GAIHN Business Case Executive Summary FINAL
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ExEcutivEsumm
ary
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BUSINESS CASE TO DELIVER BETTER,
SOONER,MORE CONVENIENT HEALTH CARE
GREATER AUCKLAND INTEGRATED HEALTH NETWORK (GAIHN)
Summary Paper
1 March 2010
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1 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
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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2 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
At a Glance
Through a network of 1050 general practitioners working in primary care teams, 11 PHOsand 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 andPHOs 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 yearsthrough 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 ofclinicians 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 ofMori, 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 accessto diagnostics, IT and training
build a new locality focus by establishing six Local Health Networks (incollaboration 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 amalgamationand co-location of services to deliver Better, Sooner, More Convenient care.
To deliver these outcomes, GAIHN will simplify and transform the health environment, withjoined-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 byimproving 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 significantefficiencies 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 coordinationand building from the strengths of the GAIHN partners.
GAIHN will systematically implement its plans over three years, with regional and localclinical leadership.
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3 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
The GAIHN business case story1. Make health Better, Sooner and More Convenient
for patients and clinicians
Faster access toradiology services
Better access to afterhours care
More healthpromotion at your
GP
Better support forpeople with chronic
disease
Phone help so you
can access the rightservices
Better care for theelderly
Greater range ofservices available
locally throughCommunity Health
Hubs
Better access to careoutside the hospital
when you are acutelyill
Care models thatfocus on your whole
whanau
Clinicians know aboutyou less duplicationof tests and questions
Whats better forpatients in GAIHN -
2010/11
Access to your ownmedical records foryou and people you
trust
Education designed tosupport you to take
control of decisionsabout your health
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 todeliver 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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4|P a g e G A I H N B u s i n e s s C a s e S u m m a r y
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.
2. Set ourselves real measurable goalsfor the whole health system
The core business case proposition for GAIHN is that it will sustainably
reduce hospital acute demand through high performing community-based 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.
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 front-
line clinicians GAIHNcommissioned to inform the
Business Case development
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5|P a g e G A I H N B u s i n e s s C a s e S u m m a r y
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 measuredthrough a set of whole system performance indicators.
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6 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
3. GAIHN is committed to new solutions for reducinginequalities
GAIHN provides new opportunities for addressing the issue of health inequalities. GAIHNS statesits 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 thehundreds 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 willembed 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.
4. Support service innovations and rapid diffusion ofgood ideas that work:Many excellent services already exist that support high needs
individuals and communities. GAIHN will rapidly spread good ideas to reduce inequalitiesacross the network. GAIHN will work constructively with the Alliance Health+ and Mori
PHO Coalition to support new models of care, such as Whnau Ora.
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.
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7 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
4. Simplifying and transforming the healthenvironment
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 acrossGreater Auckland.
New focus on locality-based resourcing through aligned Local Health Networks, led byPHOs.
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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8 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
5. Improving clinical practice across the patientjourney
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 termcondition 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).
Acute care (Adults and child/youth)
GAIHN will implement initiatives across the network that targetthe drivers of acute demand (ED presentations and acute hospitaladmissions). The 2010/11 work plan will focus on:
Extending and strengthening the Primary Options forAcute 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:
oco-ordination across all providers of acute care
o walk-in nurse assessment clinics.
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.
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9 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
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% ofpractices
Optimising general practice systems for immunisation, screening, counselling and support.
6. Improving tools and enablers for quality clinicalpractice
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 arefully 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:
Knowledge Management:Making sure that relevant information is available to providersand 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 whomay 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.
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.
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10 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
Resource Management:Information systems support frontline clinician decision makingand 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 andaccountabilities 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 hospitalservices 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
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.
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.
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11 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
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 ofWhnau 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 HealthHubs. 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
1Acknowledge Tamaki Healthcare, Te Kupenga o Hoturoa Charitable Trust and Francis Group for the Whnau
Ora plans
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12 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
GeneralPractice is
Medical
Home
Healthconsumers
Hospital andDHB
communityservices
Self referral walk in andafter hours
General Practice
registered patient
Examples of GP referrals
Diagnostics
Chronic conditions
support team
Acute episode support/observation
After hours care
Devolved secondarycare services
Community support
services
Discharge care
Local Health Networksupports GPs from any
PHO
Appropriate direct GP
relationship with hospital,
clinicians and privatespecialist services
Supports GP manage patient needs in
the community
Appropriate care and interventions
in collaboration with GP
Real time medical notes
Training and developmentopportunities for general practice
staff
Provide scale to enable
shift of services
Integrated care
Devolved secondaryservices
Devolved
community services
Private medicalspecialist services
Appropriate
referrals
DHB strategichealth programmes
Credentialed services andnetwork of clinicians fromhub, hospital, community
and local general practice
Other socialagencies
Reduces ED
admissions and acute
demand on hospitals
Improves mgt of
acutes, electivesand discharge
Improvedlocal access
to serivces
CommunityHealth Hub
Patients remainregistered with theirfamily medical
practice
Multidisciplinary,multiservice centre
Local HealthNetwork supports
care integration
A&M services
Improved
care and
continuityfor patients
Improved clinical management ofacutes, electives, discharge and
long term conditions
LocalH
ealth
Netwo
rk
and
Comm
unity
HealthH
ub
Whnau Ora Centre
Primary Services
GPs, Nurses, Others
Secondary Services
Mm, Pp& Tamariki,
LTC, Others
GAIHN CHH(Othercomplementary
localities)
DHB
Services
Shared
Services
GP Practices
Other
Services
After
HoursMarae
Rnanga
Mori Health
Providers
Social
Services
Economic & Social
Development
Clinical
Networks
Tertiary
Education(incl. School of
Population Health)
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13 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
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 CoordinationTelephone Triage
Walk In Clinics
Prevention Smoking Cessation
CVD Risk
Assessment
Immunisation
Health Promoting
Practices
Clinical enablers
Access to diagnostics Direct Access to X-
Ray, CT, MRI &
Ultrasound
Direct Access to X-
Ray, CT, MRI &
Ultrasound
Direct Access to X-
Ray, CT, MRI &
Ultrasound
IT Shared ElectronicCare Plans
Shared ElectronicCare Plans
Shared ElectronicCare Plans
Shared ElectronicCare Plans
Population Health
Tools
Locality-based infrastructure
Local health
networks
Improved
Communication
Improved
Communication
Improved
Communication
Improved
Communication
Enhanced General
Practice
Walk In Clinics
After hours
Multidisciplinary
Teams
Multidisciplinary
Teams
Community Health
Hubs
Community Based
Beds
Specialist Advice
After hours
Specialist Clinics
Whnau ora centres Links to social
services
Outreach services Multidisciplinary
Teams
Multidisciplinary
Teams
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14 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y
8. Improving the capability and productivity of ourworkforce
GAIHN understands that workforce is both a key constraint and enabler of sector performance. Ourworkforce 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.
9. Creating regional leadership that bringsorganisations 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.
Professionals working together as a
team and not doing their own thing. We
need to agree that we all can togetherimprove 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.
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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 theGAIHN 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 resourcingand 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 community-
based 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, infrastructureand 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 andcontracting 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
Examples include regionally consistent care pathways, oneplan (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.
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.
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12. Creating financial systems that improve productiveinvestment
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, servicesto 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 toachieving 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 anddirect 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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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 stakeholdersto 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 ofnumbers 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 responsiblefor 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 servicesare 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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Community-based
intervention
Assess theresultantimpact onhospitaldemand
If loss or ineffective modify or stop.
GAIHN makes decision will freed up resourcego to efficiency bottomline or for re-investment
If benefit - define
efficiency and extractfreed up resource
Saving
New system and culture requirements
Improvedlinkage of community
activity and ED/outpatientstrends etc
Improvedimpact
measures
Develop ability to extractfreed up resource
Enable informed decisionmaking about best use of
sector resource
GAIHN defines bestinvestment areas
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 toimplement change fast
Year 1 Year 2 Year 3
Clinical infrastructure: Establish andpilot LHNs, EGP and CHHs
Clinical Enablers: Establish regionalenablers to support quality clinicalpractice access to diagnostics, POAC,HPP, Optimising general practice,telephone triage etc
Models of care: Develop consistentregional models of care for LTC,prevention and acute. Acute /COPD focus in year 1 expand to cover new conditions and greater % of practices
Expand scope of services and coverage across Greater Auckland
Focusforserviceand
infrastructureimprovements
Expand scope of enablers and % of practices
High needs innovations: Begin togrow innovative models e.g.whanaucentred models and whare orangainitiatives
Phasing of change
Resourcing environment: Establishnew resourcing and contractingenvironment pilot alliancingapproaches
Evolutionary transition from old to new resourcing environment
Evaluate and expand successful models
Impa
cton
health
outco
mes
,patien
texp
erienc
ean
dus
eof
money
Approx10 - 30% impact
Approx 20 70%impact
Approx 60-90%impact
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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.
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 ourimplementation 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 stage-
gate 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.
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 makethe IHCF work in totality, certainly
in the next few years happy to be
convinced otherwise.
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15. Next steps to build our business planFollowing 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.
GAIHN
Busin
essCase
ongoin
gdetailed
develo
pment
GAIHN
Regio
nalPlan
develo
pment
Busine
ssCase
Boardsignoff
1 March 2010 30 June 2010
Challenge in GAIHN shortterm work plan
Time
GAIHNw
orkplanand
stageofre
adiness
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.
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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 criteriaBusiness case
assessment criteriaGAIHN response
1 The nature and expected magnitude of benefits that will flow fr om the proposed service improvement initiatives, including how theproposal expects to:
1.1 Support the delivery of theGovernments 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), designedin 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 from2012/13. This pathway was chosen to create a more manageable set of initiatives for 2010 and to create relieffor hospitals from acute demand pressures.
GAIHN is addressing the health targets directly through its models of care, clinical enablers and localityinfrastructure 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 needscommunities. The magnitude of impact will be across more than 1000 GPs and associated primary healthteams. Approximately 300,000 health consumers will be impacted by the establishment of six Local HealthNetwork and three Community Health Hubs from 2010/11.
These initiatives, including Enhanced General Practice and Whanau ora centres will continue roll out across theregional over the three years of the business case. The aim is to have coverage of the whole GAIHN catchmentby 2013/14
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1.2 Contribute to health sectorproductivity and qualityimprovement;
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 costeffective 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.
1.3 Lead to the rapidestablishment of IntegratedFamily Health Centres inappropriate locations;
Development of environment across Greater Auckland to support market-led response to amalgamate generalpractice and develop collocated services. Seeking market-led response from general practice and A&Ms.
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Three Community Health Hubs developed during 2010/11, to support improved access to services, bettercapability 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)
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.
1.4 Support the shift of servicesfrom secondary care toprimary care;
Community Health Hubs are being explicitly developed to support the shift of services from hospital tocommunity, as many services require scale and cannot be devolved to smaller sites. Three CHHs (one in eachDHB) 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, Betterpatient 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 servicesleads to improved team-based healthcare.
Note links to workforce development, GAIHN performance indicators and learning environment to support shiftof service.
1.5 Reduce acute demand onpublicly funded hospitalservices;
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 EDadmissions (see financial chapter)
1.6 Ensure a wider range ofhealth services are deliveredincluding but not limited toextended hours, walk-inaccess, 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, laboratoryspecimen collection andsome on-site processing,day-stay surgical proceduresand observation beds
On site laboratory testing is proposed for the Community Health Hubs and will be a component and EnhancedGeneral 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 forcommunication with patients and whanau.
The CHHs will support many services such as day stay surgery and observation beds (see details in localityinfrastructure and workforce chapters)
The new Locality Infrastructure will lead to team based care models and use of technology to support patientsout of hospital. Including on-line access to their own records.
1.7 Support better managementof patients with chronicconditions to slow diseaseprogression;
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 primaryprevention.
In Year One, GAIHN will:
implement the Health Promoting Practices Quality Framework across at least 10% of practices - includingCHHs
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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 thewider primary health careworkforce and supportmultidisciplinary teams;
The development of new locality infrastructure (Local Health Networks, Enhanced General Practice, CommunityHealth 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 andallied 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 alliancecontracting.
The locality infrastructure supports teams that link into social services.1.9 Provide for workforce
development, training andinnovation in the primarycare setting;
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 newhealth 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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Supporting the LHN establishment especially with the skills required to support improved resourcing andcommissioning at a locality level.
Workforce development as a tool to enable multidisciplinary teams this will include training multidisciplinaryteams together as new centres are established
Addressing inequalities providing new skills through the Health Promoting Practice programme across multiplepractices to improve the clinician patient interaction in terms of the way Maori, Pacific and other high needs
people live their lives.
1.10 Achieve the aboveobjectives in a way that iscost effective and assuresquality and safety for usersof services.
The establishment of the regional Active Clinical Network, provides for a new leadership centre for clinicalprogramme 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.
GAIHN is proposing new performance measures that will allow for much improved analysis of businessperformance and clinical performance.
Alliance contracts aim to lock in performance measures across multiple providers involved in delivering tocommon outcomes.
The fundamental approach to GAIHN performance improvement is to build from what works well now, make itscalable 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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2The capability and capacity of the respondent to deliver major service improvement initiatives in suppo rt of these benefits,
including:
2.1 Ownership and governancearrangements;
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. Thestrength 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 form-follows-function as the GAIHN agenda unfolds.
2.2 Strength and experience ofthe clinical leadership;
GAIHN draws on some of New Zealands most experienced clinical leaders from both a clinical andclinical/managerial perspective. Clinicians have guided many of the aspects of this business case.
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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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 integratedchange 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 performancemeasures 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 tosimultaneously manage risk and the need for rapid change. The proposal describes the stage gate process sin
detail.
2.5 Information managementthat enables new models ofcare, and improves qualityand efficiently deliverservices.
The GAIHN organisations include some of New Zealands largest and most experienced primary healthorganisations with regard to information management design and deployment in the primary care environment
GAIHN is working from existing platform for the Auckland regional IS strategic plan, that is driving the longterm IT infrastructure investment.
GAIHN is seeking to modify RIS10-20 to focus on key infrastructure for the proposed models of care and localityinfrastructure 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 The strength of relationships betw een the various parties, and partnership arrangemen ts with key stakeholders, including;
3.1 The degree of engagementand/or support from DHBs,specialist clinicians,practitioners from a range ofdisciplines;
The Business Plan outlines the significant effort GAIHN has put into engaging with the health workforce andhealth leaders (including on-line surveys, summits, well attended clinical workstreams, NGO forums, mini-
summits at hospitals and normal PHO and DHB communication channels).
There has been robust clinical dialogue around many of the GAIHN initiatives. For example the detaileddiscussion 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 Casedevelopment 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 manyof the initiatives which is a qualification all partners share.
3.2 Experience in meaningfulengagement with consumersand the community.
PHOs participating in the Network are committed to consumer engagement and many include consumerrepresentation within their governance structures.
Network members have dedicated community services which link with local communities, iwi, and communityorganisations. These relationships will be supported and strengthened through GAIHN.
Consumer representatives have attended the GAIHN summits and direct consumer involvement will increase asthe 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 andhealth consumers.
Iwi have been invited to join the GAIHN partner group. There are opportunities for manawhenua involvement inlocal health networks.
Community Health Hubs will provide the infrastructure for more meaningful engagement around health servicesand 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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