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The Northland Diabetes Strategy He Kaupapa Oranga mo te Mate Huka I Roto I Te Tai Tokerau Successfully Taking Action for Northland Diabetes Adopted by the Board December 2006 Acknowledgements The Diabetes Planning Group would like to acknowledge the following key stakeholders who provided comment throughout its development and the peer reviewers who commented on the final document. Veronica and Te Rore Neho Tom Parore Thea Symays Ross Whimp Queenie Kauwhata Vicky Corbett Tracy Wortelboer Chris Frost Dallas Alexander Joe Wickcliffe and family Graheme Comer Nancy Yakkas Jean Gardener Wendy Lunjevich Primecare practice nursing staff Anne Braithwaite Sue Wordsworth Wendy Buckley Isabelle Cherrington Inia Eruera Rhoena Davis Dr Alan Davis Liz Allen Richard Smith Eve De Goey Carol Evans Susan Harris Arlene Baldwin Jane Holden Kim Clarkson Mandy Bax Chris Farrelly Vicky Tyrrell Angela Thornton Stephen Jackson Dr Nick Chamberlain Jenni Moore Di Lawson David Overton Dr Nicole McGrath Fiona Ross Glenis Turner Mereana Waaka - Murch Jeanette Wedding Daniella Tylkowski Joy Jansen Jim Callaghan Ngaire Rae Phillipa Butterini Dagmar Schmitt Judy McCardy Chris Tipa Rose Lightfoot Catherine Turner Taane Thomas Witi Ashby Agnes Maddren Northland Pacific Island Trust Diabetes Northland Henrietta Sakey The Strategy was peer reviewed by: Dr Sandy Dawson, Chief Clinical Advisor, Clinical Services Improvement, Clinical Services Directorate, Ministry of Health Lyn Taylor, Primary Care Portfolio Manager, Hutt Valley DHB Kate Smallman, Diabetes Projects Trust, Counties Manukau Contents 1 TU 2 TU 3 TU 4 TU 5 TU 6 TU 7 TU TU Executive summary ................................................................................................................1 UT TU UT TU UT UT UT UT UT UT Development of STAND .........................................................................................................4 2.1 Northland context ..........................................................................................................4 2.2 National context ............................................................................................................4 UT TU UT TU TU UT TU UT UT Diabetes and its treatment .....................................................................................................6 3.1 What is diabetes? .........................................................................................................6 3.2 Life course approach to chronic care management ......................................................9 3.3 Effective treatment ......................................................................................................10 TU UT TU UT TU TU UT TU TU UT TU UT UT UT Prevalence and service provision ........................................................................................11 4.1 New Zealand ...............................................................................................................11 4.2 Northland ....................................................................................................................11 TU UT TU UT TU TU UT TU UT UT Reducing inequalities ...........................................................................................................23 5.1 Background .................................................................................................................23 5.2 How can we reduce inequalities in diabetes? .............................................................24 5.3 Tools to assist in reducing inequalities .......................................................................24 5.4 He Korowai Oranga ....................................................................................................25 TU UT TU UT TU TU UT TU TU UT TU TU UT TU UT UT UT UT Priorities for action ...............................................................................................................28 6.1 Implementing HEHA and strengthening health promotion ..........................................28 6.2 Children and diabetes .................................................................................................35 6.3 A patient-centred clinical care pathway ......................................................................38 6.4 Review existing services for those with diabetes ........................................................43 6.5 Develop an effective coordinated workforce ...............................................................45 6.6 Information systems that best support STAND ...........................................................51 6.7 A district-wide coordinated approach ..........................................................................53 TU UT TU UT TU TU UT TU TU UT TU TU UT TU TU UT TU TU UT TU TU UT TU UT UT UT UT UT UT UT Evaluation of stand and Performance measures .................................................................55 7.1 Developing Key Performance Indicators (KPIs) .........................................................55 7.2 Proposed Approach to KPIs .......................................................................................57 TU UT TU UT TU TU UT TU UT UT Glossary .....................................................................................................................................60 Figure 1. TU Figure 2. TU Figure 3. TU UT The structure of He Korowai Oranga .........................................................................5 UT TU UT TU UT TU UT The progression of type 2 diabetes ............................................................................6 UT Changes in age-adjusted death rates in the USA for diabetes, stroke and cardiovascular disease ...............................................................................................8 UT Figure 4. TU Figure 5. TU UT TU Continuum of Wellbeing and Disease ........................................................................9 UT Estimated prevalence of (total number of people with) type 2 diabetes in Northland, 2005 ........................................................................................................12 UT TU UT Figure 6. TU Figure 7. TU Figure 8. TU Incidence (new cases) of Type 2 diabetes in Northland, 2005 ................................13 UT TU UT TU UT TU UT Mortality attributable to diabetes in Northland ..........................................................13 UT Northlanders with diabetes, by ethnicity, who are registered with PHOs, May 2005 .........................................................................................................................14 UT Figure 9. TU Numbers of people with diabetes receiving Annual Free Checks by PHO area and deprivation level, 2004 calendar year .......................................................16 UT TU UT Figure 10. Reductions in cardiovascular morbidity and mortality from one intervention ...........18 TU UT TU UT Figure 11. Northlanders with diabetes, by ethnicity, who have received retinal screening within the past two years ..........................................................................................18 TU UT TU UT Figure 12. Hospitalisations for diabetes, age standardised rate/100,000, 1996-2000 ..............20 TU UT TU UT Figure 13. Hospitalisations for diabetes, age standardised rate/100,000 by ethnicity, 1996-2000 ................................................................................................................20 TU UT TU UT Figure 14. Northland DHB patients with primary or secondary diagnosis of diabetes, financial years 2000-01 to 2004-05 estimated .........................................................21 TU UT TU UT Figure 15. Admissions to hospital for people with diabetes, Northland 2001-2005 ..................21 TU UT TU UT Figure 16. Growth in renal replacement therapy 2002-2005 among people with diabetes .......22 TU UT TU UT Figure 17. Northland diabetes indicators 2003-2005 ................................................................22 TU UT TU UT Figure 18. Reducing Inequalities Framework ............................................................................26 TU UT TU UT Figure 19. Health Equity Assessment Tool ...............................................................................27 TU UT TU UT Figure 20. Individual factors affecting health status ..................................................................27 TU UT TU UT Figure 21. Secondary care referral protocol ..............................................................................40 TU UT TU UT Figure 22. The diabetes care pathway ......................................................................................41 TU UT TU UT Figure 23. Current service provision relating to diabetes in Northland .....................................47 TU UT TU UT Figure 24. Outcome measures for STAND ...............................................................................56 TU UT TU UT Figure 25. Key performance indicators for STAND ...................................................................57 TU UT TU UT Figure 26. Proposed health outcome KPIs for STAND .............................................................58 TU UT TU UT Figure 27. Proposed process outcome KPIs for STAND ..........................................................59 TU UT TU UT 1 EXECUTIVE SUMMARY Strategy development STAND (Successfully Taking Action for Northland Diabetes), the Northland diabetes strategy, has been developed by the Diabetes Planning Group to advise the Northland District Health Board (DHB) on how to address the growing epidemic of diabetes in Northland. STAND has been developed collaboratively with primary and secondary care providers, community stakeholders and people with diabetes. Further work will be necessary to implement STAND and monitor progress. The overall aim of STAND is: “To create an environment that stops people getting diabetes, slows its progression, reduces its impact and improves the quality of life for those diagnosed with diabetes.” Diabetes prevalence An estimated 5,644 Northlanders have been diagnosed with either type 1 and type 2 diabetes. Estimates of those undiagnosed range from a third to a half of this number. The impact of diabetes on illness and mortality is significant, not just from the disease itself but from its complications. The prevalence of type 2 diabetes is increasing both in New Zealand and around the world. With the number of people with diabetes in New Zealand predicted to double by 2011, the burden of diabetes and its complications will rise significantly. Part of this increase derives from demographic trends (population growth, an aging population, increasing proportions of Maori, Pacific and Asian people). However 30% of the increase will be a consequence of obesity which is becoming increasingly common. Complications and costs Apart from the direct cost of diabetes, the disease has a big impact on other areas of health spending including: heart attacks strokes lower limb amputations eye disease renal failure maternity services, due to large, sick babies and difficulties in birthing Diabetes cannot be viewed in isolation from cardiovascular disease because there is now clear evidence that diabetes and pre-diabetes (impaired glucose tolerance and impaired fasting glucose) are an underlying cause of up to 80% of coronary heart disease (CHD). A Northland Cardiovascular Strategy is also being developed and will integrate with STAND to form a major part of an overall Northland chronic disease strategy. Preventing diabetes and minimising its impacts STAND’s approach emphasises prevention, early detection and early intervention (using the Leading for Outcomes Continuum of Wellbeing and Disease as a framework). Poor diet, obesity, and reduced levels of exercise are major risk factors for diabetes, so efforts to improve lifestyle behaviours in the general population are given priority. If precursor risk factors begin to develop, early identification of them can enable damage to be reversed and health regained. The Northland Diabetes Strategy Page 1 of 67 Once the disease becomes established, regular monitoring and treatment regimens (which are evidence based) should be agreed between health workers and people with diabetes and are essential to maintaining health status and reducing the strain on health services. Modelling shows that over the next 5 years, diabetes will account for 156 deaths from stroke and heart attack if Northland patients with diabetes remain on their current treatments. By ensuring all those at high risk are prescribed a statin (cholesterol-lowering drug), 20 deaths, 30 strokes and 20 heart attacks could be prevented. Inequalities Northland’s high level of deprivation and high Maori population, means it faces an enormous challenge to control and prevent diabetes in its population. While Maori comprise about 30% of the Northland population, 43% of people who have diabetes are Maori. Northland’s avoidable hospitalisation rate for diabetes is nearly twice the national average and the Maori rate of hospitalisation for diabetes is three times the Northland rate and five times the national rate. Mortality rates for diabetes-related conditions are up to 8 times higher for Maori. Maori present at a younger age than non-Maori for admission with diabetes and more Maori die of diabetes than non-Maori. One of the key themes of STAND is to reduce inequalities for Maori and other high needs populations. This means we should: work within the framework of the Treaty of Waitangi to address issues for Maori; specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership equitably resource Kaupapa Maori programmes or any new or expanded initiatives all workforce development initiatives aim to achieve a culturally responsive service, as measured by the recipients improve case detection and case management through incentives or other measures improve uptake of retinal screening so that 80% of Maori receive screening at least biannually the Funder should continue to set and monitor ethnic-specific targets carry out data improvement which enhances ethnicity information continually strive to identify and address barriers to people accessing programmes and care Priorities for action STAND is built around 7 action areas. These, with their major recommendations are: 1 Implementing Healthy Eating Healthy Action and strengthening health promotion: Develop a plan of action for implementation of Healthy Eating, Healthy Action (HEHA) in Northland; the Diabetes Strategy Coordinator will need to work alongside key stakeholders in the development and implementation of the plan which should be negotiated among Northland providers to identify priorities, responsibilities, linkages and timeframes. Devise a plan of action for strengthening health promotion coordination and activity by concentrating on the recommendations of the stocktake of Northland health promotion providers undertaken in 2004 by three of the Northland PHOs. 2 Children and diabetes Develop a consistent, coordinated approach to reducing the prevalence of factors which predispose children to type 2 diabetes by concentrating on: the prenatal environment breastfeeding The Northland Diabetes Strategy Page 2 of 67 Verbatim quotes have been inserted in boxes throughout the strategy, reflecting the prominence the group considers should be given to the patient journey. childhood obesity intersectoral approaches reducing inequalities 3 A patient-centred clinical care pathway Further develop a patient-centred clinical care pathway for Northland. Carry out regular audits of practice to monitor compliance with the pathway. Carry out regular audits of the patient experience to monitor satisfaction with changes to the pathway. Continue to support enhanced primary care through primary prevention, diabetes screening, annual free checks, and chronic care management. Develop pathways specific to the needs of Maori. Improve case detection and case management through incentives or other measures for Maori. Improve uptake of retinal screening so that 80% of Maori receive screening at least biannually. Continually identify and address barriers to people accessing programmes and services in Northland. 4 Review existing services for those with diabetes Carry out a review of all diabetes-related services throughout Northland. Equitably resource kaupapa Maori programmes or any new or expanded initiatives. Explore ways to enhance whanau, hapu, iwi, and community development. 5 Develop and support an effective coordinated workforce Develop a workforce action plan that is aligned to the needs of people with diabetes in Northland. 6 Information systems that best support STAND Clarify the impact of the MoH national diabetes database (due to be available by the end of 2005) before embarking on a diabetes information systems strategy for Northland. 7 Develop a district-wide coordinated approach Employ a Diabetes Strategy Coordinator within the Northland DHB’s Service Development and Funding team who will work closely with the community in partnership to implement STAND with recommendations to ensure that collaboration and coordination occur. Ideally, this individual will have linkages with the community and proven knowledge in health promotion. For all priorities: Work within the framework of the Treaty of Waitangi to address issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership. The Northland Diabetes Strategy Page 3 of 67 2 DEVELOPMENT OF STAND 2.1 Northland context Diabetes has for several years been one of the major health needs identified in Northland DHB’s annual plans. In September 2004 the Diabetes Planning Group was set up by the General Manager Service Development and Funding to advise Northland DHB on how it should approach diabetes. The Diabetes Planning Group set up 5 focus groups which covered: health promotion primary care services “[Diagnosis] was a hell of a shock; you want to fight secondary care services against it. You need to Maori and Pacific people’s needs talk to someone for at the views of patients and their families least half an hour [but] I The feedback received from these groups formed the basis of the 7 priority action areas of STAND. spent 3 minutes with my health care professional at diagnosis. Information came in dribs and drabs.” STAND will be a significant component of the Northland DHB’s District Strategic Plan, due for completion later in 2005. However, the work will not end there; once the strategy is finalised, there will remain the tasks of implementing it and monitoring progress over the next few years. 2.2 National context The approach taken in STAND has been guided by key documents and requirements which exist at national level. The New Zealand Health Strategy identifies 13 priority health objectives for implementation. One of these is to reduce the incidence and impact of diabetes. STAND reflects the commitment of the Northland DHB to recognising and implementing the articles of The Treaty of Waitangi. This includes: 1 TP PT Treaty based relationships, the terms of which are defined and developed in partnership that the Treaty-based world view (that is, looking from both perspectives) needs to be embraced as a development agenda so that Maori have a proper place and can function as Maori in organisations within the sector that there is an ability for Maori to operate from an independent position as a result of the overarching Treaty relationship that all people have a place and role in the community when the Maori position is secured The Treaty provides a fundamental framework for reducing health inequalities in Northland through putting into action the principles of partnership, participation and protection. It is shown in: setting targets for prioritising the funding of Maori health and disability initiatives taking account of Northland's population profile and health needs analysis building Maori provider capacity in service delivery 1 TP PT Report from Te Wero and its work to support the community and voluntary sector alongside the Taskforce, 2003. The Northland Diabetes Strategy Page 4 of 67 improving upon quality issues He Korowai Oranga and its action plan Whakatataka develop The Treaty of Waitangi into a framework that enables its articles and principles to be applied to the health sector. Figure 1 summarises He Korowai Oranga’s approach. The 4 pathways are later used as analytical tools in the reducing inequalities section of STAND. Figure 1. The structure of He Korowai Oranga Whanau Ora Overall aim Directions Maori aspirations and contributions Crown aspirations and contributions Key threads Building on the gains Rangatiratanga Pathways Whanau, hapu, iwi, community development Maori participation Reducing inequalities Effective service delivery Working across sectors Outcome and performance measures Resource allocation Monitoring, research and evaluation Treaty principles: partnership, participation, protection The Ministry of Health’s (MoH’s) Leading for Outcomes (LFO) model has also been used in the development of STAND. The Continuum of Wellbeing and Disease (Figure 4) takes a life course approach, describing in stages a progression from health to development of disease and potential death. It implies the desirability of healthier lifestyles to prevent chronic disease. The LFO ‘river’ diagram (Figure 2) illustrates the progression of diabetes through the life course. The Northland Diabetes Strategy Page 5 of 67 3 DIABETES AND ITS TREATMENT 3.1 What is diabetes? Diabetes mellitus is a complex condition in which the body is unable to control the amount of glucose (sugar) in the blood, either because the hormone insulin does not work effectively or there is an absence of insulin. Uncontrolled diabetes can lead to metabolic disturbances that increase the risk of long term complications and affect a number of the body’s systems. Figure 2 shows the typical development of diabetes over the course of a lifetime. Figure 2. The progression of type 2 diabetes (Adapted from the Ministry of Health’s Leading for Outcomes material) Factors such as socioeconomic conditions, community, environment, culture, work and individual choice impact on biological risks Before conception Maternal diabetes Critical point at which risk turns into diabetes Antenatal Diabetes progression is inevitable but is slowed with changes in behaviour and medical treatment Birth Gestational diabetes Risk of diabetes developing later in life may be raised in the womb Diabetic Biological risk of diabetes (eg obesity) Diabetes can be prevented if identified in early stages Death Risks develop as we grow and age Source “I had to ask my doctor to be referred to the nurses. All my GP said was I’ve got to do something about my blood sugar, but what should I do? No-one tells you about how to lose weight.” Lake River Sea The majority of people who have diabetes either have type 1 or type 2 (the other main type is gestational diabetes which some women develop during pregnancy, though there are also other causes). In New Zealand, around 10% of those diagnosed will have type 1 diabetes and 90% type 2 diabetes. Both type 1 and 2 are on the increase. In type 1 diabetes, the pancreas produces insufficient insulin and usually presents with symptoms of extreme tiredness and thirst. Onset is usually rapid and can result in acute emergency admission. Uncontrolled hyperglycaemia or high blood sugar can lead to ketoacidosis, a serious condition characterised by high glucose levels, ketones in the urine, vomiting and drowsiness which can cause multiple system failure and death. Type 1 diabetes may develop at any age and can be the result of genetic factors. Its cause lies in viral infection and a breakdown in the body’s autoimmune systems (not lifestyle). The Northland Diabetes Strategy Page 6 of 67 Type 2 diabetes has complex causes, including reduced sensitivity to circulating insulin, and is usually related to excess weight gain. In other words, diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). It is treated by lifestyle modifications in the first instance (exercise and a healthy diet) and due to the nature of the condition, many individuals will need treatment with tablets or insulin at some stage during their life. The onset of type 2 diabetes is usually much slower; patients may not display any symptoms for many years, and seek help only when complications occur. Diabetes can have a major impact on the physical, psychological and material wellbeing of individuals and their families and can lead to complications associated with the disease. People with type 2 diabetes are sometimes mistakenly told they have a ‘mild’ condition, but research shows that type 2 diabetes is as likely as type 1 to cause serious complications. Diabetes can have a debilitating effect for the person diagnosed. Life may be less enjoyable and there is an increased risk of cardiovascular disease, kidney problems and serious complications affecting the eyes and feet. There is no cure for diabetes and individuals are mostly responsible for managing the condition themselves. People with diabetes do not always have symptoms, in which case a diagnosis may not be made until complications have already developed. The United Kingdom Prospective Diabetes Study (UKPDS) found that up to 50% of people with type 2 diabetes have complications on diagnosis. The increasing number of people with type 2 diabetes is driven by several factors. These include population growth, an aging population (which drives some 20% of the expected growth in the prevalence of diabetes) and increasing obesity, which accounts for an additional 30% of the expected growth in prevalence of diabetes. Up to 40% of Maori children are overweight or obese and type 2 diabetes is an increasing problem among children and adolescents. It is estimated that 25% of severely obese children have impaired glucose tolerance. Ministry of Health analysis 2 currently ranks diabetes fourth in relation to the number of disability life years lost across the population, behind ischaemic heart disease (IHD), stroke and chronic obstructive pulmonary disease (COPD). As diabetes often contributes to stroke and IHD, but is not recorded as such, the real loss in disability adjusted life years (DALYs) may be much greater than this. In the past 25 years, while there has been a drop in the ageadjusted death rate for chronic diseases such as stroke and cardiovascular disease, the death rate for diabetes has risen (Figure 3 over the page). 3 TP PT TP PTP Diabetes is rarely a primary cause of death. However, in the US, the diabetes agestandardised death rate rose 6% per year during 1991-96, in contrast to the trend for other chronic diseases (Figure 3); a similar trend is expected in New Zealand. Maori death rates are 4.6 times higher than the total population (47.4 compared with 10.3/100,000 population). 4 It is not possible to assess trends because of changes to ethnicity coding, however almost two-thirds of Maori and Pacific peoples with diabetes will probably die from their diabetes compared with one third of Europeans with diabetes. 4 P P TP 2 TP PT PT Our Health, Our Future, Hauora Pakari, Koiora Roa: The Health of New Zealanders. Available at http://www.moh.govt.nz/moh.nsf/by+unid/6910156BE95E706E4C2568800002E403?Open . Diabetes 2000. Health Funding Authority, 2000. Available at TU 3 TP PT UT http://www.moh.govt.nz/moh.nsf/by+unid/4735077ED3FD9B56CC256A41000975CA?Open . TU 4 TP PT UT The Management of Type 2 Diabetes. NZ Guidelines Group, Dec 2003. Available at http://www.nzgg.org.nz/index.cfm . TU UT The Northland Diabetes Strategy Page 7 of 67 Figure 3. Changes in age-adjusted death rates in the USA for diabetes, stroke and cardiovascular disease 5 TP 5 TP PT PT Type 2 diabetes: managing for better health outcomes. (Prepared by PriceWaterhouse Coopers for Diabetes NZ.) Diabetes NZ, 2001. Available at http://www.diabetes.org.nz/resources/pwcreport.html . TU The Northland Diabetes Strategy UT Page 8 of 67 3.2 Life course approach to chronic care management The MoH’s Leading for Outcomes work includes a model of the Continuum of Wellbeing and Disease (Figure 4) which divides the population into groups according to their level of health or progression along a scale of illness. STAND adopts this approach as a convenient way of analysing the various degrees of diabetes and the impacts these have on both individuals and health services. Figure 4. Continuum of Wellbeing and Disease (Adapted from the Ministry of Health’s Leading for Outcomes material) End stage Healthy population Precursor risk At risk Asymptomatic Mild symptoms Development of attributes that might lead to disease later. Damage accumulates, risk factors combine, likelihood of disease increases. Clinical indicators of disease exist though individual may not be aware of them. Symptoms begin to have an impact. Damage can be reversed through change in lifestyle and reducing risk factors. Health can be regained, the process reversed. Advanced symptoms Symptoms and complications lead to significant loss of health and independence, and often hospitalisation. Severe debilitation, hospitalisation and intensive, costly treatment or palliative care. Disease state, cure impossible. Damage often becomes irreversible, and at best can be repaired or ameliorated through treatment and monitoring. Disease management Screening and detection STAND’s 7 key action areas cover parts of the continuum in the following ways (the numbering reflects the order they appear in section 6, not any particular priority): Reduce inequalities 6.1 Implementing Healthy Eating Healthy Action, strengthening health promotion 6.2 Children and diabetes 6.3 Patient-centred clinical care pathway 6.4 Review existing services for those with diabetes 6.5 Develop an effective, coordinated workforce 6.6 Information systems that best support the strategy 6.7 A district-wide coordinated approach The Northland Diabetes Strategy Page 9 of 67 There is increasing evidence that many non-communicable diseases such as cardiovascular disease and diabetes are determined not just by risk factors in mid to adult life, but by behaviours throughout life. The life course approach encompasses factors that date back to infancy and “There is a real lack of childhood, and even back to before birth. The information. When you’re traditional lifestyle model approach to chronic Maori, you say it’s all right and disease, on the other hand, focuses almost put it off. We need more exclusively on adult risk factors. information in Maori and you need to say how it is, but in a The life course model also considers the social way that doesn’t belittle them interventions which result in behavioural changes or call you fat or huge. You across all stages of lifespan (gestation, infancy, need a different approach” childhood, adolescence, young adulthood and midlife) which may affect risk of disease later on. 6 TP 3.3 PT Effective treatment Despite the rapid growth in diabetes and its increasingly early onset, there is strong evidence to show that: the onset of diabetes can be delayed or even prevented 7 effective management can increase life expectancy and reduce complications self management is crucial to effective diabetes care 8 TP TP PT PT Good management can reduce the risk of serious complications at an early stage. This means prompt diagnosis, regular checks to identify serious complications at an early stage, and treatment to control blood glucose levels. Better blood glucose control reduces eye disease by one quarter and renal (kidney) disease by one third; effective eye screening and treatment can reduce blindness by one half and early intervention for foot problems can reduce amputations by two thirds. 9 “I think you need a book, like Diabetes Support and education is crucial so that individuals can manage and You, which tells this complex disease effectively themselves. In the long term, you what to do and is empowering patients is the key to improving health and reducing comprehensive. This demands on services. has been a great help to me, but we needed it 20 years ago.” TP 6 TP PT PT Life course perspectives on coronary heart disease, stroke and diabetes. WHO, 2001. Available at http://search.who.int/search?ie=utf8&site=default_collection&client=WHO&proxystylesheet=WHO&output=xml_no_dtd&oe=utf 8&q=life+course . TU UT 7 TP PT Diabetes Prevention Progam Research Group (Washington), 2002. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Eng J Med, Feb 2002. Available at http://content.nejm.org/content/vol346/issue6/index.shtml . Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ 2002; 325, 746. Available at http://bmj.bmjjournals.com/content/vol325/issue7367/ UK prospective diabetes study (UKPDS), 1998. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in people with type 2 diabetes. Lancet 1998; 352: 837-853. Available at TU 8 TP PT UT TU 9 TP PT UT http://www.thelancet.com/journals/lancet/article/PIIS0140673698070196/fulltext TU The Northland Diabetes Strategy Page 10 of 67 UT 4 PREVALENCE AND SERVICE PROVISION 4.1 New Zealand Diabetes affects about 200,000 people in New Zealand but only half of them have been diagnosed. The prevalence of diabetes across the population of New Zealand is currently estimated to be 4%. In the next 20 years, it is projected that the prevalence of diabetes in New Zealand will, if left unchecked, increase by: 90% in Maori 109% in Pacific peoples 39% in Europeans 5 P 4.2 P Northland What the data tells us about diabetes in Northland The number of people with diabetes in Northland is rising rapidly. Although we don’t have exact numbers, it is estimated that 5,644 Northlanders have so far been diagnosed with diabetes; between a third and a half of the diabetic population are undiagnosed, so the total number may be as high as 8,000. Diabetes occurs more frequently in Maori and Pacific peoples. While Maori are 30% of Northland’s population, 43% of known individuals with diabetes are Maori. Control of diabetes in Northland leaves much room for improvement: About a third of people in Northland diagnosed with diabetes have blood glucose levels that are poorly controlled. This figure rises to more than 40% among Maori and nearly 40% among Pacific peoples. Preventive measures are not well utilised. Less than 40% of individuals known to have diabetes receive an annual free check. Of these only about two-thirds have had a retinal screen (eye check) during the last 2 years. Complications of diabetes are a significant and growing user of hospital services. Hospital service use in Northland is 1.7 times that of New Zealand as a whole. Between 2001 and 2005 the number of admissions to hospital for diabetes-related conditions grew 3.3 times from 726 to 2,376. The average number of days those people have had to stay in hospital have risen from 3.95 to 4.84. The Northland Diabetes Strategy Page 11 of 67 Northland, in common with the rest of New Zealand, is experiencing a growing epidemic of type 2 diabetes. As one of the most serious chronic diseases facing Northlanders, diabetes has been identified as a priority for Northland DHB. Northland has a high level of deprivation and a high Maori population, and it will be an enormous challenge to prevent, control and manage the condition. Maori and Pacific peoples are at particular risk of diabetes. There is also growing evidence that type 2 diabetes is being diagnosed at a much earlier age in children and young adults. Ministry of Health prevalence statistics do not currently include the under 25 year old age group, but Northland has at least 25 young people with type 2 diabetes known to secondary care services. Inequalities, Maori and diabetes in Northland Figures 5 and 6 show that diabetes occurs at a much younger age for Maori. Because Maori life expectancy is 12 years lower than non-Maori in Northland, there are much fewer Maori in older age groups with diabetes. Figure 5. Estimated prevalence of (total number of people with) type 2 diabetes in Northland, 2005 10 TP PT 800 Number of people 700 600 500 Maori Pacific Other Total 400 300 200 100 0 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 Age group 10 TP PT Northland Regional Diabetes Team report for 2005. The Northland Diabetes Strategy Page 12 of 67 70-74 75-79 80-84 85+ Incidence (new cases) of Type 2 diabetes in Northland, 2005 11 Figure 6. TP PT 70 Maori Pacific Other Total Number of people 60 50 40 30 20 10 0 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age group Maori suffer from the effects of diabetes more than others in the Northland population. They have a higher incidence (number of new cases) of type 2 diabetes than the general population. 12 Maori in Northland are at least 25% more likely to die of diabetes-related illnesses and at a younger age than Non-Maori (Figure 7). 13 TP PT TP Figure 7. PT Mortality attributable to diabetes in Northland 25 Maori Pacific Other Total Number of people 20 15 10 5 0 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age group Maori and non-Maori with diabetes are accessing annual free checks at a similar rate and number in Northland. This equity between Maori and non-Maori has consistently been one of the best in New Zealand. However, fewer Maori have good control of blood glucose (see Figure 17). 11 TP PT 12 TP PT 13 TP PT Northland Regional Diabetes Team Report for 2005. Reti S, 2004. Diabetes in Northland. Northland Regional Diabetes Team Report for 2005. The Northland Diabetes Strategy Page 13 of 67 In 2004/05, prevalence of retinopathy (eye disease) among people with diabetes in Northland was higher for Maori than non-Maori (20% all ethnicities, 24% Maori). Retinopathy prevalence in the Northland’s total population is higher than New Zealand’s. The Northland Regional Diabetes Team report for 2005 states: It is pleasing to see that after the drop in retinal screening in 2004, the number of people screened in 2005 is similar to previous levels in 2002 and 2003..... In 2004 there was a 20% difference between Maori and Europeans, and this year this has been reduced to 7%. 14 TP PT Maori and Pacific peoples also have a higher percentage of people with diabetes who smoke (26% compared to 12% in the European population). Efforts in cardiovascular risk factor reduction are important measures to improve health outcomes. Diabetes in the primary care setting It is estimated that 5,644 people with diabetes (type 1 plus type 2) are registered with primary care providers in Northland (Figure 8). Prevalence data suggests that there might be as many as 8,000. This concurs with statements that up to 50% of those with diabetes are undiagnosed (MoH; PriceWaterhouse Coopers, 2001). Maori comprise 30% of Northland’s population, though the proportion of Northlanders with diabetes who are Maori should be lower than this figure because of their younger age structure. Their actual share is 43% (2,433 out of 5,644). Figure 8. Northlanders with diabetes, by ethnicity, who are registered with PHOs, May 2005 Ethnicity Number % of total Maori 2,433 43% Other 3,145 55% 65 1% 5,644 100% Pacific Total Enhancing primary care Primary prevention strategies. Lifestyle interventions do seem to be effective in patients with impaired glucose tolerance. An intensive dietary modification and exercise programme in the USA resulted in a 58% reduction in incidence of diabetes. 15 In the US, the National Diabetes Prevention and Control Programmes have shown that individualised care through comprehensive diabetes assessment, education, referral, and follow-up care through innovative partnerships is very effective. Although exercise and physical activity can reduce people’s risk of developing type 2 diabetes, particularly among those with elevated fasting glucose levels and impaired glucose tolerance, translating this knowledge into effective public health actions is not easy. TP PT Diabetes and CVD risk screening programmes. This Northland pilot programme, organised through Northland DHB, has screened 1,000 high-risk patients in 2 areas of Northland. It has demonstrated: the benefit of screening for diabetes, with a 3% yield of new diagnoses 14 TP PT 15 TP PT Northland Regional Diabetes Team Report for 2005. Diabetes Prevention Progam Research Group (Washington), 2002. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Eng J Med, Feb 2002. Available at http://content.nejm.org/content/vol346/issue6/index.shtml . TU The Northland Diabetes Strategy UT Page 14 of 67 the high proportion of these patients with high cardiovascular risk – 20% have a greater than15% risk of developing cardiovascular disease (angina, heart attack or stroke) in the next 5 years6 the difficulties general practices have of reaching those with the highest risk the importance of opportunistic screening rather than relying on a formal recall system Screening for diabetes must be accompanied by screening for CVD risk and vice versa. It may be that patients can better understand the concept of a greater than 20% (1 in 5) chance of having a heart attack or stroke in the next 5 years, rather than a risk of developing diabetes, which is still to many a largely asymptomatic disease. Another project in the Far North is screening Maori males for cardiovascular risk in the community. It is being extended to all high-risk patients and will be assisted by the Northlandwide rollout of the Predict electronic decision support tool for cardiovascular disease and diabetes. There is a clear need for widespread opportunistic diabetes and CVD screening in general practice and in Maori and Pacific provider and community health clinics. This should ensure the screening pathway remains intact and that people with newly diagnosed diabetes can access appropriate care and treatment. Prompts for screening of high-risk groups via patient management systems, and the use of HbA1c for screening those patients who may not return for a fasting plasma glucose, may be some of the pragmatic and innovative ways needed to ensure that as many high risk people as possible are screened for diabetes. Annual Free Checks. This is an initiative to provide people with diabetes with one free primary care visit a year. Northland DHB is working with Northland PHOs to significantly increase the number of Annual Free Checks performed each year. A template is filled out either manually or electronically, and a checklist of examinations, investigations and interventions is performed. The results are collated in a regional database and the Regional Diabetes Team uses these to produce a yearly report. Results from an overseas study 16 suggest that a structured approach to care can achieve positive results: 59% decreased their weight (mean decrease of 2.8%) 9.7% stopped smoking 43% reduced HbA1c (blood glucose) to less than the threshold level of 8 a 10.4% reduction in mean HbA1c in 12 months (from 9.52 to 8.53) TP PT Figure 9 (over the page) overlays the deprivation map of Northland with, by PHO, the number of people with diabetes currently enrolled with a GP and receiving annual free checks. There is possibly some service overlap in the population of Kaiwaka, who are seen in secondary services, but under the care of a PHO within the Waitemata DHB’s area. Diabetes Chronic Care Management. Disease management is an evidence-based approach to health service planning and provision that offers a more integrated and holistic approach for patients with chronic disease. Care is focussed on people with the disease and their experience of the complete clinical course of the condition, rather than viewing their care as a series of discrete encounters with different parts of the healthcare system. ‘CarePlus’ is a PHO programme which assists general practices to provide free extended quarterly visits for patients with diabetes complications or more than one chronic condition to ensure that all areas of diabetic care are addressed. The emphasis is on evidence-based care and reliance on guidelines (via either electronic means or hardcopy manual guidelines ) which should ensure a consistent standard of care is delivered. A care plan is developed in partnership between the patient and their primary care provider. 16 TP PT Tilyard M, 2002. New diabetes therapy. (Slides from a presentation to NZ Primary Care Conference.) The Northland Diabetes Strategy Page 15 of 67 Figure 9. Numbers of people with diabetes receiving Annual Free Checks by PHO area and deprivation level, 2004 calendar year Northland Enrolled pop. Dec 04 146,302 People receiving AFCs 2,555 Percent of enrolled pop. 1.7% Te Tai Tokerau PHO Enrolled pop. Dec 04 41,469 People receiving AFCs 249 Percent of enrolled pop. 0.6% Hokianga PHO Enrolled pop. Dec 04 People receiving AFCs Percent of enrolled pop. Approximate PHO catchment Coast to Coast PHO (part of Waitemata DHB) Whangaroa PHO Enrolled pop. Dec 04 People receiving AFCs Percent of enrolled pop. 3,218 164 5.1% 6,633 313 4.7% Tihewa Mauriora PHO Enrolled pop. Dec 04 People receiving AFCs Percent of enrolled pop. 8,729 376 4.3% Kaipara PHO Enrolled pop. Dec 04 12,008 People receiving AFCs 248 Percent of enrolled pop. 2.1% Manaia PHO Enrolled pop. Dec 04 74,245 People receiving AFCs 1205 Percent of enrolled pop. 1.6% There is increasing recognition that the system changes and strategies required to improve one chronic disease are the same as those found to improve care for other chronic conditions. Evidence internationally 17 and from the Counties Manukau Chronic Care Management Programme 18 indicates that disease management programmes incorporating these changes can: improve patient health outcomes reduce avoidable hospital admissions potentially save total health care expenditure achieve this with high levels of patient and provider satisfaction TP TP PT PT 17 TP TP Luft H S, 2003. International perspectives on disease management. (Slides from a presentation to a NZ Disease management conference.) 18 Ogle M, 2003. Implementing chronic disease management in Northland. (Unpublished paper prepared for Northland DHB.) PT PT The Northland Diabetes Strategy Page 16 of 67 The benefits of intensive management of diabetes and adherence to guidelines that occur in Chronic Care Management programmes is demonstrated in the UK Prospective Diabetes Study 19 . The study group’s average blood pressure dropped from 154/87 to 144/82 over an 8 year period, which had the following benefits: 32% reduction in deaths related to diabetes 44% reduction in strokes 34% reduction in diabetic retinopathy progression 47% reduction in visual loss TP PT The US Veterans Affairs organisation looks after nearly 4 million people. They found 20 that better control of diabetes among their 82,000 diabetic patients was associated not with direct clinical care but with organisational characteristics such as: integrating computerised health information systems into the care of persons with chronic illness to produce reminders (in Northland this relates to Chronic Care Management annual free checks) developing multidisciplinary teams to address specific concerns (Healthy Eating, Healthy Action, retinal screening) actively involving physicians in quality improvement programmes (clinical governance, accreditation, PHO performance programme) giving primary care providers greater authority to implement clinical initiatives and develop staffing arrangements notifying patients of changes (patient-held care plans) TP PT Kaiser Permanente 21 have identified the following additional features: attending more than 70% of clinic appointments frequent self-monitoring of blood glucose TP PT Clinics with all the good features and few or none of the bad ones obtained average reductions of 2.0 to 2.5% in HbA1c levels more than clinics not having these characteristics. The UK Prospective Diabetes Study 21 showed that a 1% reduction in HbA1c leads to a 21% reduction in risk of diabetes related complications and death, so the implications are considerable. P P Data from Northland’s diabetes database has shown the benefits that could be gained from one initiative, namely prescribing cholesterol-lowering drugs (statins) to all eligible people with diabetes (Figure 10). This suggests that if, as recommended in the national guidelines, every Northlander with diabetes who had a greater than 15% risk of having a cardiovascular event (angina, heart attack or stroke) was prescribed a statin, then over the next 5 years, we could prevent 30 heart attacks, 19 strokes and 20 deaths from cardiovascular disease. Other interventions such as improving blood glucose control or becoming physically active may produce even greater health gains. 19 TP PT UK Prospective Diabetes Study Group, 1998. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. BMJ; 317: 703-13. Available at http://bmj.bmjjournals.com/content/vol317/issue7160/ . Jackson GL, 2005. Veterans Affairs primary care organisational characteristics associated with better diabetic control. American Journal of Managed Care, 2005; 11: 225-237. Karter A J, 2005. Achieving good glycaemic control. American Journal of Managed Care, 2005; 11: 262 –270. TU 20 TP PT 21 TP PT The Northland Diabetes Strategy UT Page 17 of 67 Figure 10. Reductions in cardiovascular morbidity and mortality from one intervention Estimated number of events in 5 years on present prescription (including current statin prescribing rates) Estimated number of events avoided in 5 years if all people with CVD risk >15% are started on a statin Coronary heart disease (CHD) 448 46 Myocardial infarct (heart attack) risk 263 30 CHD mortality 102 13 Cerebrovascular accident (CVA, or stroke) 163 19 Total cardiovascular disease 865 90 CVD mortality 156 20 Retinal screening Diabetes is the most common cause of avoidable loss of vision in people of working age. It can be reliably detected by regular retinal screening, which involves a digital photograph being taken of the retina and a visual acuity (eye test) check. Between 6% and 39% of people with type 2 diabetes have retinopathy at diagnosis, with 4% to 8% having sight-threatening disease. Retinal screening coverage (Figure 11) dropped between 2003 and 2004. Although it recovered again in 2005, overall coverage for the total population is still below the MoH target of 80%. Prevalence of retinopathy appears to be higher in Northland (20% total across all ethnicities) than other District Health Boards (Waikato 9-10%, Lower Hutt 11-12%). Figure 11. Northlanders with diabetes, by ethnicity, who have received retinal screening within the past two years 100% 90% 85% 80% 70% 83% 75% 73% 69% 75% 69% 67% 60% Maori Pacific Other Total 54% 50% 40% 30% 20% 10% 0% 2003 The Northland Diabetes Strategy 72% 68% 67% 2004 2005 Page 18 of 67 Northland DHB undertook a review of retinal screening service provision during 2004/05, with a view to improving delivery of services and uptake of screening. The following areas for improvements were identified: database information and data capture protocols and standing orders within the clinic patient information and outpatient letters turn-around times between patient appointments and delivery of results clinic booking procedures, administration of the clinics and process through the system rates of DNAs (did not attends) at clinics camera transportation To gain the perspective of service users, a patient satisfaction survey was undertaken throughout Northland. Comments overall were positive. Results (total sample 112) included: 5 people said they hadn’t had opportunity to change their appointment 1 person said they hadn’t received enough notice of their appointment 3 said that their choice of venue was not convenient 11 patients waited longer than 20 minutes before being first seen 3 said they were not satisfied with the explanations given for the procedure all 28 people who received additional eye drops before screening were happy with the explanations given for the procedure 4 people said that the letters explaining their screening results were not satisfactory MoH recommends that retinal screening services should use screening cameras that are nonmydriatic (that is, avoid the need for eye drops to dilate pupils). Since Northland DHB purchased such a camera, patient satisfaction has improved, but not as much as anticipated because about two-thirds of patients still need eye drops. It is hoped that future process improvements will reduce this figure. The new system offers immediate views of the eye, a good teaching experience and user involvement, earlier cataract detection and fast tracking, and there has been no recall of any patients as a result of poor camera views, which did occur with the previous system. As a result of the review to the retinal screening service, the following changes have been undertaken or are in the process of occurring: all patients are telephoned prior to their appointment to confirm their attendance a process is occurring to ensure appropriate registration of the database new referral forms master tracking and audit sheets for clinics review of protocols, grading criteria, patient letters and information, turn-around times, process and flow charts in line with best practice guidelines clinic settings and community venues sought to improve access regular team meetings to review the continuing process Diabetes in the hospital setting Northland’s avoidable hospitalisation rate for diabetes (those who wouldn’t have to go to hospital if their condition had been managed well in the community) is nearly twice the national average. Maori rates are higher than non-Maori. Diabetes on its own is seldom a reason for admission to hospital. In 2004 Northland DHB needed 10,047 bed-days to treat people who had diabetes, though less than 1% of them were admitted because of the condition; the rest were admitted for other reasons, many of which were complications associated with diabetes. The disease has a big impact on other areas of health spending including: The Northland Diabetes Strategy Page 19 of 67 renal services amputations eye disease cardiovascular disease (heart attacks and strokes) pregnancy (large babies and difficulties in birthing, and diabetic imprinting on babies) intensive care services for with patients with undiagnosed diabetes Northland’s age standardised rate of hospitalisation for diabetes of 133 per 100,000 is 1.7 times the overall New Zealand rate of 77 per 100,000 (Figure 12). Figure 12. Hospitalisations for diabetes, age standardised rate/100,000, 1996-2000 Area Number of cases Rate per 100,000 SRR** 95% CI for SRR 952 133.3 1.7 1.55-1.92 13,609 77.3 1.0 - Northland NZ Data source: NMDS, Ministry of Health Medium series population projections based on 1996 Census data **SRR: standardised relative ratio, using NZ rate as the base, Within this total population figure there is a bigger relative difference for Maori (1.9 times in Northland) than for non-Maori (1.2 times) (Figure 13). Figure 13. Hospitalisations for diabetes, age standardised rate/100,000 by ethnicity, 19962000 Total discharges, 1996-2000 Average annual rate per 100,000 SRR** 95% CI for SRR Maori Northland NZ 532 2,967 390 210 1.9 1.0 1.68-2.15 - Non-Maori Northland NZ 420 10,642 81 70 1.2 1.0 1.01-1.35 - Ethnicity / area NMDS financial years, 1996-2000, Ministry of Health, medium series projected population, June years 1996-2000 Figure 14 shows diabetes-related admissions (which are graphed in Figure 15) and length of stay, both of which have continued to increase steadily over the last 4 or 5 years. Admissions have increased by 3.3 times from 726 to 2,376, while average length of stay (a measure of the complexity or severity of patients’ conditions) has increased by nearly a quarter from 3.95 to 4.84 days. Of the patients described by Figures 14 and 15: more than 25% of patients admitted with heart failure had a secondary diagnosis of diabetes amputation rates remain unchanged despite the increasing prevalence in diabetes, which may be due to the implementation of the at-risk foot clinic 203 people were admitted to Northland DHB services with renal failure as a result of diabetes in the year ended 1 June 2002 The Northland Diabetes Strategy Page 20 of 67 Figure 14. Northland DHB patients with primary or secondary diagnosis of diabetes, financial years 2000-01 to 2004-05 estimated 2000/01 2001/02 2002/03 2003/04 2004/05* 374 7 309 36 726 831 22 1019 69 1941 1027 26 1181 49 2283 1070 18 1310 56 2454 972 19.2 1332 52.8 2376 Total bed days Maori Pacific European Other Total 1335 36 1342 156 2869 3684 65 4385 201 8335 5055 124 5023 206 10408 4665 113 5054 215 10047 4129 62 5239 161 9592 Length of stay Maori Pacific European Other Total 3.57 5.14 4.34 4.33 3.95 4.43 2.95 4.30 2.91 4.29 4.90 4.77 4.25 4.20 4.56 4.36 6.28 3.86 3.84 4.09 5.10 3.90 4.72 3.66 4.84 Admissions Maori Pacific European Other Total * Estimated based on year-to-date data. Figure 15. Admissions to hospital for people with diabetes, Northland 2001-2005 2500 Number of people 2000 Maori Pacific Other Total 1500 1000 500 0 2001 2002 2003 2004 2005 est. Age group Renal replacement therapies are programmes designed to manage people who have end stage renal failure or whose kidneys are no longer able to function normally. Figure 16 shows that since 2002 there has been an increase in the number of patients on renal replacement therapy (which includes 5 treatments: in-hospital haemodialysis; home haemodialysis; peritoneal dialysis; kidney transplants; pre-dialysis treatment). The Northland Diabetes Strategy Page 21 of 67 Figure 16. Growth in renal replacement therapy 2002-2005 among people with diabetes Numbers of patients 100 80 60 40 20 0 2002 2003 2004 2005 Year Diabetes trends At the moment, providers in Northland might just be keeping control of demand on services for diabetes over the total population. As Figure 17 shows, any movements in service usage are minimal and fairly equally divided between improvement and deterioration. This relatively steady state is an achievement in itself given the ever-rising need for services for diabetes. Results for Maori are a mixed bag. The percentage of Maori with diabetes who receive retinal screens (68%) is now close to that of the non-Maori non-Pacific population (75%) after a worrying widening of the gap in 2004. However, two measures remain concerning for Maori: people with diabetes within a formal annual free check programme, which declined from 47% to 39% for Maori between 2003 and 2005 of this group, those with HbA1c over 8% (indicating inadequate management of the condition) which after improving in 2004, jumped to 48% in 2005, higher than the 2003 level Figure 17. Northland diabetes indicators 2003-2005 Total Maori 2003 2004 2005 Population 146,340 Pacific Other 2003 2004 2005 2003 2004 2005 48,374 1,980 63 2003 2004 2005 95,986 Expected prevalence of diabetes (no.) 5,407 5,173 5,397 2,302 2,312 2,430 62 69 % of population 3.7% 4.8% Diabetics receiving Annual Free Check (AFC) 44% 39% 43% 47% 43% 39% 38% 20% 23% 41% 36% 45% Diabetics receiving AFC without effective management (HbA1c<8) 35% 32% 33% 46% 42% 48% 33% 38% 73% 25% 23% 23% Diabetics receiving AFC who have had retinal screen within 2 years 74% 69% 72% 71% 54% 68% 63% 85% 67% 76% 83% 75% 3.2% 3,042 2,799 2,898 3.2% Diabetes-attributable lower limb amputations 33 17 2 14 Amputations /1000 diabetics 6.1 7.4 31.9 4.6 The Northland Diabetes Strategy Page 22 of 67 5 REDUCING INEQUALITIES “Tini whetu ki Te rangi, He iti pokeao ka Ngaro.” “A small cloud overhead will obscure the stars; even a small group can overcome the multitudes.” 5.1 Background Inequalities in health status (quantified throughout section 4.2) exist across a number of key dimensions: between the general population and Maori between the general population and Pacific people between the general population and high deprivation populations Evidence from the Netherlands shows that health systems can contribute to the overall decrease in inequalities. 22 The approach that needs to be taken has been identified in the Alma Ata declaration of 1978: 23 TP TP PT PT “Inequalities should be confronted using a primary health care approach”. The invited commentary in the 2005 MoH report Decades of Disparity 2 24 , describes the impact of inequality in the following way: TP “When I was diagnosed, no-one told me how important it is [to change my lifestyle completely] and at diagnosis this information is crucial. You have to put your foot down and tell them straight.” PT “What is it in the health sector that creates and maintains inequalities in health? This research gives an indication that it may be the access to and pathways through health care that systematically discriminate against people with low incomes and therefore deny them the same opportunities to health as those with higher incomes.” “I had the same experience [of lack of information at diagnosis] and I was diagnosed only a year ago. It wasn’t a proper lab form; the receptionist at the lab helped me as she could see I was very nervous and telephoned the Diabetes Centre for me.” The main barriers to access are listed as: financial barriers – inability to afford payments or prescriptions or existing debts with GPs geographic and transport barriers to reaching services lack of understanding of health issues and screening programmes barriers within the health system cultural barriers – failure of services to provide information in a culturally appropriate manner The Maori focus group identified that key to the delivery of good services is: to ensure delivery by trained individuals who understand the issues and experiences of Maori that these services should be delivered as close to the people as possible 22 TP PT Mackenbach, cited by Crampton in: Decades of Disparity 2. Ministry of Health, 2005. Available at http://www.moh.govt.nz/moh.nsf/by+unid/1999A3F85F9DA156CC256FE9000AD7FC?Open TU 23 TP PT 24 TP PT UT Alma-Ata declaration. International conference on Primary Health Care, Alma-Ata, USSR, Sept 1978. Decades of Disparity 2. Ministry of Health, 2005. Available at http://www.moh.govt.nz/moh.nsf/by+unid/1999A3F85F9DA156CC256FE9000AD7FC?Open TU The Northland Diabetes Strategy Page 23 of 67 UT Community change rather than purely health focussed solutions also need to be sought. Health and other groups should work jointly towards shared goals, provide positive activities to help uplift the esteem and knowledge of the whole community and promote a sense of oneness. This may include approaches that enable communities to take ownership of problems, implement their own solutions, and identify community leaders. The Maori focus group also agreed that a change in focus needed to take place as there were still perceptions amongst individuals that diabetes was not a serious disease, and would inevitability exist in some families. One comment was: “Can the community work together to extend the life of our kaumatua so their grandchildren can learn more from them?” Energies should be directed towards preventive activities, using models such as the Ngati and Healthy Project, which focuses on making healthier and culturally appropriate food choices. Pacific peoples Northland has only one small contract aimed specifically at Pacific peoples and one part-time district nurse assigned to the specific health needs of Pacific peoples. The Pacific population within Northland is small (2.1% of our total population in 2001), though it is growing more rapidly than other subgroups of the population. Pacific people’s issues are gaining increasing prominence in planning. 5.2 How can we reduce inequalities in diabetes? Reducing inequalities is a prime driver in Northland DHB’s planning, prioritisation and funding. It is expected that from 2005 onwards all major strategies, plans and priorities will require ‘filtering’ by the application of tools (described in section 5.3) to assess how effectively they will reduce inequalities. “I have no complaints. I had sufficient information given to me by my doctors, but I had no choice, I had to go onto tablets. I was an adult and had some assistance. We had general discussions, but it was sufficient. The doctors are busy” This filtering process will apply during the implementation of the priorities for action, around which section 6 is structured. To ensure that the implementation of STAND is carried out effectively, the appointment of a Diabetes Strategy Coordinator (section 6.7) is suggested. The Coordinator will work with the Regional Diabetes team and other stakeholder groups and mechanisms to implement STAND. 5.3 Tools to assist in reducing inequalities MoH has developed the Reducing Inequalities Framework (Figure 18 over the page) as a tool to identify factors which cause or worsen inequalities, and the Health Equity Assessment Tool (Figure 19) to assist in developing approaches to overcome inequalities. The ‘big picture’ factors identified in the Reducing Inequalities Framework can be brought down to the level of the individual; the table in Figure 20 depicts how the social and economic determinants of health may get ‘under the skin’ to ultimately affect health at an individual level. The Northland Diabetes Strategy Page 24 of 67 5.4 He Korowai Oranga One of the key threads of He Korowai Oranga’s (Figure 1) is reducing inequalities in health status. He Korowai Oranga’s 4 pathways for improving Maori health are a useful framework for assessing how plans approach reducing inequalities. The analysis below uses the pathways to categorise the actions proposed throughout the ‘priorities for action’ sections in the remainder of this strategy. HKO pathway Recommendations relating to the pathway (summarised version) Whanau, hapu, iwi, community development Enhance whanau, hapu, iwi, community development (in service review section 6.4). Maori participation Address health promotion issues for Maori through the frameworks of the Treaty of Waitangi and He Korowai Oranga (in all 7 sections). Effective service delivery All 8 recommendations under the patient-centred clinical care pathway section, which relate to: audits on compliance with pathway and patient satisfaction pathways specific to Maori improved case detection and management for Maori improved uptake of retinal screening addressing barriers to care [Also note comments from the Maori focus group about how services should be delivered, documented in section 5.1.] Equitably resource Kaupapa Maori programmes (in service review section 6.4). All professional development courses to be culturally competent in their delivery and encompass a reducing inequalities focus. All workforce development initiatives to aim for culturally responsive services. Funder to continue to set ethnicity-specific targets. Working across sectors Information on ethnicity to be an integral part of all data systems. Implementation plans for HEHA and health promotion. Workforce development for people in sectors outside health promotionspecific services. Collaboration at local, regional, national levels, including between health promotion, community organisations and primary care practitioners. The Diabetes Strategy Coordinator will work with the Regional Diabetes Team and other diabetes governance groups and mechanisms to implement all parts of STAND. He Korowai Oranga emphasises Whanau Ora, whose approach applies equally well to Maori and non-Maori, and is aligned with STAND’s life-course approach. The Northland Diabetes Strategy Page 25 of 67 Figure 18. Reducing Inequalities Framework 25 TP PT 1 Structural Social, economic, cultural and historical factors fundamentally determine health. These include: economic and social policies in other sectors: macroeconomic policies education labour market housing power relationships (eg stratification, discrimination, racism) Treaty of Waitangi – governance, Maori as Crown partner 2 Intermediary pathways The impact of social, economic, cultural and historical factors on health status is mediated by various factors including: behaviour / lifestyle environmental – physical and psychosocial access to material resources control – internal, empowerment 4 Impact Interventions at each level may apply: nationally, regionally and locally at population and individual level The impact of disability and illness on socioeconomic position can be minimised through: income support antidiscrimination legislation deinstitutionalisation / community support respite care / carer support 3 Health and disability services Specifically, health and disability services can: improve access – distribution, availability, acceptability, affordability improve pathways through care for all groups take a population approach by: identifying population health needs matching service needs to these health education 25 TP PT Reducing inequalities in health. Ministry of Health, 2002. Available at http://www.moh.govt.nz/moh.nsf/by+unid/523077DDDEED012DCC256C550003938B?Open . TU The Northland Diabetes Strategy UT Page 26 of 67 Figure 19. Health Equity Assessment Tool The following set of questions has been developed to help in considering how particular inequalities in health have come about, and where the effective intervention points are to tackle them. 1 What health issue is the policy / programme trying to address? 2 What inequalities exist in this health area? 3 Who is disadvantaged most and how? 4 How did the inequality occur? What are the mechanisms by which it was created, and is it being maintained or increased? 5 What are the determinants of the inequality? 6 How will the programme address the principles of the Treaty of Waitangi (specifically partnership, participation and protection)? 7 Where / how will the programme intervene to tackle this issue? (Use the MoH Intervention Framework and the ToW to guide thinking.) 8 How could this intervention affect health inequalities? 9 Who will benefit most? 10 What might the unintended consequences be? 11 What will you do to make sure the programme reduces or eliminates inequalities? 12 How will reduction in inequalities be measured? Figure 20. Individual factors affecting health status 26 TP Health-related behaviours: no smoking moderate alcohol intake no illicit drug use no problem gambling regular exercise adequate sleep low-fat diet safe sex 26 TP PT PT Individual factors Sufficient disposable income to afford: stable adequate housing nutritious diet adequate health care adequate educational opportunities safe working conditions with high job control Psychosocial factors: social support spouse or confidant(e) strong ethnic identity open sexual identity positive future prospects perceived control Reducing inequalities in health. Ministry of Health, 2002. Available at http://www.moh.govt.nz/moh.nsf/by+unid/523077DDDEED012DCC256C550003938B?Open . TU The Northland Diabetes Strategy UT Page 27 of 67 6 PRIORITIES FOR ACTION 6.1 Implementing HEHA and strengthening health promotion Recommendations Develop a plan of action for implementation of Healthy Eating, Healthy Action (HEHA) in Northland; the Diabetes Strategy Coordinator will need to work alongside key stakeholders in the development and implementation of the plan which should be negotiated among Northland providers to identify priorities, responsibilities, linkages and timeframes. Devise a plan of action for strengthening health promotion coordination and activity by concentrating on the recommendations of the stocktake of Northland health promotion providers undertaken in 2004 by three of the Northland PHOs. Work within the framework of the Treaty of Waitangi to address issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership. Process The Diabetes Strategy Coordinator (section 6.7) should coordinate the development of a HEHA implementation plan, with assistance from diabetes governance groups and key workers such as the Public Health Dietitian. A HEHA implementation plan will only be workable if all organisations that have a stake in promoting healthy lifestyles are involved in discussions. Evaluation measures Development of a Northland plan for implementing HEHA. Background Studies have concluded that nutrition, physical activity and the prevention of obesity are major risk factors in the development of diabetes. 27 The Nutrition and Burden of Disease study estimated that 11,000 deaths (40 percent of all deaths or 37 percent of years of life lost) in 1997 may have been “The important thing is to attributable to the joint effect of sub-optimal diet and educate the children. I tell physical activity levels. This includes over 85 percent of them it can stop right here.” ischaemic heart disease, 70 percent of stroke mortality, 80 percent of diabetes mortality and 6 percent of all cancer “Teach from the cradle.” mortality. Of these deaths, approximately 8,000–9,000 reflect diet and 2,000–3,000 reflect physical inactivity. 28 TP PT TP PT The Ministry of Health’ s Healthy Eating Healthy Action framework 29 is designed to provide DHBs and other agencies with an integrated policy framework to help bring about changes in the environment in which New Zealanders live. Improving nutrition, increasing physical activity TP 27 TP PT 28 TP PT PT Diabetes Prevention Programme Research Group (Washington), 2002. Nutrition and the burden of disease: New Zealand 1997-2011. Ministry of Health, 2003. Available at T http://www.moh.govt.nz/moh.nsf/by+unid/7B9C6DE0D0AC6483CC256D7A000B58AB?Open TU 29 TP PT UTTT Healthy Eating, Healthy Action. Ministry of Health, June 2004. http://www.moh.govt.nz/moh.nsf/by+unid/CD182E2C03925C09CC256EBD0016CF4B?Open . TU The Northland Diabetes Strategy UT Page 28 of 67 T and reducing obesity will require multiple actions by many agencies, which will require a collaborative approach and strong commitment. The remainder of this section is based around 3 key areas for action: (a) Establish Food and Physical Activity Accords (b) Continue the development of a Regional Physical Activity Plan (c) Strengthen health promotion in Northland The first two areas concern Northland DHB (including its public health team), MAPO, district and regional councils, Sport Northland and other parties working collaboratively and intersectorally. The third is based on a more general need to improve the implementation of health promotion across providers in Northland. Especially this requires more emphasis on training and coordination and utilising successful models such as Diabetes Projects Trust community events and lifestyle programmes, Mangere Healthy Kai, the Ngati and Healthy programme etc. (a) Establish Food and Physical Activity Accords Food and Physical Activity Accords may be developed in several contexts, including: schools workplaces food and beverage industry Schools Good nutrition and adequate exercise during childhood and adolescence protect against chronic disease in later life. Children’s levels of physical activity during school are dropping, and children are eating more energy-dense foods, both factors in the increasing levels of obesity. 30 TP PT Schools provide an opportunity for the health and education sectors to jointly work towards improving nutrition and physical activity levels for the majority of school-aged children. However there are many challenges for the health sector in achieving change in the education sector. The MoH-funded Health Promoting Schools (HPS) programme enables schools and service providers to work in a more coordinated and effective way involving students, teachers, principals, Boards of Trustees, the wider school community and the health and physical activity sectors. HPS entails a whole-of-school approach, providing an umbrella for a range of initiatives to address wellbeing within the school community. Currently approximately 30 of Northland’s 150-plus schools participate in HPS, and a further 50 have indicated they will be Health Promoting Schools by the end of 2005. There are a number of organisations providing services and support to schools, but the nature of the support is inconsistent across Northland with a variety of providers and funders operating at either local or national levels. It is essential that any new initiatives, such as developing a school Food and Physical Activity Accord, are developed with the early involvement of all key stakeholders. Northland DHB is committed to exploring the most effective process for developing school Food and Physical Activity Accords. Priority should be given to improvements in high 30 TP PT Barnfather, 2004. The Northland Diabetes Strategy Page 29 of 67 deprivation, low socioeconomic schools. Realistic and achievable goals are essential. Goals for schools across Northland might be something like: schools serve only water or sugar-free drinks by 2010 100% of primary schools provide 1 hour of exercise per week by July 2007 (Min Ed expectation) 70% of primary schools provide 30 minutes exercise a day by 2010 50% of secondary schools provide 30 minutes exercise a day by 2010 100% of schools should have audited health menu canteens by 2010 Other options might include the development of school garden projects, free healthy school breakfasts or lunches, after-school care with healthy afternoon tea provided, healthy snack vending machines and/or tuck shops as well as healthy ways to fundraise. Process: NDHB / MAPO to meet with Ministry of Health personnel leading HEHA and Health Promoting Schools programmes to discuss the project. NDHB / MAPO to meet with other identified key stakeholders to establish a planned approach to achieving the desired nutrition and physical activity outcomes. All key stakeholders to agree to an implementation plan with milestones and measurable objectives to be completed by an agreed date. “[Education about diabetes] should include family and cooking workshops would be useful in groups” Forge links and maintain a process of consultation with the education sector, including the School Principals Association and the Northland branch of the New Zealand Health Teachers Association. Workplace Northland DHB has the opportunity to become a healthy lifestyles role model for other Northland workplaces. Northland DHB could develop a Food, Nutrition and Physical Activity Policy to encourage healthy and active lifestyles among its staff. Involvement of the DHB’s health promotion and occupational health teams would be vital. The programme could later be rolled out to other health providers, large industries and retailers throughout Northland. A survey of Northland DHB employees will give important baseline data on diet and activity levels prior to implementation of this aspect of STAND. Providing advice on flexible activity options. These could include: provision of Green Prescriptions within Northland Health’s Occupational Health Service workforce activity buddies / mentors promotion of physical activity within Northwords with NDHB gym being only one option encouraging pedometer use. Northland Health currently has 40 pedometers, and these could be used on a loan basis or for departmental challenges departmental challenges identifying ‘at-risk’ staff who could benefit from additional support and assistance to achieve healthy lifestyles Goals would need to be jointly developed, but possible options could be: only healthy food choices are available in cafeterias, vending machines and volunteer food trolleys by 2010 The Northland Diabetes Strategy Page 30 of 67 10% increase in Northland DHB staff who are defined as physically active (have 30 minutes physical activity per day or at least 2.5 hours physical activity per week) by 2010 Food and beverage industry The changing food environment over the past 20 years is a major contributor to the current obesity epidemic. 31 These changes have increased the disparity in diabetes rates in that, generally, people with lower incomes tend to eat low-cost, high-fat, high-sugar, and high-salt takeaway foods more than is considered healthy. Children from these families are also less likely to eat a proper breakfast at home and a nutritious lunch at school. 32 TP PT TP PT In recognition of their responsibility, major food producers and retailers in NZ signed the Food Industry Project in September 2004, committing the signatories to supporting the MoH’s Healthy Eating Healthy Action (HEHA) framework. A demonstration pilot is likely to be instigated in the Counties Manukau DHB region. Northland could offer to be involved in the first phase of any national roll-out once the pilot has been commenced. (b) Continue to develop a Regional Physical Activity Plan Physical inactivity is common, affecting approximately one-third of New Zealanders, and comes second only to smoking as a modifiable risk factor for poor health. It accounts for 8% of all deaths (approximately 2,000 per annum). The NZ Health Survey 2002/03 indicated that 61% of Northlanders were either overweight or obese, and 48% were inactive. Reti’s 2004 survey suggested slightly lower figures: 48% overweight or obese and 39% inactive. [About how well cultural needs are met]: “I’m well taken care of.” “I talk on the Marae about diabetes and kidney failure – you need someone with the experience of diabetes. The food has changed on the Marae and it’s due to that Maori programme. It’s wonderful to see”. The benefits of physical activity are now widely accepted and recognised by both government and non-governmental agencies. These benefits include health and wellbeing, personal development, social cohesion, economic development, reducing health care and justice system costs, reducing antisocial and self-destructive behaviour and enhancing quality of life. There is evidence that increasing physical activity can help prevent diabetes as well as improve quality of life and 33 independence in older age groups. The potential advantages in all sorts of areas from increasing physical activity are evident. TP PT One of the major findings of the 2001 Ministerial Taskforce on Sport Fitness and Leisure was that the current recreation and sport structures are fragmented and lack integration at national, regional and local levels. A review of evidence 34 shows that a multi-pronged approach is necessary: TP PT National political endorsement and commitment along with collaboration of a wide range of government and non-government agencies. Creation of, or enhanced access to, places for physical activity combined with informational outreach activities in a range of settings including workplaces, community and schools. 31 TP PT 32 TP PT 33 TP PT 34 TP PT Critser, 2003 FAO/ WHO Expert Consultation, 2003; Barnfather D, 2004; Ministry of Health, 2003 Jepson R, 2000. The effectiveness of interventions to change health related behaviours: a review of reviews. MRC Social and Public Health Sciences Unit, Glasgow. Chamberlain N, 2004. Te Tai Tokerau Oranga Pumau: Northland Healthy Action. (Unpublished report for Northland DHB.) The Northland Diabetes Strategy Page 31 of 67 Community-wide campaigns such as support and self-help groups, counselling for physical activity, risk factor screening, community events and the creation of walkways. Point-of-decision prompts to encourage stair use, such as motivational signs placed close to lifts and escalators. Interventions such as behavioural modification, health education, health risk appraisal, exercise prescription, physical education curriculum programmes have a significant effect on increasing physical activity. Interventions that encourage walking and do not require attendance at a facility are most likely to lead to sustainable increases in overall physical activity. Patients do respond positively to GP-based lifestyle advice to take more exercise. Recruiting or reaching people through general practice is thought to be an excellent way to make contact with the target population, especially key at-risk groups. Clear physical activity intensity and duration guidelines for different age groups are required; 30 minutes activity a day may not be enough to recommend for children. Physical activity programmes that are tailored to the needs of individuals appear to be more effective than general health education or health promotion messages. Maintaining long-term behavioural change in physical activity is difficult, but even small changes would have enormous public health benefits. The most effective interventions in youth seem to be those that favour reducing sedentary behaviour; for example there is evidence that reducing the amount of TV watching by children increases the amount of physical activity and reductions in obesity. 35 TP PT Some of the specific actions coming out of the Healthy Eating Healthy Action (HEHA) implementation plan that will be addressed by a regional physical activity strategy are: Form an inter-agency steering group for cross-sectoral implementation of HEHA. Lead the development of new physical activity policies and strategies. Develop regional physical activity plans. Develop district-level alliances and networks between health agencies and territorial local authorities to inform and influence district planning. Stocktake of existing programmes. Develop and implement (in cooperation and with the assistance of local communities) community nutrition and physical activity policies in schools, preschools, churches, hospitals and health services, tertiary institutions and marae. Prioritise settings with high-need groups. Develop and implement a walking and cycling strategy. SPARC (Sport and Recreation Council of NZ) has identified the need to address the issue of fragmentation and lack of integration at a regional level. A Regional Physical Activity Plan (RPAP) which provides a cohesive strategic framework to support all relevant organisations in Northland to achieve their goals is an encouraging development. The intention is to improve the way each organisation contributes to national and regional goals of getting more people, more active, more often. Northland has been identified by SPARC as the next region ready to undertake such a project, and they and Northland DHB are the major financial contributors to the development of the 35 TP PT MacDonald B, 2003. Promoting physical activity and nutrition within a primary health care environment. A report for the Ministry of Health, Northland DHB, Waitemata DHB, Auckland DHB, CMDHB and MAPO. The Northland Diabetes Strategy Page 32 of 67 RPAP. Other key stakeholders are Far North, Kaipara and Whangarei District Councils, Northland Regional Council, MAPO, Northland Secondary School Sports Association and Sport Northland, who will coordinate the development of STAND. Representatives from each of the key stakeholders will sit on a Project Steering Group (for governance and key decision making) and a Project Working Team (for guidance, coordination and monitoring). The aim will be to develop a strategy and implementation plan for the Northland region that clearly identifies measurable strategic aims for the most effective and efficient delivery of physical activity, including how physical recreation and sport organisations and other associated organisations can work together to maximise the benefits of physical activity for Northland’s population. ‘In 2 Action’ (having recently developed the Auckland regional physical activity strategy) have been awarded the project management contract which will be completed by mid 2006, enabling recommendations to be incorporated into future annual and long term plans of participating organisations. On adoption of the final strategy, an Implementation Legacy Group will be set up to guide the actions arising from the document and facilitate ongoing reviews. (c) Strengthen health promotion coordination and activity Recommendations Devise a plan of action for strengthening health promotion coordination and activity by concentrating on the recommendations of the stocktake of Northland health promotion providers undertaken in 2004 by three of the Northland PHOs. The recommendations were: increase training and workforce development for health promotion within Tai Tokerau and facilitate health promotion training opportunities for people in sectors outside the health promotion workforce Tai Tokerau Health Promotion Network and the Tai Tokerau Public Health Association facilitate collaboration at local, regional and national levels PHOs to enhance links between health promotion / community organisations and primary health care practitioners (especially practice nurses) to develop and strengthen health promotion skills identify service gaps Process Devising a plan and monitoring progress should be the responsibility of the Diabetes Strategy Coordinator (section 6.7) working in partnership with the Regional Diabetes Team with assistance from diabetes governance groups and mechanisms, and key providers of health promotion services and programmes. Evaluation measures Development of a plan. Reports by the Diabetes Strategy Coordinator on activities to strengthen health promotion coordination and activity. The Northland Diabetes Strategy Page 33 of 67 Background The Northland health promotion environment is diverse and complex, with activities being provided by a number of providers and funded by a number of funders. Recently PHOs have also been charged with health promotion activities. Where possible PHOs should undertake consultation with providers who have similar interests to avoid duplication and strengthen outcomes. Planning for health promotion activities should reflect the fact that Maori have the worst health statistics in Northland. There should also be a process of consultation and working collaboratively to strengthen participation of all their communities in their implementation, including whanau, hapu and iwi, through appropriate ongoing partnerships, including the involvement of community leaders in decision making. 36 TP PT “I’ve been helped by the Ki a Ora Ngatiwai nurses and I’m very lucky to have them [because] they are so personal. But we need to use all the professionals.” As is the case in schools, there is a risk that there will be service gaps, duplication and fragmentation of services. There has been an attempt to align these activities and share information by the formation of the Tai Tokerau Public Health Association and Health Promotion Network. NDHB / MAPO and the MoH Northern Region GM and staff will continue to utilise existing forums such as the Northern Region Public Health Steering Group for strengthening and coordinating health promotion activity regionally (including Auckland) from a funding and planning perspective. NDHB / MAPO will also provide leadership in developing new processes and mechanisms to address Northland-specific issues, such as those identified above, with the MoH, PHOs and health promotion providers. 36 TP PT Te Tai Tokerau / Northland health promotion stocktake, October 2004. (Unpublished report undertaken by 3 Northland PHOs: Manaia PHO, Kaipara Care Inc, Te Tai Tokerau PHO.) The Northland Diabetes Strategy Page 34 of 67 6.2 Children and diabetes Recommendations Develop a consistent, coordinated approach to reducing the prevalence of factors which predispose children to type 2 diabetes by concentrating on: the prenatal environment breastfeeding childhood obesity intersectoral approaches reducing inequalities Work within the framework of the Treaty of Waitangi to address the issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership. Process The activities listed above are not delivered through diabetes-specific services, instead originating from more general approaches to improving child health. The Diabetes Strategy Coordinator (section 6.7) should monitor progress on these in partnership with the Regional Diabetes Team with assistance from diabetes governance groups and mechanisms. Where appropriate there should be advocacy for changes or improvements to ensure the needs of children are met more effectively. The Coordinator should also ensure that the needs of children are incorporated into diabetes-specific planning originating out of STAND. Evaluation measures Breastfeeding rates. Childhood obesity rates. Reports on intersectoral initiatives, particularly to monitor progress on any defined outcome measures (eg advocacy role of the Child Health Lifestyle clinic). “Kids [with diabetes] need to meet kids that are older and foster relationships” Background Current services appear to provide adequately for children with type 1 diabetes. If any issues require attention, they will be identified as part of the service review (section 6.4). A life-course approach to controlling chronic diseases such as diabetes is essential. It starts with maternal (prenatal) health and antenatal nutrition, pregnancy outcomes, exclusive breastfeeding for 6 months, and child and adolescent health. It reaches children at schools, adults at worksites and other settings, and the elderly. It encourages a healthy diet and regular physical activity from youth to old age. The life-course approach is also consistent with the Whanau Ora approach of the He Korowai Oranga. The Northland Diabetes Strategy Page 35 of 67 Breastfeeding There is substantial and mounting evidence that changes to diet and lifestyle early in life significantly reduce the incidence and impact of type 2 diabetes. 37 These changes should begin in-utero by addressing maternal nutritional status, followed by improved infant feeding practices. This approach is supported by the World Health Organisation, MoH, and the New Zealand Paediatric Society as well as being demonstrated in several cross-sectional studies. 38 TP PT TP PT These studies collectively involved more than 70,000 children and concluded that children exclusively breastfed in the first 3 to 5 months of life are 30% to 45% less likely to be obese than those who were artificially fed. Protection was shown to increase in direct relationship to breastfeeding duration and exclusivity, and the effects were found to last beyond infancy into adolescence. NDHB is committed to raising exclusive breastfeeding rates in the first 6 months of life by: working closely with all lead maternity carers to ensure all hospital maternity / obstetric facilities meet Baby Friendly Hospital Initiative standards and provide ongoing resources to maintain the standard prioritising new services that focus on improving breastfeeding rates among vulnerable populations demonstrating leadership as an employer by having an effective breastfeeding policy and facilities to support staff and contractors who are breastfeeding their own children participating in and/or promoting intersectoral initiatives that support breastfeeding-friendly environments Childhood obesity 31% of New Zealand children, 62 percent of Pacific children and 41% of Maori children are overweight or obese. Childhood obesity can lead to early onset of diabetes and is a strong predictor of adult obesity. With the exception of breastfeeding there is little national policy or service provision targeting good nutrition and physical activity in the early years. Over the next 5 years Northland DHB will prioritise available funding to address childhood obesity. However there needs to be a multi-pronged strategic approach by targeting at risk populations by with culturally appropriate services using evidence-based effective interventions. In order to do this, appropriate information, referral and follow-up systems will need to be implemented. Northland DHB’s Child Health Centre currently runs the Lifestyle Clinic, a service for children and their whanau who are at risk from developing serious health issues in the future. The Lifestyle Clinic is for 5-14 year olds who have a BMI in the 97th centile for their age. The aim of the intervention is to slow down weight gain and encourage the family as a whole to make changes and be more physically active. Families attend an initial visit followed by 6 week intensive group sessions, where the coordinator, a paediatrician, dietitian, a clinical psychologist and Sport Northland discuss such things as healthier lifestyle options and pressures from the food industry. They also provide each child with a pedometer to measure their level of activity. Follow up is arranged at intervals over the next two years. 37 TP PT 38 TP PT Toschkle, Koletzko, Grote and Von Kries. Identifying children at high risk for obesity at school entry by weight gain during the first two years. Armstrong J and Reilly J. Early life risk factors for obesity in childhood, a cohort study. BMJ Aug 2005; 331: 454. The Northland Diabetes Strategy Page 36 of 67 Intersectoral approaches An environment needs to be developed in which parents have the knowledge and ability to provide appropriate nutrition and physical activity for their children. This could be achieved by truly intersectoral approaches. Some ideas: Form a new partnerships with the Ministry of Social Development to better identify at-risk children and families so that maternity and well-child service providers can provide more intensive support or referral where necessary. “Family support is definitely important. I’ve been diabetic 16 years and have a son of 7 years who always knows what to do for me. The ambulance men came to me once and they didn’t know how to use the meter, so my son had to show them! Information needs to be given gradually.” The Northland Diabetes Strategy Strengthen the capabilities of well-child services, general practice and Maori providers to assess children with developing obesity risks, and ensure early and appropriate referral. Strengthen and build on the work achieved in the Child Health Centre’s Lifestyle Clinic. This involves further strengthening of the partnership with Sport Northland which provides the activity component of these programmes and advocacy on issues related to child obesity. Develop a more comprehensive and detailed strategy for reducing childhood obesity which must include links with the school environment. Page 37 of 67 6.3 A patient-centred clinical care pathway Recommendations Further develop a patient-centred clinical care pathway for Northland. Carry out regular audits of practice to monitor compliance with the pathway. Carry out regular audits of the patient experience to monitor satisfaction with changes to the pathway. Continue to support enhanced primary care through primary prevention, diabetes screening, annual free checks, and chronic care management. Develop pathways specific to the needs of Maori. Improve case detection and case management through incentives or other measures for Maori. Improve uptake of retinal screening so that 80% of Maori receive screening at least biannually. Continually identify and address barriers to people accessing programmes and services in Northland. Work within the framework of the Treaty of Waitangi to address issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership. Process Initially the pathway should be developed by the Diabetes Strategy Coordinator (section 6.7) working in partnership with the Regional Diabetes Team with assistance from diabetes governance groups and mechanisms. Locally agreed guidelines such as those in Figures 21 and 22 over the page) should be used as a basis, as well as national guidelines and frameworks. These define the role of health care professionals and include criteria for referring people with diabetes. The pathway should be agreed in partnership with local diabetes planning groups, Maori providers, other NGO providers and patients (including the a patient focus group such as the one involved in the development of STAND). Whatever system is adopted, it is important to consider how easy it is to access services, particularly for isolated and deprived patients who experience difficulties in travelling and accessing services. Evaluation measures Pathway to be developed and agreed by 2006. Involvement of key groups described above to be demonstrated. Background If people with diabetes are to successfully manage their condition they need a clear understanding of what care to expect, who does what and when. A key challenge for diabetes services is delivering patient-centred services that overcome the fragmentation, poor coordination and lack of integration that may have characterised care in the past. Given the wide range of health care professionals from whom people with diabetes receive care, it is no surprise that many patients as well as health care professionals are left unclear about how to navigate their way round the health system. The Northland Diabetes Strategy Page 38 of 67 Services should be focussed on people with the disease and their experiences, providing a holistic approach, involving their whanau, rather than viewing their care as a series of discrete encounters with the health care system. A care pathway also provides patients with evidencebased care which should ensure a consistent standard is delivered to all. A patient-centred pathway will support the individual with diabetes to make informed decisions about their care, give structure to those providing it, provide integrated care for patients and improve the quality of life for people with diabetes and their families. Good self care depends as much on getting the right social support and information and enjoying emotional wellbeing as it does on medication. Integrated care requires of health care professionals that they promote autonomy of patients, work collaboratively, tailor approaches to meet Maori needs, work towards locally agreed policies and share patient records. [To access advice about diabetes management after hours]: “I have no idea.” “I would ring an ambulance or go to A&E.” “You need to let people know when you’re diabetic.” People with diabetes should be involved in making decisions on the management of their conditions. In its simplest form a care plan is a jointly agreed and owned strategy for managing an individual’s diabetes and is usually for a one year period. Such patient-centred consultation styles have been shown to increase motivation and improve patient satisfaction, wellbeing and self care. This calls for a shift away from paternalistic approaches towards a “I did not realise how more equal relationship based on partnership and joint serious diabetes was at decision making. It also requires that services be first. Perhaps I might adapted and developed to meet Maori needs, which may have taken it more include a reassessment of how some providers deliver seriously if I knew then services, where they are delivered and the nature of their what I know now.” interactions with Maori patients. The choices people make about managing their diabetes have a major impact on the long-term outcome of the condition. These choices are in turn significantly influenced by the education and information people receive, both at diagnosis and during their lifespan. This allows information to be reinforced and provides opportunities for updates on new technologies and techniques. There is significant evidence from self management programmes of the benefits of involving people and their whanau in their own care. 39 TP PT Patient education programmes should enable people to: 40 come to terms with diabetes and understand that it is a lifelong condition know the basics of the condition and potential complications understand the importance of controlling blood glucose levels, blood pressure and other risk factors and how these are achieved understand the importance of regular clinic attendances, the need for good foot care, eye checks and other areas where complications can be prevented or their onset delayed understand the need for healthy eating patterns and exercise, and the ways in which lifestyle can be modified to maximise wellbeing have the skills to manage insulin, injection techniques and hypoglycaemia understand the effect of illness and what action to take when they are ill understand the services, who does what, points of contact for advice and support especially out of hours TP 39 TP PT 40 TP PT PTP Dose adjustment for normal eating (DAFNE), expert patients programme (UK). Audit commission report, testing times, 2000. The Northland Diabetes Strategy Page 39 of 67 Figure 21. Secondary care referral protocol Physician Dietitian Podiatrist Psychologist Diabetes nurse educators / specialist Group selfmanagement programme Type 1 and type 2 diabetes under 30 years. Diabetes in pregnancy. Type 2 diabetes with multiple complications. Passenger endorsements (LTNZ requirement). Other causes of diabetes, e.g. Cushing’s, acromegaly. Type 1 and type 2 diabetes under 30 years. Diabetes in pregnancy. Significant unintended weight loss or weight gain. Carbohydrate counting. Coeliac disease. Type 2 diabetes with multiple complications such as hyperlipidemia. Neuropathy (unable to sense 10g monofilament). PVD foot pulses not palpable + 2 of the following: capillary refill >5 seconds poor foot colour, shiny foot hairless feet/toes intermittent claudication with rest pain thickened nails past history of ulceration and/or amputation active foot ulcer (recently discharged from hospital) complicated non-diabetic foot conditions such as club foot Patient must be willing to attend. Needle phobia. Anxiety depression, eating disorders. Persistent ineffective self-management skills impeding diabetes management. Neuro-psychological assessment. Newly diagnosed type 1. Diabetes in pregnancy. Paediatrics. Initiate insulin (if unable to in primary care). Type 2 diabetes, multiple complications. Frequent hypoglycaemic episodes. All patients newly diagnosed with type 2 diabetes and others who could benefit from an update. The Northland Diabetes Strategy Page 40 of 67 Other options for patients Written, verbal or email advice to consultant. Supermarket tours via Diabetes Northland. Private podiatrist. Private psychologist. Adult mental health services. Green Prescription. Sport Northland. Smokefree programme. Iwi providers. Diabetes Northland. Verbal advice from nursing staff. Figure 22. The diabetes care pathway Prevention Early identification Initial assessment Assess those who need specialist advice, such as children, adults who are unwell and have ketones present, adults with ketoacidosis or hyperosmolar coma. Initial advice Explain condition and management, taking into account emotional state and cultural / social background. Provide leaflets, etc. Discuss possible impacts re work and LTNZ. Psychological support Diabetes health care team to assess impact of diagnosis and discuss anxieties and concerns with person and identify immediate support (whanu, carers, friends). Diagnosis Initial assessment. Initial information. Psychological support. Treatment, dietary advice begins. Initial care and management planning. First year Structured education. Continued psychological support. Optimised blood glucose control. Advice and treatment to prevent and manage CVD risk factors. Agree continuing plan of care. Take account of needs of individuals and population groups (teens, residential care). Maori-specific programme for patient education. Treatment begins Initial treatment includes insulin therapy where appropriate, advice on diet, monitoring, physical activity, giving up smoking. Initial care planning and management Care planning, usually reviewed annually, is at the heart of managing a person’s diabetes. The Northland Diabetes Strategy Events-related care Diabetic ketoacidosis Hyperosmolar nonketotic syndrome (HONK) Severe hypoglycemia Major treatment change CONTINUING CARE Annual review: Explore any concerns. Assess ability to manage self care. Advise on healthy lifestyle choices. Review metabolic control. Monitor physical growth and development in children. Weight management. Surveillance for long term complications and other problems such as depression. Agree revised plan of care. Cycle of care continues. Page 41 of 67 Pregnancy Hospital admission Residential care Other new complications New erectile dysfunction New stroke New coronary heart disease New ‘at risk’ foot New eye complication Major life event. know about patient groups and how to access other people with diabetes understand that diabetes management is a continuous process and treatment can be adjusted in light of changes in life and lifestyle encompass cultural and religious needs Specific key action areas Review existing clinical pathways and protocols based on best practice, and develop and operationalise them into practice by formation of a clinical advisory group. Review current guidelines for special patient groups such as children, prisoners, vulnerable adults. “I always say to people don’t be a statistic, and here I am a statistic on a kidney machine. Some people don’t realise that you may not need tablets or insulin, but it’s still important.” Involve PHOs, clinical boards and Northland DHB clinicians in reviewing criteria for access to secondary services and shared arrangements, and disseminate these criteria to ensure the pathway is implemented in primary and secondary care. Decrease smoking rates among people with diabetes by referral to quit smoking programmes. Each person with diabetes should have a patient-held agreed plan of care. Seamless transfer of patients and information between services and providers. As part of their care pathway all patients should have timely access to retinal screening programmes. Develop structured patient education programmes along with guidelines on their delivery and structure. Develop a Northland-specific culturally competent information booklet on services for people with diabetes and how to access them. Progress measures Improvement in end points and specific measures such as HbA1c and lipids. Fewer complications. Improved retinal screening uptake. More satisfaction with services, as demonstrated through patient surveys. Each individual to have a patient-held agreed plan of care by 2008. Structured education programmes available and accessible to all by 2008. The Northland Diabetes Strategy Page 42 of 67 6.4 Review existing services for those with diabetes Recommendations Carry out a review of all diabetes-related services throughout Northland. Equitably resource kaupapa Maori programmes or any new or expanded initiatives. Work within the framework of the Treaty of Waitangi to address issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership. Explore ways to enhance whanau, hapu, iwi, and community development. Process The review should be carried out by a project worker under the oversight of the Diabetes Strategy Coordinator (section 6.7) working in partnership with the Regional Diabetes Team with assistance from diabetes governance groups and mechanisms. It will focus on Northland DHB-funded organisations and contracts, but will also develop recommendations for consideration by any services along the continuum of care. The review will entail gathering information on numbers and types of services, composition of the workforce and levels of cultural competency, levels of training and expertise, and linkages between providers. Evaluation measures Review to be completed within 6 months and reported to the General Manager Service Development and Funding, Northland DHB. Background In order to prioritise work within STAND, there needs to be a full review of diabetes services throughout Northland in health promotion, primary services and [Concerning the accuracy of or secondary care. The review should link in with other variability in information from reviews taking place, including the development of a health care professionals]: patient-centred clinical care pathway (section 6.3), “GP doesn’t tell me much.” Northland DHB’s Clinical Services Plan, and workforce initiatives (section 6.5). It will develop a plan of action “Doctors are busy and have to: other obligations, and if they maximise coordinated, cost effective diabetes care miss something I ring up.” reduce inequalities in prevalence and severity of “It’s a shared responsibility diabetes, and in access to services (such as rates of between you and the doctor.” Annual Free Checks, retinal screening) improvement in case detection and case management to meet ethnic-specific targets identify effective models of care ensure quality services, including competencies throughout the workforce develop key performance indicators, and communicate and monitor these throughout the sector equitable rescourcing of Kaupapa Maori programmes The Northland Diabetes Strategy Page 43 of 67 The rapid increase in prevalence of diabetes must be better managed across providers. Particular focus needs to be placed on Maori, given their higher prevalence of diabetes, poorer blood glucose control and higher rates of hospitalisation. The patient experience National strategies for planning diabetes services cite user involvement in planning diabetes services as an essential tool for achieving the vision. User involvement should encompass a range of activities from patient surveys to recruiting patients onto local team groups. Whatever form it “My son has been diagnosed a takes, the purpose is to ensure that the views of people year and it was a huge shock; with diabetes are taken on board during any planning we were numb. When we were and decision making on services. released home there was no safety net and we would have As part of the diabetes strategy planning group, a appreciated home visits by patient focus group with whanau involvement was someone who knew what to do. formed and members interviewed about their When we got home, it was like experiences. Quotes from these interviews are bringing a new baby home. scattered throughout the text in the shaded boxes, Giving an injection was my reflecting the importance the Diabetes Planning Group worst nightmare.” places on the journey people with diabetes take through the health system. The Northland Diabetes Strategy Page 44 of 67 6.5 Develop an effective coordinated workforce Recommendations Develop a workforce action plan that is aligned to the needs of people with diabetes in Northland. Work within the framework of the Treaty of Waitangi to address issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership. Specific tasks Gather information during the service review (section 6.6). Address coordination of training, professional development and competency for diabetes-specific workers via a career pathway which recognises skills, courses attended and competencies obtained. “There are doctors and doctors, and some are better than others. Mine rang me after hours to give me more information, but you have to talk and discuss things with them.” Consider the needs and issues faced by staff in other organisations who deal with people who have diabetes. Develop accredited courses specific to the management of diabetes in response to identified gaps in skills and knowledge. All courses to be culturally competent in their delivery and encompass a reducing inequalities focus. All courses to emphasise the patient experience. Collaborate with other organisations concerning research and maintain and form linkages with universities where appropriate. All workforce development initiatives aim to achieve a culturally responsive service, as measured by the recipients. Process The workforce action plan should be part of the responsibilities of the Diabetes Strategy Coordinator (section 6.7) working in partnership with the Regional Diabetes Team with assistance from diabetes governance groups and mechanisms. The service review should include the gathering of relevant workforce information and identification of issues. However, the workforce action plan itself will require further in-depth research and discussion and should be developed as a separate exercise once the service review is completed. Evaluation measures Successful recruitment and retention. Reduced staff turnover. Staff perceptions, including job satisfaction. The patient experience and satisfaction surveys (see section 6.3). Professional development attendances. Development of an accredited course. Identification of scopes of practice based on national guidelines. Review and benchmarking of existing recommendations. The Northland Diabetes Strategy Page 45 of 67 Cultural competence training. Training for staff to ensure consistent recording of ethnicity across providers. Background People with diabetes need care from a wide range of health care professionals. Services also require management and facilitation skills which are essential to good diabetes care. Patterns of care for patients with diabetes have been undergoing change, with increased emphasis on the person with uncomplicated type 2 diabetes being managed in the primary care setting. “[Information about diabetes] should be passed on and talked about at home. They ask you questions and make you aware.” New approaches to managing services in Northland have to be considered to prevent services becoming overburdened and enable staff to cope effectively with the challenges they face. This may include workforce development and role re-design that emphasises competencies, training / education and flexibility rather than job titles. The provision of the nurse practitioner role is key to providing support and expertise in workforce development initiatives. The diabetes care pathway must provide access to the correct skills necessary to provide appropriate care. These include communicating and listening, awareness of Maori needs and perceptions, education and support, diagnosis, investigation and examination, clinical management, record keeping and administration. Practice nurse interviews occurred either by phone interview or in person during the development of STAND. The following concerns were expressed about patient management and their own personal ongoing educational needs. Access to podiatry services was an issue that arose often; not being able to offer a quality service for patients due to time constraints as well as not always knowing how best to navigate the systems in the interests of the patient. Some felt that the implementation of chronic care management would help remedy the lack of time available to deliver a good quality Annual Free Check. Self management courses for patients were well utilised, but some practice nurses knew of patients who due to work commitments were unable to access this service through secondary care. In meeting their own educational needs, practice nurses in Whangarei felt well supported, but other areas only had access to a diabetes update once a year. Those interviewed felt that a clinically based course, which provided them with a practical skills workshop, would enhance their practice. Levels and types of staffing The principle behind workforce change initiatives must be that all members of the integrated diabetes team are competent to provide effective services. A core education curriculum should be developed based on a core competency framework, which offers individuals a course for obtaining the necessary skills, knowledge and attitudes required. There has been very little work carried out either nationally or otherwise that reflects safe standards of practice that should exist around the provision of care in chronic diseases such as diabetes. The service review proposed in STAND should at least remedy that situation in Northland. Comparing diabetes staffing with other DHBs is problematic because of variations in levels and types of need across DHBs. However, some information is available from a comparison with UK data. The Northland Diabetes Strategy Page 46 of 67 Diabetes UK makes the following care recommendations for core staffing levels for an average district general hospital 41 per 250,000 populations (though these are for a larger population, they do not allow for the needs of a population thinly spread across a large geographic area such as in Northland): TP PT At least 28.75 sessions per week should be dedicated to diabetes care by a consultant physician with specialist training in diabetes. At least 4.0 FTE diabetes specialist nurses. 1.5 FTE state registered dieticians with a special interest in diabetes. A full time district coordinator. 2.0 FTE state registered podiatrists. A consultant paediatrician(s) supported by paediatric specialist nursing, dietetic and psychology services. A consultant obstetrician(s) with a special interest in the management of pregnant women supported by midwives with special interest and training in diabetes. At least one consultant ophthalmologist specialising in diabetic eye disease. At least one psychologist with a special interest in diabetes. One UK study carried out in 2001 42 found that although the extra workload emanating from the rising prevalence of diabetes had been met in primary care, hospital care had not seen a drop in workload. This has implications for future health planning. TP PT A study by PriceWaterhouse Coopers 43 reports that currently Northland is under-resourced in specialist physician, podiatry provision and dietetic services. TP PT Current service provision in Northland Figure 23 describes organisations and programmes relating to diabetes in Northland. The list is not exhaustive, but it indicates the range of services involved. It includes services specifically targeted at diabetes, as well as those that address risk factors such as diet and physical activity that relate to several diseases. To enable implementation of some of the actions in STAND (especially the review of services and workforce development) the list will need to be expanded and more detailed information gathered on each service. The services have been grouped by stages along the Continuum of Wellbeing and Disease. Figure 23. Current service provision relating to diabetes in Northland Continuum stage (see section 3.2) Current services and programmes Healthy population / precursor risk Breastfeeding advocacy Baby Friendly Hospital Initiatives Health Promoting Schools Sport Northland, SPARC, Kiwi Walks, Push Play Community based exercise and nutrition programmes 41 TP PT 42 TP PT 43 TP PT Recommended core staffing levels for an average district specialist care team. Diabetes UK, 2000. Whitford, Roberts, 2004. Changes in prevalence and site of care of diabetes in a health district 19912001. Diabetic Medicine. Type 2 diabetes: managing for better health outcomes. (Prepared by PriceWaterhouse Coopers for Diabetes NZ.) Diabetes NZ, 2001. Available at http://www.diabetes.org.nz/resources/pwcreport.html . TU The Northland Diabetes Strategy UT Page 47 of 67 Continuum stage (see section 3.2) Current services and programmes Green prescriptions Community garden projects Korikori A Iwi (culturally appropriate food and activity programmes for Maori) National Heart Foundation / Te Houtu Manawa Maori Well child / tamariki ora services Public health nurses (NDHB) Public Health Unit (NDHB) Family Start (family at risk services) At risk Child Health Centre Lifestyle Clinic (NDHB) Recall to GPs of patients with impaired glucose tolerance Pregnancy care of gestational diabetes and follow up Diabetes screening (opportunistic and targeted) for those at risk Community based nutritionist in Tihewa Mauriora (20 hours) Asymptomatic Self management education programme via Diabetes Centre Diabetes Northland Dietitian services (NDHB) Mild symptoms Supermarket tours Smoking cessation Annual free checks and monitoring via GPs, including arranging plans of care Iwi, community and practice nurse educators Renal and cardiovascular risk assessment Retinal screening service / private ophthalmologist Private podiatrist Advanced symptoms Chronic care management programme by general practice teams Iwi provider nurses Foundation for the Blind NDHB services: Psychologist At-risk foot clinic run by podiatrist Diabetes nurse specialists and educators Vascular assessment limited access Specialist advice via secondary services Nephrology / renal services Community Assessment and Rehabilitation Service (CARS) Pharmacist The Northland Diabetes Strategy Page 48 of 67 Continuum stage (see section 3.2) Current services and programmes Cardiac Rehabilitation Medical Outreach Disease state management nurses End stage Dialysis / renal care (NDHB) District nursing (NDHB) Iwi provider services Community, home care Palliative care As a start in describing the nature of the diabetes workforce in Northland, the following table groups providers by source of funding. DHB funded GPs and practice nurses Some diabetes screening and health education (diet and exercise), diabetes management advice, some use of guidelines, episodic care. Mix of opportunistic and planned interventions. Less than 50% of Northland population get diabetes free checks. Some areas do not achieve their contracted volumes while others over-deliver. Questions remain about capacity of sector to increase diabetic free check numbers if contracted volumes are increased. Maori provider organisations Disease state management nurses are a scarce resource. Most of the 400 free checks for diabetes are performed by GPs in these organisations. A 0.2 FTE position dedicated to care of Pacific people, but not diabetes care specifically, operates under the district nursing service. Diabetes Centre A secondary service. Provides diabetes specialist advice, diabetes nurse education, holds some secondary service clinics in the community, dietician services and supermarket tours, inpatient management, insulin pump therapy, paediatrics, management of renal patients, management during pregnancy, atrisk foot clinic by podiatrist, psychologist, retinal screening service, and self management programme for patients with type 2 diabetes. Should only be severe end of spectrum or post-discharge patients, but some overlap with community / GP primary care services. Potential for duplication. Diabetes specialist One 0.5 FTE specialist for all of Northland, hence services and availability need to be rationed. Retinal screening, ophthalmology Contracted to screen 2,240 people a year. Review of services taking place to improve uptake and reduce did-not-attend rates. Patient satisfaction high among consumers. Podiatry At-risk foot clinics currently provided by one FTE podiatrist for NDHB. Newly appointed podiatrist working for Hauora Whanui. Children and young adult services Secondary care of children and youth with diabetes (usually type 1 although increasing number of type 2 in grossly obese children) when it is not appropriate for these patients to be managed in primary care. Review of clinic provision for children and their families taking place. Child Health Centre Lifestyle Clinic. Diabetes in Specialist service. All pregnant women should be screened with an oral The Northland Diabetes Strategy Page 49 of 67 pregnancy polycose test and all pregnant women with gestational diabetes should be referred to an obstetrician. Diabetes nurse educators/ specialists There are 7.0 FTE diabetes nurse educators across primary and secondary services. They provide input into obstetric, paediatric and medical services. The hope is that there will be a decrease in referrals to the Diabetes Centre as practice nurses and GPs are upskilled and provide much of this education. Included is a 1.0 FTE position in Whangarei to improve access to PHO funding. A community worker (non-nursing) is employed in the Tihewa PHO region and one day a week by NDHB. Ministry of Health funded Public Health Unit A number of programmes by Northland DHB’s Public Health Unit based at Dairy House in Whangarei that potentially influence diabetes: Smokefree, healthy food choices in schools, adolescent health clinics, Heartbeat Awards, 5+ a day, jump rope, healthy breakfasts. Non-DHB funded Diabetes Northland Provides public education, member support, increased awareness, diabetes supplies etc. Sport Northland NDHB is working with Sport Northland to enter into an memorandum of understanding on how health and other sectors can work together to promote physical activity programmes such as the Green Prescription, He Oranga Poutama etc. The Northland Diabetes Strategy Page 50 of 67 6.6 Information systems that best support STAND Recommendations Clarify the impact of the MoH national diabetes database (due to be available by the end of 2005) before embarking on a diabetes information systems strategy for Northland. Work within the framework of the Treaty of Waitangi to address issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership. Issues to be considered in a future information systems strategy: Review of systems currently in place. Work with MoH and providers to pilot and establish a dataset to prevent duplication. Agree dataset and key indicators with MoH and key stakeholders. Link up retinal screening database with other information systems, primary care databases. Continue of efforts to develop protocol for sharing of information between primary and secondary care. “Everyone reacts differently when told. We had a warning when my daughter was diagnosed, but it was still a shock. I think as a family we never got taken through the process and the system needs to appreciate that. It needs to be individualised.” Use information from the register and other demographic data to make estimates about future demands on services, and work with providers and patients to plan towards these estimates. Funder to continue to set and monitor ethnic-specific targets. Information on ethnicity to be an integral part of all data systems. Process The Diabetes Strategy Coordinator (section 6.7), with assistance from the Regional Diabetes Team and diabetes governance groups and mechanisms, should monitor progress on the implementation of the national database, and also develop a diabetes information systems strategy at the appropriate time. Evaluation measures Integrated diabetes IT system to be fully operational by 2010; to be able to capture data, assist in planning for high need patients and expose gaps in service provision. All activity is captured and should have data on Annual Free Checks, HbA1c, lipids, all retinal screening results and follow up recommendations. Secondary care should have access to primary care disease register information. Other secondary care data (such as myocardial infarction, congestive heart failure, amputations, renal failure, discharge summaries) should be available at PHO level. Ethnicity data recorded throughout all datasets. Two-way information reporting. Web-based look-up available to all providers of the combined clinical database. Service duplication does not occur. The Northland Diabetes Strategy Page 51 of 67 Background In order to provide high quality patient-centred services health care professionals need access to the necessary resources. As diabetes is a complex condition that involves many systems within the body (and of the health services that deal with these) a comprehensive information management system is essential to keep track of an individual’s care and health. In practice this means information sharing across the whole pathway of care to enable access to the information required and eliminate duplication of procedures. This should involve accurate registers to identify people with diabetes and provide structured programmes for systematic review and recall mechanisms, reliable data to support audit and quality improvement. Such an approach solves the historic problem of a variety of workers (doctors, nurses, podiatrists, optometrists and others) involved in delivering patient care, based in different locations, having to make copies of patient records. Ethnicity should be captured accurately at all stages of the patient journey in light of the high prevalence and severity of diabetes among Maori and to monitor progress among Pacific people. The Northland Diabetes Strategy Page 52 of 67 6.7 A district-wide coordinated approach Recommendations Employ a Diabetes Strategy Coordinator within the Northland DHB’s Service Development and Funding team who will work closely with the community in partnership to implement STAND with recommendations to ensure that collaboration and coordination occur. Ideally, this individual will have linkages with the community and proven knowledge in health promotion. Work within the framework of the Treaty of Waitangi to address issues for Maori. Specifically this means involving Maori at all levels and stages of health system planning and delivery through processes that reflect the principles of partnership Specific responsibilities include: Monitor progress in reducing inequalities (section 5). Develop a plan of action for implementing Healthy Eating, Healthy Action in Northland (section 6.1). Devise a plan of action for strengthening health promotion coordination and activity (section 6.1). Develop a consistent, coordinated approach to reducing the prevalence of factors which predispose children to diabetes by concentrating on breastfeeding, childhood obesity and intersectoral approaches (section 6.2). Further develop a patient-centred clinical care pathway (section 6.3). Carry out regular audits of practice to monitor compliance with the pathway. Oversee the project worker who will carry out the review of all diabetes- related services throughout Northland. Carry out regular audits of the patient experience to monitor satisfaction with changes to the pathway. Carry out a review of all diabetes-related services throughout Northland (section 6.4). “I’ve had 5 different nurses at the Diabetes Centre and wasn’t contacted for a while. My file was at the main hospital and there was no follow on from one nurse to the next.” Identify workforce issues (as part of the review of services). Develop a workforce action plan once the review of services is completed (section 6.5). Develop an information systems plan (during 2006, once the MoH national database becomes available) (section 6.6). Communicate STAND to stakeholders through a variety of forums and processes. Support the development of STAND by establishing a governance structure based upon the groups established during its formulation. Advocate for resources to be committed to the strategy development process. Establish under the General Manager Service Development and Funding appropriate governance groups and mechanisms to support the Diabetes Strategy Coordinator. The Northland Diabetes Strategy Page 53 of 67 Process Prepare a proposal to employ a coordinator and project worker for submission to the General Manager Service Development and Funding. The Coordinator’s responsibilities should be monitored and supported by diabetes governance groups and mechanisms. Evaluation measures Establishment of the Coordinator position. Progress on the specific responsibilities listed above. The Northland Diabetes Strategy Page 54 of 67 7 EVALUATION OF STAND AND PERFORMANCE MEASURES Setting specific targets is problematic because ambitious or challenging goals need to be balanced against achievable performance measures. The size and rate of growth of the diabetes epidemic and our increasingly obese population present huge and difficult challenges. Primary prevention to reduce the prevalence of obesity (such as through HEHA) is sensible and appealing, but there is no universal agreement on how to achieve effective implementation of such programmes. Best clinical practice such as CVD risk screening, prescribing statins, performing annual free checks and so on provides more defined and predictable outcomes. However, it is still dependent on provider and patient compliance, clinical governance and equitable access to primary care. 7.1 Developing Key Performance Indicators (KPIs) The performance framework for STAND should: recognise multiple stakeholder needs reflect that performance indicators are to cover a number of timeframes, specifically short term outputs, medium term outcomes and long term outcomes There are three key groups of stakeholders who have their own specific needs and requirements. Responsive key performance indicators (KPIs) will need to be developed for each of these groups: Community: Provide a clear easily communicated set of short (early wins), medium and long term outcomes that are motivational and meaningful for the broader community. Health services and health professionals: Provide a direction and set of measures that are meaningful and motivational for health services and health professionals. Management and governance: Provide short term management indicators that are based on the District Annual Plan reporting used by Northland District Health Board (NDHB). The KPIs should: be driven by the Leading for Outcomes (LFO) Framework provide a focus and shape to the programme over the long term by maintaining attention on key performance areas align performance over the long term (15 year), medium term (5 year) and short term (1 year) be linked to things we can actually measure (and intend to measure) manage the expectations of the community and health services be rational, logical and evidential, and fit with the intended evaluation framework reflect a focus on reducing inequalities Figure 24 table summarises the outcomes which could be used to measure the success of the STAND. The Northland Diabetes Strategy Page 55 of 67 Figure 24. Outcome measures for STAND Short term outcomes Intermediate outcomes Long term outcomes Among people with diabetes: Implement STAND T T Implement HEHA and strengthen health promotion T Increase the number of children enrolled in healthy lifestyle programmes Widespread and consistent use of patient-centered clinical care pathway Review existing services for those with diabetes Develop an effective coordinated workforce Information systems that best support the strategy A district-wide coordinated approach Change knowledge attitudes of: people at risk providers Increase the percentage of people with diabetes who: have Annual Free Check are in a Chronic Care Management programme have 2-yearly retinal screening have HbA1c <8 stop smoking lose weight exercise >2.5 hours per week have routine flu and pneumococcal vaccinations Increase the percentage of people with diabetes who: improve self care increase physical activity improve weight control Reduce hospitalisations Reduce amputations, reduce blindness Reduce heart attacks, strokes, renal failure Improve health-related quality of life Delay death Reduce disparities in diabetes outcomes Individual behavioural changes: consumers providers Policy and environmental + changes System changes Performance will need to be formally reported to the following groups: Northland Diabetes Strategy Steering Group Northland Regional Diabetes Team Northland DHB/MAPO Service Development and Funding Team NDHB Corporate Management Group (CMG) the Board of NDHB Note: The evaluation process will measure the performance of STAND across a large number of areas and in greater detail. Detailed evaluation feedback will complement the KPIs. The Northland Diabetes Strategy Page 56 of 67 7.2 Proposed Approach to KPIs The proposed approach to developing KPIs for STAND is to have three levels of KPI development and reporting: health outcomes process outcomes management outcomes Where possible the health and process outcomes should be reported by ethnicity and deprivation rating in order to reflect the risk factors and reducing inequalities goals of the programme. Health outcomes and process outcomes will be reported annually, where possible. Some measures, such as those dependent on the implementation of national surveys, will be reported on less frequently. Health and process outcomes will be based on the Leading for Outcomes (LFO) framework. Management reporting will be based on District Annual Plan (DAP) and Indicators of DHB performance (IDPs), as well as financial reporting against budget. Reports will be collated quarterly. KPIs may change from year to year as the programme develops. Figure 25 outlines the proposed approach to KPIs for Northland. Figure 25. Key performance indicators for STAND KPIs Reported by Based on Reporting regularity Risk groups, including: Maori Pacific South Asian (Indian) ‘other’ Leading for Outcomes (LFO) model used in STAND programme design and evaluation. Annually where possible, though less often where data is collected less frequently (eg by national survey). Health outcomes 15-year high-level whole population health outcomes for STAND. 5-year high-level whole population health outcomes for STAND. Yearly short-term health outcomes. Deprivation 9/10. Avoidable hospitalisation data. Regional Diabetes Team reports and database. Process outcomes 5 year goals for changes in process outcomes that will contribute to achieving the STAND health outcomes. Yearly short term process outcomes Risk groups, including: Maori Pacific South Asian (Indian) ‘other’ LFO model used in STAND programme design and evaluation. Annually where possible. DAP and IDP reporting requirements. Quarterly. Deprivation 9/10. Management outcomes District Annual Plan (DAP) and Indicators of DHB Performance (IDPs) targets for The Northland Diabetes Strategy Dependent on each indicator’s requirements. Page 57 of 67 KPIs Reported by Based on Reporting regularity programme outputs financial reporting against budget May change from year to year as NDHB targets and MoH IDPs are revised. Suggested KPIs for each of these dimensions are described in Figures 26 and 27. These are still in draft form and will need further refinement and peer review by the evaluation team (there are a number of options which include University of Auckland School of Population Health who are evaluating Counties Manukau DHB’s Lets Beat Diabetes strategy and SHORE / Whairiki from Massey University who are involved in Northland’s CVD Strategy and have evaluated other Northland projects) and key stakeholders such as clinical and community representatives. Figure 26. Proposed health outcome KPIs for STAND Goals Reduce the rates of obese and overweight people and hence slow the rate of progression towards diabetes Slow progression of diabetes so people remain complication-free for longer Reduce harm from diabetes complications 10% increase in the number of people who are physically active (>2.5 hours per week). 10% increase in life expectancy for people with diabetes. Halve the life expectancy gap for Maori and Pacific people with diabetes, compared to the general population. After 10 years (by 30 June 2016): 1,000 fewer people with diabetes than without STAND. 10% drop in overweight from 2005 rates. 5% drop in obesity from 2005 rates. Halving of rate of obesity in year 9 students. 80% have HbA1c<8. 20% reduction in rates of avoidable hospitalisation of people with diabetes for heart attacks, strokes, renal failure, blindness, amputations. After 5 years (by 30 June 2011): Rise in obesity levels in general population stopped. 10% drop in obesity in year 9 students. Children as active as the rest of New Zealand (currently 15% below). The Northland Diabetes Strategy 5% increase in the number of people who are physically active. 75% have HbA1c<8. Page 58 of 67 20% closing of the gap on life expectancy for Maori and Pacific people with diabetes, compared to the general population. 10% reduction in rates of avoidable hospitalisation of people with diabetes for heart attacks, strokes, renal failure, blindness, amputations. Figure 27. Proposed process outcome KPIs for STAND Goals Reduce the rates of obese and overweight people and slow the rate of progression towards diabetes Slow progression of diabetes so people remain complication free for longer Reduce harm from diabetes complications 80% of people with diabetes have had their disease identified and all of them are on a diabetes register. 100% of people with diabetes complications are enrolled in Northland’s Chronic Care Management programme (CCM). 90% of people with diabetes on the diabetes register have an Annual Free Check. 100% of people with diabetes complications have access to appropriate specialist services in a timely and equitable manner. 5 year goals (by 30 June 2011): 70% of schools support 30 minutes of physical activity every day. 30% reduction in the proportion of sugar to nonsugar soft drink beverages sold in Northland. All people with diabetes who have an annual free check have 2-yearly retinal screening. 80% of people with diabetes have patient-held self care plans. 100% of people with diabetes are offered CVD risk assessment, flu and pneumococcal vaccinations. 100% of people with diabetes enrolled in Northland’s CCM programme have patient-held self care plans. Proposed management outcome KPIs The seven key action areas of STAND have functional leadership hubs. Diabetes services review complete by 31 December 2005. 80% of provider contracts signed by 31 March 2006. Programme stays within budget. 90% of clinical and process KPIs are met. The Northland Diabetes Strategy Page 59 of 67 GLOSSARY Terms in italics have their own separate entry. Term Explanation A chronic condition caused by excess secretions of growth hormone from the acromegaly pituitary gland, characterised by enlargement of the head, hands and feet. acute Used to describe an illness or injury, either mild or severe, which lasts for a short time. age-standardised, agestandardising Some features occur at different rates at different ages; heart disease, for example, is more common in older age groups. Thus if 2 population groups have different age structures (as Maori and European do), their rates cannot be compared directly. Agestandardising is a statistical process which converts data from different populations as if it came from the same (standardised) population. The resulting rates are not ‘real’, but they are comparable. angina A symptom of coronary artery disease characterised by central, crushing chest pain which radiates to the jaw, neck or one or both arms. annual free check (AFC) A Ministry of Health-funded initiative to provide people with diabetes with one free primary care visit a year. An important part of managing the condition and keeping people as well as possible. avoidable hospitalisation A potentially avoidable hospitalisation signals the occurrence of a severe illness or injury that, theoretically, could have been avoided. Potentially avoidable hospitalisations fall into two subcategories: preventable hospitalisations: hospitalisations resulting from diseases preventable through population-based health promotion strategies ambulatory sensitive hospitalisations: hospitalisations resulting from diseases which could have been prevented or treated in a primary health care setting (such as vaccine-preventable diseases, early recognition and excision of melanoma, effective blood sugar control in people with diabetes) Baby Friendly Hospital Initiative A World Health Organisation-sponsored programme which aims to actively promote breastfeeding through education of health care workers in maternity and neonatal services. blood glucose See glucose. body mass index (BMI) A measure of whether an individual’s weight is within an appropriate range. It divides weight in kilograms by height in metres squared. (See also obese, overweight). cardiovascular disease (CVD) Related to the heart (cardio) and circulatory (vascular) system. The term includes both coronary heart disease and stroke. CarePlus A special funding programme which gives PHOs extra funding to deal with people with higher health needs, such as those with 2 or more chronic health conditions. This allows health workers to spend more time with patients for assessing, developing a care plan, and monitoring and adjusting the plan. The intention is to improve the quality of life of people under the scheme while at the same time reducing demand on health services. cerebrovascular accident (CVA) The clinical term for stroke. The Northland Diabetes Strategy Page 60 of 67 Term chronic Explanation Used to describe an illness, disease or disability of long duration, and which has developed slowly. Chronic conditions are usually permanent or incurable, so that management to minimise discomfort and cost of services is important. (See also acute). chronic care management (CCM) programme An approach to planning and providing health services for people with chronic disease. It aims to avoid the common experience of care being experienced as a series of disconnected encounters with different parts of the health system, and create a more integrated and holistic approach. This not only results in higher patient satisfaction but uses resources more effectively. chronic obstructive pulmonary disease (COPD) A disease which involves usually irreversible obstruction of the airways. Characterised by difficulty breathing, wheezing and a chronic cough. Most commonly caused by smoking. claudication Limping or lameness. coronary heart disease (CHD) Damage to the heart caused by not enough blood flowing through the heart’s blood vessels, either because they have become blocked plaques or blood clots. Used interchangeably with ischaemic heart disease. Cushing’s An increased concentration of glucocorticoid hormone in the bloodstream , which is produced by the adrenal gland . One of its consequences is diabetes. TU TU UT TU UT UT TU TU UT UT daypatient See hospitalisation. DC District council. deprivation, deprived Describing those with high, often multiple, needs (often used loosely to mean ‘poor’, though income is only one of the factors considered). The most widely quoted source of data on deprivation is the NZ Deprivation (NZDep) scale which analyses 5-yearly Census data to describe deprived populations. Once ‘deprivation index’ scores are calculated across the whole of New Zealand, the data is divided into deciles, 10 population groups of equal number. (These deciles are calculated differently, and use a different scale to the school deciles used by the education system.) DHB District Health Board. diabetes A complex condition in which the body is unable to control the amount of glucose (sugar) in the blood, either because there is not enough of the hormone insulin or it does not work effectively. Uncontrolled diabetes can lead to metabolic disturbances that increase the risk of long term complications and affect a number of the body’s systems. 90% of diabetes is type 2, acquired as a consequence of unhealthy lifestyle, and is usually related to excess weight gain; onset is gradual. About 10% of diabetes is type 1, a result of the pancreas malfunctioning whose cause lies in viral infection and a breakdown in the body’s autoimmune systems (not lifestyle); onset is usually rapid and can be life-threatening (see ketoacidosis). dialysis Filtering blood to remove waste products. See haemodialysis, peritoneal dialysis, renal replacement therapies. disability-adjusted life year (DALY) Years of Life Lost (YLL) is a method of estimating years of healthy life lost due to premature death. The DALY method extends this to include years of life lost in states of less than full health, broadly The Northland Diabetes Strategy Page 61 of 67 Term Explanation termed ‘disability’ for the purposes of this calculation. District Annual Plan (DAP) Northland DHB’s statement of its intentions for the coming year. (See also District Strategic Plan.) District Strategic Plan (DSP) Northland DHB’s statement of its intentions, based on the needs identified in the HNA, over the coming 5 or 10 years. Prepared once every 3 years. (See also District Annual Plan.) ethnicity A measure of cultural affiliation defined by Statistics New Zealand as a social group whose members share a common origin, claim a common sense of distinctive history and destiny, possess one or more dimensions of collective individuality and feel a sense of unique collective solidarity. fasting glucose See glucose. Food in Schools Often-used term for the National Heart Foundation’s School Food Programme. Fruit in Schools A Ministry of Health-driven programme to promote health and wellbeing in high need primary schools. It involves a Health Promoting Schools / whole-school-community approach to promoting 4 priority areas (healthy eating, physical activity, sun protection and smokefree), as well as the provision of fresh fruit for children in eligible primary schools in high-need areas. FTE Full-time equivalent glucose, impaired glucose tolerance, fasting glucose test Glucose is one type of sugar, our main source of energy into which carbohydrates are converted. Impaired glucose tolerance is a condition in which glucose exists in the blood at levels which are higher than normal, but not enough to be labelled as diabetes. It is measured during a fasting glucose test, when a person who has fasted for at least 8 hours has a blood test to measure their blood glucose level. If the result of this is clear, a glucose tolerance test is performed, in which a patient is given a large amount of sugar and their body’s response measured. Green Prescription (GRx) Written advice about physical activity from a health professional (typically a GP), given to a person as part of managing their health. haemodialysis A type of dialysis that filters the blood through a special machine or filter. See also peritoneal dialysis, renal replacement therapies. HbA1c Blood glucose; see glucose. Health Promoting Schools (HPS) A Ministry of Health-driven programme in which schools sign up for a whole-of-school approach to promoting health and wellbeing (that is, it links all aspects of school life into a health promoting framework). They are assisted in this process by HPS advisors in the local DHB. Healthy Eating, Healthy Action (HEHA) A Ministry of Health-driven strategy which aims to identify, promote, and coordinate programmes for healthy nutrition and appropriate physical activity at national, regional, community and iwi levels. Health Needs Analysis (HNA) A 3-yearly statement of the needs identified by Northland DHB as having the highest priority. The basis of the District Strategic Plan. HEAT Health Equity Assessment Tool. A series of questions designed by the Ministry of Health that enable a service or plan to be assessed for its effectiveness in reducing inequalities. He Korowai Oranga The national Maori health strategy published by the Ministry of The Northland Diabetes Strategy Page 62 of 67 Term (HKO) Explanation Health (see also Whakatataka). Hospitalisation The process of attending hospital as a patient. There are 3 main types: inpatient (a patient who stays at least one night in hospital), outpatient (a person who is seen in a non-inpatient setting, or ‘clinic’, by a specialist after referral from a GP) and daypatient (a patient who undergoes an operation or other procedure in hospital and able to return home without staying overnight). The term ‘hospitalisation’ is often used loosely to mean one or any combination of the 3 types. hyperglycaemia The presence of excess glucose (sugar) in the blood. hyperlipidemia The presence of excess lipids or fats in the blood; the clinical equivalent of, in everyday terms, ‘high cholesterol’. hyperosmolar coma A severe condition that can occur in people with diabetes. Results in loss of consciousness due to too many molecules of glucose in their system causing changes in the distribution and balance of essential fluid and electroytes. Occurs in dehydration, uremia, and hyperglycemia with or without ketoacidosis. hypoglycaemia Abnormal decrease of glucose (sugar) in the blood. IDPs Indicator of DHB Performance, one of a group of measures applied by the Ministry of Health to every DHB to assess their performance and the health of their populations. incidence The number of new instances of a disease or illness in a defined group of people over a particular period of time (compare with prevalence). inpatient See hospitalisation. intersectoral Used to describe relationships between health and other sectors, often other government organisations, TAs (compare with intrasectoral) intrasectoral Used to describe relationships between organisations within the health sector (compare with intersectoral). ischaemic heart disease (IHD) Damage to the heart caused when not enough oxygen reaches the heart tissue because the blood supply is either obstructed or inadequate in volume or pressure. Used interchangeably with coronary heart disease. ketoacidosis A serious condition caused by excess levels of acid in the body accompanied by an accumulation of ketones. Characterised by high glucose levels, ketones in the urine, vomiting and drowsiness which can cause multiple system failure and death. ketones See ketoacidosis. key performance indicators (KPIs) A set of measures which suggests progress is being made in dealing with the ‘big issues’. Leading for Outcomes (LFO) A Ministry of Health-driven effort to gather evidence about how to make changes to health systems as part of wider improvements in in society’s health. It focuses on outcomes – the effects that actions have, and defining what works well – to suggest the sorts of changes health services need to work together to make, in order to achieve wider societal goals. The Northland Diabetes Strategy Page 63 of 67 Term life-course, life-course continuum, life-course approach Explanation Another name for a model of disease progression developed by Leading for Outcomes. It maps the flow of chronic disease from early risk through to advanced symptoms, complications and death. One of the aims is to get health services to think about how they could work together better to keep people towards the ‘left-hand’ end of the continuum. Lifestyle Clinic A programme run by NDHB’s Child Health Centre for children who are obese. As well as slowing down the child’s weight gain, the whole family is encouraged to make changes and become more physically active. LMC Lead maternity carer. LTNZ Land Transport New Zealand. Maori provider A provider of health services which is run by Maori for Maori (as distinct from a ‘mainstream’ provider who deals with Maori clients or patients). MAPO A Maori co-funder organisation, Northland DHB’s funding and planning partner (the name persists from the days when they were called ‘ Ma ori p urchasing o rganisations’). NDHB deals with 2: Te Tai Tokerau MAPO (whose responsibilities for Maori correspond with the DHB’s responsibilities for the population bounded by the Whangarei and Far North territorial local authority areas) and Tihi Ora MAPO (whose responsibilities for Maori coincide with the DHB’s responsibilities for the Kaipara district). U U U U U U MI Myocardial infarction, the same as acute myocardial infarction. In everyday terms, a ‘heart attack’. MoH Ministry of Health. MSD Ministry of Social Development. NDHB Northland District Health Board, which has 2 parts, NDHB Funder and NDHB Provider. The NDHB Funder is that part of NDHB that has been legislated to carry out the funding function for health services in Northland. The funder assesses needs, sets priorities for services, allocates funds, lets contracts to providers, and monitors performance. The NDHB Provider is that part of NDHB that provides health services (as distinct from the NDHB Funder). The majority of the Provider Service’s funding goes on Secondary care services. In the strategy documents, ‘NDHB’ refers to the whole organisation with involvement as relevant in each case from the funder or from the provider arm. neuropathy A general term meaning damage to the peripheral nervous system, that part of the nervous system that is outside the central nervous system (CNS) in the brain and spine. It connects the CNS to sensory organs throughout the body. NGO Non-government organisation, any organisation which is not part of the public sector. In the health sector it usually refers to health service providers, though it applies more widely than that. It ecompasses the private and voluntary sectors, therefore including many organisations which are funded wholly or partly from the public purse but are not part of a formal government structure. Major NGOs include PHOs and Maori providers. non-mydriatic Not requiring the use of eye-drops to dilate the pupil. The Northland Diabetes Strategy Page 64 of 67 Term obese, overweight Explanation Degrees of excess weight, as defined by the Body Mass Index (BMI). Overweight = BMI 25-29 for Europeans, 26-31 for Maori and Pacific. Obese = BMI 30+ for Europeans, 32+ for Maori and Pacific. (Acceptable figures differ across ethnic groups because of variations in bodily composition and how this relates to risk of developing health problems such as heart disease and diabetes). opportunistic screening Taking advantage of opportunities as they arise, such as during a GP visit, to assess individuals for health problems (as distinct from a formal population-based programme of screening, such as the Cervical Screening Programme). People may not realise that they have signs or symptoms already developing, so this is an important way of catching problems (especially chronic diseases) early, when they are more likely to be preventable or are easier to treat. outcome The result of an action. As distinct from an output, which is a measure of an activity rather than the result it has. An operation to mend a broken leg is an output, while the return to full function of the leg is the outcome. In a bigger picture sense, a focus on outcomes aims to analyse how effectively health services are provided and how well they work together. outpatient See hospitalisation. patient management system A system for managing data about all the people to whom an organisation provides services. peritoneal dialysis A type of dialysis that involves a thin tube being inserted into the peritoneum (the thin tissue that lines the abdomen) from which body wastes are removed. See also haemodialysis, renal replacement therapies. podiatrist A health worker who specialises in foot care. Predict A computer programme which assists GPs to assess and make treatment decisions on people with cardiovascular disease and diabetes. prevalence The total number of instances of a disease or illness in a defined group of people at any one time (compare with incidence). primary health care Health services provided in the community which people can access themselves. The most well known are those provided by general practitioners, though they also include pharmacy services, private physiotherapists and, increasingly, nurse practitioners. (See also secondary services, tertiary services). Primary Health Organisation (PHO) A group of providers of primary health care services whose responsibility is to look after the people who enrol with them (those who are ‘on the register’). PHOs include GPs as well as a whole range of primary health care providers and practitioners (Maori and community health service providers, nurses, pharmacists, dietitians, community workers, and many others). As well as providing traditional primary health care services, PHOs must improve access to services for those with higher needs (such as Maori or those with chronic health conditions), have a focus on preventing ill health (rather than waiting till they are visited by sick people) and improve the way services work together. The Northland Diabetes Strategy Page 65 of 67 Term RDT Explanation Regional Diabetes Team. A team formed to oversee issues related to diabetes and suggest improvements to such things as information collection and service provision. The RDT makes an annual report to the Ministry of Health. Membership includes NDHB Funder, Te Tai Tokerau MAPO and various Northland providers. reducing inequalities Inequalities in the health status of populations exist by socioeconomic status, ethnicity, gender, age and geographical areas. The reducing inequalities approach is about recognising these and proactively planning, funding and delivering services to reduce these differentials. renal Of the kidneys. renal replacement therapies One of the functions of the kidneys is to remove waste products from the body. When people develop end-stage renal failure or their kidneys are no longer able to function normally, they will require a form of renal replacement therapy to carry out this function. Treatments include haemodialysis and peritoneal dialysis. retinal screening The process of checking the eyes for the presence of retinopathy (damage to the retina), a common complication of diabetes. The test involves a digital photograph being taken with a special camera, and an eyesight (visual acuity) test. retinopathy See retinal screening. risk factor A factor, which may be biological (such as a genetic predisposition) or associated with behaviour (such as smoking), that increases the likelihood of a disease developing. secondary services, secondary care Hospital services which people can access only through a referral from a primary health care worker. (See also primary health care, tertiary services). SIA Services to Improve Access. A Ministry of Health programme which provides funding for PHOs, on top of their core funding for normal general practice services, to reduce inequalities for populations which have the poorest health status. PHOs must meet clear criteria in order to receive the funding. socioeconomic status (SES) Social position along a scale (which runs, in everyday terms, from ‘rich to ‘poor’), as measured by criteria such as income level, occupational class or educational attainment. SPARC Sport and Recreation NZ, a government-funded organisation which counts among its aims getting Kiwis active and carrying out surveys on physical activity. Sport Northland has close links with SPARC. specialist A physician or surgeon, usually based in a hospital, who has undertaken extra training on top of the normal medical degree to specialise in a particular type of service or disease. Also called a consultant. Sport Northland A trust, part of a nationwide network of regional sports trusts, which aims to encourage healthy lifestyles through regular participation in sport and/or physical activity. Their vision is to ‘Get More Northlanders Active’. A majority of their funding comes from Sport and Recreation NZ. STAND Successfully Taking Action for Northland Diabetes, the Northland DHB Diabetes Strategy. The Northland Diabetes Strategy Page 66 of 67 Term statin Explanation A drug taken to lower the level of cholesterol in the blood. stroke A condition due to a lack of oxygen to the brain, usually caused by a blood clot. Can lead to paralysis, coma and speech problems that are often reversible to some degree. type 1 diabetes, type 2 diabetes well-child services See diabetes. Primary care and community services provided by nurses and doctors that monitor and assess children to achieve their best possible health and detect any existing or potential health needs. They are provided according to a Ministry of Health schedule which describes, at various stages from birth to age 5, the services to be provided, topics to be addressed and support all children and their families are entitled to. Whakatataka The national Maori health action plan published by the Ministry of Health; the implementation plan arising out of He Korowai Oranga. Whanau Ora A Ministry of Health-driven process aimed at supporting healthy Maori families which emanates from He Korowai Oranga. It aims to identify and extend whanau strengths and build them into initiatives throughout the health sector. The Northland Diabetes Strategy Page 67 of 67
