Part 2: Are district health boards planning, funding, and delivering services together?

Regional services planning in the health sector.

In this Part, we discuss our findings about whether regional services planning is, as intended, increasing collaborative working between the organisations, networks, and workstreams that make up public health and disability services. We discuss:

Although the extent of collaborative working had increased, it was not yet business as usual in some regional activities. Those we spoke to about what drives collaborative working cited factors such as the strength and duration of previous relationships, commitment and dedication, trust, financial incentives, good leadership – and sometimes crisis. Some saw regional services planning requirements as the "glue to make things stick". Others viewed it as an administrative procedure not linked to accountabilities.

Planning together

The Review Group envisaged that some long-term planning would inform whether services should be provided at local, sub-regional, or regional level. Although it is not a specific requirement of regional services plans, we expected to see evidence of those decisions having been made by year three, together with a supporting narrative of the rationale and the benefits to be gained.

We expected that reviews of models of care would be well under way as a forerunner to changes. Canterbury DHB is well advanced in this, with more than 480 care and clinical pathways set up in the Canterbury sub-region. The Midland region has a "map of medicine" project under way to prepare clinical pathways starting in primary care. All regions were taking part in this sort of activity to some extent.

We visited the Northern region and the South Island region and reviewed the regional services plans of all four regions. All four regions had changed how they made decisions to take account of regional services planning. Figure 2 describes the approach taken by the South Island region.

Figure 2
South Island Alliance model of governance

In the South Island, an alliance framework has been adopted to put regional services planning into effect. The region chose the alliance approach because it had learned that the approach could enable complex services to be put into effect quickly without having to disrupt organisational structures. The South Island DHBs felt that such a framework was needed to work out where regional priorities should be placed, because the South Island DHBs are dispersed and are at different stages of integration.

The South Island Alliance is governed by an Alliance Board and is led by a Leadership Team. A set of core principles based on "best for patients; best for system" guides the Alliance. The Alliance's Strategic Planning and Integration Team provides a strategic and integrated view to the Alliance's approach to putting regional planning into effect. Clinical leadership is represented in the Service Level Alliances, or workstreams. The Service Level Alliances support the planning and funding functions of the DHBs. The Programme Office, which is hosted by Canterbury DHB, provides support for regional activities. All DHBs contribute their skills, expertise, and resources as required. The Alliance arrangement has allowed the South Island DHBs to have collective ownership of risks and outcomes, joint decision-making, and an open approach to sharing information. The region reports that this has led to more trust among the region's DHBs.

In 2012, the Alliance evaluated how effective it was. The results show that, although most agree on the need for a common and complementary capacity for the region, roles and responsibilities could be better understood. It is important that the region prepares an overall outcomes framework to ensure that the Alliance is meeting its purpose. We understand that this work is under way.

We found the speed of change to be quicker where:

  • There were already positive and trusting relationships. Sometimes, this was the result of having worked together in the past to solve a shared problem. Where this had happened, people reported that the region spoke with "one voice".
  • Relationships were relaxed and more informal – for example, people picking up the phone rather than setting up a meeting, and chief executives having a pragmatic leadership style.
  • The DHBs in a region are geographically close to one another - it was easier to discuss collaborating on services in a large metropolitan area than in a region with two major centres of population.
  • Historical levels of capital investment in buildings had been high. In areas with buildings in poor condition, there was a tendency to be more parochial. This was because there was a greater pressure to put the local population first.
  • There was a clear understanding, based on sound evidence from clinicians, of where it made sense to collaborate regionally, sub-regionally, or locally.
  • There was clear ownership and leadership of the regional services plan within the region.
  • There was active clinical leadership from chief medical officers and other clinicians on regional governance groups and at the head of service and clinical networks.
  • Regional chairpersons, chief executives, and chief financial officers met regularly, gave time to strategic and operational thinking, and had ways to resolve disputes. Face-to-face meetings were easier in the metropolitan areas than elsewhere.

Some of the problems we found were:

  • Planning took place in isolation – with people not talking to one another about connections between plans. For example, in one region, the cancer-services network was not taking part in discussions about information systems and the network's activities were poorly represented in the draft regional services plan.
  • Regional services planning was not being considered as "business as usual". Evidence of this was that some elements of regional plans were little more than an aggregation of items from individual DHB plans. Regions told us that incentives to plan together were sometimes not strong enough.
  • Meetings of decision-makers were rare or irregular.
  • It was rare for primary health organisations to be involved in regional services planning discussions, and even more so for private sector providers. This can mean that the regional services plans are too focused on hospital activity, when new models of care need a wider variety of settings and providers.
  • There was a lack of measurable targets and some long time frames for action.

Allocating resources to deliver regional services

We expected that DHBs would identify areas of joint investment in services. Good progress had been made in administrative, planning, and other back-office functions. As we noted in paragraph 1.8, the Review Group considered how to reduce back-office costs to increase spending on frontline care. We found that:

  • all regions have put resources into regional support arrangements for joint planning, monitoring, and information systems;
  • one DHB was sharing with other DHBs a patient administration system that it had paid for;
  • one region centralised buying to replace expensive equipment throughout the region, and the region's DHBs were jointly investing in radiology services;
  • three regions have each agreed to pool their information technology capacity and management arrangements;
  • regional investment in information technology is happening, in line with NHITB priority programmes such as patient administration systems, imaging, and e-referrals; and
  • DHBs are all required to use some national services and contracts led by HBL.

To test whether the benefits were being redirected to the front line, we asked the regional offices for details of their costs, compared to the previous arrangements, but net of any savings arising from regional services planning. We were told that this information was not available, so we were unable to assess whether the intended effects were being realised.

We saw limited evidence of DHBs and others funding services together. Some alternatives to pooling money were in place, such as sharing staff or initiating service-level agreements between DHBs or between DHBs and other agencies (where a service is provided in return for a payment).

A successful initiative was the pooling of money for bariatric (weight loss) surgery. Each region had pooled the money available, and had devised jointly agreed criteria to ensure equity of access.

The most significant barriers to funding together were expressed as:

  • DHBs prioritise spending on their local population. They are not always able to meet local demand and had to balance the books – so regional funding would not be a priority, nor would paying for a regional facility from just one host DHB.
  • Outside the metropolitan areas, moving people (and their caregivers) or clinical teams around is more difficult, and conflicts with initiatives for care to be more convenient.
  • Inter-district flows are the default way that money follows patients around the health system, irrespective of where the patients are treated. However, inter-district flows can be a barrier in several ways. For example, a DHB in financial deficit may want to retain patients (as a way of keeping money assigned to a patient within their DHB). This can undermine regional approaches to elective surgery, which aim to ensure that hospital operating theatres throughout the region are used efficiently to treat more people sooner.

Changes in how services are delivered because of regional services planning

We looked at two aspects of service delivery – access and patient flows.


We expected to see that work was taking place to agree regional thresholds for patients' access to services. We expected this agreement to be followed by a common set of clinical protocols. Having the agreed thresholds and protocols would make it easier for patients to travel between points in the health system, irrespective of where they live in a region. The thresholds and protocols are important for ensuring equitable access to health care.

We saw clear evidence of regional approaches to cancer services where regional planning was already routine before the introduction of regional services planning (see Part 4).

Apart from cancer services, those we spoke to provided limited evidence of using or preparing regional thresholds and protocols. Canterbury and West Coast DHBs are working closely on a model of care that increases sharing of resources. The Central region is working on a single service for orthopaedics. This could mean one sub-regional or regional waiting list, or that patients can travel to other hospitals, to get a better match between resources and demand. The South Island region is beginning to draw up service agreements through its alliance framework.

We saw a few other examples of regional access during our fieldwork and during consultation about this report. Some of the basic building blocks needed to support regional service delivery have been slow to develop.

However, some projects under way will help to support better access (see paragraph 7.30). As pathways and thresholds become more standardised throughout regions, it should be easier to build good systems to manage patient access and information.

Patient flows

We looked into the pattern of inter-district flows of patients.

Regional services planning envisages that people go to large tertiary hospitals for complex care and to smaller district hospitals for less complex needs. The aim of this approach is two-fold:

  • to make district hospitals more sustainable by carrying out uncomplicated, planned surgery – such as hernia repairs – for patients who live outside the district as well as local people; and
  • to help ensure that medical and surgical staff at large hospitals preserve their specialist competencies – by making sure that staff see enough patients with complex needs.

Because funding follows the patient to where they receive treatment, this should remove one of the barriers to working regionally. In our view, if nothing had changed in the inter-district flow data, it would suggest regional services planning was having little, if any, effect.

We expected that, after putting regional services plans into effect, the Ministry would track the proportion of patients accessing regional resources outside their home DHB.

We analysed some data about inter-district flows, which indicated that patient flows to tertiary hospitals were increasing, but flows away from them were not. This information was not easily accessible, so we concluded that the Ministry was not tracking regional flows.

However, we found out that the Ministry was comprehensively monitoring, and doing some good quality analysis, of patient activity to ensure that DHBs met the national target for elective surgery. This information contains details of patient flows within, and outside, each region. The Ministry uses this information to work out whether regionally agreed targets for the number of operations are being delivered. It would seem to be relatively straightforward to modify this analysis to include a section on how patient flows change over time. There is further potential to enrich this picture, by capturing information about patient flows that do not depend on the default way of moving money around – for example, by monitoring new models of care such as telehealth and community outreach clinics.

In Part 3 and Part 4, we look at the specific effects of regional services planning on two workstreams – capital investment and cancer treatment.

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