southern dhb board meeting - agenda · 2020-05-01 · 7.1.1 verbal report of 29 april 2020 meeting...

Southern DHB Board MeetingBy Zoom

05/05/2020 09:30 AM - 11:30 AM

Agenda Topic Presenter Page

1. Opening Karakia

2. Apologies 2

3. Declarations of Interest 3

4. Minutes of Previous Meeting 11

5. Matters Arising

6. Review of Action Sheet 18

7. Advisory Committee Reports 22

7.1 Finance, Audit & Risk Committee Jean O'Callaghan 22

7.1.1 Verbal report of 29 April 2020 meeting 22

7.1.2 Drawdown - Interim Works and Critical Infrastructure Works, Dunedin Hospital

23

8. CEO's Report CEO 24

9. Finance and Performance CEO 41

9.1 Financial 41

9.2 Volumes 46

9.3 Performance 47

10. Annual Plan/Budget 2020-21 Update EDSP&C

11. COVID-19 Update CEO 55

12. E-Bikes EDFP&F 99

13. Resolution to Exclude the Public 101

Southern DHB Board Meeting - Agenda

1

APOLOGIES

No apologies had been received at the time of going to print.

2Southern DHB Board Meeting - Apologies

2

SOUTHERN DISTRICT HEALTH BOARD

Title: INTERESTS REGISTERS

Report to: Board Meeting

Date of Meeting: 5 May 2020

Summary:

Board, Committee and Executive Team members are required to declare any potential conflicts (pecuniary or non-pecuniary) and agree how these will be managed. A member who makes a disclosure must not take part in any decision relating to their declared interest.

Interests declarations, and how they are to be managed, are required to be recorded in the minutes and separate interests register (s36, Schedule 3, NZ Public Health and Disability Act 2000).

Changes to Interests Registers over the last month:

ß Terry King and Moana Theodore’s entries updated.

Specific implications for consideration (financial/workforce/risk/legal etc):

Financial: n/a

Workforce: n/a

Other:

Prepared by:

Jeanette KloostermanBoard Secretary

Date: 28/04/2020

RECOMMENDATION:

1. That the Interests Registers be received and noted.

3

Southern DHB Board Meeting - Declarations of Interest

3

SOUTHERN DISTRICT HEALTH BOARDINTERESTS REGISTER

Member Date of Entry Interest Disclosed Nature of Potential Interest with Southern DHB Management Approach

Dave Cull (Board Chair) 09.12.2019 Daughter-in-law employed as a nurse by Southern

DHB25.02.2020 Board Member, Cosy Homes Trust

25.02.2020 President, Local Government New Zealand (until July 2020)

25.02.2020 Trustee, Weller Trust (Property investment)

25.02.2020 Director, Popaway Ltd (Property investment)

David Perez (Deputy Chair) 13.05.2019 Director, Mercy Hospital, Dunedin SDHB holds contracts with Mercy Hospital. Step aside from decision making.

13.05.2019 Fellow, Royal Australasian College of Physicians13.05.2019 Trustee for several private trusts

Ilka Beekhuis 09.12.2019 Patient Advisor, Primary Birthing FiT Group for Dunedin Hospital Rebuild

09.12.2019 Member, Otago Property Investors Association

09.12.2019 Secretary, Spokes Dunedin (cycling advocacy group)

15.01.2019 Paid member, Green Party

15.01.2019 Former employee of University of Otago (April 2012-February 2020)

John Chambers 09.12.2019 Employed as an Emergency Medicine Specialist, Dunedin Hospital

09.12.2019 Employed as Honorary Senior Clinical Lecturer, Dunedin School of Medicine

Possible conflicts between SDHB and University interests.

09.12.2019 Elected Vice President, Otago Branch, Association of Salaried Medical Specialists

Union (ASMS) role involves representing members (salaried senior doctors and dentists employed in the Otago region including by SDHB) on matters concerning their employment and, at a national level, contributing to strategies to assist the recruitment and retention of specialists in New Zealand public hospitals.

09.12.2019 Wife is employed as Co-ordinator, National Immunisation Register for Southern DHB

09.12.2019 Daughter is employed as MRT, Dunedin Hospital

Kaye Crowther 09.12.2019 Life Member, Plunket Trust Nil09.12.2019 Trustee, No 10 Youth One Stop Shop Possible conflict with funding requests.09.12.2019 Employee, Findex NZ

14.01.2020 Trustee, Director/Secretary, Rotary Club of Invercargill South and Charitable Trust

14.01.2020 Member, National Council of Women, Southland Branch


4



Lyndell Kelly09.12.2019 Employed as Specialist, Radiation Oncology,

Southern DHB

Involved in Oncology job size and service size exercise and may be involved in employment contract negotiations with Southern DHB.

18.01.2020 Honorary Senior Lecturer, Otago University School of Medicine

18.01.2020 Daughter is Medical Student at Dunedin Hospital

Terry King 28.01.2020 Member, Grey Power Southland Association Inc Executive Committee

28.01.2020 Life Member, Grey Power NZ Federation Inc

28.01.2020 Member, Southland Iwi Community Panel

ICP is a community-led alternative to court for low-level offenders. The service is provided by Nga Kete Matauranga Pounamu Charitable Trust in partnership with police, local iwi and the wider community.

14.02.2020 Receive personal treatment from SDHB clinicians and allied health.

03.04.2020 Client, Royal District Nursing Service NZ Ltd

Jean O'Callaghan 13.05.2019 Employee of Geneva Health Provides care in the community; supports one long term client but has no financial or management input.

13.05.2019 St John Volunteer, Lakes District Hospital Nil Taking six months' leave.Tuari Potiki 09.12.2019 Employee, Otago University

09.12.2019 Chair, NZ Drug Foundation09.12.2019 Chair, Te Rūnaka Ōtākou Ltd*

09.12.2019 Member, Independent Whānau Ora Reference Group

09.12.2019 *Shareholder in Te KaikaLesley Soper 09.12.2019 Elected Member, Invercargill City Council

09.12.2019 Board Member, Southland Warm Homes Trust09.12.2019 Employee, Southland ACC Advocacy Trust

16.01.2020 Chair, Breathing Space Southland (Emergency Housing)

16.01.2020 Trust Secretary/Treasurer, Omaui Tracks Trust

19.03.2020 Niece, Civil Engineer, Holmes Consulting Holmes Consulting may do some work on new Dunedin Hospital.

Moana Theodore 15.01.2019 Employee, University of Otago

15.01.2019 Co-director, National Centre for Lifecourse Research, University of Otago

15.01.2019 Member, Royal Society Te Apārangi Council

15.01.2019Sister‐in‐law, Employee of SDHB (Clinical Nurse Specialist Acute Mental Health)

15.01.2019 Shareholder, RST Ventures Limited

27.04.2020 Nephew, Casual Mental Health Assistant, Southern DHB (Wakari)

Andrew Connolly (Crown Monitor)

21.01.2020 Employee, Counties Manukau DHB

21.01.2020 Deputy Commissioner, Waikato DHB

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5



21.01.2020 Southern Partnership Group21.01.2020 Health Quality and Safety Commission21.01.2020 Health Workforce Advisory Board21.01.2020 Fellow Royal Australasian College of Surgeons21.01.2020 Member, NZ Association of General Surgeons21.01.2020 Member, ASMS

Roger Jarrold (Crown Monitor)

16.01.2020 CFO, Fletcher Construction Company Limited

16.01.2020 Member, Audit and Risk Committee, Health Research Council

16.01.2020 Trustee, Auckland District Health Board A+ Charitable Trust

16.01.2020Former Member of Ministry of Health Audit Committee and Capital & Coast District Health Board

23.01.2020 Nephew - Partner, Deloitte, Christchurch


6


EXECUTIVE LEADERSHIP TEAM

Employee NameDate of Entry

Interest DisclosedNature of Potential Interest with Southern District

Health Board

Kaye CHEETHAM 08.07.2019 Ministry of Health Appointed Member of the Occupational Therapy Board

Mike COLLINS 15.09.2016 Wife, NICU Nurse

01.07.2019 Capable NZ Assessor Asked from time to time to assess students, bachelor and masters students final presentation for Capable NZ.

Matapura ELLISON 12.02.2018 Director, Otākou Health Ltd Possible conflict when contracts with Southern DHB come up for renewal.

12.02.2018 Deputy Kaiwhakahaere, Te Rūnanga o Ngai Tahu Nil

12.02.2018

Chairperson, Kati Huirapa Rūnaka ki Puketeraki (Note: Kāti Huirapa Rūnaka ki Puketeraki Inc owns Pūketeraki Ltd - 100% share).

Nil

12.02.2018 Trustee, Araiteuru Kokiri Trust Nil

12.02.2018 National Māori Equity Group (National Screening Unit)

12.02.2018 SDHB Child and Youth Health Service Level Alliance Team

12.02.2018 Otago Museum Māori Advisory Committee Nil

12.02.2018 Trustee, Section 20, BLK 12 Church & Hall Trust Nil

12.02.2018 Trustee, Waikouaiti Maori Foreshore Reserve Trust Nil

29.05.2018 Director & Shareholder (jointly held) - Arai Te Uru Whare Hauora Ltd

Possible conflict when contracts with Southern DHB come up for renewal.

Management of staff conflicts of interest is covered by SDHB’s Conflict of Interest Policy and Guidelines.

3


7





Health Board

Chris FLEMING 25.09.2016Lead Chief Executive for Health of Older People, both nationally and for the South Island

25.09.2016 Chair, South Island Alliance Leadership Team

25.09.2016 Lead Chief Executive South Island Palliative Care Workstream

25.09.2016 Deputy Chair, InterRAI NZ

10.02.2017 Director, South Island Shared Service Agency Shelf company owned by South Island DHBs

10.02.2017 Director & Shareholder, Carlisle Hobson Properties Ltd Nil

26.10.2017 Nephew, Tax Advisor, Treasury

18.12.2017 Ex-officio Member, Southern Partnership Group

30.01.2018 CostPro (costing tool) Developer is a personal friend.

30.01.2018 Francis Group Sister is a consultant with the Francis Group.

20.02.2020 Member, Otago Aero Club Shares space with rescue helicopter.

Lisa GESTRO 06.06.2018 Lead GM National Travel and Accommodation Programme

This group works on behalf of all DHBs nationally and may not align with SDHB on occasions.

04.04.2019 NASO Governance Group Member This group works on behalf of all DHBs nationally and may not align with SDHB on occasions.

04.04.2019 Lead GM Perinatal Pathology This group works on behalf of all DHBs nationally and may not align with SDHB on occasions.

Nigel MILLAR 04.07.2016 Member of South Island IS Alliance group This group works on behalf of all the SI DHBs and may not align with the SDHB on occasions.

04.07.2016 Fellow of the Royal Australasian College of Physicians

Obligations to the College may conflict on occasion where the college for example reviews training in services.


8





Health Board

04.07.2016 Fellow of the Royal Australasian College of Medical Administrators

Obligations to the College may conflict on occasion where the college for example reviews training in services.

04.07.2016 NZ InterRAI Fellow InterRAI supplies the protocols for aged care assessment in SDHB via a licence with the MoH.

04.07.2016 Clinical Lead for HQSC Atlas of Healthcare variation

HQSC conclusions or content in the Atlas may adversely affect the SDHB.

29.05.2018 Council Member of Otago Medical Research Foundation Incorporated

12.12.2019 Daughter employed by Harrison-GriersonA NZ construction and civil engineering consultancy - may be involved in tenders for DHB or new Dunedin Hospital rebuild work

Nicola MUTCH Chair, Dunedin Fringe Trust Nil

07.08.2019 Father, Mayoral candidate for Waitaki District Removed 27.11.2019

Patrick NG 17.11.2017 Member, SI IS SLA Nil

17.11.2017 Wife works for key technology supplier CCL Nil

18.12.2017Daughter, medical student at Auckland University and undertaking Otago research project over summer 2017/18.

Julie RICKMAN 31.10.2017 Director, JER Limited Nil, own consulting company

31.10.2017 Director, Joyce & Mervyn Leach Trust Trustee Company Limited

Nil, Trustee

31.10.2017 Trustee, The Julie Rickman Trust Nil, own trust31.10.2017 Trustee, M R & S L Burnell Trust Nil, sister's family trust

23.10.2018 Shareholder and Director, Barr Burgess & Stewart Limited

Accounting services

Specified contractor for JER Limited in respect of:

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9





Health Board

31.10.2017 H G Leach Company Limited to termination Nil, Quarry and Contracting.

21.10.2019 Member, Chartered Accountants Advisory Group

Gilbert TAURUA 05.12.2018 Prostate Cancer Outcomes Registry (New Zealand) - Steering Committee Nil

05.04.2019 South Island HepC Steering Group Nil

03.05.2019 Member of WellSouth's Senior Management Team Reports to Chief Executives of SDHB and WellSouth.

Gail THOMSON 19.10.2018 Member Chartered Management Institute UK Nil

22.11.2019Deputy Chair Otago Civil Defence Emergency Management Group, Coordinating Executive Group

Jane WILSON 16.08.2017 Member of New Zealand Nurses Organisation (NZNO)

No perceived conflict. Member for the purposes of indemnity cover.

16.08.2017 Member of College of Nurses Aotearoa (NZ) Inc.

Professional membership.

16.08.2017

Husband - Consultant Radiologist employed fulltime by Southern DHB and currently Clinical Leader Radiology, Otago site.

Possible conflict with any negotiations regarding new or existing radiology service contracts. Possible conflict between Southern DHB and SMO employment issues.

16.08.2017Member National Lead Directors of Nursing and Nurse Executives of New Zealand. Nil


10

Minutes of Board Meeting, 7 April 2020 Page 1

Minutes of the Southern District Health Board Meeting

Tuesday, 7 April 2020, 9.30 amBy Zoom

Present: Mr Dave Cull ChairDr David Perez Deputy ChairMs Ilka BeekhuisDr John ChambersMrs Kaye CrowtherDr Lyndell KellyMr Terry KingMrs Jean O’CallaghanMr Tuari PotikiMiss Lesley SoperDr Moana Theodore

In Attendance: Mr Andrew Connolly Crown Monitor (until 12.48 pm)Mr Roger Jarrold Crown Monitor (from 10.17 am until

12.37 pm)Mr Chris Fleming Chief Executive Officer (until 1.00 pm)Mr Mike Collins Executive Director People, Culture &

Technology (from 11.30 am)Mrs Lisa Gestro Executive Director Strategy, Primary and

CommunityDr Nigel Millar Chief Medical OfficerDr Nicola Mutch Executive Director CommunicationsMr Patrick Ng Executive Director Specialist ServicesMs Julie Rickman Executive Director Finance, Procurement

and Facilities (until 11.00 am)Mrs Jane Wilson Chief Nursing and Midwifery Officer Ms Jeanette Kloosterman Board Secretary

1.0 OPENING KARAKIA

The meeting was opened with a karakia by Mr Tuari Potiki.

2.0 APOLOGIES

An apology for possible lateness was received from Mr Andrew Connolly, Crown Monitor, and an apology for an early departure was received from the Executive Director Finance, Procurement and Facilities.

It was resolved:

“That the apologies be accepted.”D Cull/L Soper

3.0 DECLARATION OF INTERESTS

The Interests Registers were circulated with the agenda (tab 3).

4

Southern DHB Board Meeting - Minutes of Previous Meeting

11


Mr Terry King declared an interest in item 9 on the public excluded agenda, Future Home Based Support Contracting Model, as a client of the Royal District Nursing Service.

It was resolved:

“That the Interests Registers be received and noted.”

D Cull/J O’Callaghan

4.0 PREVIOUS MINUTES

It was noted that there was an error in the wording of item 7.0, Valuing Patients’ Time - ED Escalation Pathway. (The word “precise” was subsequently amended to “précis” of the plan to develop an ED/hospital escalation pathway.)

It was resolved:

“That, with the above correction, the minutes of the meeting held on 3 March 2020 be approved and adopted as a true and correct record.”

L Soper/T Potiki

5.0 MATTERS ARISING

There were no matters arising from the previous minutes that were not covered by the agenda or action sheet.

6.0 ACTION SHEET

The Board reviewed the Action Sheet (tab 6). Management advised that:

ß Many of the actions had been deferred due to COVID-19 response activity.

ß Equity and cultural considerations would be added to business cases and operationalised. The CEO suggested that this point remain on the action sheet to ensure these matters were embedded.

A report on CT capacity had been drafted but unfortunately was not completed prior to the commencement of the COVID-19 challenges. The paper contained proposals to undertake more outsourcing and increase internal capacity at an estimated cost of $1.8m, which would enable volumes to be caught up in about eight months. Management would endeavour to submit a paper to the next meeting.

Valuing Patients’ Time

The Board requested a progress report on the development of an ED escalation pathway for its July 2020 meeting.

It was resolved:

“That the action sheet be noted”

I Beekhuis/L Soper


12


7.0 ADVISORY COMMITTEE REPORTS

Hospital Advisory Committee

The unconfirmed minutes of the Hospital Advisory Committee meeting held on 2 March 2020 (tab 7.1) were taken as read.

Dialysis Unit, Southland Hospital

Dr David Perez, Chair of the Hospital Advisory Committee (HAC), informed the Board that he had not yet received a request from the group wishing to present to the May HAC meeting regarding a dialysis unit at Southland Hospital.

Telemedicine

The Executive Director Specialist Services (EDSS) advised that only patients with appointments that had to be held in the hospital were being brought in, which had increased telemedicine activity.

A general discussion ensued on the development of guidelines, training and funding for telemedicine.

The Chief Medical Officer agreed to circulate guidelines on telemedicine to Senior Medical Officers (SMOs).

It was resolved:

“That the unconfirmed minutes of the Hospital Advisory Committee meeting held on 2 March 2020 be noted.”

D Perez/I Beekhuis

Finance, Audit and Risk Committee

Mrs O’Callaghan, Deputy Chair of the Finance, Audit and Risk (FAR) Committee,gave a verbal report on the FAR Committee meeting held on 19 March 2020, during which she advised that the Committee:

ß Received a briefing on COVID-19, which was an emerging risk at the time;

ß Received the Health and Safety Report and noted that critical risk profiles were being worked on;

ß Reviewed the Health and Safety Charter (tab 7.2.4) and recommended that the Board roll it over;

ß Received the clinical risk register and noted that over time data would be added to quantify risk and measure progress;

ß Received the financial report and savings plan progress reports for the month;

ß Received the external audit plan for 2020 and the proposed fee for that was being followed up by the Board Chair;

ß Reviewed capital expenditure and strategic risks;

ß Recommended that the Board approve the revised terms of reference for the Finance, Audit and Risk Committee (tab 7.2.2) and the Bribery and Corruption Policy (tab 7.2.3).

4


13


It was resolved:

“That the Board approve:

ß The Finance, Audit and Risk Committee’s Terms of Reference, with the addition of asset management to the scope section;

ß The Bribery and Corruption Policy;

ß The Health, Safety and Welfare Charter.”

J O’Callaghan/L Soper

8.0 CHIEF EXECUTIVE OFFICER’S REPORT

The Chief Executive Officer’s monthly report (tab 8) was taken as read.

COVID-19

The CEO gave a presentation on the COVID-19 strategy and plan (tab 8).

Mr Roger Jarrold, Crown Monitor, joined the meeting at 10.15 am.

During an extensive discussion, management answered questions on the screening of patients for COVID-19, guidelines for staff, personal protective equipment (PPE), the inclusion of equity in decision-making, testing demographics, obstetrics and maternity services, planning for elective services to come back on stream, and communication with patients.

The importance of Mental Health, including alcohol and drug issues, in future planning was noted.

General

The CEO then highlighted the following sections of his report.

ß There had been little progress with the development of the 2020/21 draft annual plan and budget due to the COVID-19 pandemic.

ß There had been an outbreak of mumps in Queenstown.

ß Influenza vaccination.

The Executive Director Strategy, Primary and Community (EDSP&C) gave an updateon the status of the influenza vaccination campaign, which had commenced early for vulnerable populations.

It was resolved:

“That the Board note the CEO’s report.”D Cull/L Kelly

The Board meeting was adjourned at 11.00 am and resumed at 11.15 am.

The Executive Director, Finance, Procurement and Facilities left the meeting.


14


9.0 FINANCE AND PERFORMANCE REPORTS

Financial Report

The Financial Report for the period to 29 February 2020 (tab 9.1) was taken as read.

The CEO commented that the result was aligned to the forecast; the biggest challenge was understanding the financial implications of the COVID-19 pandemic. The Ministry of Health (MoH) had provided some additional funding for primary care, and DHBs were required to provide NGOs and contracted providers with certainty of income, however the MoH had not yet clarified how they were going to resource DHBs.

Cash Flow

The CEO advised that a cash advance had been received and some equity was expected to address the year-end issue, however he cautioned that risk may be replaced with COVID-19 related issues.

COVID-19 Costs

The CEO answered questions on quantifying the cost of COVID-19. He advised that new costs were being captured, however in many areas, such as ED and Orthopaedics, it was difficult to track additional cost, as activity had reduced but not fixed costs, such as staffing. A method of reconciliation would have to be developed, which took into account opportunity cost.

Volumes

A summary of volume throughput to 29 February 2020 (tab 9.2) was taken as read.

Performance Dashboard

The CEO informed the Board that the performance dashboard (tab 9.3) was still under development.

The Board requested that:

ß The legibility of the graphs be improved by increasing the resolution and/or reducing them to six per page;

ß That colour coding be added to results that were affected by COVID-19.

Meeting Frequency and Format

The Board discussed utilising current meeting slots in a more focused way, supplemented with informal briefings from management, to ensure the Board was fully informed. It was suggested that a Board work plan be drafted for the next 3-4 months.

It was resolved:

“That the reports be noted.”

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15


10.0 CORRESPONDENCE

The Board received the following correspondence:

ß Minister of Health’s Letter of Expectations for 2020-21 (tab 10.1)

ß A ministerial direction to support the national response to COVID-19 (tab 10.2).

It was resolved:

“That the correspondence be noted.”

11.0 ACQUISITION OF LAND FOR ROAD, CLYDE

The Board considered a request from Central Otago District Council to legalise part of a an existing road (Mutton Town Road) under the Public Works Act 1981 to correct the historic formation of the road on private property (tab 11).

It was resolved:

“That, subject to confirmation the land is not subject to first right of refusal under the Ngāi Tahu Claims Settlement Act, the Board:

1. Support the legalisation (acquisition of Southern DHB land for road); and

2. Authorise consent being sought from the Minister of Health to dispose of the land in question.”

L Soper/T Potiki

PUBLIC EXCLUDED SESSION

At 12.00 pm it was resolved:

“That the public be excluded from the meeting for consideration of the following agenda items.”

General subject: Reason for passing this resolution:

Grounds for passing the resolution:

Minutes of Previous Public Excluded Meeting

As set out in previous agenda.


Public Excluded Advisory Committee Minutesa) Hospital Advisory

Committee, 2 March 2020

b) Finance, Audit & Risk Committee, 20 February and 19 March 2020

Commercial sensitivity and to allow activities and negotiations to be carried on without prejudice or disadvantage

Sections 9(2)(i) and 9(2)(j) of the Official Information Act.

CEO’s Reporta) Funding b) Provider Issues

Commercial sensitivity and to allow activities and negotiations (incl commercial and industrial negotiations) to be carried on without prejudice or disadvantage



16




Lake District Hospital Review

To allow activities and negotiations to be carried on without prejudice or disadvantage


Contract ApprovalsPrimary and Community Contract RolloverRefugee Services



South Island Patient Information Care System



Primary Care Funding for COVID-19



Future Home Based Support Contracting Model



New Dunedin Hospital



It was resolved:

“That the Board resume in open meeting and the business transacted in committee be confirmed.”

The meeting closed at 1.30 pm.

Confirmed as a true and correct record:

Chairman: __________________________________

Date: __________________

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17

Southern District Health Board

BOARD MEETING ACTION SHEETAs at 28 April 2020

DATE SUBJECT ACTION REQUIRED BY STATUS EXPECTED COMPLETION

DATEFeb 2020 Fleet Vehicle

Management(Minute item 5.0)

Quarterly progress reports to be provided.

EDFPF June 2020

Sept 2019

Oct 2019

Mar 2020

Apr 2020

Valuing Patients’ Time (VPT) - ED EscalationPathway(Minute item 9.0)

(Minute item 4.0)

(Minute item 7.0)

(Minute item 6.0)

Update to be provided on the development of an ED escalation pathway.

Timeframe to be provided.

ß A timeline and précis of the plan to develop an escalation pathway to be submitted to the next meeting.

ß Discharging patients earlier in the day to be made a priority.

Progress report to be submitted to Board in July.

EDQCGS

CEO/EDSS

EDSS

Raised at Clinical Council, plan being developed.

Due to COVID-19, a response to this action has been delayed.

September 2020

July 2020

Feb 2020 Clinical Council(Minute item 5.0)

Quarterly reports to be submitted to Board.

CEO/EDQCGS

Will be submitted to DSAC/CPHAC meeting.

Feb 2020 Trust and Bequest Funds(Minute item 6.0)

Breakdown of donated funds held by SDHB to be provided.

EDFPF Report attached. April 2020May 2020

Feb 2020 Risk(Minute item 6.0)

Top five major risks to be reported to the Board quarterly.

CEO Will be reported at Board meeting closest to end of each quarter.

April 2020

6

Southern DHB Board Meeting - Review of Action Sheet

18


DATEFeb 2020 Resourcing Implication

of PHARMAC Decisions(Minute item 8.0)

Further information to be provided, including explanatory detail on the growth areas, eg the number of patients receiving high cost drugs over time and the clinical areas involved.

EDSPC An update has been provided as part of the CEO report. Please note that remains a work in progress.

June 2020

Feb 2020

Apr 2020

Performance Dashboard(Minute item 9.0)

(Minute item 9.0)

ß Caseweights per FTE to be added as a productivity indicator;

ß Graph axes to be reviewed;ß Guidance to be provided on

each graph.

Legibility of graphs to be improved by increasing the resolution and/or reducing them to six per page.

EDQCGS

EDQCGS

In development.

Complete

Complete

Reporting format to be reviewed.

April 2020May 2020

Feb 2020 CT Capacity(Minute item 9.0)

ß All options (including resourcing) and recommendations for addressing short and medium term CT capacity to be developed.

ß A business case (including theclinical case) for a second Dunedin CT to be developed in consultation with Southern Alliance.

EDSS Additional outsourcing undertaken for urgent non deferrable CT scans.Proposal developed for short to medium term solution on Board agenda.

Business case for additional CT Scanner will be a part of the refreshing of the Annual Plan.

Mar 2020

April 2020

Business Cases(Minute item 8.0)

(Minute item 6.0)

Equity and cultural considerations to be added to the business case template.

CEO Noted and being implemented.

To remain on action sheet to ensure these considerations are embedded.

Mar 2020 Funding and PBFF(Minute item 9.0)

To be a Board training/orientation topic.

CEO Schedule for workshop in May before FARC (will be held either face to face or by video conferencing depending on the status of Covid-19)

May 2020


19


DATEMar 2020 Change Management

and Benefits Realisation Plan(Minute item 11.0)

Clinical input into the plan to be made explicit, equity embedded from the start, and a key added to the plan timeline chart.

CEO Will be woven into the plan when it is updated, iteratively, in coming months.

Mar 2020 Annual Plan 2019/20 Progress Report(Minute item 12.0)

ß Further information to be provided on diabetes services.

ß Management to investigate and report back on stroke services and the accuracy of the statement that, “patients with acute strokes not being managed in the Dunedin Acute Stroke Unit … aretypically post-operative patients”.

ß Progress reporting to be provided for all high risk areas.

ß PHO performance indicators to be submitted to the Community & Public Health Advisory Committee.

EDSP&C A more detailed report on what is being done to help meet national targets is currently being developed.

Management have followed up with author and the comment was to highlight shared care arrangements in place across teams for this group. Wording will be carefully considered in the future, to avoid confusion.

Quarterly reporting will be reformatted from next quarter to prioritise the presentation of high risk/critical areas (noting that the MoH quarterly reporting requirements have been significantly reduced whilst DHB’s are managing COVID-19)

Under way.

May 2020

Complete

May 2020

Complete

Apr 2020 Telemedicine(Minute item 7.0)

Guidelines on telemedicine to be circulated to SMOs.

CMO Actioned Complete

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20


Title: TRUST AND BEQUEST FUNDS

Report to: Board


Summary:

The Southern DHB (formerly Otago DHB and Southland DHB) has accumulated under the heading Custodial Funds balances which comprise income in advance for specific application to operating and capital expenditure. In summary, these balances historically referred to as “trusts and bequests” are categorised as follows:

For the most part, the Research funds are attributable to Health Research South projects, being the research partnership between Otago School of Medicine and Southern DHB.

We are now undertaking a cross-check to source documentation to confirm the basis for “holding” these amounts on the balance sheet. The bequests, donations, education and social balances have accumulated over time, e.g. donation from Countdown Kids, against which capital expenditure has been progressively applied.

However, in a number of instances the amounts appear to be historical. Therefore the investigation into the background and proposed application is being traced back to source information.


Financial: Yes

Workforce: N/A

Other: N/A

Prepared by: Presented by:

Julie RickmanExecutive Director Finance, Procurement & Facilities


RECOMMENDATION:

That Board note the categories of income in advance held on the balance sheet, collectively described as “Custodial Funds”.

Categorised as: $Bequests 698,055Donations 1,277,528Education 1,107,026Social 247,927Research 5,066,212Total funds reported in Balance Sheet 8,396,748


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FINANCE, AUDIT AND RISK COMMITTEE MEETING, 29 APRIL 2020

Verbal Report from Jean O'Callaghan, Deputy Chair, Finance, Audit and Risk

Committee. 7.1

Southern DHB Board Meeting - Advisory Committee Reports

22


FINANCE, AUDIT AND RISK COMMITTEE29 April 2020

RECOMMENDATIONS TO BOARD:

The Finance, Audit and Risk Committee recommends that the Board pass the following resolution.

Drawdown - Interim Works and Critical Infrastructure Works, Dunedin Hospital

“That the Board approve the request for a further drawdown of capital funding for Dunedin Hospital interim and critical infrastructure work projects.”

7.1

Southern DHB Board Meeting - Advisory Committee Reports

23


Title: CHIEF EXECUTIVE OFFICER’S REPORT

Report to: Board


Summary:

Considered in this paper are:

ß General information and emerging issues


Financial: As set out in the report.

Workforce: As set out in the report.

Equity: As set out in the report.

Other: As set out in the report.

Document previously submitted to:

Not applicable, report submitted directly to the Board.

Date: n/a


Chris FlemingChief Executive Officer


Date: 28 April 2020

RECOMMENDATIONS:

1. That the Board:

∑ Note the attached report;

∑ Discuss and note any issues which they require further information or follow-up.

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Southern DHB Board Meeting - CEO's Report

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CHIEF EXECUTIVE OFFICER’S REPORT

1. PURPOSE

This report is provided to update the Board on key issues and activities for the District Health Board (DHB). The intention is to raise key issues but it is also to inform the Board on wider issues which are occurring within the Southern Health System. The Board are requested to:

∑ Note this report

∑ Discuss and Note any issues which they require further information or follow up.

2. ORGANISATIONAL PERFORMANCE

There are three papers on the agenda under finance and performance:

∑ Finance report

∑ High Level Volumes

∑ Performance Dashboard.

Financial performance for the month of March is favourable to plan by $578k reducing the year to date unfavourable result to $5.417 million adverse to plan. The result is somewhat distorted by three unknowns:

∑ The impact of the under performance on planned care as a consequence of reducing activity to respond to COVID-19. On a year to date basis we are now 218 caseweights behind plan. We are awaiting clarification as to what we should assume about revenue (given a significant proportion of costs are fixed), so we have assumed that the Ministry will wash up the under performance, but replace it with a new funding line to recognise our costs are largely fixed. There is a risk of $1.1 million if the Ministry take a hard line on performance.

∑ Additional costs attributable to the COVID-19 response. We are still trying to identify all the costs associated with COVID-19, to 31 March $318k of costs have been captured, however we believe this is understated with significant training resources being applied, but charged directly to other cost centres.

∑ Any funding MOH will provide to recognise costs incurred in extraordinary times.

Presently, apart from the adjustment for electives, we have not assumed any additional revenue. The Ministry will be looking for variable cost savings attributable to the clinical activity we did not carry out. From a staffing perspective there are no savings, almost the opposite has occurred as there is less annual leave being taken and we expect this will occur in April as well. The Ministry have an expectation that leave will be encouraged, however with lockdown restrictions, the appetite for staff to take leave is limited. From a clinical supplies and outsourced clinical services perspective, the savings are reflected in the results, however they are showing up as lower overspending. Clinical supplies to the end of February have averaged an overspend of $765k per month and the month of March reduced to $257k, and outsourced clinical services has previously been overspent at the rate of $180k per month and reduced to $95k for the month of March.


25

It is difficult to forecast the year end result at this stage due to so many uncertainties associated with COVID-19 and assumptions around planned care recovery. It is clear that the planned care recovery will require the spending of resources in outsourcing, and we assume the Ministry will not attempt to offset the funding provided during the lockdown with future planned care recovery, but until confirmed this is a risk.

From a volumes perspective, activity is well down. Emergency department activity is down 23.4% on the same month last year, with Dunedin down 26.3%, Lakes 21.6% and Southland 20.5% (noting that the lockdown only started on 25 March,so only one week of lockdown in this month’s results). Medical caseweights are down 15.5% on the same month last year, surgical caseweights are down 18.4% (acute down 8.4% and electives down 27.8%). Maternity, as would be expected,was around the same level, while Mental Health bed days were down 6.2%.

3. COVID-19

Responding to COVID-19 has been the core focus of all within the DHB over the past two months. To this end, this report is shortened and an extensive update on COVID-19 is included as a separate paper (see Item 11).

As Chief Executive, I have been impressed with the overall approach to how all of our staff and contracted providers have responded to the unprecedented impacts on how we work, live and play, and have acted with utmost professionalism in how we have tackled the challenges. This is all the way through the system from those have been heading the charge in public health around contact tracing, primary care establishing Community Based Assessment Centres (CBACs) and reengineering how primary care operates, the way frontline staff who have had to reengineer how they have managed patient presentations, the uptake of telemedicine, the separation of red and green streams and making the tough decisions as to what is non deferrable work, through to the back office staff many of whom have embraced working from home and working in a digital manner.

As we move into Level 3 care needs to be taken to ensure that we do not lose the benefits gained, and then in particular when Level 2 is introduced we very carefully monitor any future cases that arise.

One of the biggest challenges will be to sift through all of the changes that have been embraced and determine which of these should become the permanent way of working versus which activities should be wound back to the more traditional approach.

The financial impact of COVID-19 on our health budget is yet to be determined. The Government has provided additional funding to cover things like enhanced contact tracing, leave funding for those who were over 70 or immune compromised, CBAC funding, supplements to capitation funding (although not the last tranche which had been promised), commitments to roll over non-government organisation (NGO)funding, and some provision for aged residential care. To date however there has been no clarity as to how funding implications on DHBs themselves will be addressed. As a DHB we have cancelled planned activity, which means revenue which is at risk subject to delivery of planned volumes has been lost, capital expenditure associated with enhancing capacity and facilities to allow for safe management of COVID-19 positive or suspected cases, and areas where additional staffing have been put in to manage the increased pressures associated with these challenges. The March results only showed a small amount of this and the April results will be more representative. The March results however showed in excess of $300k of additional operating expenditure and a potential loss of revenue of

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$1.1 million. Unbudgeted capital expenditure of approximately $2.5 million has been incurred. We will work with the Ministry of Health to determine how appropriate financial arrangements will be identified.

4. ANNUAL PLAN 2020/21

The Ministry is adjusting 2020/21 annual planning processes and timelines in consideration of COVID-19. Central Government Agencies have advised they are exploring a range of options, including potentially modifying legislative requirements to assist entities to manage legislative planning and reporting requirements and they expect to be in a position to provide updates later in April.

The Ministry is also considering how the impacts of COVID-19, the Level 4 national lockdown and the future path to recovery are likely to impact on the planning advice previously provided. In light of these issues, the Ministry has adjusted the previously advised planning timelines as below:

∑ Feedback on first draft plans and advice on updated planning guidance that includes any new guidance/COVID-19 impacts to be issued mid-May (this date may extend if a national lockdown period extends).

∑ No revised sections/full drafts of 2020/21 annual plans or regional services plans or second draft financial templates will be expected at this stage until at least mid-June. Dates will be confirmed dependent on any legislative modifications that may occur.

∑ The Ministry’s financial monitoring team will continue to stay in contact duringApril regarding the financial templates provided to date.

The reality is that our annual plan that we drafted and submitted early in the year seems somewhat divorced from reality now. To this end, it is sensible that the Board and the Executive Leadership Team take the opportunity to realign the annual plan to the recovery needs as well as matching to the Board work programme and priorities. A presentation made to the DHB Chairs is attached (see Appendix 1)which shows some very clear priorities and expectations which need to be incorporated into the plan.

The budget expectations also need to be dramatically reviewed as there is no alignment to resourcing which may need to be aligned to recovery and further COVID-19 activity. Timing is still being worked through.

5. RESOURCING IMPLICATIONS OF PHARMAC DECISIONS

PHARMAC funding decisions are increasingly impacting Southern DHB services. These include additional demand for infusion services, follow up clinics, nursing and clinician assessment, training and education, imaging and labs. Decisions having the greatest impact (both directly and indirectly) are the high-cost pharmaceuticals.PHARMAC prescribe strict criteria in order to control access to funding for both initiation and continuation of treatment. These criteria include providing documentation of, for example, baseline and ongoing monitoring of tumour size and burden, genetic testing, evidence that the patient is benefitting from and tolerating treatment. This is often in addition to the monitoring necessary to provide clinical care.

Whilst the overall DHB cost (including operational costs relating to new investment)is factored into PHARMAC evaluations, the actual operational (non-Pharmaceutical) funding does not directly follow via the Ministry of Health. There have been cases where PHARMAC have materially underestimated national impact/volume of new


27

investment at a DHB and the impact at DHB level is not considered. PHARMAC consultation on investment decisions is short (generally three to six months) and is no way linked to DHB budget cycle.

At its February meeting, the Board requested that further information be provided, including explanatory detail on the growth areas such as the number of patients receiving high cost drugs over time and the clinical areas involved.

A group has been formed, led by the Strategy and Planning Manager and with business analyst support, to quantify the cost and resource impacts for the most heavily impacted service, being oncology. The group has met and initiated work to develop a model to that is expandable across other services within the DHB.

The objectives are:

∑ To quantify the resource implications of recent (three years) and upcoming investments and the cumulative impact.

∑ Develop a robust costing system to assist with the development of the above.

∑ Develop a process to roll out to other services relating to pharmaceutical (and also non pharmaceutical) investment.

∑ Develop a model to be used to inform budget requests and enable the DHB to engage with PHARMAC and Ministry of Health through appropriate channels.

∑ To provide a cumulative record of the impact of PHARMAC decisions.

The resource allocated to this work has been fully committed with the COVID-19response and will resume as soon as possible.

6. PRIMARY MATERNITY PROJECT

Public feedback on the configuration of primary maternity facilities in Central Otago and Wanaka continues to be received. A revised timeline for this work will be confirmed in April 2020.

The April meeting of the Maternity Steering Committee will focus on prioritising the work programme in light of COVID-19 pressures and resourcing.

The new Project Manager commenced work in March. Their initial focus has been onmeeting key contacts and reviewing existing documentation. Shortly after starting, the Project Manager was in COVID-19 isolation following travel. They are currently redeployed to the Southern DHB Emergency Operating Centre (EOC) in a Logistics role.

7. DIRECTOR OF MIDWIFERY ROLE

We are now able to announce that Heather LaDell has been appointed to this permanent position. Heather has been in the acting Director of Midwifery role since September 2019. Heather is passionate about building practice communities that enable midwives and other health practitioners to partner with women to provide best care. She is a strong advocate for midwifery to be valued and respected as a profession and is committed to increasing the profile and voice of midwives at all levels. Heather is a New Zealand educated registered midwife with a breadth of experience including most recently as acting Director of Midwifery, working to improve the primary maternity system of care, developing and implementing Southern’s Maternity Quality and Safety Programme and a clinical background as an

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lead maternity carer (LMC) midwife. Heather has also been active at a national level on relevant maternity groups.

8. INFLUENZA VACCINATIONS

There have been issues with the supply of influenza vaccines to primary care this year due to unprecedented demand, supply issues related quality requirements, changes to eligibility criteria and furthermore complicated by vaccine brand changes disrupting supply. Primary care in some instances have missed out due to pharmacy and private occupational providers being over supplied. There have been discrepancies across the practices, particularly affecting the larger practices who needed to order and receive larger quantities. Immunisation coordinators have redistributed vaccines mainly from private occupational health providers and student health in Dunedin to practices.

Support to providing influenza immunisation to Southern DHB staff has been a priority for the team.

The Ministry of Health are instructing DHBs on prioritising flu vaccination based on equity and vulnerable population. The Ministry are talking about instructing DHBs to set up pop up vaccination clinics. Online vaccination training is being set up to increase our Māori vaccination workforce. As at 16 April we have had permission to set up pop-up vaccination clinics on local Marae as with work with Victoria Bryant from population health to identify suitably qualified Māori nurses to support this approach.

9. MENTAL HEALTH, ADDICTIONS & INTELLECTUAL DISABILITY (MHAID)

Ministry of Health – He Ara Oranga

We continue to await further information from the Ministry regarding the roll out of the Integrated Primary Mental Health Programme. The outcome of the proposals for expansion and/or replication of existing Māori and Pacific primary services, increase in Nurse Practitioners and Enrolled Nurses in primary health, the youth primary mental health proposal have been delayed as the Ministry and services focus onCOVID-19. A further expression of interest to place a mental health nurse educator in the Emergency Departments in Dunedin and Invercargill and support to scope a NGO peer led crisis support service for people in distress presenting to ED has been submitted to the Ministry. This is similarly delayed.

Suicide Post Vention

The Ministry have launched an initiative to increase support for post vention work.This will provide a much needed resource for the several post vention groups thatoperate across the Southern District under the guidance of the WellSouth based Suicide Prevention Coordinator.

Continuum of Care Review Planning

The focus of this review will be on all mental health and addiction services that are funded by the Southern DHB with an aim to identify opportunities for system improvement which would include better access to services at all points across the continuum of care and achieve better integration between primary, community and acute services. Feedback on the draft terms of reference was requested more widely during March. A potential review team has been identified and contacted. The restrictions of COVID-19 are impacting on this review progressing further at this time.


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Full Health Round Table NZ Chapter Report

Work is being undertaken to understand why the Health Round Table data is different to the data that the National Mental Health Key Performance Indicator (KPI)programme extracts and uses to benchmark DHBs and drive quality and performance improvement across the continuum of care.

Learning from Adverse Events (Health Quality Safety Commission (HQSC) project)

The team has commenced co-design consultation but this and other work has been put on hold until the COVID-19 lockdown is finished. If this extends significantly we will explore how work can proceed.

Connecting Care (HQSC project)

Dunedin and Invercargill are both looking at Plan Do Study Act (PDSA) cycles. In Southland the current cycle is a discharge calendar for the first two weeks post discharge with hints for consumers and their families. The project group has been put on hold while staff are prioritising COVID-19 response.

Health Quality Safety Commission (HQSC) Zero Seclusion Programme

The project continues. The impact of the Emergency Department managing people presenting acutely with methamphetamine intoxication will be interesting to monitor over the next few months. The potential for delirium toxify is better managed in a medial setting rather than a psychiatric setting.

Health Connect South (HCS) Steering Group

Work on HCS capability has proceeded. The document tree is being developed with a plan to begin trialling it in one service in the next few weeks, with the aim that all documents across MHAID services can be uploaded consistently under clearly identified labels/files. This trial has been delayed due to COVID-19 work, but the value of this has been highlighted within COVID-19 planning as it is key to haveaccess to an electronic record rather than reliance on a mix of paper and electronic patient records, with the paper record currently being the source of truth and completeness.

Forensic Framework Review

The visit from the Ministry has been postponed due to the escalating COVID-19focus nationally. The Ministry advises they will contact us in due course.

Māori Mental Health transition to MHAID

In Southland the team have begun with identifying priority areas of work and establish regular input into identified key meetings. The team has also participated in their first cultural training afternoon to build the cultural competency of the work force this was very well received. In Otago the kaioranga are establishing their roles in their new teams. No significant issues have arisen to date.

Suicide Prevention Action Plan

The Southern District Suicide Prevention Action Plan for the period covering 2020-2023 has been approved by WellSouth. The document evolved from a period of consultation through co-design processes in 2018 and it takes its policy context from the national Suicide Prevention Strategy and Action Plan 2019-2029, Southern DHB’s Raise Hope Strategy, WellSouth’s own Primary Health Strategic Plan and the Southern Health Primary and Community Strategy. The Mental Health and Addiction Network Leadership Group have supported its approval.

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The draft strategy defines four key objectives, as follows:

∑ Support families, whanau, hapu, iwi and communities to prevent suicide and self-harm and promote wellbeing

∑ Support families, whanau, hapu, iwi and communities after a suicide

∑ Improve services and support for people at high risk of suicide and self-harm

∑ Strengthen the infrastructure for suicide and self-harm prevention.

Forensic Mental Health Services Funding

As part of the Budget 2019 initiatives for mental health and addiction there is provision in a number of areas for additional investment which are in various stages of approval, sign off and action. This included the following:

∑ In community FTE for adult forensic services of $3.4m over three years. We received a contract for signature which is based on discussions/negotiations with the Ministry that occurred towards the end of 2019.

∑ In community FTE for youth forensic services of $0.95m over four years. We have provided detail to the Ministry of Health on FTE that we can provide for the funding envelope and have been advised that a contract will follow in the next few weeks.

∑ For prison in-reach services an amount of $50k over three years. With a strong suggestion from the Ministry of Health that we look towards the use of telehealth in how we apply the funding.

10. CARE CAPACITY DEMAND MANAGEMENT (CCDM)

The Safe Staffing Healthy Workplaces (SSHW) Unit's Governance Group sent a letter on 26 March to all DHB Chief Executives, Directors of Nursing and Union Leaders outlining CCDM priorities during the COVID-19 crisis. Their key messages are:

1. Continue to use TrendCare well to reflect your changing workplace requirements. This will be important for monitoring patient acuity and making staffing decisions.

2. Continue with your variance response management system in DHBs where it is up and running. This will be important for recording and responding to the frontline pressures – how it is for you. Now more than ever your variance response systems will be needed for the job they are designed to do.

The Southern DHB CCDM Programme Manager has been working in the Dunedin Hospital EOC and this will need to be revisited so that CCDM business as usual can resume as soon as possible.

11. NATIONAL LOCUM PROJECT UPDATE

In the last few weeks the National Locum project has reached its completion in terms of signing of agencies and finalising of the rate card, this covers RMO and SMO rates for locum assignments. Within the next three months a locum passport will be developed and will be a standard way for locum information to be shared from agency to DHBs so as to save time associated with confirming bookings.

We currently have six agencies signed up as a preferred supplier list, their agency percentage varies between 13-15%, savings will be made by us through approaching the cheaper agencies in the first instance and through the locking of locum rates (some of which have decreased in daily rate).


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New agencies are able to join the agreement through HPL. Whilst all Service Managers in Dunedin and many in Southland have had the rate card communicated to them, we would like a formal communication to be sent out to ensure the agreement is adhered to, should any DHB not comply with the agreement it will be to the detriment of all DHBs.


28 April 2020

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DHB Performance and COVID-19 Response:

Key areas for consideration for DHB Board Chairs

17 April 2020


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Context

• The COVID-19 pandemic has significantly disrupted health service delivery across the country. New Zealand is currently at Alert Level 4, which aims to eliminate the transmission of COVID-19 within New Zealand’s borders. This strategy appears to be working. The number of new cases is falling, with the majority of cases being related to overseas travel or known cases. Border quarantine has been put in place. While there are a number of significant case clusters, these are being traced to limit community outbreak. With continued vigilance, the chance of widespread community outbreak is expected to remain low

• DHBs have responded well in preparing for COVID-19, and in managing the care of probable and known cases. DHBs are managing high expectations and a range of pressures. We want to thank Board Chairs for the efforts they and their DHBs have made in this challenging and uncertain time

• We also think it is prudent to remind ourselves of the health needs of all New Zealanders, some of whom have been waiting longer for care than expected prior to the COVID-19 pandemic. There is a significant risk that, without appropriate balance, focusing on COVID-19 alone compromises the short and longer-term care and outcomes of New Zealanders. DHBs have a key accountability to ensure the efficiency and effectiveness of care for their populations, and to collaborate together to enable this

• The COVID-19 pandemic is expected to continue for some time longer. Therefore, the ‘new normal’ is with us now. In times of disruption and uncertainty, it is easy to become reactive. While some things are beyond our control, we can take a proactive approach to shaping the ‘new’ normal for health in New Zealand

• For example, moving to Alert Level 4 has necessitated rapid and innovative changes to health care delivery e.g., use of virtual models of care (e.g., virtual consults), and ensuring the health workforce are working at ‘top of scope’. Some of these innovations have been achieved, although there may be wide variation across DHBs. Additionally, some innovations have not achieved the scale or pace expected. There is some evidence to suggest that outpatient appointments that could be conducted virtually are simply being cancelled – impacting the timeliness of care for patients

• We need to track and monitor the innovations that are occurring, and ensure they are available to all populations across New Zealand - so we can continue to improve our health system and meet health needs in a financially sustainable way

2

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Key considerations for DHB BoardsBalancing the tension between being prepared for now and ensuring future sustainability

3

Quality and safety

1. What mechanisms has your DHB put in place to ensure that

ongoing high quality care is available for patients while reducing the

risk COVID-19 presents to staff and others?

2. How is your DHB understanding the clinical risk of delays in

caring for patients as a result of COVID-19?

3. What monitoring processes has the DHB put in place to ensure

that care is not compromised in commissioned primary

and community services?

4. How is your DHB Board ensuring assurance reporting for high

quality and safe care as a result of COVID-19 for both care of

COVID-19 positive and non-positive patients?

Access

1. How is your DHB ensuring that virtual care is used as a mechanism

to enhance access to services and reduce the impact of cancellations?

How will this be embedded in future models of care?

2. What planning activities has your DHB conducted to plan for the

impact on demand from the COVID-19 response (e.g. planned care,

deferred visits to GPs)?

3. How far and in what ways is your DHB identifying and prioritising

those of highest clinical risk in the community – for care now, and

during catch-up?

4. How is your DHB developing regional and private partnerships to

ensure access to services?

5. How is your DHB communicating with impacted patients (e.g.

whose planned surgery has been cancelled), and being clear on

processes about what to do if their condition deteriorates?


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Key considerations for DHB Boards cont’dBalancing the tension between being prepared for now and ensuring future sustainability

4

Financial1. How is your DHB tracking performance against plan? What are the

drivers for areas of variance, and how are they being managed?

2. What is the COVID-19 spend to date, and what is the impact of this

spend? Are you managing both revenue and expenditure in the

COVID-19 response?

3. How has your DHB modified its savings plan in the context of the

COVID-19 response and lower than usual activity? What savings have

been factored in from deferred work?

4. What future investments, such as capital expenditure, have you

brought forward as a result of preparing for COVID-19 efforts? How

have you revised this in your future plans?

5. How is DHB managing its cash position? What plans are in place to

manage the request to pay creditors / suppliers within 10 days?

6. What oversight is in place regarding financial delegations and sign-

off on expenditure?

Workforce1. What workforce planning has been undertaken to ensure staff

availability for catching up on deferred work? How is your DHB

managing and mitigating future staff leave risks?

2. What health and wellbeing actions are planned or completed to

ensure that staff are supported during this time, and as the DHB

ramps up activity to catch-up on deferred work?

3. How is your DHB capturing innovations in workforce models,

and how these can be appropriately embedded into future ways of

working?

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Reported impact of COVID-19 on DHB Provider ServicesCOVID-19 responses have significantly impacted the system’s ability to deliver usual care

5

DHBs have appropriately prioritised preparations for managing the potential demand for care from patients with or suspected to have COVID-19. As New Zealand reached Alert Level 3 and then 4, a major reprioritisation of health services occurred. DHBs have been required to track and report the impacts of COVID-19 on DHB Provider Arm services to the Ministry of Health*. To date, 19 of the 20 DHBs have completed this template to varying degrees of completeness. The quality of the data provided has been variable, making it challenging to form a system-wide view of the true impact of COVID-19. Going forward, it is critical that DHBs work towards a consistent approach to reporting so national, regional and local planning can be based on robust and timely information.

Up until the 12th of April, DHBs reported the following impacts below. Note all numbers should treated as indicative, and incomplete.

Planned care inpatient events cancelled

Outpatient appointments cancelled

Acute care inpatient cancellations

CT, MRI and US cancellations

COVID-19 tests undertaken (including community)

COVID-19 patients treated COVID-19 patient hours on wards

COVID-19 patient hours in ICUs

49,807

* Non-DHB services will also have been impacted. These impacts have not been tracked and reported to date.

7,388

138

57,211

4,936 942

8,16159


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• At as 29 February, the sector was ~3% ahead on Planned Care interventions, with 11 DHBs ahead of plan

• Minor procedures were the main driver of planned care being ahead of delivery. Most DHBs were behind plan on inpatient surgical discharges, which tend to involve procedures to alleviate more complex patient needs

• 17 DHBs were non-compliant with ESPI 2 affecting more than 14,000 patients, and 19 DHBs non-compliant with ESPI 5 affecting nearly 10,000 patients

• Nearly all DHB populations were experiencing delays in access to CT and MRI diagnostics, and for many, delays in access to interventional cardiac procedures

• More than 80% of patients were receiving their first cancer treatment within 31 days. However, more than 600 patients waited longer than a month

• With over 7,000 planned care inpatient interventions and nearly 60,000 outpatient attendances reported as cancelled, there will be a significant ‘bow wave’ of demand looming as New Zealand de-escalates on COVID-19 Alert Levels. This will be compounded by the risk that patients have been deferring seeing their GPs, and GPs have been deferring referring patients into DHB care

6

●

●●

Level

13.0% 13.8% 15.5% 18.4% 19.1% 9,614National 10.7% 11.1% 11.1% 11.0% 12.1%

1.5% 9 ▲0.8% 1.0% 0.9% 0.5% 0.5% 1.6%Whanganui 0.9% 2.1% 0.4%

17.8% 20.7% 17.8% 13.1% 37 ▼8.7% 11.7% 12.0% 15.0% 16.3% 12.1%West Coast

▲8.5% 8.6% 9.9% 12.1% 11.8% 633Waitemata 3.3% 4.8% 6.3% 6.1% 7.4%

90 ▼20.1% 24.7% 29.1% 26.9% 23.7% 24.6%Wairarapa 17.3% 16.2% 15.9% 16.3%

14.1% 725 ▲3.4% 3.9% 4.0% 4.3% 8.2% 11.6%Waikato 5.5% 5.3% 3.7%

126Tairawhiti 4.2% 2.8% 3.8% 6.3% 4.9%

386 ▼24.0% 26.8% 27.9% 29.5% 26.9% 25.0%Taranaki 21.1% 24.0% 25.0% 23.0%

1,256 ▲22.8% 23.6% 25.4% 26.9% 30.8% 35.4%Southern 16.1% 17.2% 19.5% 20.4%

▲6.9% 10.1% 16.6% 24.2%

7.4%

24.7%

▼11.6% 11.3% 14.4% 11.2% 8.5% 6.8%South Canterbury 9.0% 11.0% 10.3%

32.1% 37.2% 42.0% 42.8% 1,104

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▲24.5% 23.8% 22.8% 22.9% 29.8% 29.7%Northland

▲25.5% 26.7% 26.4% 28.5% 33.0% 34.2%MidCentral 28.1% 27.0% 26.6% 24.5%

▲10.8% 12.7% 14.6% 16.8% 21.0%

13.6%

667

296Nelson Marlborough 6.4% 4.9% 6.2% 7.6% 7.6%

163 ▲6.1% 7.0% 7.7% 8.6% 8.7% 12.3%Lakes 4.0% 3.8% 4.8%

540Hawke's Bay 27.7% 25.5% 22.9% 20.8% 19.7%

▲8.1% 7.9% 11.2% 12.3% 13.4% 19.4%Hutt Valley 22.3% 25.5% 31.6% 31.1% 706

151 ▲2.0% 2.6% 3.3% 3.8% 4.4% 5.0%Counties Manukau 2.8% 2.4% 3.8% 2.4%

▲19.2% 21.1% 22.5% 29.5%

5.0%

34.4%

145 ▲2.2% 2.3% 3.3% 3.8% 4.7% 5.9%Capital and Coast 4.2% 3.9% 2.5%

24.8% ▲17.0% 17.9% 16.0% 16.5% 19.6% 22.3%Canterbury 23.3% 26.0% 26.6% 1,418

7.1% 7.7% 6.9% 8.1% 9.9% 10.2%Auckland 7.9% 8.5% 7.8%

4.6% 6.4% 8.5% 12.6% 13.1%Bay of Plenty 6.4% 6.1% 5.5% 4.9% 4.5%

3 mth TrendJan Feb

661 ▲

462

7.0%

▲

DecNovMay

2019

ESPI 5 BY DHB

Jun Jul Aug Sep OctImp Req

2020

19 Non Compliant DHBs

Figure 2. Planned Care example: ESPI 5

Prior to July 2013 the definition of ESPI 5 is the number of patients waiting over 6 months for Treatment. Between July 2013 and December 2014 the definition of ESPI 5 is the number of patients waiting over 5 months for Treatment, and from January 2015 ESPI 5 is the number of patients waiting over 4 months for Treatment.

● This symbol identifies DHBs for which their waiting list are overstated due to data

issues related to recent Patient Management System upgrades.

Planned Care trendsPrior to COVID-19, the sector was 3% ahead on Planned Care interventions. However, most DHBs were behind on plan for surgical inpatient discharges

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Financial trends (without COVID-19 impact)In January, the sector forecast a higher FY deficit. With reduced activity, costs should also reduce

• Against a full year budgeted deficit of $497 million, the sector wide deficit was $306 million after eight months of the financial year

• In January, DHBs re-forecast the year-end deficit at $559 million, with higher than planned expenditure being the key driver of the re-forecast (e.g., outsourced personnel, outsourced clinical services and clinical supplies)

• The average monthly actual spend at February was $1.544 billion per month, up from $1.422 at the same time in 2018/19. March to June are typically higher spending months. If similar patterns as the past two financial years occurred in 2019/20*, then the year-end result would be around $730 million - an increase of $233 million on budget, and $171 on the January re-forecast

• Savings of $58 million would be required each month to meet the target year-end result, savings of $43 million to meet the re-forecast position

• Given much lower activity in DHB Provider Arms in March and April (e.g. most hospitals running at less than 60% occupancy), it is expected that core operational costs should be lower, particularly in areas such as clinical supplies, and savings against plan can be made. It is critical that core operating expenditure is, and continues to be, well controlled, as the government's fiscal position is under extreme pressure

7

$1,400

$1,450

$1,500

$1,550

$1,600

$1,650

$1,700

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

$M

illi

on

Revenue (actual and forecast)

Expenses (actual and forecast)

Expenses (planned)

Figure 1. Revenue and expense trends 2019/20

Revenue and expenses are forecast on the basis of the average of 2017/18 and 2018/19 (excluding Holiday Pay provisions) monthly changes from February to June. A similar pattern is observed in both years.

* Excludes impact of 2018/19 Holiday Act provisions


39

Next steps• Gain feedback from Board Chairs to identify the key information they will find beneficial to guide Board Chair / Ministry of

Health weekly meetings and future interactions on Governance and DHB Performance

• Develop a regular tracking report for Board Chairs / DHB Chief Executives / Ministry of Health that highlights a national view of the impact of COVID-19, and identifies areas of risk and key considerations for short and long-term planning

• Develop monthly DHB Performance Programme snapshot reports to DHB Chairs and Chief Executives that outlines a DHB specific review of COVID-19 response and "business as usual"

• Establish a COVID-19 recovery planning framework for DHBs to complete leading into the 2020/21 financial year, alongside broader annual planning processes

8

8


40

1Financial Report: March 2020

Southern DHB Financial Report

Financial Report for: 31 March 2020Report Prepared by: FinanceDate: 14 April 2020

Report to Board

This report provides a commentary on Southern DHB’s financial performance for the month and year to date ending 31 March 2020 and the financial position as at that date.

The net deficit for the month of March was $3.9m, being $0.6m favourable to budget. The net deficit for the period ending 31 March 2020 was $28.1m, being $5.4m unfavourable to budget.

During March 2020, Revenue was $0.9m favourable to budget. Workforce costs were $0.2m unfavourable to budget across all workforce categories. Clinical Supplies were $0.3m unfavourable to budget, a significant drop on previous months as a result of reduced hospital activity due to COVID-19.

Financial Performance Summary

Month Month YTD YTD LY YTD LY Full Year Full Year

Actual Budget Variance Actual Budget Variance Actual Actual Budget

$000 $000 $000 $000 $000 $000 $000 $000 $000REVENUE

89,996 89,130 866 F Government & Crown Agency 806,497 802,522 3,975 F 763,210 1,020,148 1,070,1401,172 1,118 54 F Non-Government & Crown Agency 8,649 8,535 114 F 8,442 11,892 11,252

91,168 90,248 920 F Total Revenue 815,146 811,057 4,089 F 771,652 1,032,040 1,081,392

EXPENSES

37,800 37,581 (219) U Workforce Costs 324,394 323,170 (1,224) U 302,425 451,823 437,4903,510 3,375 (135) U Outsourced Services 31,269 29,346 (1,923) U 29,624 39,624 38,754

8,383 8,126 (257) U Clinical Supplies 76,364 69,986 (6,378) U 71,217 96,479 93,657

5,176 4,783 (393) U Infrastructure & Non-Cl inical Supplies 43,899 42,333 (1,567) U 39,523 60,062 56,77737,233 37,528 295 F Provider Payments 341,236 340,565 (671) U 327,630 438,921 454,704

2,924 3,291 367 F Non-Operating Expenses 26,127 28,383 2,256 F 25,600 34,476 38,522

95,026 94,684 (342) U Total Expenses 843,289 833,783 (9,506) U 796,019 1,121,385 1,119,904

(3,858) (4,436) 578 F NET SURPLUS / (DEFICIT) (28,143) (22,726) (5,417) U (24,367) (89,345) (38,512)

*Includes One-Off Increase in Hol idays Act 2003 Provision $34,116k

**Includes One-Off Impairment of National Oracle Solution $5,127k


Statement of Financial PerformanceFor the period ending 31 March 2020

Revenue (Year To Date)

Government and Crown Agency revenue includes additional funding for Pay Equity and In Between Travel (IBT) which offsets the increased expenditure in Provider Payments.

On a year to date basis we are 218 caseweights behind our Planned Care volume delivery to our population. The Ministry of Health have indicated that they will be washing up planned care revenue, but that they will be giving us an additional funding stream to recognise that most of the costs are still incurred attributable to the cancellation of planned activity.

We have therefore adjusted Planned Care revenue for the shortfall of 218 caseweights. However, given that until activity commenced on COVID-19 we were delivering Planned Care close to agreed targets. Therefore, in anticipation of COVID-19 funding from the Ministry of Health we have recognised an equivalent amount of funding to offset the shortfall and overall there is a nil net revenue impact.

9.1

Southern DHB Board Meeting - Finance and Performance

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Expenditure (Year To Date)

Total Expenses year to date were $843.3m and includes unbudgeted one-off costs for the Measles Outbreak $0.3m and Neurosurgery $1.3m (excluding IDF Outflows and additional hospital transfer team). Neurosurgery medical workforce is currently insufficiently resourced to maintain a safe roster and therefore Canterbury DHB is providing cover for this service.

Workforce Costs are $1.2m unfavourable to budget year to date. This does not include the financial risk of an estimated $0.4m each month ($4.8m annualised) for the Holidays Act 2003.

Outsourced Services are $1.9m unfavourable year to date. This reflects the continued cover for SMO vacancies in Surgical and Medical Imaging areas and service provision to reduce wait backlogs.

Clinical Supplies are $6.4m unfavourable year to date. Air Ambulance, Blood Products and Implants & Prostheses are contributors to the unfavourable variance. Air Ambulance activity has increased significantly with Neurosurgery patients being transported from/to Dunedin. The increase in Air Ambulance usage has led to a review of the patient assessment process for determining transport resource, whether that be fixed wing, helicopter or road ambulance. The increase in Implants and Prostheses reflects an uplift in orthopaedic activityparticularly in Southland.

Infrastructure and Non-Clinical Supplies are $1.6m unfavourable year to date. The overspend primarily arising from Cleaning & Orderly Services, Software Maintenance and Telecommunications. The Cleaning and Orderly Services include the SECA settlement which increases the ongoing cost for these services. While we continue to review the levels of cleaning and orderly input required, we have new areas such as the Intensive Care Unit for which there is additional cleaning and older areas, which require careful cleaning to maintain infection prevention standards. The Software Maintenance costs include licencing fees for Microsoft Software which is a national contract negotiated by the Ministry of Business, Innovation & Employment (MBIE) for All of Government during 2018. As far aspracticable, we manage other expenditure to offset the additional expenditure on the Microsoft contract. Our Telecommunications costs continue to be regularly reviewed in conjunction with our supplier to mitigate any ineffective spend.

Provider Payments are $0.7m unfavourable year to date. This is driven largely by the additional costs incurred in Home Support and other Disability Support Services and areoffset by additional revenue from Government and Crown Agency.

Non-Operating Expenses are $2.3m favourable year to date. The Depreciation charge is lower than budget, reflecting the timing and category of capital expenditure.


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Financial Position Summary

As at Actual Budget Budget As at

30 Jun 2019 31 Mar 2020 31 Mar 2020 30 Jun 2020 31 Mar 2019

$000 $000 $000 $000 $000

CURRENT ASSETS

7 Cash & Cash Equivalents 7 7 7 8

47,353 Trade & Other Receivables 52,578 45,393 45,213 49,443

5,762 Inventories 5,703 5,148 5,235 5,190

53,122 Total Current Assets 58,288 50,548 50,455 54,641

NON-CURRENT ASSETS

323,050 Property, Plant & Equipment 332,124 348,228 346,288 325,211

4,505 Intangible Assets 2,847 7,602 10,393 4,156

327,555 Total Non-Current Assets 334,971 355,830 356,681 329,367

380,677 TOTAL ASSETS 393,259 406,378 407,136 384,008

CURRENT LIABILITIES

9,895 Cash & Cash Equivalents 9,819 27,712 44,587 8,725

63,925 Payables & Deferred Revenue 100,393 66,567 62,804 62,339

922 Short Term Borrowings 956 964 784 1,055

112,595 Employee Entitlements 112,854 111,708 91,680 71,093

187,337 Total Current Liabilities 224,022 206,951 199,855 143,212

NON-CURRENT LIABILITIES

1,568 Term Borrowings 1,305 804 783 1,731

19,362 Employee Entitlements 19,362 18,149 18,756 18,149

20,930 Total Non-Current Liabilities 20,667 18,953 19,539 19,880

208,267 TOTAL LIABILITIES 244,689 225,904 219,394 163,092

172,410 NET ASSETS 148,570 180,474 187,742 220,916

EQUITY

300,969 Contributed Capital 305,274 331,760 354,813 282,780

108,502 Property Revaluation Reserves 108,500 108,500 108,502 108,502

(237,061) Accumulated Surplus/(Deficit) (265,204) (259,786) (275,573) (170,366)

172,410 Total Equity 148,570 180,474 187,742 220,916

192,584 Opening Balance 172,410 172,410 172,410 192,585

(89,345) Operating Surplus/(Deficit) (28,143) (22,726) (38,512) (24,364)

69,878 Crown Capital Contributions 4,303 30,790 54,551 52,695

(707) Return of Capital - (707)

- Movements in Reserves -

172,410 Closing Balance 148,570 180,474 187,742 220,916


Statement of Financial Position

As at 31 March 2020

Statement of Changes in Equity

9.1


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Cash Flow Summary

YTD YTD Full Year LY YTD

Actual Budget Variance Budget Actual

$000 $000 $000 $000 $000

CASH FLOW FROM OPERATING ACTIVITIES

Cash was provided from Operating Activities:

Government & Crown Agency Revenue 833,616 808,173 25,443 1,071,528 760,461

Non-Government & Crown Agency Revenue 8,422 8,395 27 11,065 8,356

Interest Received 223 140 83 187 87

Cash was applied to:

Payments to Suppliers (500,687) (489,977) (10,710) (649,567) (470,608)

Payments to Employees (318,454) (322,515) 4,061 (453,068) (300,855)

Interest Paid - - - - -

Capital Charge (5,138) (5,194) 56 (10,500) (5,735)

Goods & Services Tax (net) 4,239 1,991 2,248 7 1,927

Net Cash Inflow / (Outflow) from Operations 22,221 1,013 21,208 (30,348) (6,367)

CASH FLOW FROM INVESTING ACTIVITIES

Cash was provided from Investing Activities:

Sale of Fixed Assets 4 - 4 - 1


Capital Expenditure (25,932) (48,804) 22,872 (57,139) (23,080)

Net Cash Inflow / (Outflow) from Investing Activity (25,928) (48,804) 22,876 (57,139) (23,079)

CASH FLOW FROM FINANCING ACTIVITIES

Cash was provided from Financing Activities:

Crown Capital Contributions 4,306 30,790 (26,484) 54,550 52,025


Repayment of Borrowings (523) (816) 293 (1,755) (920)

Net Cash Inflow / (Outflow) from Financing Activity 3,783 29,974 (26,191) 52,795 51,105

Total Increase / (Decrease) in Cash 76 (17,817) 17,893 (34,692) 21,659

Net Opening Cash & Cash Equivalents (9,888) (9,888) 0 (9,888) (30,377)

Net Closing Cash & Cash Equivalents (9,812) (27,705) 17,893 (44,580) (8,718)


Statement of Cashflows

For the period ending 31 March 2020

The cash position at 31 March 2020 reflects revenue received in advance from the Ministry of Health in both late February (noted previously) and late March (COVID-19). Althoughoverall additional expenditure including Clinical Supplies and Outsourcing caused Payments to Suppliers to be higher than budget, the Operating cash flows are favourable to budget by $21.2m. Payments to Employees were $4.1m lower than budget due to the end of month pay period timing.

Investing Activity outflows are favourable to budget by $22.9m, reflecting the timing of spend on Capital Expenditure and is currently higher than the same time last year.

Cash from Financing is unfavourable to budget by $26.2m, due to timing of the Ministerial approval of Deficit Support Funding.


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Capital Expenditure Summary

YTD YTD Over FY19 YTD FY19 Full Year

Actual Budget Variance Under Actual Actual

Description $000 $000 $000 Spend $000 $000

Land, Bui ldings & Plant 10,322 27,365 17,043 U 11,102 15,327

Clinical Equipment 9,952 11,653 1,701 U 8,578 12,574

Other Equipment 370 199 (171) O 353 406

Information Technology 2,426 4,276 1,850 U 2,965 4,158

Motor Vehicles 3 - (3) O - 44

Software 2,859 5,311 2,452 U 83 121

Total Expenditure 25,932 48,804 22,872 U 23,081 32,630


Capital Expenditure - Cash Flow

For the period ending 31 March 2020

Property, Plant and Equipment and Intangible Assets are a combined $335.0m, being $20.8m less than the budget of $355.8m.

Land, Buildings and Plant is $17.0m underspent in projects including Queenstown LakesHospital Redevelopment, Dunedin Hospital ICU, Southland MRI and Deferred Maintenance.

The Queenstown Lakes Hospital redevelopment has been completed although further work is scheduled for mid-year to complete the sub-project work, in particular on birthing areas.

Clinical Equipment is $1.9m underspent with project timing for various items of equipment. The Cardiac Catheter Laboratory and Lamson Tube projects were both completed under budget.

The Dunedin Hospital ICU development has been delayed due to unresolved issues with the ventilation systems and is likely to remain so until a better understanding of COVID-19impact is obtained. Software is $2.5m underspent, the timing of investment on FPIM (Oracle upgrade) and SI PICS (Patient Management) projects being two of the major contributors.

9.1


45

Mar-19 YEAR ON YEARYTD

Mar-19

YEAR ON

YEAR

Actual Budget Variance % Variance Actual Monthly Variance Actual Budget Variance % Variance Actual YTD Variance

Medical Caseweights

1,146 1,506 (361) -24% 1,405 (260) Acute 13,278 12,904 375 3% 12,795 483

319 327 (8) -2% 329 (9) Elective 2,939 2,634 305 12% 2,701 238

1,465 1,833 (369) -20% 1,734 (269) Total Medical Caseweights 16,217 15,538 679 4% 15,497 720

Surgical Caseweights

1,283 1,296 (14) -1% 1,401 (118) Acute 10,699 10,936 (237) -2% 11,112 (413)

1,083 1,378 (295) -21% 1,498 (417) Elective 11,665 12,000 (335) -3% 12,048 (384)

2,365 2,674 (309) -12% 2,899 (534) Total Surgical Caseweights 22,363 22,936 (572) -2% 23,160 (797)

Maternity Caseweights

109 95 15 16% 115 (5) Acute 909 803 106 13% 810 98

335 368 (33) -9% 329 6 Elective 3,070 3,166 (97) -3% 3,165 (95)

444 463 (19) -4% 444 1 Total Maternity Caseweights 3,978 3,969 8 0% 3,975 4

TOTALS

2,538 2,897 (360) -12% 2,921 (383) Acute 24,886 24,642 242 1% 24,718 168

1,737 2,073 (336) -16% 2,156 (420) Elective 17,673 17,800 (127) -1% 17,914 (241)

4,274 4,970 (696) -14% 5,077 (803) Total Caseweights 42,559 42,442 115 0% 42,632 (73)

TOTALS excl. Maternity

2,428 2,803 (374) -13% 2,806 (378) Acute 23,977 23,840 137 1% 23,908 69

1,402 1,705 (303) -18% 1,827 (426) Elective 14,603 14,634 (30) -0% 14,749 (146)

3,830 4,507 (677) -15% 4,633 (804) Total Caseweights excl. Maternity 38,580 38,473 107 0% 38,657 (77)

Mar-19 YEAR ON YEARYTD

Mar-19

YEAR ON

YEAR

Actual Budget Variance % Variance Actual Monthly Variance Actual Budget Variance % Variance Actual YTD Variance

2,435 2,932 (497) -17% 2,596 (161) Mental Health bed days 23,980 25,917 (1,937) -7% 24,249 (269)

Mar-20 Mar-19 YEAR ON YEARYTD

2019/2020

YTD

Mar-19

YEAR ON

YEAR

Actual Actual Monthly Variance Actual Actual YTD Variance

Emergency department presentations

3,063 4,159 (1,096) Dunedin 32,123 33,582 (1,459)

847 1,081 (234) Lakes 9,919 9,578 341

2,752 3,460 (708) Southland 27,364 29,063 (1,699)

6,662 8,700 (2,038) Total ED presentations 69,406 72,223 (2,817)

Treated Patients (excludes DNW and left

before seen)

Mar-20 YTD 2019/2020

Mar-20 YTD 2019/2020

9.2


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Performance Dashboard Southern

28/04/2020 1 / 2

9.3


47

Performance Dashboard Dunedin

28/04/2020 1 / 2


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Performance Dashboard Invercargill

28/04/2020 1 / 2

9.3


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Performance Dashboard Tile DefinitionsTile Image Tile Description

Safety 1st data.

ComplaintsThe number of internal complaints (from website, phone, email, letter, health and disability, comment form, etc) per month.ResolutionsThe percentage of complaints that were resolved within 35 working days.

RestraintsSafety 1st data.The number of restraint events per month.SeclusionsiPM data.The number of seclusion events per month.


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iPM data.

EventsThe number of patients re-admitted acutely to any inpatient specialty within the same hospital within 7 days, excluding short stay events.IP DaysNumber of admissions to any inpatient specialty.RatesRe-admissions / total admissions * 100iPM data.

AcceptedThe monthly number of First Specialist Appointment (FSA) referrals received and accepted. Some FSA referrals received will be awaiting an outcome, they are not displayed.DeclinedThe monthly number of FSA referrals received and declined. Some FSA referrals received will be awaiting an outcome, they are not displayed.Safety 1st data.

The monthly number of reported staff adverse events categorised by severity assessment codes 1-4 and by 'N/S' (Not Specified).

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Safety 1st data.

The monthly total number of all reported staff adverse events.

iPM data.

The number of deaths in hospital based on iPM discharge type.

iPM data.

Caselength MinutesThe monthly number of caselength minutes. Caselength = anaesthetic time (a) plus the procedure time (p) for all specialties and theatres. (a) = anaesthetic start time to ready for procedure start time, (p) = procedure start time to procedure completed.Actual List UtilisationActual list utilisation = caselength utilisation / total session time. For all specialties and theatres.Total Session MinutesFor all specialties and theatres.Target Utilisation (85%)The agreed target theatre utilisation rate.


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Scheduled Time (hours)The monthly amount of hours that the included theatres were scheduled to be in use.Actual Time (hours)The monthly amount of hours that the included theatres were in use.

Both series display the theatre times for a subset of theatres.Dunedin tab: DNTH1 to DNTH9 inclusiveInvercargill tab: OR1 to OR4 inclusiveSouthern tab: Dunedin tab theatres and Invercargill tab theatres

The time period is limited to the most recent six (rather than 12) complete financial months for performance reasons.The monthly number of patients who have their procedure postponed after their surgery is scheduled.

The monthly average number of days that patients stayed in hospital.

ED VolumeThe monthly number of presentations to ED.ED Non BreachesThe monthly number of presentations to ED that went from triage to departure within six hours.

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The number of patients whose wait for a First Specialist Appointment (FSA) will exceed a four month wait, and hence breach ESPI 2, by the end of the current financial month if no more appointments are made.

The number of patients who have been waiting longer than four months for an FSA displayed in 30-day time-waiting bands.

The number of patients whose wait for surgery will exceed a four month wait, and hence breach ESPI 5, by the end of the current financial month if no more surgeries are completed.

The number of patients who have been waiting longer than four months for surgery displayed in 30-day time-waiting bands.

The monthly number of patients who have been discharged with a length of stay greater than seven days.

The percentage of CT examinations completed each month within the MoH target of 42 days from request date.


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1


Title: Southern District Health Board – COVID-19 Update

Report to: Board


Summary:

ß Report updating the Board on Covid 19


Financial: Yes

Workforce: No

Other: No

Document previously submitted to:

N/A Date:

Approved by: Date:


Chief Executive Officer Chris FlemingChief Executive Officer

Date: 27/04/2020

RECOMMENDATION:

For noting.

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Southern DHB Board Meeting - COVID-19 Update

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2

1. Background

As the Board are aware, the Government announced an alert level system for COVID-19 on 21 March 2020. This alert level was to provide clarity nationally in terms of escalating restrictions on human contact, travel and business operations. At the time of the announcement, New Zealand went immediately into alert level 2. Then two days later New Zealand moved to alert level 3 with level 4 then being enacted 48 hours later at 11:59pm on Wednesday 25 March 2020.

The details of the alert system is attached for completeness.

Prior to the moving into lock down a lot of preparation work had been undertaken to ensure the health system was able to operate under the restrictions, and the public health effort of testing and contact tracing was well established.

This report is to provide an extensive overview of what we have been through, the facts, the uncertainties, the results, and our plans for moving forward. This has been the core of all activities over the past six weeks.

2. The Mission

Early on it was identified that we needed to establish a clear mission for our response to COVID-19, and this was set at:

1. Minimise the number infected with COVID-19

2. Limit the harm to people with COVID-19 - RED

3. Maintain an effective acute and urgent care health system - GREEN

4. Look after our health community

5. Support planning and provision of wider community support

6. Maintain a viable health system for the long term.

We set the mission with these six stages to ensure that we actually focussed on each of them to ensure we didn’t simply wander around aimlessly responding and reacting to many of the challenges we encountered.

Subsequently to the success of the last four weeks, we have slightly modified the mission in as much as we have modified the first point to “Stamp out COVID-19”, this is because of where we find ourselves as a country this is now a very real prospect. It will however be very dependent on the Government maintaining closed borders until such time as a vaccine becomes available.

3. The Modelling

Central to the planning for the Southern Health System is the modelling, prior to gaining some degree of consistent modelling there was a risk of everyone being experts and using their own judgement as to what we should be planning for. The challenge is determining what the R0 value if for Corona Virus. In essence, the R0 value represents the number of people that each person infected with the virus passes the virus on to. At the time the first modelling was undertaken the R0 value assumed was 2.5, that is for each person who contracts the virus they will infect 2.5 other people. By comparison the Ebola and the Zika Virus had a R0 value of around 2 while Measles have a basic R) Mvalue of around 14 to 15. When the Prime Minister announced the decision to remain in Alert Level 4 until 11:59pm on 27 April and then move to level 3 she indicated that the R0 value across New Zealand was now 0.48. Where the R0 value is sitting directly impacts the spread and as such also the demand on the health system and the ultimate mortality.


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3

The intelligence briefing that we received on 6 April showed the following projections:

Scenario 1 Scenario 2 Scenario 3

Optimistic Plan for Worst Case

Max ICU Occupancy 9 31 56ICU - Days where occupancy is greater than 12 0 60 76ICU - First Day where Occupancy is greater than 12 #N/A 07 June 2020 25 May 2020ICU - Bed nights where occupancy is >12 0 694 1878

Scenario 1 Scenario 2 Scenario 3

Optimistic Plan for Worst Case

Max Inpatient Occupancy 50 184 329Inpatient - First Day where Occupancy is >2691 #N/A #N/A 27 June 2020Inpatient - Days where occupancy is >269 0 0 27Inpatient - Bed nights where occupancy is >269 0 0 1052

1269 beds is the estimated capacity available for COVID patients across the system

This meant that in the worst case scenario had the virus continued per the projections at the timewe would have needed 56 ICU beds and 329 hospital beds for the treatment of COVID-19 positive cases. Even with the ICU expansion plans the ICU resource would have been overwhelmed on

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4

25 May, and hospital beds would have been overwhelmed, on 27 June. The moderate, plan for option, saw ICU peaking at 31 beds on 7 June, while hospital beds would have been okay. Even in this option, while we physically had the capacity to manage this number of ICU patients, the workforce would have been seriously stretched and there would have been dramatic impacts on other services.

A couple of weeks later however the current modelling, as a consequence of the impact of the lockdown now shows the following:

Scenario 1 Scenario 2 Scenario 3ICU hospitalisation rate: 0.7% 2.5% 4.4%Max ICU Occupancy 1 4 8ICU - Days where occupancy is greater than 12 0 0 0ICU - First Day where Occupancy is greater than 12 - - -ICU - Bed nights where occupancy is >12 0 0 0

Note: the spike and drop at the beginning is caused by the noted inpatient recovering

Scenario 1 Scenario 2 Scenario 3Hospitalisation rate: 0.7% 2.5% 4.4%Max Inpatient Occupancy 7 26 46Inpatient - First Day where Occupancy is >2691 - - -Inpatient - Days where occupancy is >269 0 0 0Inpatient - Bed nights where occupancy is >269 0 0 0

1269 beds is the estimated capacity available for COVID patients across the system


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5

Note: the spike and drop at the beginning is caused by the noted inpatient recovering

In essence this is now reporting that the moderate plan assumptions indicate that we will have adequate capacity in ICU and the hospital, and in fact would only need to initiative stage 2 of the ICU plan for a very short period of time. The challenge however is that the model is unable to predict what the impact of moving to alert level 3 will be and then ultimately alert level 2. The success of the lockdown period is that with everyone living within their bubble the ability to contract the virus has been dramatically reduced, and even if one does, the ability to infect others has been deliberately limited to the people within their bubble. With loosening of controls this risk increases.

The DHB is therefore taking the original “plan for” scenario which saw demand of 31 ICU beds and 184 hospital beds as the scenario to plan for, but we will implement to the latest model. What this means is we are looking forward to what is required if we need to enact the 31 ICU / 184 hospital bed option and ensure we understand lead times, but we are only implementing actions to meet the current projections and where lead times for the now worst case scenario are long.

4. The Cases

There has been considerable interest in the location of cases. While this is understandable,unfortunately community reactions to positive results have been in some instances very unfortunate. There have been examples of positive cases being treated very poorly including unwillingness to accommodate individuals who needed appropriate accommodation, through to ostracising and bullying of individuals / families in smaller communities. This is very unfortunate and reflects poorly on how people react to fear and uncertainty. No-one who has contracted the virus contributed to the contraction, this is simply an exceptionally infectious virus.

To this end we are only reporting cases by Territorial Local Authority (TLA). The position at the time of writing this report the tables below show the current results:

The table below shows that at 1:00pm on 27 April the total cases of confirmed of probable are 216 cases of which a total of 200 cases had recovered, and sadly 2 deaths.

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6

The graph below shows the number of new cases per day being reported. One can see that at the time of when the lockdown (level 4) came into effect the number of cases increased significantly for a period. This was to be expected and the impact of the lock down was expected to be seen 10 days later, so around 5 April. This can clearly be seen in the numbers below with volume of new cases from 6 April being dramatically down despite the number of tests remaining very high. It is pleasing that there has now been 11 days of no new cases in our district (note: the graph below does not include 21 to 27 April which were all zero).


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https://app.powerbi.com/reports/c7833123-3bbc-4cf4-ba49-fac7009750e1/ReportSection819982131821b8b4612e?pbi_source=PowerPoint

7

The impact on the hospitals has been relatively low, it should be noted these are the positive cases,but on top of this are a higher volume of cases which have been admitted as suspected COVID-19. On the surface one could debate that the actions taken have been too great because we have prepared ourselves for an influx which ultimately has not occurred, however the modelling above and how fast it has changed needs to be recognised. In the event that the modelling at the time of the lockdown had eventuated we would have needed every bed possible.

Occupancy of the hospitals have also reduced significantly reaching a low of 328 beds on 7 April and is back up to 435 on 21 April. Pre COVID-19 normal bed occupancy sits at around 580 per day.

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https://app.powerbi.com/reports/c7833123-3bbc-4cf4-ba49-fac7009750e1/ReportSectiond820ae1be841789a92ce?pbi_source=PowerPoint

https://app.powerbi.com/reports/c7833123-3bbc-4cf4-ba49-fac7009750e1/ReportSectionc734bc2a3b1704b00fda?pbi_source=PowerPoint

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5. The Approach Taken

The approach that has been taken to managing the situation has been:

PUBLIC HEALTH

The focus and energy of public health has been essential to the success to date. Public health has focussed on testing and contact tracing. Effective contact tracing and isolating close contacts has been vital to the outcomes achieved. From mid-March onwards, the entire public health service (PHS) has been focused on our response to COVID-19. On 14 March, the first case was notified in the district and as of 27 April 2020, the Southern district has 216 cases of COVID-19.

Key elements of the response has included:

∑ Border Health

From 29 February the Ministry of Health required all international flights into the district to bemet at the border by public health and public health information was provided to incoming passengers. Southern has three international airports, but the work was predominantly at Queenstown and Dunedin airports. As the border health restrictions tightened this required additional resource. This was so there was adequate capacity to ensure that all health arrivalcards were completed including that passengers stated where they would self-isolate for 14 days. During this time 174 international flights were met.

Criteria was also in place at seaports. PHS developed a COVID-19 pre-arrival Public Health declaration form. Every ship arriving from international waters completed this form and declaredany illness on board to ensure that appropriate response occurred. All cruise ships are disallowed from entering New Zealand until 30 June 2020. This doesn’t apply to cargo ships. Should any passengers – via sea – be unwell, then the ill traveller procedures at the airports/seaports are enacted, which includes a clinical assessment by St John.

∑ Technical Advice

Medical Officers of Health continue to provide input into health system planning through the technical advisory group.


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∑ Case Management and Contact Tracing

A process for case management and contact tracing has been established. A team of nurses are involved in talking with the case to identify their movements while infectious to establish who their close contacts are that need to be traced. The cases are then monitored daily to assess how they are doing and monitor any changes in symptoms – either deteriorating or improving, and making an assessment as to when a case has recovered.

Once close contacts are identified, a team undertake the contact tracing to isolate the close contacts and give them appropriate health advice. All close contacts are monitored until 14 days after the last exposure. Again this is to ensure we are monitoring their health so that if they become unwell they are referred for testing.

Much of the daily monitoring is done via an email survey via a system called REDCAPS. Contacts using this system respond daily to emails. Staff check that this has occurred and contact tracers will phone the close contacts should any change in symptoms be reported or if they haven’t sent a daily email.

We have 100 people involved in contact tracing currently across the Southern district. This includes a range of staff from Public Health South, the wider DHB as well as external agencies such as local councils. Another 35 people are available to assist from the wider DHB, including from the University of Otago, if we need to scale up our teams further.

Due to our decreasing numbers of cases we are currently scaling down our capacity. We are aware case numbers are likely to increase at some point when lockdown restrictions are relaxed, so we are looking at how we can also surge up our capacity should this be required.

We have utilised in a limited way the national contact tracing service. This has been used for a small number of cases but we have had concerns over visibility of when all close contacts where traced. It is important that for complex cases and clusters it is important to have the capability to see all aspects of investigation and contact tracing. There are some updates being made to a national contact tracing solution (based on the sales force system) which will address these concerns. However, until all the functionality of current systems are in place Southern will not be using it. This is likely to help streamline some of our current processes.

The government has recognised that the investment in Public Health has been limited in the past decade. This issue has been raised consistently with the Ministry of Health by District Health Boards over the years, however it is not until one gets to an event like this that one realises the impact of under investment. The Ministry has provided one off funding of a little more than $1 million to our Public Health team to address the response to date and are reviewing and intending on investing further to strengthen our ability. A copy of the external review report commissioned by the Ministry into contact tracing is attached.

The Ministry have recently distributed metrics of Public Health Unit Performance. They measuring performance on 4 indicators:

∑ Symptom onset to (swab) test – the target is that 80% should be completed within 48 hours. In Southern we don’t achieve 80% until 10 days which is the same result as the rest of the country

∑ Swab test to notification of test result – the target is 80% within 24 hour. Southern achieves 100% within 1 day

∑ Notification of test result to tracing of close contact – the target is 80% within 48 hours, Southern is one of the better performers on this target achieving it, while the country as a whole only achieves 9 days

∑ Symptom onset to tracing of close contact – the target is 80% within 5 days. Southern only achieves 80% in 11 days and is yet one of the better performers, as a country 80% is not achieved until 23 days.

While there is room to improve, Southern’s performance overall is very positive, particularly given the fact that it had just come out of the Measles challenge and has had to achieve these results without the ability to recruit addition staffing due to the lock down. The staff that have been utilised

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have been redeployed staff working in contact tracing and case management as well as existing staff working up on hours and overtime to achieve the results. Some resources from other local organisations have also been used which we are grateful for.

PRIMARY CARE

WellSouth Primary Health Network has formed an Emergency Operating Centre (EOC) in response to COVID-19. The focus is to work closely with general practice around operating a different model of care. Up to 70% of usual activity is now being delivered by phone.

Close to $70 million is being distributed to District Health Boards, Primary Health Organisations, general practices and pharmacies to support the primary care COVID-19 response, with $15m distributed directly to support general practice on 31 March 2020 and $7.8m distributed to general practices on a per COVID-19 test basis. This is an initial payment intended to contribute to primary care’s response (including virtual consultations) to minimise community spread.

Community Based Assessment Centres (CBACs) have been established in Dunedin, Invercargill and Queenstown. The WellSouth EOC is focused on ensuring sustainability of these centres as well as planning to scale up the capacity for community testing across the district. General practice is also providing COVID-19 responses across the district. The volumes are highlighted in the table below:

Level of activity at CBAC and GP

COVID-19 activity by Territorial Local Authority (TLA)


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The demographic distribution of COVID-19 testing can been seen on the graphs below:

LABORATORY TESTING

In the early days of COVID-19 our specimens had to be sent out of district for processing. Southern Community Laboratories (SCL) however developed innovative solutions which brought the ability for testing to Dunedin and it also saw a different way of processing the testing enabling a 3.5 hour turn-around from the commencement of the processing until the result was available. Processes used elsewhere batch process tests, meaning that the turnaround time was very dependent on when the swab was received relative to the scheduled batch processing times.

We have had difficulties with transporting swabs around the district, however these issues have been resolved. The turn-around is clearly impacted in areas outside of Dunedin relative to the need to courier swabs around the district. There have also been times when availability of reagents required to process the tests have been delayed due to international logistics challenges.

This said, overall however Southern has enjoyed relatively rapid turn-arounds when compared to some other districts.

LAKES DISTRICT HOSPITAL

Lakes District Hospital admitted the first COVID-19 positive patient in the South Island on 14 March. On 18 March a second COVID-19 positive patient was admitted. Both these patients were international tourists. These admissions necessitated a rapid cycle of planning to prepare the ward for COVID-19 positive patients, to develop ‘red’ and ‘green’ zones and to develop neutral pressure rooms and makeshift anterooms to enable safe use of personal protective equipment (PPE) and adherence to infection prevention and control standards. Extensive education with staff has occurred and multiple processes have been developed to guide practice, and develop pathways to support safety of staff and safety of patients.

The Lakes District Hospital team have worked closely with Queenstown Lakes District Council Civil Defence Emergency Management (QLDC CDEM) to develop solutions to the issues facing tourists with a positive diagnosis plus their cohorts.

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There has been a significant reduction in attendances at the Emergency Department – the last week of March saw a 60% decrease from the first three weeks. Admissions have also been reduced. Patients with the longest lengths of stay have been the COVID-19 positive patients.

Lakes District Hospital also have three staff members who have tested positive for COVID-19. This resulted in 18 staff being stood down for 14 days as per Public Health advice. The ward was closed for 48 hours whilst all staff were tested, to exclude an asymptomatic positive worker. ED remained open at all times. The clinical teams worked collaboratively to ensure rosters were covered. Fortunately, the reduction in presentations has meant clinical requirements have been met, despite the reduced workforce. The support of Executive Leadership Team and the Directorate has been excellent. Lakes District Hospital staff feel part of an organisation where people matter, staff are valued and the leaders listen and respond.

The Lakes Maternity service was relocated to the Oral Health building opposite the hospital. Women who have birthed there have tended to go home following the birth as Ministry of Health advise no partners should visit post-natally, and most prefer to be in their home ‘bubble’ with the support of their whanau. This move freed the maternity wing to become a potential red zone for COVID-19 positive patients.

As inpatient numbers reduce we hope to adapt the COVID-19 escalation plan to enable the Maternity wing to become a ‘green’ zone and the ward can be a ‘red’/‘orange’ zone. This would allow Maternity services to relocate back into their original premises, the birthing pool and bathroom to be installed, thus providing an enhanced service for pregnant women and attracting them back to the safe service on offer at Lakes District Hospital Maternity.

RURAL TRUST HOSPITALS

The response of the Rural Hospitals to COVID-19 has been commendable. Each has established an Emergency Operation Centre (EOC) and extensive planning has been undertaken to ensure they can respond to the challenges ahead. They have been represented at the Emergency Coordination Centre (ECC) by Karl Metzler, Chief Executive of Gore Health. The Chief Executives and Clinical Leads have met virtually on a regular basis, facilitated by Dr Hywel Lloyd, Medical Director Strategy, Primary and Community. These meetings have enabled a coordinated response to planning across the District. Several of the Rural Trust Hospitals are reliant on medical locums to fill up to 50% of their roster. Access to locums has reduced, with travel restrictions in place. Hospitals with full complements of staff have tried to support those facilities with staffing deficits. Different opportunities for support in service delivery in the future are being explored.

AGE RELATED RESIDENTIAL CARE

Aged related residential care (ARRC) is one of the groups most vulnerable to COVID-19. The Community Directorate have undertaken a series of roadshows around the district with ARRC providers where discussion focussed on planning for COVID-19, potential scenarios and pathways, and how the sector could work together. Each meeting resulted in agreement to work as a collective in clusters. Each of the seven clusters has a lead and the leads meet with DHB Portfolio Manager and other staff twice-weekly virtually.

When moving to a Community EOC, it was identified that ARRC was one of the biggest risk areas and additional support was required in DHB planning and sector planning and support. An ARRC group was established to support the EOC and directorate leadership team. This group includes expertise from ARRC/Older Persons’ Health, Mental Health for Older Persons’ Health and palliative care. The group focussed on how the DHB would support ARRC if they had a COVID-19 positive resident. This could be everything from clinical support through to staffing support.

On 11 April the Director-General of Health announced that DHBs were required to undertake a readiness assessment on every ARRC facility, including a site visit. The ARRC group supporting the Community EOC has played a major part in getting this process designed and implemented. This process has required a significant ramping up of resources. We have included/recruited senior registered nurses and nurse practitioners from the wider health system (hospitals, infection prevention and control, mental health and hospice) to assist.


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In under four days the team has developed a self-assessment tool using Survey Monkey, sent it to all ARRC (and Mental Health) facilities in our district, reviewed the responses, prioritised the providers by risk, undertaken the first three virtual meetings, and scheduled a total of 72 virtual meetings at a time suitable with providers.

MENTAL HEALTH

The COVID-19 planning and implementation of this has been the priority for the Southern Mental Health and Addiction System. A whole of system approach has been taken with DHB and non-government organisation (NGO) services both having well developed plans and preparing to support the approximately 6,300 people who access services for moderate to severe mental illness at any one time. Again, a sense of collaboration and working together has prevailed.

Crisis, inpatient and residential services continue to be provided with modifications to ensure patient and staff safety. Community and non-residential services have changed significantly with many staff working remotely and keeping connected with their patients via technology. The Mental Health, Addictions and Intellectual Disability (MHAID) directorate has focused on maintaining a ‘one system’ approach with a clear communication cascade, high level plans supported by detailed plans, daily briefing reports, weekly newsletter, twice a week NGO forums, and the status of DHB and NGO provided services circulated to ensure everyone knows the status of all services within the Southern Mental Health and Addiction Service.

Activity dropped off in the latter part of March and into April. However, the service had considerable challenges to work through along with the Ministry of Health to ensure the complex legal requirements of the Mental Health Compulsory Assessment and Treatment Act were delivered during the lockdown. Close working problem solving between the Director of Area Mental Health Services (DAMHS) and the Courts was required to ensure that patients’ legal status did not lapse.

During March and into April the focus was on maintaining services during level 4. The focus has now shifted towards planning for business as usual as the level 4 time period comes to an end. A starting high level draft is in development and will be supported by detailed clinical team plans that will enable services to adapt to the changing demands driven by COVID-19. March saw many changes to systems and ways of working, for example, the use of technology that will provide a strong platform for the future. Working remotely has given new impetus to the need for an electronic record with Health Connect South and how documents are saved, gaining momentum.

The psychosocial response during and going forward for many years to COVID-19 is one that will likely require ongoing and increasing attention. The MHAID Allied Health Director has been key in developing a package for the DHB workforce and a resource pack for primary health.

REFUGEE HEALTH

All affected cities have been advised by the Ministry of Business, Innovation and Employment (MBIE) that there is a temporary suspension of new cohorts of refugees arriving into New Zealand. This is part of the New Zealand government’s COVID-19 emergency response. As such, inter-agency meetings between Dunedin and new South Island resettlement cities (e.g. Ashburton and Timaru) continue to be held. And there are currently ~1,000 former refugees being supported by the refugee health programme within the Southern DHB catchment.

WellSouth is developing social media (WhatsApp) groups that will be language specific for refugees – Arabic, Farsi, and Spanish. While these social media groups provide benefit at all times, they can be particularly important in a level 4 situation, as there are concerns that level 4 lockdown is only adding to real experiences of social isolation for former refugees. The WellSouth Mental Health Coordinator is developing wellness videos that will be posted and shared on the WhatsApp groups.

As we have a rights-based refugee health model, the ambition continues to be to minimise the development of unique services specifically for refugees. Consequently, as COVID-19’s future health impacts are unknown, we do have an agile service that is integrated into Southern DHB’s broader universal services.

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The following issues require further work:

∑ The vacant position of Refugee Primary Health Team Leader, which has been vacant for 12 months. Our ability to address operational issues and service development has been compromised by this vacancy

∑ The development of a mental health delivery model for former refugees

∑ The lack of a Farsi speaking Health Navigator that leads to isolation and delayed or non-delivery of navigation and orientation for Afghani former refugees.

The Programme Lead of Refugee Health will continue to engage with WellSouth in efforts to see progress in the above. Meanwhile, continued consideration and mitigation of COVID-19 impacts on the service will take place.

POPULATION HEALTH SERVICE

Some of the Population Health staff have been redeployed to the Public Health South EOC to assist with case management, case monitoring and contact tracing.

The following are deemed as essential services to continue work during COVID-19:

∑ Immunisation – immunisation outreach for children under 6 years of age; and immunisation advice and support to practices.

∑ Cervical Screening – cervical screening has reduced services running as per the National Cervical Screening Programme (NCSP) directive in relation to COVID-19. Essential services continues to support colposcopy, general practice and women are continuing.

∑ New Born Hearing Screening

∑ Sexual Abuse and Treatment (SAATS)

∑ Sexual Health and contraception continues with a reduced service

∑ Violence Intervention Programme – with additional staff deployed to support this programme.

∑ Public Health Nursing – continues to provide follow up of current at risk children and their whanau via telephone consultation and referrals for youth health clinics with triage of more complex cases to sexual health.

∑ Support to primary care.

The Population Health Service is reviewing services in terms of recovery and this may require new models of care, for example, for Before School Checks where all service was stopped with the lockdown except for telephone follow-ups.

DISTRICT ORAL HEALTH SERVICE

COVID-19 guidance from the Dental Council released at Alert Level 2 advised that all non-essential and elective dental treatment should cease and only essential emergency treatment should be provided. Essential/emergency dental care is defined as uncontrolled facial swelling, uncontrolled bleeding, facial trauma and pain that cannot be controlled by medication. All dental treatment is regarded as high risk due to the aerosols generated. Impact is widespread for services both in the community (children) and hospital and includes:

∑ One double mobile dental unit has been loaned to the Faculty of Dentistry for emergency dental treatment of COVID-19 patients

∑ One double mobile shifted to Southland Hospital for ‘red’ stream dental patients

∑ Working closely with Faculty of Dentistry to ensure equity of access to emergency care across district

∑ Phone triaging, medical management of pain and emergency care only provided over alert level 4 – this is likely to continue, with restrictions to aerosol generating procedures during level 3 and level 2


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∑ Exploring staff redeployment options to support other population health services

∑ Virtual/phone consultations and targeted prevention options are being worked up.

EMERGENCY DEPARTMENTS

The national lockdown has had a direct impact on the numbers presenting to the Emergency Departments (EDs), which has consistently been down by 50% or more per day on regular volumes. The flow into the ED on both sides has been significantly changed at both hospitals in response to the COVID-19 crisis, with ‘green’ (no suspicion of COVID-19) and ‘red’ (suspected COVID-19) streams.

In Dunedin, patients now present at what used to be the main entrance to the hospital. If they are ‘green’ they are re-directed back out onto the main concourse and down to the regular ED entrance. If they are ‘red’ they are flowed through a section of the main hospital foyer which has now been separated from the rest of the foyer with temporary walls, and enter the ED observation area, which is being kept separated from the rest of the ED. Plans have also been developed (but will only be implemented if required) that would involve expanding the ‘red’ space into the current green space and creating a new ‘green’ space where the fracture clinic and day surgery currently reside.

In Southland, ED patients are also flowed into what was the main entrance to the hospital, and this has also been partitioned off. ‘Red’ patients are flowed back out along a new footpath to the rear of the ED whereas ‘green’ patients are flowed through the main entrance and into the ED.

INTENSIVE CARE UNITS

As the Dunedin Intensive Care Unit (ICU) only has two negative pressure rooms (and can therefore only accommodate two COVID-19 ICU patients), the management team and clinicians have developed a robust plan that would see additional ICU pods opened if COVID-19 volumes increased beyond two COVID-19 positive patients.

The first trigger point in their plan is more than two patients. This triggers the movement of the current ‘green’ patients into the gastroenterology space and the use of the first stage of the ICU as a ‘red’ space for the treatment of COVID-19 patients. The next trigger is more than 10 COVID-19 ICU patients. At this point a second ‘red’ pod is opened (ICU stage 2, for which temporary air handling units are being installed to make the space a better fit for purpose than it was previously). And at more than 22 COVID-19 ICU patients a final expansion into the post anaesthesia care unit (PACU) space occurs. These stages would allow for the treatment of up to 32 COVID-19 patients. This plan was one of the first to be comprehensively completed and capital expenditure worth approximately $2m has been approved to enable all phases of the plan to be activated if required.

The staffing implications were also huge with almost 200 additional staff being required to cope with this. Planning and training remain underway as we do need to be prepared even though the likelihood of the need being realised is low.

INPATIENT WARDS

In Dunedin, one of the existing wards, Ward 7A, has been re-assigned as a COVID-19 ward and COVID-19 or COVID-19 suspect patients have been admitted into this ward. This ward can accommodate up to 27 patients.

Work has also neared completion to repurpose the assessment, treatment and rehabilitation ward on the 6th floor to house further COVID-19 patients if/as required. This would allow capacity to grow up to another circa 25 COVID-19 patients, providing for up to circa 53 COVID-19 patients in total.

Once again however all sites have encountered problems particularly around negative pressure rooms and the ability to be able to secure physical areas from the perspective of viruses escaping. While Covid 19 is droplet spread there remains fear of the unknown as there have been many health professionals contract the virus from patient contact internationally. While in Southern we do not have any confirmed cases of patient to staff transmission, Public Health were unable to ascertain the source of COVID-19 for the first staff member in Lakes District Hospital who contracted the virus

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and while this staff member did not provide any direct care to confirmed cases in Lakes they were inthe vicinity of this patient. One therefore cannot categorically rule out the risk that the virus may have been contracted in this manner. The Lakes facility indeed had many modifications required and while their ability to manage cases is much improved if one was building a facility now it would be different to allow for this in the future.

OUTPATIENT ACTIVITY

Outpatient activity has been significantly changed in response to the crisis. Whereas practically all outpatient activity was previously via face to face clinic appointments, only patients who have to be present for an appointment are now being invited to the hospital for their appointment and those whose appointments can be completed by videoconference or telephone are having their appointments in this manner.

As we have reorganised to deal with COVID-19 we have lost some of our outpatient capacity, but this is not as significant as we had initially feared. A snapshot of the services who we had worked up recovery plans for, and their status pre-COVID-19 emerging as an issue and their current status according to the most recent data available is as follows:

ESPI Status of Key Services Previously Under Recovery Plans

This shows that our ESPI breaches for these services deteriorated by about 27% from 16 March to6 April. This is only part of the outpatient picture for these services. We are in the process of building up a picture of the deterioration of each of our circa 40 services across both hospitals, both in terms of ESPI 2 breaches (patients waiting over four months for their first specialist assessment) and in terms of delayed follow up appointments.

Some services have been hit worse than others. For example, our ophthalmology service was previously delivered from a crowded waiting room. Social distancing requirements have meant that we have had to cancel the majority of outpatient appointments and this will lead to a particularly large backlog for this service and a long pathway to recovery.

We have established a separate hospital entrance, area and flow for our ‘red’ (COVID-19 suspected) patients. Paradoxically, this will become even more important as we leave lockdown, because we will be working hard to recover backlogs and we will have more people arriving at the hospital for an outpatient appointment than we currently do.

ELECTIVE SURGERY

Consistent with the other district health boards, we have reduced surgery to acute and urgent elective surgery only. This means that up to 60% of elective surgery (routine, deferrable surgery) has been deferred and a significant backlog is developing. We will need to recover this backlog, but it will present a significant challenge for us.

We anticipate having ‘red’ and ‘green’ flows, a ‘red’ operating theatre, social distancing rules and so on in place for some time to come. These will all lead to us having less capacity than we did pre-lockdown. However, the expectation on us (and of us upon ourselves) will be that we recover our backlogs as fast as possible, and this requires more capacity. We have been asked to prepare agreements to ‘underwrite’ the private hospitals with capacity arrangements in place that cover their fixed costs for an initial 12 week period.


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As we leave level 4 lockdown for level 3 we are still working through the process of the role of the private hospital in our recovery process. Our planning assumes that we will be able to secure some capacity for an extended period of time to provide opportunity for us to recover the under delivered surgery. This is however still being negotiated. The Ministry of Health has been discussing underwriting the private hospitals during the lock down but while we have had discussions nothing has materialised to date. We await decisions from the Ministry of Health. We are working towards positioning our capacity contracts with them to maximise this opportunity if it presents itself. In the meantime we have additional cardiothoracic surgery lists going at Mercy Hospital in Dunedin each week, and we have our regular weekly outplaced list continuing at Southern Cross in Southland.

MĀORI HEALTH

The Māori Health Leadership Team have been actively involved in the COVID-19 response across the health system, especially in the ECC and EOCs.

Māori Health directorate staff have been deployed in variety of locations, including the WellSouth 0800 line and their EOC. Kaiawhina are designated essential services and we are working on setting up blue and green teams in our hospitals in our attempts to reduce the risk of cross contamination. Some of our nursing staff have been redeployed to working in the Invercargill and Dunedin CBACs.

Māori Providers are receiving all Southern DHB communications in order to keep up to date with what is happening in the health sector. This includes updates on the current situation, important information around hospital lockdowns and CBACs and other information. We have also sent out separate communications to Māori providers outlining additional resources and relevant information like http://www.uruta.maori.nz/, https://covid19.govt.nz/help-and-advice/for-maori/tikanga-maori-and-gatherings/ and advice for cancer patients and their whānau. Distribution of Tangihanga guidelines from the Ministry of Health and telephone support to all Māori providers in the district at least weekly over the coming weeks. There has been some confusion over what PPE is required and we are responding to queries as they arise. Providers are looking to limit face to face contact and generally work from home by phone. Some Māori Providers are also actively working to deliver food parcels to whānau who require this support.

All Papatipu Rūnanga Marae and offices are closed, with staff working from home. TRONT has provided support on pandemic planning and have a large team (30 staff) phoning kaumatua. Some Rūnanga have also established kaumatua telephone trees and are working to support kaumatua within their local communities including providing cooked food and produce. As the national lockdown gets traction we will have members who start to experience real economic hardship and emotional distress resulting from isolation. There’s consideration within Te Rūnanga how staff might link to Papatipu Rūnanga so we create a communication/distribution chain that doesn’t double up our efforts. We are in communication with TRONT now coordinating our collective energies.

COVID-19 Ngā Hau e Whā Marae (Murihiku) community plan – Daniel Tawaroa presented a planningtemplate at a hui on 21 March. He is recommending a COVID-19 planned approach to Murihiku/Otākou regional Kōhanga Reo and Tūmuaki of Te Wharekura o Arowhenua. At Alert level 4 Ngā Hau e Whā Marae will be closed completely for tangihanga. Tangihanga support/guidance to be provided by telephone contact and/or video conferencing. Tangihanga support extended to whānau pani at the passing of a whānau member the day prior to the national COVID-19 lock-down. All support extended to the whānau during the national lock-down is by telephone, including the 'whakanoa whare' process.

Hygiene packs are going to be distributed through Te Putahitanga which landed in 14 April in Christchurch. These will be distributed through Māori health and social service agencies with the aim of reaching at risk Māori. The DHB will support where required.

We have been working with the national ICU clinical leads and the University of Otago 1000 minds team looking at the development of an ICU prioritisation tool for COVID-19. Priority criteria from our perspective ought to consider:

∑ Priority to Tamariki and Mokopuna.

∑ Priority to Hapu wahine, and wahine likely to have children in the future or with dependants.

∑ Kaumatua leaders and navigators of whakapapa, Te Reo and Tikanga.

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http://www.uruta.maori.nz/

https://covid19.govt.nz/help-and-advice/for-maori/tikanga-maori-and-gatherings/

https://covid19.govt.nz/help-and-advice/for-maori/tikanga-maori-and-gatherings/

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∑ Whakapapa Māori if all other determinants are equal.

∑ BMI given less weighting than functional movement.

∑ Smoking given lower weighting.

We are working with Te Tumu Whakarae and the Iwi Chairs forum in our attempts to ensure this tool has a clear equity position, which has been a challenge for the ICU teams and the University of Otago.

Official tangihanga guidelines were amended as at 30 March. The Māori health team developed the embedded panui aimed at providing detail to DHB employee and has been communicated to all staff.

The Māori Health Leadership Team are meeting with a small IGC Southern Māori Pandemic Group. The CMSIO has taken responsibility for the development of a localised plan which will focus on the acute response moving forward to psychosocial recovery. The Southern Māori Pandemic Group is being chaired by Odele Stehlin and has included Justine Camp, Emma Wyeth, Victoria Bryant and Sue Crengle. Weekly meetings have been scheduled with the Māori Health Leadership Team moving forward. The plan is being circulated to IGC members currently with view to it being then taken to the board.

The Chief Māori Strategy and Improvement Officer is working with a cross sector of DHB, Police, Rural Hospitals, Funeral Directors and Communio on developing a plan for mass casualty if required.

6. Recovery

STAGES FOR THE PANDEMIC

The diagram below highlights the waves that we will need to go through. We are coming to the end of the first wave but are about to enter the 2nd Wave where the impact of resource restriction on urgent non-COVID conditions will present, and this will be followed very quickly by the third wave of recognising the impact of interrupted care on chronic conditions.

The 4th Wave is of significant concern as the impact of the lock down has had far reaching impacts on everyone. There have been the obvious impacts on our workforce who have been required to work in different ways and at times have been concerned about the risks and potential exposures working on the front line has created. There is also the very real pressure that those staying at home in their bubble would have created in particular concerns about family violence, as well as alcohol and substance abuse. The third component is the economic impact in terms of those who have lost their employment and those suffering financial hardship as a consequence of the lock down and the inevitably long tail of impact which New Zealand will see until the economy and the country are back to a position of the new norm. These issues will increase demand for primary care and mental health care needs significantly. It will be vital that we are active in our planning and response to this.

The temptation will be to believe that as we move to level 3 and then hopefully very shortly thereafter to level 2 that the crisis is over but the reality is that the real impacts are only starting to be felt.


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IMMEDIATE STEPS FOR RECOVERY PHASE ONE

As a Southern Health System we have determined that we will resume as many services as we possibly can, however this will be on the proviso that:

∑ Staff will be expected to return to the workplace where it is safe to do so

∑ Screening measure for staff and patients will remain in place

∑ Planned activity will recommence where

- Red and green streaming of patients / clients are possible

- Physical distancing and other safety measures are able to be maintained between patients

∑ Staff with any symptoms must remain at home

∑ Capacity to manage surges in demand must be secured.

Recovery planning for deferred work is presently underway. Outpatient and elective surgical activities will recommence on Tuesday 28 April, however we will continue to be not up to full capacity as we need to provide space, capacity and workforce to ensure that we can safely operate and flex up if we have a further wave of COVID-19 presentations. A brief overview of recovery planning to date will be given at the Board meeting.

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New Zealand COVID-19 Alert Levels Summary• The Alert Levels are determined by the Government and specify the public health and social measures to be

taken in the fight against COVID-19. Further guidance is available on the Covid19.govt.nz website.

• The measures may be updated based on new scientific knowledge about COVID-19, information about the effectiveness of control measures in New Zealand and overseas, or the application of Alert Levels at different times (e.g. the application may be different depending on if New Zealand is moving down or up Alert Levels).

• Different parts of the country may be at different Alert Levels. We can move up and down Alert Levels.

• Essential services including supermarkets, health services, emergency services, utilities and goods transport will continue to operate at any level. Employers in those sectors must continue to meet health and safety obligations.

• Restrictions are cumulative (at Alert Level 4, all restrictions from Alert Level 2 and 3 apply).

Published 16 April 2020

Level 1 – PrepareThe disease is contained in New Zealand

Level 2 – ReduceThe disease is contained, but the risk of community transmission remains

Level 3 – RestrictHigh risk the disease is not contained

Level 4 – LockdownLikely the disease is not contained

• COVID-19 is uncontrolled overseas.

• Isolated household transmission could be occurring in New Zealand.

• Household transmission could be occurring.

• Single or isolated cluster outbreaks.

• Community transmission might be happening.

• New clusters may emerge but can be controlled through testing and contact tracing.

• Community transmission is occurring.

• Widespread outbreaks and new clusters.

• Border entry measures to minimise risk of importing COVID-19 cases.• Intensive testing for COVID-19.• Rapid contact tracing of any positive case. • Self-isolation and quarantine required. • Schools and workplaces open, and must operate safely. • Physical distancing encouraged.

• No restrictions on gatherings.• Stay home if you’re sick, report flu-like symptoms.• Wash and dry hands, cough into elbow, don’t touch your face.• No restrictions on domestic transport – avoid public transport

or travel if sick.

• Physical distancing of one metre outside home (including on public transport).

• Gatherings of up to 100 people indoors and 500 outdoors allowed while maintaining physical distancing and contact tracing requirements.

• Sport and recreation activities are allowed if conditions on gatherings are met, physical distancing is followed and travel is local.

• Public venues can open but must comply with conditions on gatherings, and undertake public health measures.

• Health services operate as normally as possible.

• Most businesses open, and business premises can be open for staff and customers with appropriate measures in place. Alternative ways of working encouraged (e.g. remote working, shift-based working, physical distancing, staggering meal breaks, flexible leave).

• Schools and Early Childhood Education centres open, with distance learning available for those unable to attend school (e.g. self-isolating).

• People advised to avoid non-essential inter-regional travel.• People at high risk of severe illness (older people and those with

existing medical conditions) are encouraged to stay at home where possible, and take additional precautions when leaving home. They may choose to work.

• People instructed to stay home in their bubble other than for essential personal movement – including to go to work, school if they have to or for local recreation.

• Physical distancing of two metres outside home (including on public transport), or one metre in controlled environments like schools and workplaces.

• People must stay within their immediate household bubble, but can expand this to reconnect with close family / whānau, or bring in caregivers, or support isolated people. This extended bubble should remain exclusive.

• Schools (years 1 to 10) and Early Childhood Education centres can safely open, but will have limited capacity. Children should learn at home if possible.

• People must work from home unless that is not possible. • Businesses can open premises, but cannot physically interact

with customers.

• Low risk local recreation activities are allowed.• Public venues are closed (e.g. libraries, museums, cinemas,

food courts, gyms, pools, playgrounds, markets).• Gatherings of up to 10 people are allowed but only for wedding

services, funerals and tangihanga. Physical distancing and public health measures must be maintained.

• Healthcare services use virtual, non-contact consultations where possible.

• Inter-regional travel is highly limited (e.g. for essential workers, with limited exemptions for others).

• People at high risk of severe illness (older people and those with existing medical conditions) are encouraged to stay at home where possible, and take additional precautions when leaving home. They may choose to work.

• People instructed to stay at home (in their bubble) other than for essential personal movement.

• Safe recreational activity is allowed in local area. • Travel is severely limited.• All gatherings cancelled and all public venues closed.

• Businesses closed except for essential services (e.g. supermarkets, pharmacies, clinics, petrol stations) and lifeline utilities.

• Educational facilities closed.• Rationing of supplies and requisitioning of facilities possible.• Reprioritisation of healthcare services.

Range of Measures (can be applied locally or nationally)Risk AssessmentAlert Level

ELIMINATION STRATEGY – New Zealand is working together to eliminate COVID-19


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Rapid Audit of Contact Tracing for Covid-19 in New Zealand Dr Ayesha Verrall University of Otago 10 April 2020

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Executive summary Rapid case detection and contact tracing, combined with other basic public health measures, has over 90% efficacy against COVID-19 at the population level, making it as effective as many vaccines. This intervention is central to COVID-19 elimination in New Zealand. New Zealand needs to anticipate a ‘new normal’ of local transmission and small clusters without alert level four restrictions, with the potential for one or more very large outbreaks over the next two years. Examples, such as the church outbreak in Korea, which reached over 4000 cases in just over two weeks, show how COVID-19 outbreaks can expand very quickly. However even large outbreaks can be brought under control without lockdowns if the public health response is ready and adequate. The capacity of the 12 Public Health Units (PHUs) in New Zealand is the primary factor limiting New Zealand’s ability to scale up its case management and contact tracing response to Covid-19. In March the workload of PHUs exceeded their capacity to conduct rapid contact tracing on occasion, even though case numbers were less than 100 per day. Expansion of the Public Health Unit workforce is an urgent need. The ‘National close contact service’ (NCCS) hub has been operational since 24 March. The NCCS was established in the Ministry of Health, together with a technology solution (NCTS), to perform contact tracing at times of high demand for PHUs. It is a scalable initiative underpinned by high quality technology. It is currently used by PHUs in a narrow set of circumstances. With better triage of referrals and protocols this could be expanded further. There are also difficulties in finding contacts that need to continue to be addressed. The NCCS is an impressive service especially considering it has been established in just weeks. However it is not a suitable nor desirable system for managing all contacts. The NCCS also has limited use in certain important situations, such as in the event of a large complex cluster or specific scenarios that require intense involvement of Medical Officers of Health. At the present time the only centrally visible performance indicators relate to the completion of tracing for contacts referred to the NCCS. However this does not capture the upstream events that impact the timeliness of contact tracing, like case referal processes and testing times. Nor does it capture contact tracing activity in PHUs. Measuring performance indicators to drive improvement is an urgent priority. This report proposes a set of indicators for this purpose. At the time of writing the Ministry of Health and local developers are building a smartphone app to assist with contact tracing. As it is not yet completed and a number of key aspects are under consideration, it cannot be meaningfully evaluated. Near instantaneous notification of contacts following case diagnosis is promising from a public health perspective, but other elements of the process of case assessment, testing and notification will still need to be optimised. High levels of uptake will also be required to achieve impact.

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Recommendations

1. The Ministry of Health should expand the capacity of Public Health Units (PHUs) to isolate Covid-19 cases and trace their contacts three to four fold for as long as Covid-19 remains a public health threat. Some of this additional capacity should include contact tracing teams that can move from one PHU to another according to need.

2. The Ministry of Health should develop a Covid-19 outbreak preparedness plan that

includes how to rapidly scale case identification and contact tracing and regain control. The plan should specify the task-shifting arrangements between PHUs and NCCS and any additional resource required to deal with up to 1000 cases per day while maintaining high performance.

3. The Ministry of Health should develop a system that monitors the case-isolation and

contact tracing process from end-to-end in the NCCS and PHUs. Recommended key performance indicators are listed in the appendix. Of these 17 indicators, 3 are critical, 3 are urgent, 10 are high priority and 1 is moderate priority. Ability to measure these indicators in real-time should be proven.

4. The NCCS and its providers must ensure close contacts in home quarantine are

contacted every day to monitor for adherence to isolation and to assess for the development of symptoms.

5. The NCCS and Medical Officers of Health should collaborate to better define referral protocols and triage systems, especially with respect to more complex or high-risk contacts.

6. The Ministry of Health should give PHUs access to the NCTS in order to retain visibility of contacts traced by the NCCS.

7. The Ministry of Health should engage with PHUs to determine if the NCTS could be suitable, with modification, as a single national contact information system.

8. The Ministry of Health should rapidly complete development of a smartphone app to assist contact tracing and pilot it in New Zealand. Evaluation of the app should include assessing the proportion of contacts identified by the app who develop covid-19, as well as other relevant parameters in the appendix.


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Introduction On 9 April 2020 I met with Ministry of Health Officials and National Close Contact Service workers and interviewed Medical Officers of Health by telephone. This report summarises my findings and makes recommendations for improvements to contact tracing to control Covid-19 in New Zealand.

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Contact tracing and Covid-19 Contact tracing is the identification and isolation of people who have been exposed to an infectious case, to prevent onwards transmission from the contact to others. The contact tracing system is the final part of a process that begins with someone who is ill with Covid-19, called an index case. The index case becomes ill and infectious, is assessed and tested, isolated and if they test positive their close contacts are traced and quarantined. The contacts of probable cases are also traced and quarantined. Contact tracing is a key preentive measure for covid-19 and is recommended by the World Health Organization (1). Ideally, contact tracing promotes good clinical management of the contact who is at risk of developing Covid-19 and who might need testing and medical care, as well preventing further disease transmission. Contact tracing is a well-established public health process that is routinely performed in public health units (PHUs) in New Zealand. In practice PHUs are often simultaneously managing index cases and their contacts in an integrated way, as they will usually share households, workplaces or social networks. This case-identification and contact tracing system has been a key component of successful control of Covid-19 in countries like Singapore, where contact tracing led to detection of more than half of Covid-19 patients (2). Transmission models show Covid-19 outbreaks could be controlled through this system provided tracing is fast enough (3). Indeed, rapid case contact management, when used with other basic public health measures, has over 90% efficacy against Covid-19 disease at a population level (4), which makes it as effective as any vaccine that might be developed. Specific characteristics of Covid-19 make contact tracing more effective than for influenza. Firstly the time from a person being exposed to Covid-19 to developing illness is longer (5-6 days) meaning there is time for contact tracing to occur. Secondly, it appears easier to identify Covid-19 cases who transmit the infection, as unlike influenza, there is as yet no evidence that asymptomatic cases transmit the disease (5). This means contact tracing is a important activity to achieve elimination or ‘stamp out’ covid-19 when case numbers are low. It also means contact tracing and other public health measures can control outbreaks, as has been demonstrated in China(6) and South Korea. This ability to reverse outbreaks through public health measures is has led the World Health Organization Director General to characterise plans to abandon or relax public health measures in the face of an outbreak as “wrong and dangerous” (7). In other words our contact tracing system needs to be suitable for moderate case numbers or clusters as well as outbreaks.

Description of the current system New Zealand’s communicable disease control system is highly devolved with 12 Public Health Units (PHUs) taking responsibility for case and contact management as well as the monitoring and evaluation of this work. PHUs are staffed by public health nurses, health


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protection officers and Medical Officers of Health who are public health medicine specialists experienced in communicable diseases control. Their routine work includes contact tracing for illnesses like tuberculosis, and during outbreaks of diseases like measles and mumps. The type of information system used for outbreaks varies across different PHUs and ranges from basic excel templates through to purpose-built clinical systems. In February and early March 2020, PHU staff were involved in aspects of border control as well as case management and contact tracing to control Covid-19. Many cases were returned travellers who had taken domestic flights, meaning the contact tracing workload was extremely high. As case numbers rose in March it became apparent that the workload would exceed the capacity of many PHUs. A hub, called the ‘National Close Contact Service’ (NCCS) was established in the Ministry of Health to coordinate centralised contact tracing. In this new model PHUs continue to receive notifications of new confirmed or probable cases from laboratories and clinicians. PHUs experiencing heavy workloads can choose to divert parts of the workflow to the NCCS. PHUs inform the case of their result, arrange their home-isolation and identify close contacts. Close contacts who live with the index case are managed by the PHU. Other contacts can be transferred to the NCCS for tracing. These lists of close contacts, which take various forms, are forwarded to the NCCS either via entry into REDCap (an existing web-based database used by some Public Health Units), secure file transfer, or email. The NCCS has developed a ‘finding service’ that seeks contact information from various health and other government datasets. NCCS staff call close contacts and advise they are contacts of a Covid-19 case and obtain the contacts’ agreement to quarantine (commonly called self isolation). The NCCS started operations using manual processes on 24 March 2020. A national contact tracing technology solution (NCTS) was developed, piloted on the 27 March and used to process all calls from 6 April. This cloud-based platform repurposes case management software designed for the National Screening Unit, called the National Screening Solution. The platform stores case and contact details linked by exposure events, and supports contact management. It provides links to existing health information sources, primarily for sourcing contact details and the unique identifier from the National Health Index. Training in use of the new system for the contact tracing process was completed for all 200 NCCS users on 6 April. The NCCS call centre is staffed by workers from a variety of professional backgrounds trained in the use of standardised scripts to guide their conversations. The call centre staff provide the close contact with self isolation advice and complete a health and welfare check. Clinical supervision is available on site by experienced Registered Nurses who can also escalate clinical questions to Public Health Medicine Physicians in the Ministry of Health. Contacts with more complex health questions are advised to contact their primary care provider for advice. Telephone translation services are also available. Following a call from the NCCS the person’s information is referred to Healthline for follow up calls, on day seven and day 14 of the isolation period. Healthline checks on the people self-isolation and their health and wellbeing. They will place additional calls if there are reasons for concern. This differs from the standard practice in PHUs, which is daily calls or sometimes text

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messages in order to ensure both adherence to quarantine or the early testing and confirmation of Covid-19 in the contact. Initially, the timeliness of the process was poor. For, example between 2 and 8 April the average time from referral to instructing a contact to isolate was 2.3 days. However this likely reflected the staff training and software changes that were occurring at the time. At the time of my audit the main remaining quality concern was that only 60% of contacts could be easily reached by phone, either because of incorrect contact details or because people choose not to answer calls from an unidentified number. Linkages between the National Health Index and other health datasets were being established to address the first problem. Planned improvements include changes to have outbound calls show a local number as the caller, rather than the current mix of four digit numbers. If the person attempts to return the missed call an explanatory text message will be sent, and by the end of April, missed outbound calls will soon be followed by a text message. The Medical Officers of Health I interviewed were broadly supportive of the concept of a ‘hub’ and agreed the NCCS could be an important part of measures to deal with the intense workload they faced in the last half of March. However, they were cautious about diverting contact tracing to the NCCS in many situations, because once they did they lost visibility of the outcome for the contact. The types of situations where that were felt to be best managed at the PHU level included:

• contacts who themselves have lots of contacts (currently these are mostly essential workers), because if the contact developed Covid-19 a new larger contact investigation could be required.

• medically complex people including rest-home residents who cannot not be adequately assessed by a call centre.

• transmission in institutional settings such as aged residential care or schools requires a high level of stakeholder engagement by a local public health official who is across all aspects of the situation.

For a greater proportion of contact tracing to be diverted to the NCCS, Medical Officers of Health would need to have access to the NCTS to be confident that the contact is traced in a timely way. This is particularly important for cluster management as otherwise second or third generation spread can be missed. Clusters that spread across multiple PHUs would also be visible. PHUs would also need to be confident that the frequency of follow up was appropriate for higher risk contacts. These areas need to be discussed further between PHUs and NCCS and appropriate triage processes and protocols refined. The underlying technology (NCTS) will also enable delegation of a case to the NCCS but this process will need to be very carefully defined, as cases need clinical care and are the highest risk group with respect to transmission. At the time of my audit the NCCS was working to establish clinical governance structure and an equity plan.


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System capacity and ability to scale PHUs are indispensable for the public health response to Covid-19. As described above, only portions of their workload can be safely transferred to the NCCS even with better protocols guiding this process. When New Zealand moved to alert level 4 on 25 March, many PHUs were at or beyond their capacity to manage cases and contacts, even with increasing support from the newly established NCCS. During that week, nationwide daily case numbers ranged from 70-86. Some PHUs have since expanded their contact tracing workforce on a temporary basis – drawing on staff normally involved in vaccination and school programmes – but this is unlikely to be sustainable once routine public health work recommences when the level 4 alert is lifted. Even these temporary increases are insufficient for the likely future workload. The capacity of PHUs is the primary factor limiting New Zealand’s ability to scale up its case management and contact tracing response to Covid-19. The NCCS model and its underlying technology is designed for scaling up and has had some experience of moderately high volumes. On 1 April, 701 contacts were traced by the NCCS. A suitable flexible workforce is being sought for the coming months. This service will be an important component of a scalable system that can be accessed by PHUs on an as-and-when needed basis. Even if the public health response to Covid-19 is improved through better surveillance and quarantine of returned travelers, the risk of further transmission remains, especially when level 4 restrictions are lifted. It is highly likely that there will be multiple instances of community transmission needing case management and contact tracing at intervals and across the country for the next year and beyond. To avoid regular nationwide returns to level 4 restrictions, PHU capacity must be increased. PHUs need the capacity to confidently manage cases and clusters through a combination of case isolation, contact tracing and potentially targeted restrictions on movement. If cases can be quickly identified and isolated and contacts quickly notified and quarantined then we have the potential to slow or stop transmission without widespread social disruption. There is also a threat of a large outbreak, as experienced in many other countries even those with strong public health systems. For example, the Shincheonji church outbreak in Korea in late February/early March rose to over 4482 cases in less than 3 weeks (8). Such situations pose a challenge for planning because exponentially increasing demand will need to be met in a short period of time. Case isolation and contact tracing remain effective against Covid-19 even during large outbreaks. Therefore as a matter of preparedness there must be a plan to rapidly scale PHU and NCCS capacity to manage up to 1000 new cases a day if needed, while maintaining the essential performance quality to minimise the chances of transmission beyond identified case contacts.

Smart phone contact tracing technology The primary way in which smartphone technology could support contact tracing is through Bluetooth detection of close contact between people’s smartphones and, if one is later found to be a case, instantaneously notifing contacts of their exposure and the need to self-isolate. There is also the potential to use QR-codes to ‘check in’ to high traffic settings like

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public transport or cafes. This latter function has received less attention but seems particularly important as many clusters appear to arise from transmission in closed crowded environments (9,10). Together, these features could identify contacts that would be missed by manual methods due to poor recall or anonymous contacts in a crowded venue. The time from case diagnosis to contact isolation could also be reduced. At the time of writing the Ministry of Health and local developers are building a smartphone app to assist with contact tracing. As it is not yet completed and a number of key aspects are under consideration, it cannot be meaningfully evaluated as part of this audit. However, it is possible to comment on some aspects of the public health impact of whatever product is developed. First, it needs to be available quickly, piloted and continuously improved. Second, potential impact will not be realised unless it is acceptable to a large proportion of the population and enjoys high uptake. Less than a fifth of the Singaporean population downloaded the tracetogether app in ten days, which, assuming random mixing, means only 1 in 25 exposures will be captured by the app and public health impact will be negligible. Third, an app will also only produce incremental improvement in the time to isolate contacts as many other steps are involved and need to be managed, as described below. Fourth, an app cannot replace the option to interact with a real person as many contacts will develop illness, have welfare needs, or face issues with accessibility. The monitoring and evaluation for a contact tracing app needs to consider the same parameters as the system as a whole, detailed below. In particular, the proportion of contacts identified by the app who develop illness should be closely followed, in case the app identifies too many low risk people and adjustments are necessary.

Reporting requirements An effective high-quality contact tracing system for Covid-19 will have the following characteristics:

• Scalable – able to respond to exponential growth in case numbers • Fast – contacts should be placed in isolation quickly. • Effective – contacts will adhere to the self-isolation direction and onwards

transmission from contacts will be rare • Equitable – high performance across age and ethnicity • Acceptable – to contacts and PHUs

A monitoring system is required to ensure the contact tracing system achieves these characteristics, and if not corrective action is taken quickly (2). A strength of the NCTS is that it allows tracking of the timeliness and completeness of contact finding and tracing (from the time of referral to the NCCS). However, the crucial measurement for contact tracing success is the time from case symptom onset to contact isolation. Data on this measurement was not available during my audit because the current monitoring system will not provide visibility of the upstream events relating to case management. The time taken to be assessed clinically, tested and notified of results should be considered components of


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a single system, and measured and managed accordingly. This will require information systems that make some clinical, laboratory and PHU processes visible at a single point within the Ministry of Health. Contacts traced through PHUs, with their various different contact information management systems, will also need to be captured. The NCTS links case and contact data and has excellent reporting functions. Extending use of the NCTS to PHUs, with appropriate support for implementation and adjustments, would offer a high quality data system for improving performance. A proposed set of reporting requirements is included as an appendix to this report. The target specified for time from index case symptom onset to isolation is based on two recent modeling reports (3,11). This is likely to need to be revised as more becomes known about the incubation period and by investigating instances of transmission from close contacts to third persons that occur in New Zealand.

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References 1. World Health Organization. Considerations in the investigation of cases and clusters

of COVID-19: interim guidance, 13 March 2020. World Health Organization; 2020. 2. Ng Y, Li Z, Chua YX, Chaw WL, Zhao Z, Er B, et al. Evaluation of the Effectiveness of

Surveillance and Containment Measures for the First 100 Patients with COVID-19 in Singapore - January 2- February 29, 2020. Morbity and Mortality Weekly Reports. 2020;69(11):307–11.

3. Hellewell J, Abbott S, Gimma A, Bosse NI, Jarvis CI, Russell TW, et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. Lancet Global Health. 2020;8(4):e488–96.

4. Wang C, Liu L, Hao X, Guo H, Wang Q, Huang J, et al. Evolving Epidemiology and Impact of Non-pharmaceutical Interventions on the Outbreak of Coronavirus Disease 2019 in Wuhan, China. medRxiv. [preprint, not peer reviewed] 2020; doi: /10.1101/2020.03.03.20030593

5. World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report – 73 [Internet]. World Health Organization. 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019

6. The WHO-China Joint Mission on Coronavirus Disease 2019. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) [Internet]. 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

7. Editorial. COVID-19: what science advisers must do now. Nature. 2020;579:319–20. Available from: www.nature.com/articles/d41586-020-00772-4

8. Shim E, Tariq A, Choi W, Lee Y, Chowell G. Transmission potential and severity of COVID-19 in South Korea. International Journal of Infectious Diseases. 2020;93:339–44. Available from: https://doi.org/10.1016/j.ijid.2020.03.031

9. Frieden TR, Lee CT. Identifying and Interrupting Superspreading Events—Implications for Control of Severe Acute Respiratory Syndrome Coronavirus 2. Emerging Infectious Diseases Journal. 2020;26(6). Available from: https://wwwnc.cdc.gov/eid/article/26/6/20-0495_article

10. Nishura H, Oshitani H, Kobayashi T, Saito T, Sunagawa T, Matsui T, Wakita T SM. Closed environments facilitate secondary transmission of coronavirus disease 2019 [preprint, not peer reivewed]. 2020 Available from: https://www.medrxiv.org/content/10.1101/2020.02.28.20029272v1.full.pdf

11. Ferretti L, Wymant C, Kendall M, Zhao L, Nurtay A, Abeler-Dörner L, et al. Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing. Science. 2020;6936:1–13.


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Appendix. Recommended reporting system for Covid-19 contact tracing

Reporting requirement Proposed performance indicator Interpretation Remedial action if target not met Priority System capacity – number of cases able to have contact tracing completed/ day, overall and by PHU

To scale up to 1000 cases and

their contacts within 5 days

This relates to the threshold at which

physical distancing measures are

introduced/reduced.

Expansion of PHU and NCCS capacity. Critical

Proportion of contacts quarantined within 4 days of symptom onset of index case (or exposure to index case)

>80% Too slow means onwards transmission

will have already occurred.

Improve time from case symptom

onset to sampling, sampling to PHU

notification of result and time from

contact isolation to isolation.

Critical

Time from case symptoms onset to test, stratified by ethnicity

<2 days in 80% Late detection delays case isolation

and potentially increases number of

contacts

Raise awareness to promote early

presentation

Adjustment of case definition to

emphasise early symptoms

High

Time from sampling of suspected case to test result (at least PHU notification of positives)

<24 hours in >80%

Slow turn-around times delay in case

isolation and contact tracing.

Adjustment to sample transport or

laboratory analysis processes

Urgent

Time from PHU notification of case to contact identification

<24 hours in >80% Delays case isolation and contact

tracing.

Increase PHU capacity, use of

smartphone apps, digital or manual

‘check in’ to venues

High

Time from contact identification to isolation

<24 hours in 80% Timeliness of contact tracing will

prevent onwards transmission

Increase contact tracing capacity at

PHU or NCCSor smartphone app.

Or explore additional data sources for

contact details.

Urgent

Number and distribution of close contacts per case Characteristics of contacts e.g. age, sex, ethnicity, occupation, exposure setting

No target This information required under

various physical distancing settings to

understand system capacity

N/A High

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Reporting requirement Proposed performance indicator Interpretation Remedial action if target not met Priority Proportion of suspected cases who should have a test, who have a test done (per case definition – though still elements of discretion in CD)

>90% Low rate means cases won’t be

detected or isolated.

Increased availability of testing

centres.

Audit of referral processes

High

Proportion of identified contacts who are traced, stratified by household or other contacts and ethnicity.

>80%

Failure to complete contact tracing

increases the likelihood of onwards

transmission.

Review systems for interviewing case.

Options for use of other govt datasets

Critical

Proportion of contacts with confirmed or suspected covid-19 at time of tracing

<20% High rates means testing, notification

and tracing process are too slow.




contact identificaton to isolation.

Urgent

Proportion of contacts with covid-19 over follow-up

No target but understanding this

parameter important as informs

whether contact definition is

appropriate.

If high definition of close contact

maybe too restrictive, if low definition

may not be restrictive enough.

To inform definition of close contact. Moderate

Proportion of contacts adhering to quarantine

>90%

Poor adherence risks onwards

transmission from contacts.

Improve advice on quarantine,

increase frequency of checks, use

quarantining apps.

High

Proportion of contacts of covid-19 positive contacts who become covid-19 positive

<1%

This is a sign of failed contact tracing

or isolation.




contact isolation to isolation.

High

Timeliness of reports

In real time Enables continuous quality

improvement.

Assess ability to develop real-time

reporting into national contact tracing

solution

High

Accuracy of reporting

proof of accuracy required Poor accuracy on these KPIs impairs

decision making especially with

respect to social distancing

interventions.

Audit High

Turnaround time for a change to any policy related to case contact management system

< 5 days Enables continuous quality

improvement.

High


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Reporting requirement Proposed performance indicator Interpretation Remedial action if target not met Priority Acceptability >80% of PHUs find the practice

acceptable

>80% of cases and contacts find

the practice acceptable

High

Priority: Critical>Urgent>High>Moderate

Abbreviations: PHU: Public health unit; KPI Key performance indicator; N/A: Not applicable.

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All District Health Boards

Memo

Date: 21 April 2020

To: District Health Board Chief Executives, Chief Operating Officers, Chief Medical

Officers, Directors of Nursing

From: Michelle Arrowsmith, Chair, COVID-19 National Hospital Response Group

Subject: Increasing and improving Planned Care in accordance with the National Hospital

Response Framework

For your: Action and Information

Background

District Health Boards (DHBs) have responded to the COVID-19 pandemic by undertaking

necessary preparatory work and operational reconfiguration. DHBs have balanced ongoing

service delivery with steps to plan for and treat patients with COVID-19. This has meant that the

focus has been on prioritising acute care and urgent Planned Care services, with many non-

urgent cases being deferred.

Whilst the risk of COVID-19 will continue to impact on delivery for some time, the number of new

cases are declining and there have been continued low rates of hospitalisation. Advice has been

requested on factors to consider when increasing delivery of Planned Care. The following advice

has been prepared by the Ministry of Health convened Planned Care Sector Advisory Group.

Key messages

• DHBs should seek to deliver more Planned Care activity as practical according to local

levels of COVID-19 impact and resources available (as per the National Hospital Response

Framework).

• Ongoing consideration needs to be given to how Planned Care can be provided in the

current environment to:

o limit the risk of COVID-19 infection

o ensure services are delivered according to clinical priority

o manage the risk of deterioration while waiting for services

o appropriately communicate with referrers and patients.

• Service delivery should continue with the positive adaptations that have been made to

limit patient contact, maximise the use of allied health and nursing workforce and provide

alternate methods of offering specialist advice and treatment.

• Health equity should be at the forefront of DHB responses and actively monitored.

• Private facilities are an important partner and need to be involved in capacity planning

discussions to make the best use of resources in the hospital system.

Signature ___________________________________________________ Date: 21 April 2020

Name Michelle Arrowsmith

Title Deputy Director General, DHB Performance, Support and Infrastructure

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Increasing and improving Planned Care in accordance with the National Hospital Response Framework

Advice from the Planned Care Sector Advisory Group

21 April 2020

Scope and aim

This guide is for all health care providers in New Zealand. It aims to help providers take a

balanced approach to increasing access to Planned Care, while taking account of the risks of

COVID-19 resurgence. The risk of COVID-19 means that many of the safety changes introduced

during the initial response to the pandemic will continue to be needed. More importantly, we

need to embrace and build on the exemplar innovations, speed and pragmatic attitude shown

during March and April so that we do not simply return to pre COVID-19 business-as-usual

processes. These ideas will be fostered in the coming days and weeks but for now this guide

focuses on the immediate challenges of increasing and improving Planned Care during the

transition from the initial period of preparation and reconfiguration. All changes to service

delivery should align with the COVID-19 National Hospital Response Framework and be informed

by the considerations below.

This guide is a ‘living document’ that will be reviewed and revised as the country hopefully

experiences a reducing impact of the pandemic. Whilst the risk of transmission of COVID-19

continues, it remains important to restrict physical interactions with patients to only those where

the clinical need dictates a physical interaction is necessary. This is designed to protect patients,

staff and the health system.

To safely increase Planned Care activity we need to consider a number of factors. These will vary

by site, but all need joint consideration and planning by all healthcare providers in each district

health board at local and regional level to maximise opportunities, minimise risk and deliver

appropriate care. This guide is intended to be broad enough for providers to use during National

Alert Level 3 and adapt according to their status on the National Hospital Response Framework. It

is also intended to be complimentary to speciality specific definitions of essential services at the

different national and hospital alert levels.

Māori and Pacific communities can experience disproportionate barriers to access for treatment

and care. Careful consideration needs to be undertaken to ensure that responses to the

pandemic do not contribute to poorer access to Planned Care or outcomes for these

communities. Providers should ensure that monitoring of Planned Care performance is

undertaken for Maori and Pacific patients and that vulnerable patient cohorts are pre-emptively

identified and managed.

1. Pathway development

For those conditions that are common and have predictable ‘needs’ such as diagnostic

requirements and clear treatment escalation guidelines, the development and wide


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implementation of joint Health Pathways across primary, secondary and tertiary care should be

prioritised. In particular, Planned Care should be delivered in community or primary care rather

than a visit to hospital whenever possible. This will include improving direct access of primary

care to diagnostic and allied health services. Access to all services will need to be prioritised

locally and regionally to balance capacity and demand across all providers.

2. COVID-19 prevalence

Real-time epidemiologic knowledge of COVID-19 prevalence in the DHB district or region will

continue to be important. So will the COVID-19 case volume presenting to and requiring

admission to hospital at a time when increased out-patient activity and treatment is being

considered or performed. It is advisable that you plan on available bed capacity taking into

account COVID-19 inpatient and ICU beds available for surges relative to your local prevalence

(mild to moderate COVID19 waves in most areas) and, as per previous years, likely winter

demand.

3. Waiting list review

In preparation for increased activity, waiting lists must be actively reviewed to identify any

patients where priority or treatment advice/options may have changed since the patient was

accepted by secondary care. All patients in each service must ultimately be prioritised against all

others in that service and not just against the others waiting on any one specific clinician’s list.

Similarly, review should occur across services as well as within them, to prioritise highest clinical

need. Where appropriate, re-discuss treatment options with patients and referrers as part of a)

informed choice and informed consent and b) moving care to primary and community settings

where possible. Patients that have been accepted for first specialist assessment (FSA) or

treatment cannot be removed unless it: is at their request; the assessment or treatment is no

longer needed; or the assessment or treatment is provided by an alternative means.

4. Facilities

It is imperative to: a) maintain “physical distancing” of one metre between workers b) two metres

between patients and c) minimise disruption of work and home “bubbles”. Therefore, all

providers, especially those that have been closed or operated at significantly reduced levels

during National Alert Level 4, need to review physical facilities throughout the entire pathway of

care, including clinical and non-clinical support services, to ensure distancing can be maintained.

Separating teams into two bubbles to reduce the chance of entire teams being stood down will

remain important.

It is also important to plan for the flow of patients through facilities to minimise the time patients

spend waiting in the same spaces as others and in the facility as a whole, as well as the total visits

each patient needs to make to each facility. This means scheduling of arrival times across

multiple specialities, ideally such that traditional waiting rooms are no longer needed.

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Facilities need to maintain a register of a) who is working together and b) visitors to each

department, so that contact tracing can be facilitated should any patient, visitor or staff member

subsequently be diagnosed with COVID-19.

It is also imperative that providers maintain or create the ability to a) rapidly (re)-instate physical

changes that can separate large volumes of suspect, probable or confirmed COVID patients, in

case numbers rise again and b) provide safe care to any patient with COVID-19.

In short, all providers need to balance the increase in numbers of patients with low risk of COVID-

19 with the potential rise in patients at high risk of, or with, COVID-19.

5. Virtual options

All patients for FSA and follow-up should be considered for a virtual consultation. The key

question for each clinician when assessing the need for a physical consultation should be: “For

this patient, what patient value is really added by me doing a physical consultation?” Where the

answer is nil or minimal, a virtual option should be prioritised.

6. Screening of patients (and any support person) for physical meetings

There is a need to have accurate risk stratification if a physical meeting with a patient is required.

Questions that can be used to screen patients to ensure risk is minimized are:

a) Have you been overseas in the last 14 days? Note the importance of this will likely

decrease with mandatory quarantining.

b) Have you been in contact with a confirmed or probable COVID-19 patient in the last 14

days?

c) Are you unwell and are any of the people in your household bubble unwell with fever or

acute (new) respiratory symptoms?

If the answer to ALL these questions is definitely NO then it is safe to proceed as normal with the

clinic, procedure or surgery from the ‘risk of having COVID-19’ perspective. This is however, just

a screening questionnaire and does not mean the patient should proceed immediately to

secondary care – see below.

7. New referrals vs follow-ups

All scheduling must be based on assessment of clinical urgency. The ratio of first specialist

assessment (FSA) to follow-up should also be re-assessed to balance the risk from both being

extra-ordinarily delayed. All new referrals should be triaged against clinical criteria as they would

be in non-pandemic times. Alternate models for providing advice to referrers and / or assessing

patients should be considered. Capacity to manage new referrals and follow-ups should be

optimised by making the best use of workforce such as allied health and nurse specialists to

screen, manage and assess patients as appropriate. Specialist advice and support should be

provided to primary care so that patients can be managed in primary and community settings

where possible. Where this is not possible, and capacity to manage referrals remains severely


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constrained, increased advice to patients and referrers is required, especially where the likely

waiting time is excessive.

8. Prioritising out-patient consultations

For physical or virtual review, priority must be based on an assessment of clinical need. Where

validated prioritisation tools exist, such as the National Referral Prioritisation Framework, these

should be utilised.

9. Prioritisation of Surgical and Interventional Waiting Lists

It is essential that clinical urgency is the over-riding principle guiding scheduling, however where

there is a clinically acceptable option to defer treatment at this time, there are a number of

important factors to consider. These factors need to be assessed both in terms of the patient and

the health system:

i. Patient factors

a) Co-morbidities and other factors that are identified as placing the patient at a higher risk

of death if they contract COVID-19. This includes age >70, BMI >40, co-existing

respiratory, renal and cardiac disease, diabetes, hypertension, immunosuppression and

pregnancy.

b) A reasonable expectation of needing ICU/high dependency care

c) Discharge issues including personal circumstances such as lives alone

d) Is the operation a day case procedure?

e) What is the risk of the condition requiring acute admission within a short timeframe?

f) Other time-critical issues where long term outcome will be significantly worsened by

further deferral of treatment.

g) Will the patient need authority to travel past police or community check points?

h) Air travel is still not routinely available so inter-DHB travel may need to be minimised.

ii. Health system factors

a. Bed state of hospital – including what is the policy re patients having single rooms only

vs. capacity?

b. Supply chain of consumables, especially PPE

c. ICU/HDU status

d. Managing system capacity and demand. It is imperative that cross-service, cross facility

and cross provider planning and coordination is maximised as siloed planning is

unacceptable. All waiting lists have grown and each health system must prioritise

collectively at local and regional level, including private providers, so that clinical risk is

minimised for all patients regardless of provider

e. Availability of community services such as district nursing, allied health, NGOs and others

to support patients post-discharge

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f. Any specific requirements of aged care sector facilities where a patient is expected to

reside following discharge from hospital

Where factors exist that indicate a need to re-consider the timing of a planned operation, the

presence of any of these factors in themselves does NOT mean a patient MUST be deferred.

These factors do, however, highlight the need for a “whole of system” approach to case selection

and, where sensible, to defer such cases that can be deferred whilst a heightened risk of COVID–

19 exists. As for outpatients, referrers and patients will need clear communications on the reasons

for deferral, timing expectations and interim management.

10. Use of private sector capacity and facilities

Consistency of distancing and scheduling will be vital between public and private. Case selection

for private must, in addition to those factors listed above, include consideration of any in-hospital

care other than at day-case level – in other words, is medical cover required overnight, and if so,

by whom? Note the private sector offers considerable opportunity for diagnostic tests and

procedures including radiology and endoscopy as well as surgery but where workforce is shared,

providers must collaborate to prioritise capacity.

11. Human resources

As we look to further increase Planned Care in the later months of 2020 it is important to be

aware we will likely face increased annual leave applications, perhaps altered school terms, and

the re-scheduling of specialist examinations by various colleges, all of which may significantly

impact staff availability.

Staff must not come to work if they have respiratory symptoms and must remain off work for at

least 48 hours after symptoms have resolved. Any staff with an acute respiratory infection must

seek an appropriate medical review +/- testing in line with the latest Ministry case definition to

exclude the possibility of COVID-19.

Staff that are able to work from home should continue to do so. The increased delivery of

telephone advice and virtual clinics are highly amenable to remote working arrangements.

Guidance and resources for DHB employees can be accessed on the following website -

https://tas.health.nz/employment-and-capability-building/employment-relations/dhb-covid-19-

workforce-faqs-and-resources/


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https://tas.health.nz/employment-and-capability-building/employment-relations/dhb-covid-19-workforce-faqs-and-resources/

https://tas.health.nz/employment-and-capability-building/employment-relations/dhb-covid-19-workforce-faqs-and-resources/


Version 2.0, released 21 April 2020

COVID 19 National Hospital Response Framework – The Process

• This Hospital Response Framework is designed to provide escalation levels to support facilities and hospitals to appropriately and safely

operate at each agreed Alert Level.

• The Framework provides high level, nationally consistent guidance to support your facility’s own emergency response procedures that will need

to be deployed at each Alert Level.

• The alert levels in this Framework are different to the Government’s National COVID-19 Alert Levels, which note that hospitals will

operate in line with the National Hospital Response Framework.

• Hospitals are expected to operate in line with their current Alert Levels and have systems and processes proactively in place to identify and

respond to any changes in levels (up or down) so that changes are made in a well-managed and planned manner with staff and resources

prepared and trained beforehand.

• It is expected that alert levels may change rapidly, and decisions are made locally at a hospital or facility to move status up or down.

• The Framework aims to ensure that patients remain at the centre of care by making proportionate responses to escalations and de-

escalations in the COVID-19 pandemic.

• This plan should identify Māori and other vulnerable populations and ensure health disparities do not increase as a result of the response to

the COVID-19 pandemic. DHBs must maintain rigorous oversight of waiting lists, including a comprehensive plan setting out the manner by

which the risk of patients deteriorating while waiting for assessment and treatment will be identified and managed.

• Te Tiriti o Waitangi and Equity are at the centre of each level of the Framework. Critically, DHB escalation and de-escalation will be taken in a

way that actively protects the health and wellbeing of Māori and other vulnerable population groups. This includes active surveillance and

monitoring of health outcomes, for Māori and other vulnerable groups, to ensure a proportionate and coordinated response to health need for

COVID-19 and non-COVID patients.

• DHBs should share their planning for management of Alert Levels with primary care and other providers.

• Daily EEC meetings should be the mechanism whereby Alert Levels are confirmed, and actions initiated in daily reporting.

• It is possible for different hospital facilities and/or departments within a DHB to be at different Alert Levels at any given time.

• The overall DHB Alert Level should be reported each day to the National Health Coordination Centre (NHCC) so that a national view of

escalation can be compiled. This will be via the NHCC DHB SitRep.

• A hospital should determine its Alert Level and readiness and reconfirm daily with senior clinicians, senior managers and other relevant

senior personnel as part of the local response plan. This decision should be clearly documented and evidenced.

• These criteria may evolve over time and be revised by the National Hospital Response Group, then reissued as appropriate.

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Version 2.0, released 21 April 2020

COVID-19 National Hospital Response Framework

COVID-19 Hospital

Readiness

GREEN ALERT

COVID-19 Hospital

Initial Impact

YELLOW ALERT

COVID-19 Hospital

Moderate Impact

ORANGE ALERT

COVID-19 Hospital

Severe Impact

RED ALERT

Trigger Status: No COVID-19 positive patients in your facility; Any cases in your community are managed and under control; managing service delivery as usual with only staffing and facility impact being for training & readiness purposes

• Screen for COVID-19 symptoms & travel history for any new Emergency Department attendances, pre-op sessions, planned admission, or clinic attendance

• Plan for triage physically outside the Emergency Department (or outside the hospital building)

• Plan to have a separated stream for COVID-19 suspected cases and non COVID-19 cases in Emergency Department

• Undertake regular training and exercises for management of a COVID-19 suspected case in the Emergency Department, Wards, Theatres, ICU/HDU

• Maintain PPE training for COVID-19 care in the Emergency Department, wards, theatres, ICU/HDU, outpatients, other relevant settings

• Plan for isolation of a single case & multiple cases/ cohorting

• Plan for Early Supported Discharge, aggressive discharge and step-down arrangements, including with other partners as appropriate (e.g. private, aged residential care, community providers)

• Plan for separate streams for staffing, cleaning, supplies management and catering

• Plan for management of referrals, and increased workload on booking and call centre teams

• Plan to have a COVID-19 capable theatre for acute surgery for a known or suspected positive patient

• Plan and prepare a dedicated COVID-19 ward

• Engage with alternative providers (such as private) to confirm arrangements for their assistance during higher escalation levels, and to fast-track urgent, lower complexity care procedures such as cataracts, endoscopy etc.

• Arrange for outpatient activity to move to telehealth and phone screening for virtual assessment, and MDTs to videoconference wherever possible

• Planned Care surgery, acute surgery, urgent elective and non-deferrable surgery to operate as usual, National Services to operate as usual, NTA to operate as usual

• Review patients on the waiting list (surgery, day case, other interventions) and group patients by urgency level

• Prioritise Planned Care surgery and other interventions by focusing on those with the most urgent need, and where ICU/HDU is required

Trigger Status (individual or cumulative): Multiple COVID-19 positive patients in your facility; community transmission is not well controlled; isolation capacity and ICU capacity impacted; significant staff absence, extensive staff redeployment, gaps not being covered

• Continue screening for COVID-19 symptoms and travel history as per Green Alert

• Activate plans as described in Hospital Green and Yellow Alert levels

• Work with palliative care and other providers to agree alternative end of life services for non-COVID patients.

• Provide Emergency Department services with prioritisation on high acuity medical and trauma care. Provide advice in non-contact settings where possible.

• Fully activate any agreements reached with private (or other) providers

• Acute surgery to operate as usual, with priority on trauma cases, as staffing and facilities allow

• Prioritise urgent non-deferrable Planned Care cases not requiring ICU/HDU care

• Review and manage all non-urgent high risk Planned Care surgery requiring HDU/ICU, adjusting the prioritisation threshold for surgery with Senior Clinician for non-deferrable cases

• Increase ICU/HDU capacity as needed, retaining cohorting of suspected COVID-19 and COVID-19 positive and non-positive patients, including moving non-COVID-19 ICU/HDU to theatre complex

• Implement acute ambulatory assessments or virtual/telehealth assessments for urgent, non-deferrable cases as staffing allows

• Manage outpatient referrals to ensure clinical and equity risk is understood and managed

Trigger Status (individual or cumulative): One or more COVID-19 positive patients in your facility; cases in your community are being managed; isolation capacity & ICU capacity manageable; some staff absence and some staff redeployment to support response and

manage key gaps

• Continue screening for COVID-19 symptoms and travel history as per Green Alert

• Activate plans as described in Hospital Green Alert, as appropriate

• Activate Emergency Department triaging in a physically separate setting

• Activate streaming of suspected COVID-19 or COVID -19 positive and non-positive patients as planned across Emergency Department, Wards, Theatres, ICU/HDU, and have dedicated COVID-19 capable theatre available

• Activate Early Supported Discharge, aggressive discharge and step-down arrangements, including with other partners as appropriate (e.g. private, aged residential care, community providers)

• Engage across other DHBs to appropriately discharge out of area patients back to domicile hospital or other setting (to be considered in conjunction with current Hospital Alert Level at other DHBs)

• Acute surgery, urgent elective, and non-deferrable surgery to operate as usual, with consideration given to repatriation processes if patient is non-domicile

• Start to move pre-op assessments and outpatient appointments to be undertaken virtually, or in an off-site setting as necessary

• Plan to defer non-urgent pre-assessments and non-urgent clinic patients if necessary, ensuring clinical and equity risk is managed

• Activate any outsourcing arrangements reached, and engage on options for supporting ‘cold trauma’ cases and less-complex urgent cancer surgery

• Planned Care surgery and other interventions to be prioritised based on urgency, and where ICU/HDU is not required, delivery should continue as much as possible

• Redeployment of staff as needed/available to ensure perioperative workforces are in place to run theatre, including anaesthesia, anaesthetic technicians, nursing. Scale back delivery of non-urgent Planned Care as needed.

Trigger Status (individual or cumulative): Multiple COVID-19 positive patients in your facility; community transmission uncontrolled; isolation and ICU at capacity; all available staff redeployed to critical care

• Emergency Department services limited to high acuity medical and trauma care

• Activate plans as described in Hospital Green, Yellow and Orange Alert levels

• Work with palliative care and other providers to agree alternative end of life services for non-COVID-19 patients.

• Continue acute surgery as staffing and capacity allows, prioritising non-deferrable, life-saving surgery

• Cancel all non-acute surgery

• Activate additional streaming, including non-COVID-19 ICU/HDU to theatre complex, or private provider if agreement reached

• As a last resort, move ventilated COVID-19 patients to repurposed ICU/HDU theatre complex for overflow; aim is to not impact on ability to meet non-deferrable, life-saving acute surgery

• Continue with acute ambulatory assessments or virtual/telehealth assessments for urgent, non-deferrable cases only, as staffing allows

• Only accept urgent outpatient referrals, but ensure clinical risk is understood and managed

•


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Title: E-BIKES

Report to: Board


Summary:

We have sought guidance from the DHB sector and legal input to develop our approach to assist employees who wish to purchase an E-Bike. In particular, our approach has been tested with Auckland DHB and Capital Coast DHB and is consistent with the policy implemented at those DHBs.

Southern DHB is committed to enhancing the health and wellbeing of our employees. We are also committed to reducing the impact of our footprint with respect to climate change. E-bikes provide an opportunity to achieve both of these desired outcomes.

While we recognise that E-Bikes may remove some of the commonly known barriers to cycling such as hilly terrain, distance and wind, there remains the risk of cycling (bear in mind that ACC claims have risen from $57,000 to $1,200,000 over five years). It is important that E-Bike riders understand the transition from a traditional bike to an E-Bike and adapt their riding to their ability and the environment in which they are riding.

Southern DHB is precluded under legislation from providing any employee loan / salary advance to employees.

However, Southern DHB is committed to assist with access to bulk discounts on E-Bikes through reputable retailers. To that end, the Procurement team are investigating retailers across the Southern DHB district willing to provide discounts for employees while providing good quality and legally compliant E-Bikes with warranties and servicing.

As part of this process, we will coordinate on behalf of our employees that the preferred retailers provide “have a go” sessions with the E-bikes. This would ensure that employees get a sense of how the E-Bikes work and enable a test of the E-Bike and allow time to understand the safety of the E-Bike.

This assistance to those employees who wish to purchase an E-Bike with their selection of E-Bike shows our commitment to reducing carbon emissions and supporting our employees to make affordable, healthy and environmentally friendly transport choices, which reduce pressure on our transport network.

Our expectation is that we will have three preferred suppliers in place by 30 June 2020. Thereafter our employees will have the opportunity to test E-Bikes in a safe environment across the District.

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Southern DHB Board Meeting - E-Bikes

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Financial: Yes

Workforce: Health and wellbeing of employees

Other: Carbon emissions




RECOMMENDATIONS:

ß That the Board note and approve the Procurement team process to source suppliers of discounted E-Bikes for employees of Southern DHB.

ß That the Board acknowledge that legislation prohibits the Southern DHB providing any loan/advance to an employee for the purchase of an E-Bike and therefore any such arrangement is not adopted.

Southern DHB Board Meeting - E-Bikes

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Closed Session:

RESOLUTION:

That the Board move into committee to consider the agenda items listed below.

The general subject of each matter to be considered while the public is excluded, the reason for passing this resolution in relation to each matter, and the specific grounds under section 32, Schedule 3 of the NZ Public Health and Disability Act (NZPHDA) 2000*for the passing of this resolution are as follows.



Minutes of Previous Public Excluded Meeting



Public Excluded Advisory Committee Minutesa) Finance, Audit & Risk

Committee, 29 April 2020



Health Roundtable Executive Briefings

Information provided in confidence.

Section 9(2)(ba) of the Official Information Act.

Elective Services Outsourcing

To allow negotiations to be carried on without prejudice or disadvantage


Short Term CT Proposal Commercial sensitivity and to allow negotiations to be carried on without prejudice or disadvantage


Contract Approvalsa) Strategy, Primary &

Communityb) Holidays Act 2003

Remediation



New Dunedin Hospital Commercial sensitivity and to allow activities and negotiations to be carried on without prejudice or disadvantage


Annual Plan 2020/21 Plan is subject to Ministerial approval

Section 9(2)(f) of the Official Information Act.

*S 32(a), Schedule 3, of the NZ Public Health and Disability Act 2000, allows the Board to exclude the public if the public conduct of this part of the meeting would be likely to result in the disclosure of information for which good reason for withholding exists under sections 9(2)(a), 9(2)(f), 9(2)(i), 9(2)(j) of the Official Information Act 1982, that is withholding the information is necessary to: protect the privacy of natural persons; maintain the constitutional conventions which protect the confidentiality of advice tendered by Ministers of the Crown and officials; to enable a Minister of the Crown or any Department or organisation holding the information to carry on, without prejudice or disadvantage, commercial activities and negotiations.

The Board may also exclude the public if disclosure of information is contrary to a specified enactment or constitute contempt of court or the House of Representatives, is to consider a recommendation from an Ombudsman, communication from the Privacy Commissioner, or to enable the Board to deliberate in private on whether any of the above grounds are established.

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southern dhb board meeting - agenda · 2020-05-01 · 7.1.1 verbal report of 29 april 2020 meeting...

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