Primary Health Care Plan

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I n c o n s u l t a t i o n w i t h :


Through a valued and skilled workforce,

primary health care services will:

be easier to access;

help people make healthier choices;

deliver quality services that reduce

inequalities and effectively address the needs

of our communities in promoting good health;

involve communities in identifying their

health needs and shaping service development.

The aim of the plan is to achieve improved

population health by encouraging people to

access community- based services early;

to understand and be supported to adopt,

where possible, a self care approach;

to empower communities to foster wellness;

and to understand the links between lifestyle choices

and environment that affect health status.

The Counties Manukau

Primary Health Care Plan

2007-2010 sets out the pathway

for further development of

primary health care services in

Counties Manukau.


Within primary health care we recognise that the Treaty of Waitangi

establishes a partnership between Maaori and

The Crown to work together under the auspices of Kaawanatanga

(Governorship),Tino Rangatiratanga (Self Determination) and

Oritentanga (Equal Entitlement).

Within Counties Manukau district this commitment is expressed in a

variety of ways which include:

The establishment of POU as a Board committee at Counties Manukau DHB; this has

provided Maaori with a forum to be involved in the decision making processes of the

Board. The inclusion of members from the Board, Maaori Providers,Tainui MAPO and

Manawhenua provides a base for an inclusive decision making process

Increasing delivery of health services by Maaori provider organisations to Counties

Manukau residents from a kaupapa Maaori base e.g.Te Kupenga O Hoturoa PHO

Increasing capacity of the CMDHB Maaori Health team to provide Maaori strategic and

operational impetus for the district

Involvement of Maaori communities in the development, implementation and evaluation

of new and existing services

Development of the Whaanau Ora Plan

Development of Maaori Health Plans by all Primary Health Organisations across Counties


We have identified the following concepts to guide the enactment of

Treaty obligations, as identified in the Whaanau Ora Plan:

Sharing responsibility for Maaori health and disability gain, with Maaori taking a lead role

Inspiring whaanau to be educated, knowledgeable and motivated about their own health

and disability

Encouraging whaanau to adopt healthy lifestyles

Facilitating Maaori participation in decisions about resourcing priority health and

disability goals

Developing the health and disability sector workforce, with a particular focus on Maaori

capacity and capability

Measuring and reducing inequalities

Increasing whaanau choice and use of quality kaupapa Maaori providers and generic


Continuously improving the DHB’s funding, planning and service delivery roles to

proactively respond to Maaori health and disability need

Engaging with Manawhenua on service development and planning


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Table of Contents



s a district health board Counties Manukau DHB (CMDHB) works in partnership with its communi-ties, Primary Health Organisations (PHOs) and other providers of services to improve the health status of the peoples of Counties Manukau. A wealth of inter-national evidence shows that health systems oriented towards primary care achieve better health out-comes for lower overall costs than systems focused on hospital care .

CMDHB’s strategic plan is based on the premise of effective primary care services in order to deliver health gain and reduce health inequalities. Locally based primary and community health services are the key to this.

Population growth, ageing and the obesity epidemic will lead to more chronic diseases over the next 20 years in Counties Manukau. This will place demands on the health system in its current form which it simply will not be able to address. Healthier lifestyles, early intervention, increased levels of clini-cian supported self care for individuals and families/whaanau and effective management by pri-mary care teams are fundamental to making the health system ‘fit for purpose’.

Realisation of this plan requires: some brave innova-tions in services design and delivery; community understanding of the role of primary health; improved health literacy and supported self manage-ment. The highest standards of clinical quality must be the norm.

Primary health care professionals in Counties Manukau work very hard to deliver services in a challenging environment and I wish to acknowledge and thank allthe health workers involved in caring for patients

The role and contribution of General Practice is cen-tral to the success of both the Counties Manukau Primary Health Care Plan and the national Primary

Health Care Strategy. General Practice teams have to continue to meet the urgent needs of their patients while still considering the ongoing require-ments for good health including preventative care and provision of health information and education. Working in this acute model is necessary to meet patients’ needs but more is required if we are to meet the challenges of the future. We need to reori-ent the system to ensure new clinical roles will emerge and people will be treated by a team, not just a family doctor

The opportunities for working intersectorially to impact the wider determinants of health care are well recognised by CMDHB. Extending this concept to develop integrated services that are collectively focused around ‘doing the right thing’ for consumers is a key feature of the innovative model of the future referred to in this plan.

As a planner for health services we often focus on how to improve the system and hence talk about what needs to change. Bear this in mind as you read this plan as it is forward looking and focuses on areas for development and improvement. Rest assured that we do acknowledge much of the cur-rent system works well. As you can see from my ear-lier comments General Practice and other primary health care services are very much valued and essen-tial to the success of the DHB.

This plan represents an exciting opportunity to raise the health status of the people of Counties Manukau over the next three years. Counties Manukau DHB is committed to working with our Primary Health Organisations, the wider sector and consumers to implement the plan. I look forward to progress being made towards delivering its objectives and the improvement in the health of our population that will result.

Geraint Martin

Chief Executive



definition of Primary Care can be taken from the New Zealand Primary Health Care Strategy 20012, which states that:

Primary health care covers a broad

range of services that include:

Participating in communities and working with community groups to improve the health of the people in the communities

Health improvement and preventative services such as health education and counselling, disease prevention and screening

Generalist first level services such as General Practice Services, Nursing Services, Community Health Services and Pharmacy Services that include advice as well as medications

First level services for certain conditions such as maternity, family planning, sexual health and dentistry or those using particular therapies such as physiotherapy, chiropractic and osteopathic services, traditional and alternative healers

(Based On World Health Organisation, Alma Ata Declaration)

As a District Health Board (DHB) Counties Manukau DHB (CMDHB) works in partnership with Primary Health Organisations (PHOs) and other organisa-tions to improve the health status of the whole com-munity. The DHB’s role is to plan, fund, provide, develop and manage contracts services to meet the

health needs of the community.

Provision of primary health care is delivered via a range of PHOs and other contracted service providers.

PHOs are accorded a key role in coordinating these services in addition to providing ‘essential services’ for their enrolled populations. PHOs are the entity through which the national Primary Health Care Strategy is delivered. General Practice in Counties Manukau is now almost exclusively contracted through PHOs.

The Primary Health Care Strategyis the foun-dation policy document for this Plan, and identifies the following six key directions:

1. Work with local communities and enrolled populations

2. Identify and remove health inequalities 3. Offer access to comprehensive services

to improve, maintain and restore people’s health

4. Co-ordinate care across service areas 5. Develop the primary health care work


6. Continuously improve quality using good information

This plan will review progress in implementing the Primary Health Care Strategy and also address the challenges facing Primary Health Care in the future.

The community of Counties Manukau is unique and diverse (some general characteristics are discussed below with more detailed population characteristics provided in Appendix One).

Counties Manukau is one of the fastest growing areas in New Zealand, with the population continu-ing to grow at over 2 per cent per annum. The res-ident population for 2006 was estimated to be around 443,000.

The key characteristics of the community are the high numbers of Maaori and Pacific people, and the relative youthfulness; around a quarter of the popu-lation are aged 14 years or under.

It is a community with high health needs and one of the highest levels of deprivation in New Zealand. Counties Manukau has 117,000 people living in areas that can be classified as very deprived - that is 34% of the district’s population (and 45% of the children). For virtually every health measure

under-taken, poor people do worse than wealthy.

We have one of the largest urban and rural Maaori population mixes in New Zealand, with disparities from issues of low socio-economic status and reduced access and utilisation of effective health care leading to poor health outcomes.

Counties Manukau has the largest Pacific population in New Zealand, with the highest birth and fertility rates, low socio-economic status, and resultant poor health status and outcomes.

Marked health inequalities exist between the least and most deprived people in Counties Manukau, and between ethnic groups. Maaori and Pacific peo-ple are heavily concentrated in areas of greater rel-ative deprivation. This poverty impacts a higher than expected rate of overall hospitalisations



Primary Health Care is the first level of health care accessible in the communities in which people live and work. The success of primary care in positively influencing health outcomes is therefore heavily influ-enced by other agencies that can have a determining contribution to people’s health status. These include but are not limited to:

Ministry for Social Development, including:

▲ Work & Income

▲ Child,Youth & Family Services


Local Territorial Authorities and Councils

Housing New Zealand

Department of Justice



Food Industry

Leisure Industry & Sports bodies

A plan that scopes three years of activity cannot realistically effect health related change across the entire sector as it is described above.

Both intra-sectoral and inter-sectoral change that achieves significant and long term health gains for communities is achieved via longer term strategies, planning and work programmes driven at policy level between sector leaders.

Examples of such inter-sectoral work that CMDHB and Counties Manukau PHOs are involved with include: Let’s Beat Diabetes, Lotu Moui, Healthy Housing, Health Promoting Schools, AimHi, and Providing Access to Health Solutions (PATHS).

Such initiatives give effect to the DHB Health Services Plan - projecting health needs 20 years into the future; and the CMDHB District Strategic Plan -directing medium term strategy, actions and out-comes 5-10 years into the future. The common prin-ciples in both types of plan are that they are future orientated, focussed on whole population health out-comes and grounded in intersectoral collaboration. We will see further development of this approach in particular in the social services and family violence pared to the national average.

There are ethnic and socio-economic differences in access to services, especially General Practice and Diagnostic services that also need to be addressed to ensure that people of all ethnic groups and all socio-economic backgrounds obtain the health care they need.

Within Counties Manukau, the work that results in Primary Health Care services being delivered to the community needs integrating across many areas and includes, but is not limited to:

Essential Services delivered through PHOs which includes services delivered by General Practice and other primary health care service providers

Pharmacy, laboratory and radiology services

Maaori Health Services

Pacific Health Services

Well Child Services

Family Planning & Sexual Health Services

Oral Health and Dental Services

School based services

Allied health services e.g. physiotherapy

Accident & Medical Clinics

Alcohol & Other Drug services

Mental Health Services

Needs Assessment and Service Coordination

Rehabilitation Services

Residential and Aged Care Services

Personal Health and Disability Support Services Many groups make up the total sector including: PHOs, Non-Government Organisations (NGOs including Special Interest Groups, Voluntary Groups etc), private businesses (Pharmacy, Dentistry, Allied Health, General Practice etc); and government agencies (e.g. DHB provider arm community services - mainly Intermediary Care, Public Health Nursing and Mental Health servic-es). Not forgetting the most important stake-holder of all - the members of the public that make up the community served.

The Primary Care workforce is equally diverse, as highlighted above and many of these profes-sions and community groups provide first point of contact, primary health care related services. A number of these are funded in whole or part by the DHB, but others remain primarily depend-ent on user paymdepend-ent and/or voluntary contribu-tion. For further information on the Primary Health Sector Workforce see Appendix Two.

It is important to understand how these individ-uals, providers, organisations and communities can contribute to the improved health status of the Counties Manukau population and to what extent they are part of the wider Primary Health Care Team, DHB and PHO networks.


areas in the future. Primary health care providers have a critical role to play in such initiatives and the activity comes together in this plan under the inno-vative model of care concept being developed as part of the Primary and Community Health Service initial-ly focussed on Mangere but eventualinitial-ly to cover the entire Counties Manukau district.

The Counties Manukau Primary Health Care Plan 2007-2010 shares the above principles. It has been drafted after consultation with the community to determine the key issues that influence understand-ing and use of primary health care services and

actively seeks to improve sector responsiveness to the needs of the population to realise improved health for all. The Plan identifies the contribution CMDHB, PHOs and Primary health care providers will make to developing healthy futures for the popu-lation served over the next 3-4 years.

It is critical that PHOs, in particular, link to intersec-toral agencies to coordinate care for individuals and assist them to navigate their way through the system as these inter-agency services may have a greater impact on a person’s health and wellbeing than many specific health interventions.

It is appropriate before moving forward with the new plan to take stock of what has been achieved in the preceding years. The original CMDHB “Primary Health Care Plan; Moving Forward Together” was written in 2002 as a response to the Government’s Primary Health Care Strategy and in the infancy of both CMDHB and Counties Manukau PHOs.

The Public Health and Disability Act (2001) charged DHBs to be responsible for the health of their entire population and subsequently the national Primary Health Care Strategy attempted to reorient the sys-tem to shift the main focus and investment in health care from individual sickness in hospitals to wellness in whole communities.

To discuss every strategy and work programme that the Primary Health Care Plan is aligned with would provide a list of activities too numerous to docu-ment in detail.

It is outside the scope of this Plan to address every area of integration. Suffice to say that the Primary

Health Care Plan 2007-2010 cannot exist or suc-ceed in isolation. It is dependent on integration with complimentary strategies, planning and work programmes that impact on the overall success of primary health care.

Some of these are included in table one below:


Strategic Linkages to 2007-2010 Plan

3.0 Our Achievements: Outcomes of the 2002-2006 Plan

Table One: Strategic Linkages

National Local CMDHB

The New Zealand Health Strategy The Primary Health Care Strategy The Maaori Health Strategy The Disability Strategy

The Mental Health Strategy & Plans The Cancer Strategy

The Pacific Health & Disability Strategy The Health of Older People Strategy Primary Health Care Strategy Implementation Work Programme 2006.

PHO Performance Management Programme

The Counties Manukau DHB District Strategic Plan The Counties Manukau DHB Health Services Plan The Counties Manukau DHB District Annual Plan Let’s Beat Diabetes Strategy

Whaanau Ora - Maaori Health Plan Tupu Ola Moui – Pacific Health Plan The Child Health Plan (Well Child) The Youth & Sexual Health Plan Maternity & Maternal Health Strategies Elective Services Plan

The Oral Health Plan Cancer Control Strategy Palliative Care Strategy Advanced Care Planning

Counties Manukau Primary Health Care Workforce Development and Action Plan (2004)

Counties Manukau Workforce Development Plan : Investing in our Primary & Community Health Care Workforce 2007-2011.

Activities covered within the local plans above are for the most part not repeated here. However, there are some specific aspects of work that are intimately related and these are discussed in Appendix Three.


The 2002 PHC plan focussed on achieving this re-orientation with some success. The aim was to start the journey in reconfiguring Primary Health Care as described in table two, below.

This transition was to support the beliefs that:

Supporting primary care as the first and usual way for people to access and use health services is the key to a healthy community and to reducing the health inequalities which are so evident in the community of Counties Manukau

The possibilities for improving health and preventing avoidable hospital admissions lie in the primary health care sector

It is important to emphasise that in the transition to achieve the above changes there has also been signifi-cant activity within the wider primary health care sector. In particular PHOs have been through a rapid establishment phase and are now delivering a cant number of additional services. This is a signifi-cant achievement given that the first PHOs only came into being five years ago.

The following progress has been made as a result of the original plan:

I. A strategic direction for CMDHB that is reliant on the success of primary health care. This direction champions:

Prevention of illness and injury and a focus on wellness and health promotion

Providing early access, detection and intervention before disease takes hold

Providing an improved level of community service to off-set the growing need for hospital management

II. Successful implementation of the first phase of the new systems and structures required for success including:

The establishment of 8 PHOs within the Counties Manukau Region

Nearly 100% uptake of PHOs by General Practice

A move from fee-for-service to capitation based funding

A shift to “low fees” environment

The establishment of Services to Increase Access (SIA) and Health Promotion (HP) funding programmes

Improved access to primary health care services

Improved understanding of a population health approach

A partnering approach being adopted between the DHB and PHOs

Emerging collaboration between PHOs

Development of a PHC Nursing team as a result of the 2003 MOH PHC Innovations

PHC Nursing, other provider and community leadership at governance level

III. Implementing Intersectoral and Integrated Care Initiatives with a Population Health Approach such as:

Let’s Beat Diabetes

Lotu Moui

The Primary Options for Acute Care Programme (POAC)

The Chronic Care Management Programme (CCM)

The Frequent Adult Medical Admissions Project (FAMA)

Healthy Housing Initiatives

Healthy Schools Initiatives

Providing Access To Health Solutions (PATHS)

Table Two: Sector Reconfiguration

Old Sector Approach New Sector Approach

Focuses on individuals Provider focused

Emphasis on treatment Doctors are principal providers Fee-for-service

Service delivery is mono-cultural

Providers tend to work alone

Looks at health of the whole population/community Community and people focused

Education and prevention have an equal emphasis Teams – facility and outreach based -are providers Needs-based funding for population care

Cultural competence in both mainstream and ethnic specific services


CMDHB wishes to acknowledge the gains made in restructuring and change management undertaken by the sector and the trends towards improved access, the reductions in admissions to hospital (particularly in children) and the decrease in inequalities.This was achieved whilst maintaining services to the community under increasing pressures and workforce constraints that raise important insight into future planning for demand and capacity. It is important to recognise this good work and the pride in the sense of value that the community places on health professionals. The sector should carry this sense of achievement forward through the next phases of change

These programmes of work have demonstrated the gains that can be achieved through such an approach and has secured the foundation for effective working relationships between health professionals and inter-sectoral partners, underpinned by evidence-based practice and information technology. A list of progress against detailed Key Performance Indicators (KPIs) relating to the 2002 plan is available in

Appendix Four.

Although we celebrate our accomplishments to date, it is now time rise to new challenges.The Counties Manukau Primary Health Care Plan 2007-2010 iden-tifies where further improvements in access to and delivery of quality primary care services can be made and the necessary actions to achieve this.

Establishing new ways of delivering health care that

reflect the health needs of our changing and growing population and that deliver the necessary improved health outcomes are fundamental to the Plan’s suc-cess. If the aims and intention of this Primary Health Care Plan are met then an effective reduction in health disparities and a healthier population in the longer term should result.

We welcome the challenge of the Primary Health Care Strategy. As a response this Plan sets out to achieve the vision of healthy communities, who understand the links between lifestyle, environment and health status and who are fully engaged with and supported by health services throughout their life to manage their health optimally.

Furthermore, while CMDHB has formed the view that there needs to be some rationalisation of PHOs to better fit with the locality based approach described in our Health Services Plan, there is no doubt that PHOs are the key to success of popula-tion health improvement and have the potential to effect further positive change though developing their community linkages.

There is a good level of optimism that the goals in this plan are achievable given the initiatives described and the goodwill that exists amongst the highly com-mitted Counties Manukau Health Workforce and the unique and special community, which it is our privi-lege to serve.

4.1 Underlying Principles

As part of developing this plan stakeholders agreed four underlying principles to further the partnerships within the sector. These principles are fundamental to the plan:



- The entire sector wants to head in a unified direction to achieve the vision of a healthy community in Counties Manukau.



- Given population growth in Counties Manukau combined with the prevalence of chronic disease, ageing workforce challenges and the current health status of the population we cannot continue to maintain the status quo within the sector.

III. Community Partnership

- The sector wishes to work with its local communities in ways which identify and remove health inequalities and which offer access to services that improve, maintain and restore health.


Quality Development

- It is the intent of the entire health sector to promote the coordination of high quality care and the sharing of information to enable this, and that all within the sector are commit-ted to building the capacity, capability and primary healthcare workforce.

It is recognised that improvement in population health outcomes (and in particular gains for communities with high health needs) requires significant investment in Primary health care services. The establishment of brand new ways of designing and delivering health care and the creation of more effective linkages between hospitals, other health providers and the community is fundamental to achieving the aims and objectives of this Plan, as is effective coordination between the health sector with other agencies e.g. housing and education.


After consulting with the community and sector providers, we have identified that the most significant gains to the overall health status of the people of Counties Manukau to be made within the time frame of this Plan, will be realised by focussing the work programme on six key areas (feedback from commu-nity consultation is listed in Appendix Five)


Community Participation in

Service Delivery and Design:

To actively involve the individual and their family/whaanau in the management of their own conditions and furthermore to go beyond consultation about services and service delivery by actively involving the community in decision making. This will be achieved through defined processes and models of governance; working directly with them in making service decisions and developing ideas and solutions regarding improved community health and well being.


Increasing Access and Reducing Health


Supporting primary care as the first and usual way for people to access and use health services is the key to reducing the health inequalities. The DHB and PHOs will work collaboratively on programmes and services such as innovative models, Services to Increase Access (SIA) and Health Promotion (HP) activities and the funding, of population screening and structured care programmes to make access to health care easier and to work to reduce health inequalities.The biggest impact on health inequalities will be the recognition and improved management of cardiovascular risk in the population. In line with the CMDHB Vision the primary care sector will place particular emphasis on Maaori and Pacific Peoples and other Communities with health disparities.


Innovative Models of Primary Care:

The further development of initiatives that shape and influence service provision and redesign across the sector with particular emphasis on work with Primary Health Organisations, General Practice and wider sector linkages in locality based services as described in the CMDHB Health Services Plan.


Supported Self Care and Chronic Care


The further development of initiatives and services that shape and influence community understanding of the links and relationship

between lifestyle, environment and health status. Two key aspects of improving health outcomes for those with long term conditions are the provision of best practice healthcare (based on current clinical guidelines) and supported self care. Self-care support is defined as the systematic provision of support, self management education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, share in decision-making, monitor and respond to their health condition appropriately, and the adoption of a healthier lifestyle.

The DHB and PHOs will work collaboratively to continually improve the current chronic care management programme to support clients to receive optimal medical care and supported self-care.


Clinical Quality Improvement:

The support and further development of a performance based culture, concentrating on PHO leadership and clinical governance to ensure that PHOs are delivering continuous quality improvement, value for money and are configured in a way that optimises integration and population health coverage.


Workforce Development:

This explicitly linked with the Counties Manukau Workforce Development Plan 2007-2011. While we need more people working in primary and community health care, it is recognised that more people alone will not address the future health needs of our community. The workforce also needs to be configured differently. This change in approach has significant implications for the primary and community health care workforce, with new roles and skills needing to be developed. Valuing our workforce and providing better support for the multidisciplinary team will be a key enabler to achieve the goals of this plan.

In keeping with the time projections, the scope of the plan will be narrower than the other CMDHB strategies mentioned in section 2.0 above. Accordingly the aspired outcomes are targeted at the short to medium term adopting a multi-year ‘programme’ approach.

Further detail concerning these priorities including a summary of the evidence is discussed in Appendix Six


The Plan was written after fourteen consultation events with the community and sector providers amongst other planning activities. These consulta-tions were held to consolidate strategic direction and to determine key issues/areas that influence and impact on understanding and use of primary health care services.

The Counties Manukau Primary Health Care Plan 2007-2010 aims to develop the primary health care sector for the people of Counties Manukau so that services :

are easier to access

help people make healthier choices

deliver quality services that reduce inequalities and effectively address the needs of our community and promote good health

involve communities in identifying their health needs and shaping service development

As a result the Plan focuses the sector in the following ways to ensure sustainability and success:

Successful change management

Upstream investment i.e. an equal focus on health prevention and maintenance as well as intervention in sickness

A ‘whole of community’ approach to health and well being

A focus on outcomes

Accountability and high quality performance (reliable, cost effective, quality services)

Future sustainability of services in terms of delivery components and configuration

Evolving models of care; configuration, workforce and structure that match the needs of a changing population

The reduction of barriers and health inequalities

An increase in access to primary care across the whole community

Whole sector coordination and integration

This Plan will be supported by multi-year work pro-grammes outlined in the District Annual Plans (DAPs).

Community and sector engagement, successful change management, communication and partnership are fundamental factors that will determine success.

The Plan is a component of the Counties Manukau DHB District Strategic Plan:

Healthy Futures 2005-2010, aligning to the six out-comes framework and intent of this strategy. The table below outlines the six key outcomes that were agreed with the community to achieve improved health for all in the next 5-10 years.

The Plan actively seeks to progress sector responsive-ness to the needs of the population in order to realise improved health for all. It identifies the contribution that the Counties Manukau District Primary Health Care Sector will make to developing healthy futures

for the population served over the next 3-4 years.

It focuses on improving community understanding of how to attain and maintain good health and emphasis-es community engagement as key to understanding

4.3 How We Developed and Aligned the Plan

CMDHB Vision

to work in partnership with our communities to

improve the health status of all,

with particular emphasis on Maaori and Pacific Peoples

and other Communities with health disparities

Table Three: The District Strategic Plan Outcomes Framework

Outcome 1 Outcome 2 Outcome 3 Outcome 4 Outcome 5 Outcome 6

Improve Community Well Being

Improve Child & Youth Health Reduce the Incidence & Impact of Priority Conditions Reduce Health Inequalities Improve Health Sector Responsiveness To Individual & Family/Whaanau Need Improve the Capacity of the Health Sector to Deliver Quality Services


community needs.

Paramount is the need to increase access to services and reduce inequalities to improve the overall health of the community. However there is also particular emphasis on the quality of provider: patient relation-ships and provider: family/whaanau relationrelation-ships, cul-tural responsiveness and patient and family supported self care.

The development of new models of care delivered at General Practice level including; the development of health education and information, early detection and screening, multi disciplinary teams and structured care to manage long term conditions are a key focus for improvements in service design and delivery with a shift in focus from the individual interaction and responding to issues one at a time to a whole of sys-tem and population based approach.

The Plan also concentrates on the ongoing support

The establishment of new ways of designing and delivering health care within the primary sector

The creation of more effective linkages and collaboration between Primary and Secondary care and the Health sector with other agencies

Append ix Sevenhighlights the target areas and

Append ix Eight detail the actual work programme developments for the next 3-5 years

The seven themes supporting our strategic direction are tabled below:

The Primary Health Care Plan is a strategic approach to achieving a healthier future for the population of Counties Manukau. The plan is based on seven key themes, endorsed by representatives of the commu-nity and the providers within it.We believe that designing our work programme in alignment with these themes is important for success.The work programme is structured to achieve:

Change in the way the community understands, accesses and uses the primary sector:

▲ Improvement in the level of understanding within the community of the link between lifestyle, environment and health status

▲ The community uses primary health for prevention not just treatment


Key Themes in the Strategy

and development of a performance based culture, con-centrating on PHO leadership, clinical governance, configuration and design to ensure that PHOs are delivering added value.

Ultimately the strategic intent of the plan is to achieve improved health for the population served via having the community understand and adopt a wellness approach, empowering them to understand the links between lifestyle choices, environment and health status and encouraging them to access community services earlier by seeking general practice support rather than hospital emergency care. Furthermore that the sector will pro-vide high quality, efficient and effective services for that community in an integrated and coordinated manner.

Seven key themes were identified in planning activities with the sector, these were endorsed in community consultations and helped define the strategic direction of the Plan.


Table Four : Seven Strategic Themes in the Plan

Themes Primary Care Strategic Intent DSP Outcomes Links

1 Community Engagement & Lifestyle Change 2 Evidence Based Clinical Work 3 Sector Change 4 Reducing Barriers 5 Performance Evaluation & Quality Improvement 6 Workforce Development 7 Integrating Information Technology

As we enable more & more people to take control of their own good health at an individual and whaanau level; a collective community shift towards good health will gain more & more energy.

Building on successes and continuing to support effective work that makes a positive difference; managing long term conditions, well child initiatives and preventing unnecessary hospital admissions.

Transforming the way we deliver services to achieve the change we seek. Success depends on relationships and cooperation as a whole community/sector

Each member of our diverse community in Counties Manukau is enabled to make healthy choices and easily access primary health services.They understand the services available to them and can use them appropriately.

Continuous quality improvement means constantly evaluating and improving what we do. Systems must be put in place to measure service quality and outcomes i.e. find out if we are getting it right. We are accountable to the community.

The workforce needs to be representative of our community, have the skills to provide what is needed and can respond when those needs change. Many solutions to workforce challenges exist within the community itself.

There have been enormous gains to patient care already achieved by information technology in primary health. The potential for further improvements and coordination between providers is enormous and work in this area must continue.

1-Community Well Being 2 -Child & Youth 3 -Priority Conditions 4 -Health Inequalities 5 -Sector Responsiveness

2 -Child & Youth 3 -Priority Conditions 4 -Health Inequalities

3- Priority Conditions 5 -Sector Responsiveness 6 -Capacity & Quality

1-Community Well Being 2 -Child & Youth 3 -Priority Conditions 4 -Health Inequalities

5 -Sector Responsiveness 6 -Sector capacity & Quality

5 -Sector Responsiveness 6 -Sector capacity & Quality


The Counties Manukau Primary Health Care Plan 2007-2010 actively seeks to progress sector respon-siveness to the needs of the population in order to realise improved health for all. It identifies the con-tribution Counties Manukau Primary Care will make to developing healthy futures for the population served over the next 3-4 years.

The success of the Plan will be assessed against the following key performance indicators (KPIs) outlined

in table six below.These key performance indictors are high level and the annual progression steps and/or targets will be detailed in the associated annual work programmes.

The indicators were set in consultation with Counties Manukau PHOs whose input and support is critical to the Plans overall success.

5.0 Measuring Success

Table Five: KPIs for the 2007-2010 Primary Health Care Plan:

DSP Outcome Domain Indicator Target

PHC Plan KPIs Deliverable by June 2010

1. Improve Community Well Being

2. Improve Child & Youth Health 3. Reduce the Incidence & Impact of Priority Conditions Community Engagement Healthy Life styles Prevent infectious disease in children Reduce complications seen from Diabetes Reduce the incidence of Cardiovascular events

All PHOs have a plan with identified processes and KPIs for engagement with communities and/or their enrolled population

Each PHO includes in its annual report progress against the above plan including processes to measure the communities and/or enrolled population’s satisfaction with services and the results.

Increase the percentage of Maaori and Pacific engaged in physical activity

Increase the proportion of 2 year olds that are fully immunised.

Proportion of the estimated number of people with diabetes receiving annual screen

Proportion of those on Diabetes Register who have an HBA1C of 8.0 or less. (Maaori & Pacific agreed at 65%)

Proportion of those on Diabetes register who have had retinal screening in the last 2

Increase the % of those enrolled in Diabetes CCM with a systolic BP < =130

Increase the proportion of Diabetes CCM Patients with an LDL < = 2.5

Proportion of people with a high [1] albumin: creatinine ratio who are on an ACE inhibitor

Cardiovascular Risk Screening coverage of ‘at risk’[ 2]

CMDHB population

Percentage of people with Cardiovascular Risk of >= 15% who are on Aspirin, Statin and ACE inhibitor

100% 100% 95% 75% 75% 75% 75% 80% 90% 50% 60%

[1] High albumin:creatinine ratio is defined as >2.5 in men and >3.5 in women or those with overt nephropathy

[2]For cardiovascular risk the ‘at risk’ population is defined as Maaori, Pacific and Indian Males 35 years and older and Maaori, Pacific and Indian Females 45 years or older and ten years older for other eth-nicities


These KPIs will be achieved by June 2010

The KPIs are aligned with the Health Targets for New Zealand released by the Director General for Health in March 2007. These target areas include some which are mostly dependent on the Primary Sector for success; childhood immunisation, avoidable hospital admissions, diabetes indicators and Nutrition and Physical Activity. The complete range of targets is available in A p p e n d i x N i n e.

(Table Five Continued)

: KPIs for the 2007-2010 Primary Health Care Plan:

DSP Outcome Domain Indicator Target

PHC Plan KPIs Deliverable by June 2010

4. Reduce Health Inequalities 5. Improve Health Sector Responsiveness To Individual & Family/Whaanau Need 6. Improve the Capacity of the Health Sector to Deliver Quality Services Increase Access to primary care for the most deprived Ethnicity Recording and outcomes Reduce avoidable hospitalisations particularly for Maaori and Pacific peoples Reduce Smoking rates in Maaori and Pacific Households Improve Breast Feeding for all mothers but particularly for Maaori. Supported Self Care The Development of After Hours care The delivery of culturally competent care Clinical Quality Improvement in Primary Care Workforce Development

Maintain the proportion of Maaori, Pacific and Deprivation quintile 5 population in Counties Manukau that are enrolled in a PHO

Maintain and improve ratio of Maaori, Pacific and Deprivation quintile 5 population’s utilisation of general practice services to “other” populations at > 1.1

PHOs to maintain or improve on accurate ethnicity recording for all enrolled patients

All indicators to be reported by Maaori, Pacific and Other,. Targets for Maaori and Pacific to be the same or better than the global target unless otherwise stated

Reduce the ASH Rate per 1000 population (with focus under 5 years, 45-64 and 0 -74 yrs)

(It is agreed the best way to achieve this is by reducing the incidence of Cardiovascular Disease and better managing those at high risk of CVD in addition to specific interventions such as POAC, FAMA, After Hours Access)

Percentage of enrolees with smoking status recorded within last 3 years in patients aged >=14 years.

Increase the proportion of infants exclusively and fully breastfed at:

6 weeks 3 months 6 months

Each PHO offers access to a Self Management Education (SME) programme

All newly diagnosed diabetics are offered group SME

Increase capacity of formal enrolments self management programmes to enable 1,000 participants per year

All PHOs after-hours plans are fully implemented providing a network of affordable and accessible after hours primary care services across Counties-Manukau.

Practices with greater than 10% Maaori and/or Pacific populations will have attended Tikanga best practice and Pacific cultural competency training programmes

Achieve targets set in the PHO Performance Management Programme

FTE Reporting of all practice/PHO staff by type (Doctors, Nurses and Community Health Workers) and FTE Achieving all the targets in the "Investing in our Primary & Community Health Care Workforce - Counties Manukau. A Workforce Development Plan 2007-2 011"

99% >1.1 90% 10% 80% 100% 100% 90% 90% 100%


The CMDHB Primary Health Care Plan defines a 5 year health strategy supported by a 3 year work pro-gramme. It proactively seeks to progress sector responsiveness to the needs of the population in order to realise improved health for all and identifies the contribution Counties Manukau DHB Primary Care will make to developing healthy futures for the population served over the next 3-4 years.

It builds upon the achievements of the initial 2002 CMDHB Primary Care Plan; Moving Forward Together, that was a first response to the

Government’s New Zealand Primary Care Strategy 2001. The work of the initial plan realised the devel-opment of sector change in the roles, functions and structures of the primary care.

It has paved the way for the 2007-2010 plan which now seeks to realise the full intent of the national Primary Health Care Strategy. The national strategy set out a ten year vision and we are half way through that timeframe. The sector has come a long way since that strategy was published but we have a long way to go in order to fully realise the vision expressed in the strategy. It is hoped that plan sets out the work pro-gramme and pathway to fully realise the goals and aspirations of the Primary Health Care Strategy.

Key areas for further development include:

Community involvement in health service planning and delivery

Primary Care (under the umbrella of PHOs) will be the first and usual means that people interact with health services

people will have easy access to comprehensive services that improve, maintain and restore their health

having people understand and adopt a supported self care approach to foster wellness, empowering them to understand the links between lifestyle choices, environment and health status

a stronger emphasis on prevention, screening and wellness in order to improve population health and reduce health inequalities

CMDHB and PHOs will work in partnership with their community, the wider health sector and with inter-sectoral agencies to coordinate care and achieve improved health for the population

using systems and information to continuously improve the quality of care and accountability for health outcomes

workforce development including building capacity and growing skills of a multidisciplinary team

6.0 Summary

The population of Counties Manukau DHB includes the territorial local authorities of Franklin, Papakura and Manukau. The population growth and composition is: The population is growing at 2-3 % per year. The popu-lation over 65 years old is projected to double from 33,800 in 2001 to 76,000 in 2021.Total Maaori and pacific populations are growing and ageing. Counties

Manukau has a higher 45-64 year old mortality rate than all of the rest of New Zealand.

The high proportion of Counties Manukau population living in deprivation has a significant impact on health and health service provision. For example the high rate of illness related to overcrowded housing and the con-sequent high hospitalisations for treatment.

The success of the Plan will be assessed in 2011 and will ultimately be reflected in any change in the health status of the community.

7.0 Appendices

Table Six: Projected Population Growth by Age Group, Statistics NZ

Year 0 - 14 15 - 44 45 – 64 65 + Total 2001 2006 2011 2016 2021 2026 % change 2001-2026 104,480 113,300 117,160 119,700 122,400 127,700 22% 174,410 191,750 203,590 211,100 222,000 232,000 33% 81,030 96,980 112,940 124,700 132,900 137,200 69% 33,790 41,140 50,390 63,200 76,400 92,000 172% 393,710 443,170 484,080 518,700 553,800 589,000 50%

Table Seven: Counties Manukau Projected Population Growth by Ethnicity

Ethnicity Other Asian Pacific Maaori % change 2001-2026 2001 198,230 47,700 78,550 69,230 Other 9% 2006 203,050 73,700 90,410 76,010 Asian 162% 20011 211,040 88,300 102,100 82,640 Pacific 81% 20016 213,930 100,600 114,470 89,700 Maaori 52% 2021 215,670 113,000 127,790 97,320 Total 50% 2026 216,140 125,000 142,290 105,570

Source: MoH Ethnic-Specific projections June 2004

Source: MoH Ethnic-Specific projections June 2004


Maaori in Counties Manukau

12% of New Zealand’s Maaori lived in Counties Manukau (including Otahuhu). Some key population figures relating to Maaori in Counties Manukau:

Maaori make up about 18% of the total district population

Within Counties Manukau, relatively few Maaori live in the areas of Howick Pakuranga (5%) and Beachlands Maraetai (7%). Maaori are over-represented in the less affluent areas of Manukau Manurewa (26%), Otara (25%) and Takanini Papakura (24%) but equitably represented in Mangere Papatoetoe Otahuhu (19%) and South Rural (16%)

The projected total fertility rate for a Counties Manukau Maaori woman is 2.8 children Life expectancy at birth is 71 years for males and 74 years for female. This far behind European and others (76.6 and 81.8 respectively)

Maaori living in Counties Manukau have a high level of deprivation – 66% live in areas with an NZDep96 decile of 8 to 10

Pacific people in Counties Manukau

36% of New Zealand’s Pacific people lived in Counties Manukau (including Otahuhu). About half these people identified as Samoan, with Cook Island (21%) and Tongan (16%) being the next largest groups. These proportions are very similar to those for all New Zealand.

Some key population dynamics relating to Pacific people:

Pacific people make up approximately 19% of the total district population

Migration to New Zealand was encouraged by New Zealand’s post-war growth in secondary industry, with many Pacific people settling in Counties Manukau’s dormitory suburbs – 46% of Counties Manukau’s Pacific people reside in Mangere or Papatoetoe or Otahuhu, 28% in Otara and 19% in Manukau or Manurewa

The projected total fertility rate for a Counties Manukau Pacific woman is 3.5 children, well above that for European and

others of 1.9. The rate is expected to decrease to 2.4 by 2021

Life expectancy at birth is 75 years for males and 79 years for females, compared with European and others (80 and 85 respectively)

Pacific people are over-represented in hospital admissions, the causes of many of which are preventable

Pacific people living in Counties Manukau have a high level of deprivation – 84% live in areas with an NZDep96 decile of 8 to 10

Asian people in Counties Manukau

27% of New Zealand’s Asian people lived in Counties Manukau. (Here ‘Asian’ refers to people of Pakistani and Indian ethnicity, through to South East Asia and East Asia, including the Philippines, Indonesia and Japan). The Counties Manukau Asian population are a demographically diverse group. Along with Others (non Maaori, non-Pacific), the Asian community on the whole can be classified socioeconomically as “least deprived”.

In terms of life expectancy and potentially avoidable mortality, the Asian population health status is simi-lar to or better than that of the Others. While the Asian population has a slightly greater number of hospital discharges that are classified as potentially avoidable compared to Others. However this group is over represented in health statistics with regard to childhood obesity and diabetes in the general population. Cultural responsiveness to the needs of Asians is also a significant barrier to access and util-isation.

Some key population dynamics relating to Asian people:

Asian people make up approximately 15% of the total district population

Life expectancy at birth was 80 years for males and 85 years for females

Asian people living in Counties Manukau on the whole have a low level of deprivation – with less than 30% living in areas with a NZDep96 decile of 8 to 10


Primary Health Organisations (PHO’s)are accountable for the health gains of their enrolled populations and are responsible for organising and delivering primary health care to them.

Non Government Organisations (NGO’s)are generally non-profit, voluntary community groups which are organized on a local, national or international level.Task-oriented and driven by people with a common interest, NGOs perform a variety of services in per-sonal health, disability and mental health within the primary care sector. Examples are: the Stroke Foundation,The Mental Health Education & Resource Centre, Family Planning, Plunket Society, Kaupapa Maaori services, etc.

General Practitionersmostly now work as part of a Primary Health Organisation. The estimated 247 fulltime equivalent (FTE) Primary Care Doctors practising in Counties Manukau equates to around 1,600 people per GP. GP’s are accountable for the health of those registered with them.The 2005 national survey highlighted that 30% of GPs were planning to have left practice by 2010 and in 2006 the analysis of CMDHB Community NGO & Primary Health Workforce Survey highlighted 282 new GPs are needed in Counties Manukau by 2021 of which 101 are additional and 181 are required to replace existing practitioners just to maintain the cur-rent GP to population ratio without taking into account the addi-tional workload from aging of the population and increased burden of disease from obesity and other lifestyle factors.

It should be noted that while there is a relative shortage of General Practitioners in Counties Manukau, the development of the multi-disciplinary Primary Health Care Teams (together with increased employment of Nurses and Community Health Workers), should result in General Practitioners realigning their workload so that some of their traditional role can be divested to others.This will assist in maintaining a viable workforce to meet future needs but requires new ways of working and building the skills of the multidis-ciplinary team.

Primary Health Care Nurseshave an evolving role in response to the Primary Health Care Strategy. Primary Health Care Nurses work autonomously and collaboratively to promote, improve, main-tain and restore health. Primary care nursing encompasses popula-tion health, health promopopula-tion, disease prevenpopula-tion, wellness care, first point of contact care and disease management across a lifespan. Primary Health Care Nurses work in wide range of roles – schools, public health nurses, well-child nurses, practice nurses, nurse special-ists, case managers, rest homes, ACC, Community organisations etc. Career pathways development is seeing nursing roles develop and build on a broader scope of practice to incorporate a population health approach.The challenge is to build on these roles to advanced Nurse Practitioner level while ensuring sustainability in the sector

Community PharmacyThere are over 80 community pharmacies in Counties Manukau which dispense prescribed medicines and related products including medicines that are bought by patients i.e. over the counter medicines. Many community pharmacies also pro-vide a range of clinical services including patient counselling and advice on the optimal use of their medication. This may include helping people to keep taking their medication as prescribed espe-cially for those with chronic conditions. This also means liaising with prescribers. There is a growing role for pharmacy in assisting people to adhere to medications prescribed and in supporting self care. The pharmacist role will change in emphasis away from pre-dominantly dispensing to other clinically focused services that assists people particularly those with long term conditions to optimise

their health and work with the rest of the primary care team to avoid harm from medications. This latter area has traditionally been carried out more by Clinical Pharmacists.

Clinical Pharmacistshave a somewhat extended role and tend to have further qualifications at the post-graduate level. Historically these more specialised pharmacists worked in hospitals but increas-ingly can be found working in community pharmacies or employed by primary care organisations.They undertake a range of activities to encourage safe, effective, and cost efficient prescribing and medicine administration. The clinical pharmacist will be involved in more pop-ulation health activities including research (clinical trials), review of those on multiple medicines, reconciling what medications are intended with what is actually taken, and evaluation etc.

Laboratoriescontract with the DHB to carry out a range of labo-ratory tests ordered by health professionals, particularly general practitioners.There are two types of tests, Schedule and non-Schedule. Schedule tests are provided free of charge to patients while non-Schedule tests are usually free from hospital based servic-es only. The demand for laboratory servicservic-es by Countiservic-es Manukau general practitioners is growing rapidly – at a rate well above popu-lation growth.This leads to significant financial pressure on the DHB, but does not necessarily reflect inappropriate use of laboratory services, given the health needs of our population.Therefore the DHB needs to support a dual focus on quality and cost containment.

Dental Servicesare provided by private providers, some of whom receive public funding for care of children and relief of pain services. Auckland Regional Dental Service (ARDS) contracted through Waitemata DHB provides a regional service predominantly focusing on child oral health and the school dental service.

Allied Health Servicesare services that are delivered by allied health professionals – health care practitioners with formal qualifica-tions (education and clinical training). This includes such professions as physiotherapy, occupational therapy, speech language therapy, dietetics and social work etc. They work collaboratively with Doctors, Nurses and other members of the health care team to deliver services in the community. The role and functions of allied health in primary care are a central theme of workforce develop-ment with the establishdevelop-ment of interdisciplinary teams in the sector.

Community Workerswork in a supported and supervised way with health professionals to deliver a range of services to the com-munity ranging form one to one patient contact to work with groups. Community Health Workers play a vital role in assisting patients and whaanau to engage with the “wider system” including health providers and intersectoral agencies to get the most benefit from the system. They will have an increasing role in assisting people to better manage their own health in the future.

Carer Supportworkers are non-regulated and assist disabled peo-ple to live independently in the community or in the residential dis-ability sector.Health Care Assistantsare often specifically trained to fulfil this role.

New Roleswill be developed and become an increasing part of the health landscape of the future. Positions such as Clinical Assistants (Medical, or Nurse Assistants) should result in health professionals being able to review and refocus workloads with some more tradi-tional, less specialised work being delegated.This will assist in main-taining a viable workforce to meet future needs.


The success of many of these related plans is depend-ent on the relationship their targeted populations have with the Primary Health Sector. To make refer-ence to only a few:

The Disability Strategywith its intent of maximis-ing visibility, function and potential within the main-stream for those with disability is a prime example.

The Health of Older Peoples Strategy,with its strong focus on providing and maintaining health related opportunities and choices for the elderly to remain valued members of their communities, remain-ing at home in their community for as long as possi-ble.

The plan for Primary Mental Healthis to take a structured approach to the management of mild to moderate mental health conditions within the com-munity as opposed to hospital services and signal the relationship with the general primary sector as being key to success. The plan integrates well with the Primary Health Care Plan as it is underpinned by a wellness philosophy and strengths based supported self care approach to conditions such as depression and anxiety.

The Well Child Plan(s) with the intent of reducing childhood disease and maximising wellbeing in chil-dren through such targeted programmes as national immunisation, maternity services, screening pro-grammes, nutrition programmes and access to oral health. Although this plan is for increased interaction for the whole community there is particular emphasis on Maaori and Pacific children due to the level of health disparities amongst these groups.

The Youth and Sexual Health Plan(s) are target-ed toward the youth population, agtarget-ed under 22 years, with a particular focus on Maaori and Pacific popula-tions who are over represented in these areas of health need.

The overall goal is to provide a consistent model of services for under 22 year olds that is free for sexual health. This would result in near universal access for this target group regardless of which locality, PHO or Practice they belonged too.

Work is concentrated on achieving consistency in areas such as access to services, sexual health educa-tion, interventions that reduce risk taking behaviours, unwanted pregnancy, teenage pregnancy and sexually transmitted disease. The success of this is dependent on relationships with this population at a primary care level.

Activity covered within the local plans is not repeated here. However, there are some specific aspects of work that have a more immediately explicit relation-ship with the Primary Health Care Plan due to the scope and timing of the projects that underpin them. These are in the areas of Let’s Beat Diabetes (LBD), Maaori Health, and Pacific Health.

Let’s Beat Diabetesis a five year plan aimed at long-term structural changes to prevent and/or delay the onset of diabetes, slow disease progression, and increase the quality of life for people with diabetes. It recognises the significant activity that already exists to prevent and manage diabetes, and creates a long-term vision to align existing activity and a con-text for new investment, based on evidence and best practice. This is a whole of society programme with ten action areas involving multiple agencies and is a plan for Counties Manukau not just the DHB. While it is branded for diabetes it is hoped the resultant work programme and interventions will deliver healthier lifestyles that will impact on global health significantly impacting on the incidence of obesity and its sequels, cancer and cardiovascular disease as well. Primary Care initiatives such as Diabetes Get Checked, CCM and the continued development of accessible retinal screening and monitoring via com-munity services (as a complication of diabetes) directly support the intent of LBD. The alignment and co dependency for success between LBD and primary care is further evident in that both plans recognise the importance of working in partnership the wider sector. LBD is also leading the way with regard to innovative models of care and finding new ways to design and deliver services to the popula-tion – a key focus of the primary health care Plan. Last, both share a philosophy of community engage-ment and empowerengage-ment for health gain which drives the work streams that support the Plans.

The CMDHB Whaanau Ora Planhas six over-arching Maaori Health priority areas:

1. Lifestyle risk factors, 2. Chronic disease,

3. Tamariki and Rangatahi health, 4. Kaumatua, Kuia and disability support

services, 5. Mental health,

6. Infrastructure development.

Areas of alignment which mutually support the suc-cess of both Plans to achieve improved health status for the population are to be realised in work streams such as CCM, where enhancement initia-tives such as He Puna Oranga and Heart Guide Aotearoa look to improve both health outcomes and overall quality of life with a particular focus on Maaori.

The former is a Maaori nurse-led service which focuses on improving the quality of life and struc-tured care for those with chronic disease(s). The latter is a self management tool designed to help patients in the home by focusing on changing and improving lifestyle behaviours through goal setting. This service has particular emphasis on reducing inequalities, targeting clients who have unequal access to cardiac rehabilitation and low completion rates.

Community initiatives such as Hauora Whaanau and Whare Oraanga, look to combine a whole family




Outline : Table Twelve: