address the broader

determinants of health and the causes of inequity for Māori, aligned to the whānau ora framework (e.g. employment, education, housing, education).

• an emphasis on prioritising community driven solutions demonstrates a commitment to focus on what matters to whānau , hapu and Iwi as well as the wider population.

• The model describes three key roles for Mahitahi Hauora: i. Making health equity a shared vision and value for everyone; ii. Fostering multi-sector collaboration; iii. Developing the community’s capacity to shape health outcomes. This focus includes a

goal to empower the community to prioritise and realise their own solutions to achieve health equity.

• By doing this we will be able to achieve the Mahitahi Hauora vision achieving healthier, more equitable communities in which the wider definition of wellbeing is realised.

The diagram seeks to describe the broader lens that Mahitahi Hauora will need to have if we are to be effective in achieving our aspiration as outlined in Te Whakaritenga document. Core to this argument is recognition that if we are to be effective in improving the health status and addressing health inequities a multifaceted approach will be required which includes steps to not only influence individual behaviours and healthy lifestyle choices but also address community-wide problems such as poverty, unemployment, low educational attainment, inadequate housing, lack of public transportation, exposure to violence, and neighbourhood deterioration (social or physical). It also recognises the importance of a place based approach in that the norms, and demographic and geographic patterns within each community will shape the lives of every individual living in that community and that this community based effect can persist over multiple generations. Mahitahi Hauora in its ambitious agenda believes that many of these factors are not intractable, and such inequities can be mitigated by community action, supported by multi-sectoral efforts. There is also the need for the right political context that prioritises making health equity a priority for everyone and puts in place policy enablers to make such services accountable for improving service access and utilization among Māori in the population.

5

Stru

ctura

l Inequitie

s, Biases, Socioeconomic and Political DriversWhānau Living

Standards

Whānau Participation in Community

Whānau Engagement with Te Ao Māori

• Employment• Transport• Housing

• Income and wealth

Access to social & support networks in own community

Increased community

capacity to achieve outcomes that matter to them

Making health equity a shared vision and value

for everyone

Healthier more equitable wellbeing

within our communities in which all individuals, whānau, can be born, play, grow, work, live,

age and die

Whānau Knowledge

Whānau Built Natural Environment

Whānau Health Fostering multi sector

collaboration

Education Technology Literate

Strong social ConnectionsSafety

Healthy Lifestyles

Mana Whenua respectedHealthy physical environment

Whānau Relationships

Community Driven Solutions

Com

mun

ity

Driv

en So

lutio

ns Community Driven Solutions

5

NOTES: Multi-sector collaboration can include partners from Hapu and Iwi, local and regional councils, fisheries, agriculture, banking finance, business/industry, economic development, education, health care, housing, MSD (human/social services), justice, land use and management, media, public health, transportation, and workforce development, among other sectors.

6

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TO DELIVER THIS PLAN WE WILL NEED TO ENSURE WE HAVE THE KEY INGREDIENTS OF PRINCIPLES, PRIORITIES, PROCESSES, PLACE AND PEOPLE. These have already been covered in greater detail in Te Rautaki/ Te Whakamahere which are summarised below. We also provide a much more detailed overview of the roles and responsibilities of the organisational structure in the attached document. A. PRINCIPLES: 1. People living in Te Tai Tokerau using health and social services will experience

outcomes that are positive including right place, right time, and right way by engaging them in their care and growing their respect and dignity. We will do this by providing an outcome focused, person and whānau centred care delivery system in or close to where people live. Our focus is on growing individual, whānau, community, hapu and Iwi engagement in the design and delivery of services so that we can develop systems of care to achieve the best outcomes for them rather than designing systems and processes around organisational silos.

2. Individuals, whānau, communities, hapu and Iwi and populations will achieve equitable self-determined wellbeing. We will do this by combining the collective efforts of all partners within the community, region and nation to work collectively to address the determinants of health and wellbeing and associated inequalities. We will bring a wider population health lens, that focuses on preventing poor health, reducing inequalities, and mobilising the capabilities of every individual to maximise their own ability to live well, get well, stay well and die well. This focus will help reduce the overall need for care and support, from existing services and make the health system more sustainable.

3. We will provide a place based focus to address the determinants of health and wellbeing. Given the challenges of rurality, geography, and population differences place or locality based solutions will need to be tailored to the local context with the relevant partners at the table such as employment, education, housing, health and social services.

4. We will grow a shared agenda and focus from relevant leaders from separate organisations and structures to make it their number one priority to work together to drive a transformation agenda that will improve health and wellbeing of the population served. To achieve this transformation agenda, we will need to grow a collaborative culture with a shared commitment to combining the resources of people’s time, energy, expertise and focus to achieve transformation at scale and pace. We will also need strong support from leaders across the sector to agree and work towards a shared outcome framework as part of a guiding coalition. We need to grow a focus on placing the whole team before the home team which makes system wide priorities the predominant shared focus of their organisation. The shared premise is that if we work together we can achieve better outcomes and a more effective use of resources.

5. Our frontline care providers will be empowered to use their knowledge, experience and expertise to develop a seamless care delivery system that makes it easy for care providers to do the right thing and to address the broader determinants of health and wellbeing. Care teams in localities will work together in collaboration and partnership to address what matters to individuals and whānau and to achieve healthier communities and improved long term outcomes. They will be encouraged to see the problem, own the problem and solve the problem and share the learning with support from an experienced transformation team.

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B. PRIORITIES 1. Supporting primary care and Māori Health providers to deliver more effective

services A key responsibility of Mahitahi Hauora is to fund and ensure the effectiveness and sustainability of the primary care system. This responsibility includes supporting and developing locally generated ideas and priorities from the middle of the healthcare system, the providers themselves, to improve the health of the population and the quality and effectiveness of healthcare delivered and to close the equity gap for Māori. A priority of Mahitahi Hauora will be to develop and spread innovations that support a change to the model of care to ensure primary care is more sustainable and able to meet the demands associated with the increase in older populations with multiple chronic conditions. Mahitahi Hauora’s role will be to support a shift from a practice model in which patient co-payments incentivise face-to-face patient visits to one in which a primary care team delivers planned proactive care for its enrolled patients. A second priority will be to grow collaboration with other partners in the health and social care system including DHBs, Māori Health Providers, Local Government and inter-sectoral Governmental and nongovernmental agencies to address the wider determinants of health and to improve service effectiveness. This collaboration will grow innovation in how the primary care sector including Māori Health providers work to address the broader determinants of health and wellbeing to provide whānau centered care as outlined in the whānau ora framework. The key priority will be to also take action to improve and sustain the wellbeing of our workforce. Without this none of the goals described will be achieved. Mahitahi Hauora will have a key role in ensuring the primary care workforce is sustainable into the future. Half of GP respondents in the latest RNZCGP survey were over the age of 52 and just over half were female. Twenty-seven percent intended to retire within the next five years. Almost a quarter reported feeling burnt out. 2. Grow the capability of Mahitahi Hauora to facilitate change. A key role of the new structure will be to act as facilitators of innovation, ensuring new primary care services are developed in ways that align financial and professional incentives for general practices. We are doing this in partnership with Northland DHB, and other intersectoral agencies. This will include primary care innovation partnership through seed funding to those practices willing to step up and trial new ways of working, and to develop the change management capability within practices to implement new models of care. Examples include healthcare homes, localities and new service innovations (such as telephone triage or on-line consultations). 3. Growing the collaborative network between Mahitahi Hauora and Northland DHB to grow a whole of system’ design innovation including setting standards of care growing accountability and sharing learnings around new innovations and models of care that are effective. The role of the Mahitahi will be to enable the acceleration and spread of change and to ensure standards are maintained so that patients across Northland are more likely to receive a consistent experience and quality of care. This includes accountability through a national performance management framework known as the System Level Measures (SLM). This framework developed in 2016, aims to stimulate a ‘whole-of-system’ approach and requires collaboration between health sector partners across a local area (responsibility for implementation with the alliances). Associated service improvement funding is provided to build quality improvement and analytic capacity and capability in primary care. Mahitahi Hauora will support the shift in the way primary care performance is monitored and incentivised, moving away from a pay-for-performance approach based around process and output targets to a set of outcome measures spanning a range of services, and aimed at encouraging integration and continuous quality improvement. This will also include through

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networks to increase the strength and function of collaborative relationships between organisations within a common locality or geographical area. 4. Develop an evidence base within primary care to help other potential adopters assess the benefits of particular innovations through quality improvement processes and research. To be effective in addressing the Māori health equity gap we need to do more to intervene early through screening, monitoring and follow-up in primary care. To achieve this will include actions to target and address the health of Māori, and to grow and support the Māori workforce. We need to understand and support more specifically innovations that will improve care for Māori, and conduct a more rigorous assessment across a wider breadth of Māori primary care providers as well as within primary care itself. 5. Work to support the plurality of general practices types and structures and to address associated barriers that will hinder improvements to the health of the population and the quality of healthcare provided. New Zealand general practices have traditionally taken on a gatekeeping role whereby patients first consult their GP before being referred to specialist services. Primary care practices play a key role in co-ordinating care for both individuals and populations. We are exploring support for the development of different types of primary care professionals to enhance the coordination of primary care and to integrate primary care services with hospital and social services 6. To grow the consumer focus in health care delivery using evidence-based care Most fundamentally this means always putting the interests of the tangata or person whānau or hapori community at the forefront of decision making and ahead of personal interest or gain. This includes understanding Māori inequities and taking steps to improve Māori outcomes. Over the next six months we will engage individuals, whānau and hapori or communities in each locality in a process to determine the priorities for that community called what matters to whānau. Our goal as Mahitahi Hauora will be to make care more accessible to our patients by supporting the development of new ways of working such as GP telephone triage, proactive care planning, online patient portals, new professional roles, new team-based ways of working. Results from the patient experience survey highlight both positive experiences of care and some issues in terms of continuity and coordination, and communication around medications, with some groups routinely reporting less positive experiences (for example, those with a mental health diagnosis). 7. Influence at a policy level At the macro level, the New Zealand Health System, is overseen by the Ministry of Health, which has emphasised the importance of quality primary care. The MoH has requested that DHBs work with primary care through an alliance framework to develop plans to achieve system-level outcomes. We aspire to be an exemplar of how this can be done at a meso and micro level. At the meso level, Mahitahi Hauora in alliance with the DHB will take responsibility for addressing what matters to primary care as well as supporting service innovations, through running programmes to incentivise their practices to change the way they operate. There is a paucity of research on exemplars of best practice and innovation. Mahitahi Hauora will take responsibility for adding to the research pool to ensure a more active backing to scale up innovations that offer value. The advantage of locally generated ideas and solutions are that they are likely to be more sustainable in times of government change. At the micro level, the plurality of general practice arrangements includes a hybrid spanning salaried staff working in centres of high socio-economic need including Māori Health providers, to smaller owner-operated practices, and to larger corporate models. The challenge therefore is for Mahitahi Hauora to incentivise change so that general practices are prepared to introduce new models of care such as localities.

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C: PROCESSES: STRENGTHENING LOCALITY CAPABILITIES ACROSS A RANGE OF PROCESSES Across the locality networks we will need to grow a system that supports effective leadership, knowledge and learning, and a broader commitment to achieve equity through improved quality and integration of health and social services to address the wider determinants of wellbeing. To achieve this, as stated we will need to shift mind-sets to deliver services based on what matters to whānau, and we will need to improve processes. These processes include clinical (access and quality of care) irrespective of employer; organisational; informational (shared record and improved analytics), financial (incentives and accountability), and potentially administrative.

Local Clinical Networks

Mahitahi Hauora Normative Integrative ProcessesIdentifying, communicating and operationalising the shared vision, goals and values across

individuals and organisations

Administrative Integrative ProcessesAdministrative support e.g. shared Human Resource Financial management to support small practices and

build links with the learning & improvement systems

• Eff ectiv

e Leadership

• Collaborative Cultu

re

• Mutual Trust

• Consis

tent

Communicatio

n

• Shared commitm

ent to

achieving equity

Financial Incentives aligned with whānau priorities,

Māori equity, & outcom

es

• Shared Accountability

• Quality M

easures

• Shared Guidelines

• Clinical Partn

ership

Information, com

munication,

technology & analytics

Organisatio

nal

Integrative

Process Financial

Integrative

Processes

ICT Integrative

Processes

Clinical

Integrative

Processes

Clinical Integrative Processes

• Income• Access to Services • Health Literacy• Housing

• Capturing Patient Experience

• Cultural Values and Beliefs

• Food Security

“What matters to Whānau” - Whānau &

community engagement

• SMO

• Care

• Care Coordinator

• Homehealth

• Dietician

• District Nurse

• Community Pharmacy

• Whānau Ora

• Clinical Nurse

• Specialist Nurse Practitioner

• SLT

• Mental health

• OT/Physio

• GP

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D. PLACE For a more detailed over view of the locality plan see attached locality planning document. Our localities strategy: We will develop three localities in the first twelve months Our locality transformation agenda has identified a number of shifts that will need to be made to deliver effective health, care and wellbeing into the future as follows: 1. A person-centred approach that delivers care and support in partnership with individuals

and, where they wish, their whānau and communities, to achieve the best outcomes for them, rather than designing systems and processes around organisational silos. This approach will be called addressing what matters to whānau based on their need and aspiration.

2. A place-based approach that involves all partners within a geographical area collaborating together to improve the health and wellbeing, rather than a focus on separate organisations and structures.

3. A model of care and support that promotes health and wellbeing, independence, community support and coordination to support self and whānau care in or close to people’s homes, to reduce the need for unplanned hospital admissions and long-term residential care.

4. A shift to prevention to improve population health and wellbeing, to reduce the overall need for care and support, rather than a reliance on providing services to meet health and care needs.

5. Better alignment between nationally and regionally set targets and the priorities identified by local partners.

6. Equality between primary care, Māori Providers and the DHB in planning the future of health, care and wellbeing, with decisions taken collaboratively from the earliest stage.

7. A better balance between responding to short-term pressures while still maintaining the focus on longer-term transformation.

What is a locality clinical network? We will work with our key stakeholders through a competitive process to identify primary care practices, Māori Providers and other agencies e.g. MSD to identify services that are committed to align their services and work more closely as part of a locality network. The selection criteria will include a commitment to a compact or set of principles that will define the key ingredients of their commitment to work together. The locality must be of sufficient size and geographical area to justify the additional resourcing and work that will be involved in establishing the area as a locality network. There must also be committed leadership on the ground so that the ongoing momentum of change can be realised into the future. There will be an investment of additional services beyond what the practices and communities already have in place. There will also a progression of funding changes to move to a more flexible reimbursement approach from year two as and when conditions of locality performance have been met. A Locality Clinical Network will be defined by a collective commitment of GP practice(s) including Māori healthcare providers, non-GP providers (including community pharmacy, dentistry, optometry), voluntary, secondary care providers and social care providers such as MSD) serving an identified ‘Locality Network Area’ with a minimum population of 30,000 people. In exceptional circumstances, Mahitahi Hauora may consider applications from other areas with a population below the 30,000-minimum population requirement where the locality clinical network is serving a community which has a low population density spread across a large rural and remote area. Locality clinical networks cannot exceed 60,000. When defining the Locality Clinical Network Area, consideration must be given to the future integrated service offering to support delivery of services to their patients and their whānau to

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deliver services closer to home. For example, this may include the requirement for provision of acute and semi-urgent care and inpatient care. In circumstances where LCNs exceed 60,000 people, the network will be required to organise itself operationally into smaller neighbourhood teams or GP clusters that cover population sizes between 30,000 to 50,000. What will be the selection criteria for a locality clinical network? The goal would be for any clinical networks that wish to apply to become a locality network to be selected prior to 30 June 2019 with locality planning commencing from 1 July 2019 based on whether they would collectively commit to meeting the draft principles described below. The plan would be for the locality agreement to be drafted including selection based on key principles described below to ensure there is a commitment to stronger collaboration within an area including GP practices, Māori Health and other providers. While collaboration may not be present at the time of signing through the first three months of 2019/20 an integrated way of working will need to be defined and established including regular MDTs between care providers, complex case management, co-design work with those in the community to define and address what matters to individuals and whānau. By 2020/21 when the LCN agreement is renewed the Network will be expected to have defined a plan to improve the wellbeing of the community including the strengthening of the network of care between social and health providers in that area. Draft principles associated with the “what matters to whānau” co-creation and “locality selection process” are as follows: 1. Putting Patient and whānau ’ First

Most fundamentally this means always putting the interests of the tangata or person whānau or hapori community at the forefront of decision making and ahead of personal interest or gain. This includes understanding Māori inequities and taking steps to improve Māori outcomes.

2. Patients as Partners The predominant force that drives the performance of our health system is the decisions patients make in their normal daily lives. To be effective at improving health care the single biggest goal is to alter patient decision making such that their decisions are more likely to maintain or improve their health. This is a key objective of all interactions we have with our patients.

3. Evidence Based Care Where evidence exists for superior approaches to treatments or practices we will seek it out and use it. Where evidence does not exist, we will commit to evaluating and learning from our experiences and sharing those experiences and learnings.

4. Resource Stewardship We understand that virtually all health resources are constrained and we will consciously work to ensure resources are used in the best interests of each person, whānau or community in the context of the impact these decisions have on our ability to care for the other people and other communities.

5. Whole Team before the Home team We aspire to a truly patient and whānau centred care delivery system in which all health and social care professionals work with patients to do all that they can to act in the best interests of that patient. We believe this concept must explicitly extend to an expectation that all health professionals caring for the same patient or population will work collaboratively together in the best interests of that patient or population.

Key building blocks for locality development to be successful include programme governance, programme management and secretariat support for the governance, access to population and outcomes data, access to user experience, capability development, access to

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a transformation team, and funding incentives through effective financial/contractual instruments that risk and reward share. The LCN will establish programme governance with membership a combination of care providers within the geographical boundary as defined in the agreement including primary care practices, other community-based providers such as Māori providers, members of the local community, and would normally cover a geographically contiguous area. In addition, Mahitahi Hauora will provide clinical and managerial leaders as well as transformation team members to be part of the Governance Group. The addition of supplementary Locality Network Support would include access to the analytics and population health team, and funding and contractual expertise. Each locality will also be supported to have access to additional services identified as required locally such as health coaches or a community pharmacist, with additional resources funded by Mahitahi Hauora or provided by the DHB. The LCN Contract will be updated annually. Flexibility will be provided in the contract for the area to develop and commission local additional services that have been identified through the community co-design process, supported by additional local resources. From 1 July 2019 the LCN will be expected to have in place the following: a. Have an agreed group of General practices and/or Māori providers (who must hold a primary medical care or other contract) to receive payments on behalf of Mahitahi Hauora. b. Have an agreed group of other Government and non-Government agencies committed to working together within the locality. c. Have in place an underlying Locality Clinical Network Agreement signed by all members, including community members. d. Have in place an accountable Network Leader, Clinical Director both Medical and Nursing, who will work across the LCN, to support and progress the integration of services and develop an improvement methodology around the strategic priority action areas. e. Have in place appropriate arrangements for patient record sharing in line with data protection legislation honouring patient opt-out preferences. E: PEOPLE To achieve the broader goals will require the collaboration of all within the health and social care system including the DHB, PHO, Primary Care, Māori Health providers other intersectoral partners and the community itself. For a more detailed overview of the DHB team see attached draft DHB locality staffing plan. The functions of the locality leaders Network Leader There is a need for new leadership roles to support the locality transformation strategy. To be effective network leaders will bring a different kind of collaborative leadership style focused on place and people, not organisations. In order to make locality based, person and whānau centred health and social care a reality we will need leaders who are fully committed to working together to transform health, care and wellbeing services to improve people’s health and care outcomes. We will also need to progress a broader strategy within each locality that includes measures to prevent poor health and address the social determinants. The leader’s role will be to support the integration of health and social services to ensure the best use of resources to improve outcomes that matter for individuals, whānau, community and populations. The leader’s role will be to overcome cultural barriers that exist within organisations and to grow an intersectoral team based culture. Successful integration requires leaders who are equipped to work collaboratively, with the right attitude and behaviours, to identify where working together will improve health and care outcomes, and to make this happen through positive partnerships.

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This means that while our plan is aspirational, it is also pragmatically focusing on a small part of the population in one locality i.e. those with complex needs and therefore we believe we are being realistic about what can be achieved in the existing environment. As partners in care from different organisations addressing the complex needs of a person or whānau will mean the partners will need to learn how to collaborate to find shared solutions to the challenges faced within the resources available. Through the shared focus round people and whānau we will identify and develop the essential components which underpin effective integration including shared commitments, shared leadership and accountability and shared systems. An additional goal of this process is to highlight the action required at a local and DHB wide level to remove and address barriers encountered so that integration can happen. This role will also need to work with the change team and data and analytics team to ensure the transformation program can be measured as to its effectiveness and to identify opportunities for innovation, proof of concept and more widespread adoption. This role will collaborate with other localities in Northland and more widely across NZ so that we good practices, can be shared including methodology for more wider spread use such as information, case studies, tools, guidance and support programmes. Locality Clinical Network Clinical Directors Each Locality Clinical Network will be required to appoint a named accountable Clinical Director for Medicine, Nursing and Allied Health who will be accountable to the members of the LCN and will provide leadership to develop and progress the strategic plans, and priorities identified through community engagement. They will also lead the Mahitahi Hauora change team who will work alongside the Network Leader and CDs and LCN members to improve the quality and effectiveness of the locality services. Once established it would be expected that the Clinical Directors will be selected from within the LCN member practices as a practicing clinician able to undertake the responsibilities of the role and meet the LCN Agreement requirements. The CDs must represent the interests of the consumer, the community foremost as well as the collective interests of the LCN. It is most likely this role will be fulfilled by a GP and Nursing Leader but this is not an absolute requirement. The Clinical Director will work collaboratively with Clinical Directors from other LCNs within Northland, playing a critical role in shaping and supporting the broader transformation agenda. They will also have a role to grow and strengthen the support network for practices and providers in the area by identifying ways to ensure full engagement of primary care in developing and implementing locality plans. The following sets out the key responsibilities for the Clinical Director: They will provide strategic and clinical leadership to the LCN, developing and implementing strategic plans, leading and supporting quality improvement and performance across member practices, and other health and social care providers (including professional leadership of the improvement activity across the network). The Clinical Director will not be solely responsible for the operational delivery and integration of locality services; however, in conjunction with the Network Leader will be collectively responsible for the performance and development of the LCN. They will develop local initiatives that enable delivery of the LCN’s agenda, working with the community to identify what matters to them, and to integrate learnings and improvements identified in other LCNs to address local needs and to ensure the expansion of initiatives are well coordinated and scalable. They will support LCN implementation of plans to improve service delivery in key strategic action priority areas which in 19/20 will be mama pepe, tamariki ora, adolescent wellbeing, and care for frail older people, Kaumātua with a specific focus on long term conditions including COPD and diabetes as described below.

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Strategic Action Priorities (SAP) In 19/20 key focus areas aligned to the redesign of the model of care for primary care and community services are depicted below and include the following: 1. Equity by 2040 by ensuring all children start well and realise the same wellbeing gains

as other children of their age (0-12); 2. Strengthening the mental health and wellbeing of youth and adolescents (13-24 years); 3. Better management of CVD and diabetes risk factors. Improved management of chronic

conditions focusing on Diabetes, and COPD; 4. Wellbeing of older people (kaumātua) is supported so that they can age in place. Better

management of older people with complex needs including frailty and end of life care.

The reason for focusing on only one Strategic Action Priorities (SAPs) per locality initially is to demonstrate how outcomes can be significantly improved through a coordinated effort between health and social care services and the value transferred (see diagram below).

LIFE COURSE

Mama Kōhungahunga Tamariki OraEquity by 2040: Children 0-12 yrs

First 2000 Days Build physical and emotional resilience in youth and adolescence in preparation for adult lifeMDT and case management to address complexneeds of children (health & social)Reduce childhood obesity

Youth (Adolescents) 13-24 yrs Adults 25-64 yrsReduce risk factors for long term conditions by improving management of CVD, & Diabetes esp MaoriImproved management of LTC (COPD, Diabetes)

Mental health wellbeing support

KaumātuaCase management for frail older people with complex needs including:multiple morbidities

Aging in placeFunctional gains

Tohenga RautakiPriority health equity issues for Mahitahi

Hauora in 19/20The ‘Double burden’ of conditions of poverty

across the life course• High rates of infectious conditions• High rates of Long Term Conditions

Health Promotion: Smoking, obesity, alcohol, sexual health Better screening and early detection of cancer

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The improvement focus may include service change, and the development of care pathways working closely with practices and the Mahitahi Governance team and other networks to develop, support and deliver local improvement programmes aligned to national priorities that can be expanded and implemented in other localities. They will develop an evaluation methodology to be used in research studies of the effectiveness of the changes and to strengthen participation by practices and other providers within the LCN. They will act as a link between the LCN and local primary care research networks e.g. rural clinical network, the Equity leader, and research institutions. They will represent the LCN at the Northland Clinical Governance Group meetings and contribute to the Mahitahi strategy and wider work of the transformation program. They will develop close working relationships with other Clinical Directors, clinical leaders of primary care, health, Māori Providers and other social care providers, local / regional councils. CDs in conjunction with the Network Leader will be responsible for identifying and mitigating any conflicts of interest. Clinical Directors will take a lead role in developing a LCN’s conflict of interest arrangements, taking account of what is in the best interests of the LCN and their patients. CDs will be responsible for appointing a Clinical Director from within the locality ensuring there is a robust selection process either via appointment, election or both. Other members of the locality transformation team Consumer experience improvement leader and change team We will need effective change capability to support the transformation of health, care and wellbeing within each locality. We will also need to provide support for already committed individuals currently providing care to have the time, space and resources needed to develop an integrated system within a locality. For genuine transformation to occur there needs to be sustained change in individual behaviour, team interactions and design of operations. Techniques for this “relentless hard work” of redesign include getting staff and patients together to design services from a starting point of what is needed, and ‘action learning sets’, which are regular meetings to jointly discuss problems, suggest solutions, and go over whether they have worked. It is essential that the change team recognise that these actions take up significant time from front-line staff who have little to spare. With workforce shortages, funding shortages, demand pressures and rising patient expectations, finding this time is very difficult but necessary. To be enduring change needs to be hardwired into the organization” so it has a higher likelihood of continuing long past the point of implementation. The change process itself, can

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be described in the three phases of inspiration, ideation, and implementation (see diagram below). 1. In the inspiration phase, perspectives from all stakeholders are gathered through

methods including literature searches, individual and group interviews, what matters to whānau workshops, listening, observation, and shadowing.

2. In the ideation phase, stakeholders brainstorm and discuss potential solutions, preferably in a creative and welcoming environment.

3. Once ideas are identified, they can be implemented in order to test prototypes. Rather than trying to perfect an idea before implementation, design thinking uses an iterative process of testing and refining in order to find a solution that works for all stakeholders.

Workforce development team This structure is designed to address the challenges and concerns I have heard in visiting primary care practices and Māori Health providers across Northland. Over the last three months, I have heard that they do not feel sufficiently supported to deal with the current demands on themselves as care providers and on their wider team particularly in light of increasing workforce shortages. GPs have informed me that increasingly they feel the workload is exceeding their capacity, they are dealing with more complex patients, and that these patients have a broader range of both health and social issues than they are able to meet within their existing team. I heard that they would welcome access to a broader team and a new more integrated model of care service delivery that would more effectively meet these needs. In feedback on Te Whakamahere - The Plan there was recognition that primary care in its present form needs to change and there is a need to move to a more multi-disciplinary way of delivering care. With workforce gaps across Northland there is no quick fix or easy solution. There are key steps that can be taken to reduce workload to a manageable level, to expand access to a wider multidisciplinary team, to provide better access to existing community based services to better support patients, and their whānau, to improve quality, and provide person-centred care as summarised below: 1. Strengthen the network of care providers available to support primary care (including

Māori providers) and patients and whānau in the community and strengthen the effectiveness of this multidisciplinary teams working within each locality;

2. We need to strengthen the role of community based care and increase access of primary care to community health services so that they are better able to meet the needs of patients and their whānau .

3. Provide a central coordination function to streamline referral processes and to support practices by providing access to a broader range of health and social services.

4. Grow a primary care workforce through increasing the training opportunities in Northland for medical, nursing and allied health staff.

5. Support primary care providers who are already in Northland where required through establishing a larger locum pool so that GPs and other primary care providers are able to be supported to have regular holidays and take leave.

6. Strengthening the leadership and input of primary care providers in decision making processes at system level.

7. Improve the information, communication and technology options for primary care so that innovative models of care can be progressed.

8. We need more time to consider the challenges that currently face primary care and to develop a longer term workforce plan that would revitalise and transform the model, to benefit all those who currently work in primary care, for patients and whānau.

Workforce experience improvement leader The key role of the workforce experience team is to make Northland a great place to work. This role will provide strategic leadership for workforce development, through assessment of

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clinical skill-mix and development of a workforce development strategy including the expanded scope of practice for professional groups and the development of new workforce roles within an integrated care delivery system such as whānau support workers and/or coaches. Nga mihi nui. Phillip Balmer Chief Executive Mahitahi Hauora