Services:

• Older People
• Youth, Children & Families
• Mental Health
• Elder Care Canterbury

Submission on “DOING IT DIFFERENTLY”
 A proposed integrated model of care

This submission is made from the perspective of Presbyterian Support Upper South Island as an organisation that is focused on wellbeing and people being well supported in their communities.

If you have any queries regarding this submission please contact Jackie Girvan, the regional manager of Presbyterian Support Ashburton, on  03 308 5868 or Sue Milligan, the researcher at Presbyterian Support Upper South Island, on 03 366 5472.

 

Executive summary

·       Definitions of health need to recognise the importance of promoting wellbeing. 

·       Promoting health and enhancing the scope of primary and community services involves recognising the role social services play in preventing ill health and promoting wellbeing.

·       Collaboration should involve health and social service agencies that have an active interest in maximising wellbeing and preventing health problems from occurring

·       Collaboration and integration could involve intersectoral action, which can achieve more than sectors acting alone in their own best interests.

·       The client should be given appropriate choice in selecting service providers

·       Services need to be responsive to clients need.  They need to be fitted around the client rather than the other way around.  This is not given enough emphasis in this document, and should be a key driver of health service delivery.

·       Information sharing is crucial to good information

·       One model of integrated care that seeks to enhance collaboration and the information process is a proposed Presbyterian Support initiative “Homeworks”.  A copy of this proposal is attached.

Our organisation

Presbyterian Support Upper South Island is a social service agency that seeks to make and lasting difference in the lives of others. In Ashburton Presbyterian Support services are coordinated from the Trevor Wilson Centre.  The Trevor Wilson Centre provides a range of counselling, social work and mentoring services to provide support to children, young people, and their families in need.   It also acts as a referral point for individuals and agencies concerned about the needs of older people living alone, providing information and practical assistance for older people as required.  We offer falls prevention courses to improve the strength and balance of older people and provide them with opportunities for social interaction.  We have recently noticed an unmet need for a social worker specifically for the planning and coordination of services and support for older people, and employed someone to help meet this need. Although she has only been employed a very short time, the social worker already has two clients who were referred specifically because of not being properly supported within the community.

Comments on Section 3: Ashburton Health Services – Doing it Differently

Strengthening Collaboration and Integration

We support the idea of strengthening collaboration and integration between health providers. Problems with the current system have been summarised in Dean (Dean 2005), which is attached.  These are:

Ø      Blurring of boundaries – confusion about “who does what?”

Ø      Separation and fragmentation of services resulting in a lack of coordination between services

Ø      Some duplication of services

Ø      No common home assessment tool for assessors and providers

Ø      Duplication of referral, administration systems and point of entry

Ø      Duplication of assessment processes has both time and resource implications for service providers.

Ø      Difficulties transferring between services

Ø      Confusion about referral options (who, where) for referrers

Ø      Lack of communication between services

Ø      Reduced awareness of involvement of other services

Ø      Services may only be involved at crisis points and feel they are “reactive” rather than “proactive” to client’s changing needs

Ø      Services providers spending large amounts of time trying to coordinate care with other services when access criteria, service boundaries and other limitations impact on service availability e.g. workforce skills.

Ø      Service gaps e.g. step up/down care, intermediate care, slow stream rehabilitation options, Maori and Pacific service providers

Ø      No access to other service’s assessment and care plan information

Ø      No care pathways for clients with multiple healthcare issues

Ø      Separation of health, social (e.g. transport and housing) and welfare needs... “no one sees me as a whole person any more”

“The overall effect is a system of care that lacks responsiveness and individuality, in spite of the best efforts of those health professional trying to administer it.  Processes are duplicated, there is no overall responsibility for care planning across clinical and support needs and there is confusion as to who can do what, when and how”

“Doing it Differently” proposes some ways of strengthening collaboration and integration to help overcome these issues. However we feel the ways proposed are insufficient to tackle the problems outlined above.  In particular we know that social service agencies can also play an invaluable part in this increasing collaboration, and feel that this should be acknowledged.

Through the services they provide, many social service agencies play a key role in the prevention of illness or disability.  For example counselling can help people who may have been at risk of mental illness, addictive, self-injurious or violent behaviour.  Falls prevention can increase strength and balance, preventing falls in older people.  Involvement in social networks also improves psychological and spiritual wellbeing.  Loneliness is a key predictor of depression, thus reducing social isolation can be seen as a preventative health strategy, whilst also enabling older people to live more full and rewarding lives. When you embrace a broader definition of health than just the absence of disease or illness, and embrace the concept of wellbeing and full and productive lives, then the role played by social service and not-for-profit agencies becomes even more pivotal.

So the ‘interface between health services’ needs to be between a number of agencies that are involved in looking after the health and wellbeing of people, rather than restricted to traditional “primary and secondary health services”.   In order for people to “benefit from a seamless journey through a well-coordinated system without boundaries” (Canterbury District Health Board 2005) intersectoral action is needed.

Intersectoral action for health has been defined by Harris as “a recognised relationship between parts of the health sector and part or parts of another sector, that has been formed to take action on an issue or to achieve health outcomes in a way that is more effective, efficient or sustainable than could be achieved by the health sector working alone (Ministry of Health 2001).  Intersectoral action involves building constructive and collaborative relationships between health and other agencies, in order to influence the broader determinants of health and wellbeing.  Intersectoral action generally takes three broad different forms, over-arching area or settings-based initiatives (such as Health Promoting Schools), issues based initiatives (such as safer community councils, and health and housing initiatives) and case management services.

We note that service collaboration and coordination amongst providers is particularly crucial when it comes to providing services for older people.  This is because interventions are often multifaceted and complex.  Often several services need to be coordinated to ensure there are no service gaps or duplication, and that each service is delivered in an appropriate timeframe. In order to ensure information is appropriately disseminated, and services coordinated in their goals and provision, co-operation between sectors, not just traditional health care providers is needed.

Presbyterian Support Upper South Island has produced a model incorporating intersectoral action in Ashburton, based on collaborative case-management.   “Homeworks” is based on an integrated model of care, and we have attached as an Appendix to this submission a detailed proposal of how such a model could work to maximise the health benefit delivered to the people of Ashburton.  This model supports individuals in the community through a system of a single point of entry to services and utilisation of a Key Worker/Care Coordinator concept.    This is similar to a model now operational in Christchurch that uses a central Referral Co-ordination Centre to manage budget and service provision for short term home support and district nursing services (Dean 2005).    It also has similarities to the Coordinator of Services for the Elderly (COSE) key worker concept, initiated by the Eldercare Canterbury project (Dean 2005). In the Homeworks model referrals would be received from the DHB or PHO. The single assessment process undertaken by the Key Worker and their ongoing involvement and review of the client simplifies the process for clients, health professionals and referrers alike.  A single assessment process could mean standardising criteria for referral, which would further facilitate coordination of services.  Currently, referral criteria differ resulting in differential service provision.  For example a client may have short term nursing from one service but long term home care services from another.  Both require separate referrals and assessments, often resulting in confusion for the client. Care is not always well coordinated. For example services may be delivered at times that are at odds. There is no point, for example, trying to shower a client whilst they are having a wound dressed.

A common referral point, with a key worker, would ensure that people have access to a variety of services, with less likelihood of gaps in service provision.  It recognises the importance of agencies working in partnership with other agencies.  It also ensures that the information process flows more smoothly, greatly reducing transaction costs.

By intersectoral collaboration we can ensure that older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. This is one of the objectives of the Health of Older People Strategy (Ministry of Health 2002).

Core services locally, specialist services from Christchurch

Ashburton contains a substantial population cluster and there is a unique need for services to be available locally.  It is the view of Presbyterian Support Upper South Island that there are good reasons to retain a strong base of specialised medical staff in Ashburton hospital.

In particular, we do not support the long term plan to make acute caesarean sections and general surgery unavailable in Ashburton.

Presbyterian Support Upper South Island believes that at times such as the birth of a child, it is important to have access to the support of family members.  Families often have other children, and it may often be impossible for the family to travel to Christchurch for the birth of their child.   When an emergency caesarean is indicated, time is often crucial, and the time spent travelling to Christchurch could prove too long. The Ashburton population is growing, and in particular the Pacific population is growing.  The birth rate of Pacific peoples, is much greater than that of Europeans, so it can be expected that there may be an increase, rather than a decline in the overall birth rate in Ashburton.  We were unsure of the exact number of caesarean sections performed in Ashburton over the years, as we noted (on page 45) that figures provided were based on reason for admission, rather than actual mode of birth (presumably some of the patient admitted for antenatal reasons or vaginal birth with complications may also have had caesareans?)  Under this model we also wondered if many of the antenatal patients would be required to stay at Christchurch hospital due to the length of their stay and the requirement to be closer to specialist services.

Enhancing the scope of Primary and Community Service

Presbyterian Support supports enhancing the scope of primary and community services.  We note that community services such as ours (as well the primary and secondary health services mentioned in the report) can be involved in providing more stream-lined and better-coordinated health services in Ashburton.  The proposed central referral agency, outlined in the Homeworks proposal attached, would help contribute to achieving this goal.

Fundamentally, enhancing the community’s scope in health provision requires a recognition that they contribute to health creation and prevention of ill health.  One area where this has been greatly undervalued is the contribution of counsellors and social workers in the mental health area.    Whilst medical remedies for depression and other psychological problems are commonly available, relatively cheap, and extremely accessible, social remedies such as therapeutic counselling are often not.  Recently we have witnessed an increasing incidence of young to middle aged adults experiencing problems with depression and anxiety and related conditions.  Many of these clients have responsibility for children. It is extremely concerning to us, as an organisation, that no assistance apart from medication is available through the public health system. This means that clients are not being empowered to choose a non-medical solution, or a mixed solution to their problems. It also often means that a bandaid is applied, rather than the underlying issues being dealt with.  Time and money spent providing advice and support to people so they can cope with life, and regain quality of life is well worth it. It has flow on benefits for entire families, and also may also reduce the need for more specialist medical services. Clients who require help but do not access such service may be at risk of serious and acute episodes that jeopardise the quality of life of family, and in extreme circumstances, the safety of family members. In this regard, we would like to note that good mental health and child and youth health should be reiterated as key health needs on page 28 of “doing it differently”.

Adequate social work provision is essential, especially for older people who may be coping with grief, socially isolated, or need help in working out the resources that are available to them for them to remain safe and well in their homes.

We support the establishment of a rapid assessment team, and sincerely hope that “putting in place community and home support services” involves access to community counsellors and social workers, for the reasons outline above.

Another area that is worth mentioning in the context of an aging population is care for the elderly.  In order to support the concept of ageing in place adequate referral to and provision of community support is essential.  Falls prevention, daycare and respite care are central for sustainable community care of the frail elderly.  Recognition of the importance of these services needs to be provided by the traditional healthcare providers, not just at a management level, but at the grassroots, where client needs are assessed.

Enhancing the scope of community services will require a commitment to developing community based wellbeing and recovery models, and a recognition that health is more than the absence of illness.  The medicalisation of health has meant an emphasis on general practitioners as primary care givers, without due recognition to other forms of primary prevention and the enhancement of wellbeing.

Ellyard has recently commented in his address to the NZIPA that “it is likely that the medicalisation and individualisation of health has now passed its peak and wellbeing and communitarian approaches will grow” (Ellyard 2005).  In the communitarian mindset a key factor is getting individuals and communities to create health for themselves, not just be the recipients  of healing provided by others. Reminding us of history, and the importance of the environment and community in public health advances, he notes that “although future health improvement will be better delivered by people with communitarian mindsets, most of those involved in the medical services are still looked in individualistic mindsets” (Ellyard 2005).    He notes that the 19th Century was one of dependence, the 20^th Century was one of independence, but the 21^st Century will be about interdependence.

Health information systems

Presbyterian Support supports the emphasis on good information systems.  We would like it noted that another critical factor for enhancing integrated services is the sharing of information, rather than just good information systems per se. 

Currently collaborative sharing of commonly required information seldom occurs. Information between providers is sometimes not relaid, which can result in an inferior service or gaps in service provision.  As one provider describes it, “the sum of the services does not always add up to a whole (service) for the client” (Dean 2005).

We would like to reiterate that one way of simplifying information processes would be to have a central referral agency, which stored all the pertinent information pertaining to a client. 

Sharing information would encourage service providers to think in a more holistic manner, rather than the current approach where people only ‘appear’ when logged in to a particular service provider and ‘cease to exist’ when they exit that service.

For these reasons, we applaud the move toward shared electronic information between secondary and primary care, but again note that it is also important that social service providers have access to the appropriate information.

Health promotion

We support the emphasis placed on health promotion as a strategy for preventing illness and disease.  We also support the emphasis placed on healthy lifestyles.  We think environmental strategies need to be employed as part of this, rather than a purely individualistic model that emphasises choice unbound by contextual parameters. 

We look forward to having the chance to contribute to the improved youth mental health and wellness programmes that will be developed.

Issues not covered in the report

Another main objective that could be considered in “Doing it Differently” is empowering clients to choose between various services. The first objective in the Health of Older People Strategy is that people need to be able to make well-informed choices about the options for healthy living, health care and/or disability needs (Ministry of Health 2002).  The New Zealand Health Strategy also states that services need to “emphasise community and health services users’ involvement at all levels” (Ministry of Health 2000).  Currently true choice of service provider is often not available, but clients are unaware of this (Dean 2005).   The best way of empowering people to choose is to ensure they are aware of all the alternative service options available to them.  Again, a central referral agency would ensure this; by ensuring the appropriate information is disseminated about all the options for care. 

Another thing “Doing it Differently” could emphasise is that the development of future services needs to be structured in such a way that services are selected to be responsive to specific client needs. This is a client-focused approach. Based on needs assessment and client input, a range of services tailored to the client’s specific needs would then be selected. This allows more flexibility in selecting strategies that are best suited to the client.

As the Ministry of Health have noted, determinants of the health of populations and communities are diverse, complex and multifactorial – and beyond the capacity of the health sector to influence on its own (Ministry of Health 2001).  Given this it would be appropriate to have a greater emphasis on the holistic view of health, rather than a narrow medicalised focus.  Throughout the discussion document “Doing it differently” we were concerned that the definition of health appears to be the absence of illness, as evidenced by constant reference to patients rather than clients.  Even if health is defined in the narrow way as the absence of illness, much healthcare intervention can be focused in the preventative area, reaching clients before they become patients.

Thank you for the opportunity to comment on this proposal

Vaughan Milner
Chief Executive Officer
Presbyterian Support Upper South Island

Bibliography

Canterbury District Health Board (2005). Doing it Differently, CDHB.

Dean, C. (2005). A Model for Community Support incorporating "Homeworks" in Ashburton, Presbyterian Support Upper South Island.

Ellyard, P. (2005). Imagining and building a sustainable general practice in a flourishing health system for the 21st century. New Zealand IPA. Christchurch.

Ministry of Health (2000). The New Zealand Health Strategy. Wellington, Ministry of Health.

Ministry of Health (2001). Intersectoral initiaives for imrpoving the health of local communities.

Ministry of Health (2002). Helath of Older People Strategy.