LET’S BEAT DIABETES - Counties Manukau Health · LET’S BEAT DIABETES A Five Year Plan to Prevent and Manage Type 2 Diabetes in Counties Manukau FINAL PLAN Endorsed by the …

LET’S BEAT DIABETES

A Five Year Plan to Prevent and Manage Type 2 Diabetes

in Counties Manukau

FINAL PLANEndorsed by the Board of Counties Manukau District Health Board

02 February 2005

Table of Contents

Part I Introduction & Overview ________________________________________ 1

Executive Summary______________________________________________________ 2

This Document __________________________________________________________ 3

A Letter From 2020 ______________________________________________________ 4

The Planning Process_____________________________________________________ 6

Diabetes in Counties Manukau____________________________________________ 10

Whole Society, Whole Life Course, Whole Family Approach___________________ 13

Part II Let’s Beat Diabetes ___________________________________________ 15

Let’s Beat Diabetes _____________________________________________________ 16

1. Supporting Community Leadership and Action ___________________________ 21

2. Promoting Behaviour Change Through Social Marketing ___________________ 30

3. Changing Urban Design to Support Healthy, Active Lifestyles _______________ 33

4. Supporting a Healthy Environment Through a Food Industry Accord ________ 37

5. Strengthening Health Promotion Co-ordination and Activity ________________ 40

6. Enhancing Well Child Services to Reduce Childhood Obesity________________ 45

7. Developing a Schools Accord to Ensure Children Are ‘Fit, Healthy and Ready to Learn’ ________________________________________________________________ 49

8. Supporting Primary Care-Based Prevention and Early Intervention __________ 55

9. Enabling Vulnerable Families to Make Healthy Choices ____________________ 59

10. Improving Service Integration and Care for Advanced Disease _____________ 64

Enablers ______________________________________________________________ 70

Part III Implementation ______________________________________________ 75

Executive Summary_____________________________________________________ 76

Scoping the task ________________________________________________________ 77

Implementation structure and process _____________________________________ 80

References_____________________________________________________________ 91

Please note: the diabetes referred to in this document is Type 2 Diabetes.

Part I

Introduction & Overview

1 FINAL PLAN 02 February 2005

Executive Summary

Counties Manukau is experiencing a growing epidemic of Type 2 Diabetes (“diabetes”).Currently there are more than 12,000 people in Counties Manukau diagnosed withdiabetes. Almost double this number remains undiagnosed. It is estimated that thenumber of people with diabetes will more than double over the next 20 years, given population growth, the ethnic, youthful and generally low socio-economic make up ofour population.

A major change to the health sector and our broader society is required to stop thediabetes epidemic.

Let’s Beat Diabetes, commissioned by Counties Manukau District Health Board(CMDHB), is a five year plan aimed at long-term structural changes to prevent and/ordelay the onset of diabetes, slow disease progression, and increase the quality of lifefor people with diabetes. It recognises the significant activity that already exists toprevent and mange diabetes, and creates a long-term vision to align existing activity and a context for new investment, based on evidence and best practice.

Let’s Beat Diabetes is a district-owned plan developed by Counties Manukau for Counties Manukau.

After extensive consultation, Ten Action Areas have been defined:

1. Supporting Community Leadership and Action

2. Promoting Behaviour Change Through Social Marketing

3. Changing Urban Design to Support Healthy, Active Lifestyles

4. Supporting a Healthy Environment Through a Food Industry Accord

5. Strengthening Health Promotion Co-ordination and Activity

6. Enhancing Well Child Services to Reduce Childhood Obesity

7. Developing a Schools Accord to Ensure Children are ‘Fit, Healthy and Ready toLearn’

8. Supporting Primary Care-based Prevention and Early Intervention

9. Enabling Vulnerable Families to Make Healthy Choices

10. Improving Service Integration and Care for Advanced Disease

The plan aligns with Government policy directions and international best practice. Strategies that focus on improved Maori and Pacific outcomes are woven through allTen Action Areas.

The plan will be supported with committed funds and a governance structure that reflects the broad societal support required for successful implementation.

The plan will be presented to the Board of CMDHB and other key stakeholder representative groups in early 2005 for endorsement and sustained funding. Developmental work and preparations will continue early 2005, with full implementationfrom 01 July 2005.


This Document

This document provides a context for a whole society response to diabetes, aframework for action and an implementation plan.

The intention is to provide a vision and shape for community partnerships over the nextfive years.

The planning process during 2005 will involve detailed programme development bycommunity partners in each of the Ten Action Areas. One of the outcomes of this more detailed work will be to refine the goals, targets and key performance indicators foreach of the Action Areas, as well as setting overall goals for the plan. The plan willcontinue to be updated as developmental work progresses.

Currently this plan does not include inpatient secondary and tertiary services or morbidobesity.

This document does not provide a detailed analysis of diabetes in Counties Manukau - this was covered in an earlier document: Diabetes in Counties Manukau – A Call toAction. This document is also not a business case and does not discuss fundingissues. This is addressed in a separate document.

The intended audience for the plan is the Counties Manukau community and district organisations and individuals who will take up leadership roles in the campaign to beatdiabetes.


A Letter From 2020

It is the year 2020. Type 2 Diabetes is still a major health problem in Counties Manukau - thenumber of people diagnosed with diabetes is greater than it was in 2010 - but positive trendsare emerging that show diabetes rates and numbers will decrease over the next decade. Weare beating diabetes!

The turning point in the battle against diabetes came in 2010, when the growth in populationobesity stabilised, and from 2012 when average weights began to decrease. Many expertshave commented on the rapid reduction in the number of obese children since 2015, with a new wave of well nourished, fit children now flowing through the primary schools.

How did we get to this point, when back in the early years of the century it seemed nothingcould stop the growth in diabetes? The simple answer is that it has been the collective efforts ofmany strategies applied over decades and a commitment from all parts of society to a sharedvision and goal – much like the smoking epidemic of 50 years earlier.

While the big gains in health have been made in the past five year (2015 – 2020), the realchanges came in the 2005 - 2010 period. Those years are remembered as the ‘hard yards’,when there was a lot of effort for little change in outcome. But they put in place many of the strategies that continue to guide us today, and most importantly, galvanised commitment and action across society.

It was during those years that the renaissance in Maori and Pacific health began, withcommunity leadership, through marae and Pacific churches, taking up the challenge of improving the health of their people, especially the young ones. The change in communityattitude and behaviour towards nutrition and physical activity seemed to reach a tipping point in2009 - adult and child obesity levels in Maori and Pacific populations began to decreasesignificantly faster than those of the general population.

The general change in community attitude had its roots in community leadership but was furthersupported by a comprehensive social marketing programme that began in 2005 and is now partof our cultural landscape. In fact, the partnerships between health sector, local government,and the food and physical activity industries, which characterises the national social marketingprogramme of today, was forged in Counties Manukau 15 years ago.

The fast food industry is now competing on product ‘health/goodness’. And while the trendstowards eating out and consuming pre-prepared food have continued, the population diet hassignificantly improved. Children cringe when they are shown some of the meals their parentsused to eat.

For more than a decade, schools have taken explicit accountability for the physical health of children while they’re at school. This has meant ensuring students get at least 30 minutes of physical activity every day. All schools in Counties Manukau actively support good nutrition.The number of children walking or cycling to school has doubled since 2010, thanks to efforts by schools, working with communities, local government, and activity organisations. Many educationalists have noted that the improved health of students has also contributed toimproved academic performance in Counties Manukau.

The Flat Bush development, which was identified as the pilot for the ‘healthy by design’ planninginitiative, is now seen across New Zealand as a watershed in urban design, with its focus onhealthy, active and socially cohesive communities. The lessons from Flat Bush have alreadybeen applied to urban developments and redevelopments across the country.

Child health has been a substantial success story, attributed to improved services and changesin attitudes towards health in the first years of life. Well Child Services are now broad in scopeand include a focus on good nutrition and chronic disease prevention, through pregnancy andfrom birth. There is a significant investment in parental education and sophisticated techniques


for identifying vulnerable families and children. Multi-sectoral support is available for vulnerablefamilies, with information systems helping co-ordinated service delivery across agencies. The Well Teen pilot for a structured health assessment of 13 year olds has now become a nationalprogramme.

Primary care has evolved (despite continual government restructuring … some things don’tchange) to have a far greater focus on disease prevention.

Primary Health Organisations (PHOs) have become sophisticated organisations, with a strongcommunity and civic presence. GP surgeries have in general been consolidated into fewerlarger centres, with the development of nurse-led healthy living and disease management teams

The primary-care based in-clinic and outreach teams have become expert at processes of family and group-based behaviour modification, which, coupled with early diagnosis, has led to a measurable slowing in disease progression and a reduction in expensive hospital-based care.Supporting the re-orientation of primary care is the continuous development of a world-leadingIT system that provides best practice advice to GP teams and to the health consumer.

Health promotion is often described as the glue in the system. A set of strong organisationseffectively link the community development, social marketing and primary care strategies at an operational level, and provide a source of community-based innovations to service design. One of the most remarkable and enduring changes during the 2005 - 2010 period was thedevelopment of the health alliances –self-organising groupings of community, health and socialservice providers - which developed long term place-based strategies to identify and support themost vulnerable families.

One of the key features of Counties Manukau’s efforts to beat diabetes has been an extremelystable governance and leadership structure. Representatives from many organisations andcommunities still form the core governance structure to beat diabetes, and the group hasbecome something of a Counties Manukau institution. This stability has been at the heart of the persistent year-on-year progress.

Another key feature that has been emphasised in academic reviews is the ‘success model’ of learning and service development that has been adopted across many health providers. Somehave likened it to ‘action research on a massive scale’ or a continuous quality improvementstrategy. But the result has been the rapid uptake of innovations in practice across providers.The ability to learn from each other is one of the defining features of the ‘Counties Manukauway’.

The final success factor was the decision by the District Health Board to invest ‘upstream’ andcommit effort and money to support strategies that reduced risk and identified vulnerable peopleat an early stage in their disease. It is these strategies that are providing payback now in termsof health sector costs and community vitality.


The Planning Process

The required outcomes of the planning process have been to develop a plan for theCounties Manukau district as a whole (not just the health sector) and to buildcommunity momentum in support of the plan. Achieving these outcomes has requiredtaking a highly participative approach, creating the foundations for long-termrelationships, collaborative partnerships and networks.

A steering group made up of community, professional and cross-sector representativeshas guided the development of the plan. The planning process has been open andtransparent at every stage. All key planning documents developed during the year andthe minutes of all the working shops and group activities have been posted on the Let’sBeat Diabetes website (www.cmdhb.org.nz) to provide a fully public view of the ideasand participants guiding the planning process. Graphic 1 below shows an outline of the planning process.

Taking a comprehensivelong termapproach

Creating an environment forcollaborativeaction

Buildingcapacity todeliver

Fosteringopendevelopment

A plan forCountiesManukau tobeatdiabetes

Key Planning Concepts

Six concepts have influenced the planning approach:

1. Guiding principles of the World Health Organisation’s (WHO) Global Strategyon Diet, Physical Activity and Health (2004)

Whilst the global strategy is aimed at the international community and national-level strategies, it contains a discussion of principles to guide action and recommendedareas of activity. The strategy provides an excellent starting point for developing along-term change programme. Key principles taken from the global strategy include:

Evidence-based strategies

Multi-sectoral action

Long-term approach

Life course approach

Broad, comprehensive efforts

Priority on most vulnerable groups

All parties accountable for policies and programmes


Culturally-appropriate, and challenge cultural influences

2. Evidence of need and effective action

The plan development has been based on needs analysis, and evidence of effectiveinterventions, whether it be international or local evidence. There are, however, someareas where there is a clear need for action but a lack of strong evidence for effective programmes. In these situations, it is critical that thorough evaluation is undertaken todevelop new evidence – a good example of this issue is in the schools programme.The plan structure and approach taken by Let’s Beat Diabetes closely aligns withinternational best practice and is reflected in many recent national and state strategies;examples include: The New South Wales Chronic Disease Prevention Strategy 2003-2007, the Australian National Public Health Partnership Prevention Chronic Disease aStrategic Framework (2001) and the US Centres for Disease Control PromisingPractices in Chronic Disease Prevention and Control (2003).

3. Sector capacity and community motivation

The plan has identified where need, evidence and good ideas intersect with the localcapacity and motivation for action. There is little point in proposing strategies wherethe community and organisations are not ready and/or willing to take up the call.Examples of finding fertile ground for action include the food industry being strongly motivated to develop tangible outcomes following the signing of the National FoodIndustry Accord; the new Family and Community Services division of the Ministry ofSocial Development wanting to work with the health sector in the area of vulnerablefamilies; and Pacific church leaders wanting to be more involved in supporting thephysical health of their communities.

4. Long term approach

The fourth key concept has been to think about the long-term implications of actions. Ittook decades to make real inroads into the threat of smoking on health. The obesityissue is far more complex and will require broad changes to our environment, societal norms and health sector capabilities before substantial positive changes and outcomes are achieved. The emphasis has been on identifying areas where actions over thenext five years will deliver positive benefit and align with a 15-year vision. Graphic 2below shows how the long-term vision creates a context for the five year plan.

time

2004 2010 2015 2020

Long termscenariosand vision

ExistingCapacityandoutcomes

Strategicgoal. 5 yearoutcomesand platformto achievevision

Context

Direction Direction

Context

Long term vision provides context for five year strategy

time

2004 2010 2015 2020

Long termscenariosand vision

ExistingCapacityandoutcomes

Strategicgoal. 5 yearoutcomesand platformto achievevision

Context

Direction Direction

Context

Long term vision provides context for five year strategy

5. Alignment with national and CMDHB overarching strategies

Key documents such as Counties Manukau District Health Board’s Strategic Plan(CMDHB 2002), Healthy Eating Healthy Action Framework (Ministry of Health, 2003), He Korowai Oranga – Maori Health Strategy (Ministry of Health, 2002) the PacificHealth and Disability Action Plan (Ministry of Health, 2002), and emerging Ministry ofHealth frameworks for chronic disease management such as Leading for Outcomes,have influenced the planning approach and processes.


6. Building on lessons from past strategies and services

Counties Manukau has a long history of strategic planning and service innovations relating to diabetes, including the work undertaken by Dr David Simmons during the1990s and the South Auckland Diabetes Report prepared in 2000. In many areas, Counties Manukau service providers have developed innovative services, some ofwhich have been sustained. One of the challenges for Let’s Beat Diabetes has been tolearn from this rich background and to create the systematic conditions that supportsustainable programmes.

7. Building on existing strengths

Let’s Beat Diabetes starts from a strong base. CMDHB has for the past five yearsinvested in improved chronic care management in the primary care sector. TheChronic Care Management (CCM) programme is well advanced and involves primary care being supported by training, information technology (IT) and decision support tools to provide structured care in the community for people with advanced diabetes. CCMis supported by Whitiora, the Middlemore Hospital Diabetes Service. Whitiora provides training for practice teams and outreach education for patients as well as clinicalservices.

Primary Health Organisations (PHOs) are increasingly developing new healthpromotion and disease prevention services. Maori and Pacific providers deliverspecific services and programmes to their respective communities. Niche providerssuch as the Diabetes Projects Trust also provide community-based health promotionand education activities. Counties Manukau has a history of health leadership fromManukau City Council with the Te Ora O Manukau/Manukau the Health City and morerecently the Tomorrow’s Manukau Health and Wellbeing Outcome Group. TheAuckland Regional Public Health Service (ARPHS), which has an office in ManukauCity, provides services aimed at improving lifestyle and environmental risk factors.


Obesity & Diabetes - Global Epidemics

The world is currently experiencing an unprecedented growth in obesity. Obesity is amajor risk factor for Type 2 Diabetes.

In 1995, there were an estimated 200 million obese adults world-wide. By 2000, thenumber of obese adults had increased to over 300 million.

The situation in New Zealand is no different. Approximately 59.5 percent of all NewZealand adult males and 48.6 percent of all New Zealand adult females areoverweight. These figures are more marked for Maori and Pacific adult populations,where 68.5 percent of Maori males, 59.2 percent of Maori females, 80.9 percent ofPacific males and 82 percent of Pacific females are overweight (Ministry of Health,2003).

The figures for children are of particular concern with 31 percent of all childrenoverweight, 62 percent of Pacific children overweight, and 41 percent of Maori children overweight.

The prevalence of obesity is increasing. Between 1989 and 1997 adult obesityincreased by 55 percent. From 1997 to 2011 obesity is expected to increase by afurther 70 percent. It has also been estimated that by 2011 approximately 29 percentof the adult population may be obese (Ministry of Health, 2002).

Diabetes – A Disease of Inequalities

Diabetes is a serious chronic disease that leads to serious complications such as heart disease, kidney failure, stroke, and blindness. People with diabetes have a reducedlife expectancy. Currently, one in 12 adults over 45 years in New Zealand have beendiagnosed with diabetes.

Diabetes is a disease of inequalities, with Maori and Pacific peoples at greater risk ofdiabetes than other New Zealanders:

21 percent of Maori males over 45 years have diabetes compared to 8.5 percent of non-Maori

20 percent of all Maori and 17 percent of all Pacific deaths are due to diabetes – compared to 4 percent of deaths amongst European New Zealanders

The lifetime risk of being diagnosed for diabetes is one-in-four for Pacific peoplesand one-in-three for Maori – compared to one-in-ten for European New Zealanders

Approximately 8 percent of Maori and Pacific adults have diabetes compared to 3to 4 percent for European New Zealanders

Estimates are that from 1996 to 2011 the total number of adults with diabetes in New Zealand will increase by 78 percent, but the relative increase for Maori andPacific peoples will be 130 to 150 percent (Ministry of Health, 2002).


Diabetes in Counties Manukau

Counties Manukau is experiencing a growing epidemic of Type 2 Diabetes. Currently there are more than 12,000 people in Counties Manukau diagnosed with diabetes.Almost double this number remains undiagnosed. It is estimated that the number ofpeople with diabetes could more than double over the next 20 years, given population growth, the ethnic, youthful and generally low socio-economic make up of ourpopulation. In the graphic below the top dotted line shows the expected growth in diabetes if the prevalence of obesity goes on increasing – which is exactly what it is doing.

0

2 0 0 0

4 0 0 0

6 0 0 0

8 0 0 0

1 0 0 0 0

1 2 0 0 0

1 4 0 0 0

1 6 0 0 0

1 8 0 0 0

2 0 0 0 0

2001

2003

2005

2007

2009

2011

2013

2015

2017

2019

2021

Num

ber

of c

ases

M a o r i P a c i f i c

O t h e r T o t a l

M a o r i a d j u s t e d P a c i f i c a d j u s t e d

O t h e r a d j u s t e d T o t a l a d j u s t e d(Lindsay A, 2003)

A disturbing feature of this epidemic is that it is no longer ‘contained’ to people agedbetween 40 and 64 years of age. The number of young people being diagnosed withType 2 diabetes, while still small, is increasing. Children as young as 6 years old arenow being diagnosed with Type 2 Diabetes.

Mothers with gestational diabetes or pre-diabetic conditions may be passing on anincreased risk of diabetes to the unborn child. With more women in the childbearingage group at risk of diabetes, the risk to future generations is increasing.

People living in low decile areas of Counties Manukau are more likely to suffer fromdiabetes. The map below shows where these areas are – which are also where thereare high rates of diabetes (dark shading).


NORTH

SOUTH

TUREWAREWA

DENE SOUTHSTON CENTRAL

URILANDS

RANGI SOUTH

NTON

M

FREEMANS BAYNEWTON

GLENAVONAVONDALE SOUTH

WATERVIEW

ST LUKES NORTH

EPSOM CENTRAL

EPSOM SOUTH

MT HOBSON

REMUERA WEST

ORAKEI NORTH ST HELIERS

GLEN INNES NORTHGLEN INNES WEST

POINT ENGLAND

ROYAL OAK

HILLSBOROUGH EAST

WESLEY

LYNFIELD SOUTH

PENROSE

MT WELLINGTON NORTH

MT WELLINGTON SOUTH

PANMURE BASIN

PAERATA-CAPE HILL

EDEN ROAD-HILL TOP

BUCKLAND

KINGSEAT

POKENO

GLENBROOKBOMBAY

HINGAIA

WHANGAPOURI CREEK

BREMNER

DRURY

RUNCIMAN

MELLONS BAY

COCKLE BAY

OTAHUHU EAST

MIDDLEMORE

PAPATOETOE WEST

PAPATOETOE NORTH

BLEAKHOUSE

ELSMORE PARK

GOLFLAND

DANNEMORA

POINT VIEW

SHELLY PARK

TURANGA

ORMISTON

ARDMORE

TOTARA HEIGHTS

WAIRERE

RANDWICK PARKHYPERION

TAKANINI SOUTH

AMBURY

ARAHANGAVISCOUNT

MANGERE SOUTH

MANUKAU CENTRAL

BURBANK

WEYMOUTH

CLENDON

PAPAKURA CENTRAL

PAPAKURA NORTH

PUKEKOHE NORTH

BLEDISLOE PARK

WAIUKU

SOUTH WAIUKU TUAKAU

INLET-MANUKAU HARBOUR

INLET-WAIUKU RIVER

Rate per 100,000

2,400 to 6,550 (13)2,000 to 2,400 (8)1,600 to 2,000 (12)1,200 to 1,600 (13)

800 to 1,200 (21)400 to 800 (33)

1 to 400 (25)

Produced by AP Lindsay, Public Health Team, CMDHB

Based on hospital admission data only, for individual CM residents hospitalised anywhere in New Zealand

(Lindsay A 2003)

The Cost of Diabetes

Diabetes is a major driver of health sector costs within both primary and secondarycare, with increased cardiovascular disease, kidney disease, stroke, lower limb ulcersand retinal damage. Diabetes has explicit social costs through loss of work andsupport payments and implicit costs through the impact of chronic disease on family and community life.


Growth in diabetes leads to a huge increase in hospital costs, social support costs andloss of economic contributions. It is estimated that a person with diabetes generateshospital costs on average 2.5 times as much as someone without diabetes – and thatthe indirect costs are as much again (PriceWaterhouseCoopers, 2001). It is alsoestimated that as the number of patients with kidney failure grows (primarily due to theincreasing number of diabetics and an ageing population), the need for new dialysisstations will grow at a level that within five years, a new satellite clinic with 20 dialysisstations would be required every year to keep up with demand (Ratanjee, 2004).

The cost of diabetes to the family and community is significant and immeasurable.Diabetes robs us of our elders and the cultural richness and wisdom they bring to oursociety. With the increasing prevalence of diabetes moving down the age-spectrum, it is beginning to rob us of our future.


Whole Society, Whole Life Course, Whole

Family Approach

International research and evidence emphatically support a ‘whole society, whole life course, whole family’ approach to beat diabetes. The graphic below, adapted from adiabetes model developed by the US Centre for Disease Control, shows the challengefor a whole-system strategy.

Society’s healthresponse

Vulnerabilitycessation

Vulnerabilityonset

Death fromcomplications

Afflictionprogression

Afflictiononset

Tertiaryprevention

Secondaryprevention

Primaryprevention

Targetedprotection

Protectedpopulation

Vulnerablepopulation

Afflictedwithout

complications

Afflicted withcomplications

Societal responsibility Health sector responsibility

Generalprotection

Adverseliving

conditions

Investment Mix?

Adapted from (Homer J 2004)

A life course approach works across all areas from universal protection of the whole population to tertiary prevention for people already with diabetes.

The ‘afflicted with complications’ area is where most of health expenditure on diabetesoccurs at present. A life course approach supports analysis of the whole system,including public health, primary care and hospital services, and encourages explicit thinking about where to invest in the progression of risk and disease.

Investment decisions need to be based on evidence of effectiveness and also on anunderstanding on how programmes impact on disease progression and health sector costs. For example, reducing complications of someone with advanced diabetes mayhave an immediate payback in reduced hospital costs, while an investment in targetedprotection, like improving the schools environment, might not provide benefits to healthsystem costs for many years, in fact decades but may have a big impact on improvedlifelong health for many people.

Let’s Beat Diabetes

The approach taken in this plan is that well constructed strategies across the lifecourse should work in synergy. For example, a person with diabetes may be better atself management with a supportive church environment, encouraging social marketing,


a family that understands their problem, healthier food options and a practice team thatis proactive and motivational. Schools are more likely to take up a fit and healthy policy if the food industry is supportive, community leaders are backing them, vulnerablefamilies are identified and helped with food choices and support services make it easy for schools to schedule regular physical activity sessions.


Part II


A Five Year Plan to Prevent and Manage Type 2 Diabetes in Counties Manukau



Aim

The aim of the Let’s Beat Diabetes plan is to stop people getting diabetes, slow the disease progression, and increase the quality of life for people with diabetes.

Strategic Approach

A range of strategies are proposed, guided by the basic concept that a ‘whole society,whole life course, whole family/whanau’ approach is required to beat diabetes, and thatfocused effort will need to be sustained over decades.

Whole society – Acknowledgment that we cannot beat diabetes without themotivation and support of the communities, institutions and businesses that make up the social fabric of Counties Manukau.

Whole life course – A focus on supporting health and preventing and managingdiabetes at all stages of disease progression.

Whole family/whanau – Acknowledgment that an individual is part of a family/whanau (or household) which has a direct influence on environmental risks,choices and decisions. Wherever possible, working with families is central to the plan.

Guiding Principles

The principles of Partnership, Participation and Protection form the constitutionalfoundations of New Zealand through the Treaty of Waitangi. These principles are alsofundamental to the practice of modern public health.

Partnership – Institutions, organisations, communities, families and individuals must work together to beat diabetes. The scale of social response required for diabetesmeans that formal partnerships based on aligned goals and civic responsibilities will need to be developed and actively sustained.

Participation – The prevention and control of chronic disease is enabled through self management and via the ongoing participation of family, community and healthprofessionals in the lives of people with diabetes. Also, for strategies to be successful, families and communities must be able to participate in service design, development and governance.

Protection – The current diabetes epidemic has been created by a newenvironment of obesity. The ‘obesogenic environment’ is a threat to the health and wellbeing of our children and families. There is an obligation on behalf ofgovernment, business and community leadership to protect citizens from thisenvironmental hazard.

Ten Action Areas

The Let’s Beat Diabetes plan is complex and wide ranging. In order for it to beunderstood by, and motivational to our diverse communities, activity has been set out under ten key action areas. They are as follows:



2. Promoting Behaviour Change Through Social Marketing

3. Changing Urban Design to Support Healthy, Active Lifestyles

4. Supporting a Healthy Environment Through a Food Industry Accord

5. Strengthening Health Promotion Co-ordination and Activity

6. Enhancing Well Child Services to Reduce Childhood Obesity

7. Developing a Schools Accord to Ensure Children Are ‘Fit, Healthy and Ready toLearn’

8. Supporting Primary Care-based Prevention and Early Intervention

9. Enabling Vulnerable Families to Make Healthy Choices

10. Improving Service Integration and Care for Advanced Disease

The Ten Action Areas reflect a range of intervention strategies, including general andtargeted protection, and primary, secondary and tertiary prevention. They are designed to fit together to form an overall strategy that reduces risk factors for diabetes and slows disease progression, while building capacity in the health sector and a sustainable whole society approach. Graphic 3 below shows the zones each actionarea is designed to influence.

Vulnerabilitycessation

Vulnerabilityonset

Death fromcomplications

Afflictionprogression

Afflictiononset

Tertiaryprevention

Secondaryprevention

Primaryprevention

Targetedprotection

Protectedpopulation

Vulnerablepopulation

Afflictedwithout

complications

Afflicted withcomplications

•Food Industry Accord

•Primary care-base prevention

•Community leadership

•Urban design

•Social marketing

•Strengthening health promotion

•Schools Accord

•Enhanced Well Child

•Integrated care

•Vulnerable families

Generalprotection

Another way of looking at the Ten Action Areas is from the perspective of the family.As shown below in Graphic 4, the family is in the centre surrounded by rings of support.The outer ring is that of the social and environmental determinants of health, whichaffect everyone. The social determinants are the responsibility of society. The innerring is that of the more direct health environment and services environment. The services environment is mostly about the relationship between individuals (andfamilies) and government funded services. These are the services that the health


sector has more control over. Strength in both circles and strength within the family is required to reduce diabetes risk factors and control disease.

Knowledge

Culture

Food

Urban environment

Socio-econom

ic

Well ChildSchool health

Health

Prom

otion

Earlyintervention

Dis

ease

man

agem

ent

Enablers

The Ten Action Areas describe the content of activities needed to beat diabetes, butthere is also a set of support activities that must be managed in order to implement the plan in a sustainable manner. These support areas or ‘enablers’ are outlined below:

1. Consumer involvement

An effective consumer forum needs to be developed, or an existing forum enhancedand actively involved in the development of new programmes and evaluation design.

2. Maori

A Maori advisory forum will be developed, or an existing forum enhanced, to ensure allnew programmes and evaluation design are culturally responsive to Maori.

3. Pacific peoples

A Pacific advisory forum will be developed, or an existing forum enhanced, to ensureall new programmes and evaluation design are culturally responsive to Pacific peoples.

4. Funding environment

The funding environment is modified and aligned to support the Ten Action Areas.

5. Learning environment

Evaluation and learning systems are explicitly supported as part of the overall investment.

6. Sustainable governance


Governance and leadership for the whole plan and for each of the Ten Action Areas is developed and supported.

7. Organisational development

Investment in workforce, particularly in primary care, will be required as will thedevelopment of an ongoing centre of excellence for whole system diabetes preventionand management in Counties Manukau.

8. Information systems

The many disconnected systems and programmes used for supporting diabetesmanagement need to be brought together over time to align with the whole systemapproach outlined in the Let’s Beat Diabetes plan.



Action Areas & Enablers



Context

The Let’s Beat Diabetes plan seeks to lay down the foundations for the long term reduction of Type 2 Diabetes in our community. These foundations are built on the understanding that real, sustainable change will require support from our whole society– from individuals, families, organisations, cultures, systems, policies and the myriaddimensions that make up our communities. Creating societal support for changerequires a proactive process of developing community leadership. Without community leadership, the Let’s Beat Diabetes plan will fail. It is individuals, within families, withincommunities, who make the decisions about their lives. Empowered communitieschange their environments through action, advocacy, local democracy and consumer choice. Our plan must work with communities in order to succeed.

The call for the community to lead and champion the fight against diabetes has beenvoiced by Maori and Pacific communities, who are most at risk from the diabetesepidemic. From our workshops, hui and fono on how to this support community leadership and change, a number of core concepts have emerged:

For Maori, it has been the need to work with the roots of culture and cultural normsin order to change behaviours that are causing diabetes. As one participant put it‘we need to change the lore’ as it applies to culture. This means working throughtraditional cultural institutions such as marae and contemporary institutions like kurakaupapa so tamariki learn and grow up in an environment where healthy eating and active living is the ‘lore’.

For Pacific peoples, it is about rediscovering, strengthening and practising thepositive aspects of their cultures and cultural practices around food and physicalactivity, and exploring opportunities for Pacific churches to be vehicles for physicalhealth promotion.

The Asian and new settlor community is diverse in its community structures and leadership. Ethnic-specific strategies will be required.

For the general population, the workplace has emerged as a place where institutions can have a tremendous positive influence on health and where there is great opportunity for improvement.

The community empowerment model, which seeks to build community connections,strength and self determination, and seeks community-based solutions to problems,has also emerged.

Programme Design

The programme design to support this Action Area is consistent with the communityempowerment model:

The strategies were developed through workshops, hui and fono, and ‘by Maori for Maori’ and ‘by Pacific for Pacific’ (please note: priority has been placed onsupporting activities for the Maori and Pacific communities, given the heightened risk these communities face from diabetes).

Let’s Beat Diabetes will support a broad range of ideas that encourage community empowerment, and utilise the strength of culture and cultural institutions to bring



about change to lifestyles and/or environments which reduce obesity or slow the progression of diabetes.

To facilitate this, Counties Manukau District Health Board (CMDHB) is proposing to set up a Community Action Fund (CAF) to support and assist initiatives that are aligned with the action plan. This funding will be available to a range of community organisations, ccessed via funding proposals.

The programme design also looks to the membership of Tomorrow’s Manukau Te Ora O Manukau/Manukau the Healthy City Outcome Group to role model healthy workplace policies. This group is comprised of key central and local government agencies and organisations in the district.

Act

ion

Pla

ns

Mao

ri

Wh

akak

ore

ng

ia t

e m

ate

hu

ka i

wae

ng

anu

i wh

anau

na

te m

oh

io m

e te

mar

ama.

To

pre

ven

t D

iab

etes

th

rou

gh

kn

ow

led

ge

and

un

der

stan

din

g.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

ers

Go

al:

T

ikan

ga

are

dev

elo

ped

an

dim

ple

men

ted

to

re

du

ce

at

risk

d

iab

etes

beh

avio

ur.

Tar

get

: ‘

Hea

lth

yea

tin

g a

ctiv

e liv

ing

’ ar

eva

lues

ado

pte

d

asan

ac

cep

ted

p

art

of

cust

om

an

d p

ract

ice.

Wha

nau,

hap

u, i

wi a

nd M

aori

com

mun

ities

of

inte

rest

dev

elop

‘hea

lthy

eatin

gac

tive

livin

g’ g

uide

lines

in c

onju

nctio

nw

ith h

ealth

org

anis

atio

ns.

Res

ourc

esw

hich

con

vert

‘hea

lthy

eatin

gac

tive

livin

g’ r

ules

/ gu

idel

ines

into

prac

tical

app

licat

ors

are

deve

lope

d (e

.g.

Bill

yT

han

dboo

ks).

R

esou

rces

nee

dto

be

targ

eted

at M

aori

envi

ronm

ent i

n bo

th la

ngua

ges.

‘Hea

lthy

eatin

g’ T

ikan

ga a

re d

evel

oped

byM

arae

, K

ohan

ga R

eo a

nd M

aori

orga

nisa

tions

in a

ll se

ctor

s.

‘Hea

lthea

ting

activ

e liv

ing’

aw

ards

are

awar

ded

annu

ally

at a

n ev

ent

toce

lebr

ate

‘wha

nau

ora’

life

styl

es.

Wha

nau,

ha

pu,

Iwi,

Mao

rico

mm

uniti

es

of

inte

rest

(e

.g.

educ

atio

n pr

ovid

ers,

spo

rt te

ams)

AR

PH

S,

Mao

ri he

alth

pr

ovid

ers,

heal

th p

rom

otio

n se

ctor

Mao

ri or

gani

satio

ns,

Mao

ri he

alth

prov

ider

s, M

aori

Hea

lth, C

MD

HB

Go

al:

T

o

iden

tify

o

pp

ort

un

itie

s (p

eop

lean

d

even

ts)

wit

hin

th

e co

mm

un

ity

toch

amp

ion

Mao

ri a

pp

roac

hes

to

red

uci

ng

Dia

bet

es.

Tar

get

:A

ca

len

dar

o

f ‘P

atu

a i

te

mat

eh

uka

’ ev

ents

is

ad

op

ted

ea

ch

year

.C

alen

dar

to

b

e d

evel

op

edw

ith

th

eco

mm

un

ity.

Wan

anga

M

ate

Huk

a ar

eho

sted

to

di

scus

s M

aori

appr

oach

es

to

beat

diab

etes

, an

dth

e ka

iwha

kaha

ere

(cha

mpi

on)

role

s to

be

play

edby

wha

nau

hapu

an

d iw

i.T

he

Wan

anga

in

clud

e M

anaw

henu

a,

kuia

/ ka

umat

ua,

cons

umer

s, r

anga

tahi

, tak

ataa

puia

nd o

ther

‘at r

isk’

Mao

ri gr

oups

.

For

mal

de

velo

pmen

t of

ka

iwha

kaha

ere

role

san

d re

spon

sibi

litie

s to

dr

ive

‘Pat

ua i

te m

ate

huka

’ are

und

erta

ken.

Rel

atio

nshi

psw

ith c

urre

nt M

aori

lead

ers

to p

rom

ote

posi

tive

Mao

ri di

abet

esm

essa

ges

are

esta

blis

hed.

T

hese

lea

ders

cou

ld i

nclu

deT

e A

taira

ngi

Kah

u,M

HA

C m

embe

rs, S

tace

y Jo

nes

and

Vee

shan

e A

rmst

rong

.

CM

DH

B,

Mao

ri he

alth

pr

ovid

ers,

Mao

ri,

Mao

riH

ealth

, M

anaw

henu

a,C

ount

ies

Man

ukau

Spo

rt

Go

al:

E

nsu

re

all

Mao

ri

un

der

stan

dd

iab

etes

an

d

the

risk

b

ehav

iou

rsw

hic

hin

crea

se t

he

chan

ces

for

get

tin

g d

iab

etes

.

Tar

get

: O

pp

ort

un

itie

s ar

e m

ade

avai

lab

lefo

r M

aori

to

ac

cess

h

ealt

hp

rom

oti

on

reso

urc

es a

nd

info

rmat

ion

on

dia

bet

es.

On-

goin

g de

velo

pmen

tof

hea

lth p

rom

otio

n re

sour

ces

are

clea

rly t

arge

ted

atM

aori,

acr

oss

the

age

spec

trum

.

Rec

ogni

sed

trai

ning

an

d ed

ucat

ion

pack

ages

fo

r de

liver

y to

M

aori

in

the

com

mun

ityar

e de

velo

ped.

The

se t

rain

ing

pack

ages

are

aim

edat

spe

cific

grou

ps, a

cros

s th

e ag

e sp

ectr

um.

A r

egul

ar t

imet

able

of

Wan

anga

Wha

nau

Ora

for

Mao

ri to

dis

cuss

dia

bete

s is

AR

PH

S,

Mao

ri pu

blic

heal

th,

heal

thpr

omot

ion

sect

or

AR

PH

S,

Mao

ri pu

blic

heal

th,

heal

thpr

omot

ion

sect

or

AR

PH

S,

Mao

ri pu

blic

heal

th,

heal

th

23F

INA

L P

LA

N 0

2 F

ebru

ary

2005

put

toge

ther

. W

here

pos

sibl

e th

ese

hui

will

lin

k in

with

exi

stin

g hu

i (e

.g.

Pou

kai,

Kap

a H

aka

com

petit

ions

et

c).

Util

ise

Mao

riev

ents

ca

lend

ar

to

prom

ote

key

‘hea

lth e

atin

g ac

tive

livin

g’ m

essa

ges.

prom

otio

n se

ctor

Go

al:

Mak

e p

hys

ical

act

ivit

ya

fun

, n

atu

ral

par

t o

f a

per

son

’s d

ay.

Tar

get

:

Mao

ri

of

all

ages

en

gag

e in

ph

ysic

al a

ctiv

ity

as a

par

to

f th

eir

no

rmal

day

.

A s

urve

y to

iden

tify

the

rang

eof

phy

sica

l act

ivity

activ

ities

cur

rent

lyca

rrie

d ou

tin

the

Cou

ntie

s M

anuk

au a

rea

by M

aori

is u

nder

take

n. I

nclu

deal

l fo

rms

ofac

tivity

incl

udin

g da

nce,

eld

erly

wal

king

cla

sses

etc

.

Wor

kw

ith r

egio

nal

and

natio

nal

bodi

es t

o id

entif

y ph

ysic

al a

ctiv

ity i

nitia

tives

curr

ently

unde

r de

velo

pmen

t, fo

r pi

lotin

g/la

unch

ing

with

in t

he l

ocal

are

a.E

nsur

e th

ere

is lo

cal i

nput

to m

ake

the

initi

ativ

e M

anuk

au–c

entr

ic.

Wor

kw

ith th

e co

mm

unity

to id

entif

y na

tura

lfit

of a

ctiv

ities

cur

rent

ly o

ffere

d an

dco

mm

unity

lead

er(s

) fo

r th

is a

ctiv

ity (

deve

lopm

ent p

roce

ss).

Pro

mot

e th

e de

velo

pmen

t of f

un, c

omm

unity

-orie

nted

act

ive

livin

g in

itiat

ives

, to

be le

ad b

y co

mm

unity

(e.

g.T

ake

Nan

/ Pop

for

a w

alk)

.

CM

DH

B,

SP

AR

C,

Cou

ntie

sM

anuk

auS

port

CM

DH

B,

SP

AR

C,

Cou

ntie

sM

anuk

ausp

ort

CM

DH

B, C

ount

ies

Man

ukau

Spo

rt

Com

mun

ity

lead

ers,

C

MD

HB

,C

ount

ies

Man

ukau

Spo

rt

Go

al:

Mak

e h

ealt

h e

atin

g a

fu

n,

nat

ura

lp

art

of

a p

erso

n’s

day

.

Tar

get

:

Mao

ri

of

all

ages

en

gag

e in

ph

ysic

al a

ctiv

ity

as a

par

to

f th

eir

no

rmal

day

.

A s

urve

y to

ide

ntify

the

ran

ge o

f he

alth

y ea

ting

initi

ativ

es a

nd r

esou

rces

avai

labl

e in

the

Cou

ntie

s M

anuk

au a

rea

is u

nder

take

n. I

nclu

de a

reas

whe

reM

aori

com

mun

ities

act

en

mas

s (e

.g.

Sec

onda

ry s

choo

ls f

estiv

al,

mar

kets

,sp

orts

occ

asio

ns,

etc.

) T

his

shou

ld in

clud

ew

hat

is h

ealth

y fo

od,

and

how

do

you

cook

hea

lthy

food

in a

hea

lthy

way

.

A ‘

heal

thy

eatin

g’ t

oolk

it (r

ouro

u) i

s de

velo

ped

to b

eus

ed a

s th

eba

sis

for

educ

atio

n/

heal

th

prom

otio

n se

ssio

nsfo

r de

liver

y in

al

l M

arae

/ M

aori

orga

nisa

tions

in th

e di

stric

t.

‘Hea

lth e

atin

gac

tive

livin

g’ m

arae

aw

ards

whi

ch a

ckno

wle

dge

the

wor

k ca

rrie

dou

t in

M

arae

to

ch

ange

th

e di

etar

yha

bits

of

ta

ngat

a w

henu

aan

d th

eir

man

uhiri

are

dev

elop

ed.

CM

DH

B, M

aori

Pub

lic H

ealth

CM

DH

B, A

RP

HS

, Mao

ri P

ublic

Hea

lthP

rovi

der

CM

DH

B, M

aori

Go

al:

R

ang

atah

i d

evel

op

a

Tik

ang

a/cu

ltu

rew

her

e th

ey

are

able

to

mak

e in

form

ed

nu

trit

ion

an

d

ph

ysic

alac

tivi

ty c

ho

ices

.

Tar

get

: R

ang

atah

i ar

eab

le t

o d

efin

ew

hat

hea

lth

yea

tin

g a

nd

act

ive

livin

g m

ean

s fo

rth

em a

s ex

amp

les

to e

very

on

e.

A r

anga

tahi

cou

ncil

to d

iscu

ss d

iabe

tes

is c

onve

ned.

M

ain

aim

of t

he fo

rum

isto

eng

age

Ran

gata

hi in

to H

ealth

foru

ms,

with

a p

urpo

se.

Wor

kw

ithyo

uth

to

iden

tify

barr

iers

to

heal

thy

livin

g an

dac

tive

lifes

tyle

sin

clud

ing:

Who

are

thei

r ro

le m

odel

s? T

he p

eopl

eyo

u lo

ok u

p to

?W

ho a

re th

eym

ore

likel

y to

take

info

rmat

ion

on b

oard

from

?W

ho w

illm

ake

a di

ffere

nce?

Wha

t thi

ngs

mak

e it

diffi

cult

to li

ve h

ealth

y,ac

tive

lifes

tyle

s?

CM

DH

B, M

aori

Hea

lth

CM

DH

B, M

aori

Hea

lth

24F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Ran

gata

hi-f

ocus

ed ‘

heal

thy

eatin

gac

tive

livin

g’re

sour

ces

are

deve

lope

d an

ddi

strib

uted

thro

ugho

ut th

e co

mm

unity

.M

aori

publ

ic h

ealth

, he

alth

prom

otio

nse

ctor

Pac

ific

peo

ple

s

Su

amal

ie i

le g

utu

a’e

oo

na

i le

man

ava

– fa

’ala

lo le

ma'

i su

ka.

A T

on

gan

-led

dia

bet

es w

ork

forc

e, r

eso

urc

edto

wo

rk t

og

eth

er w

ith

th

e C

ou

nti

es M

anu

kau

co

mm

un

ity

to s

erve

ou

r fa

mili

es.

Ou

r ai

ms:

(1)

Ke

hao

faki

’i h

ota

u n

gaa

hi f

amili

mei

he

suka

an

d (

2) K

e le

va’i

lele

i e s

uka

‘i h

e fa

mili

.

Tam

ate

i te

toto

ven

e.

Om

ai k

e ka

u f

akal

atah

a ke

tu

ku h

ifo

e g

agao

su

ka k

i lal

o.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

ers

Go

al:

Lea

der

ship

Pac

ific

p

eop

les

lead

ersh

ip

gro

up

sw

ork

wit

h

the

hea

lth

se

cto

r to

le

ad

Pac

ific

co

mm

un

itie

s’ f

igh

t ag

ain

std

iab

etes

.

Tar

get

: G

rou

ps

esta

blis

hed

by

Ap

ril 2

005.

Eth

nic-

spec

ific

lead

ersh

ip g

roup

s es

tabl

ishe

d to

lead

the

Pac

ific

com

pone

nt o

f th

e ‘C

omm

unity

Le

ader

ship

an

d A

ctio

n’

activ

ity

area

of

the

Let’s

B

eat

Dia

bete

s pl

an.

Pac

ific

chur

ches

as

part

ners

and

cha

mpi

ons

for

heal

th p

rom

otio

nw

ill b

e su

ppor

ted

to p

rovi

de c

omm

unity

set

tings

for

serv

ice

prov

isio

n.

Rep

rese

ntat

ives

fro

m t

he e

thni

c-sp

ecifi

c gr

oups

app

oint

edto

the

Let’s

Bea

t D

iabe

tes

Gov

erna

nce

Gro

up.

The

eth

nic-

spec

ific

lead

ersh

ip g

roup

s, s

uppo

rted

by

the

heal

th p

rom

otio

nse

ctor

, cha

mpi

on, p

rom

ote

and

enco

urag

e he

alth

y ea

ting

and

phys

ical

act

ivity

to th

eir

vario

us c

omm

unity

grou

ps a

nd o

rgan

isat

ions

. K

eygr

oups

incl

ude:

Chu

rche

s an

dch

urch

gro

ups

H

omes

E

arly

chi

ldho

od c

entr

es a

ndpr

e-sc

hool

s

Wor

kpla

ces

V

illag

em

eetin

gs

Ex-

Stu

dent

sA

ssoc

iatio

ns

Pac

ific

com

mun

ities

, C

MD

HB

, et

hnic

-sp

ecifi

c le

ader

ship

gr

oups

,he

alth

prom

otio

n se

ctor

25F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Go

al:

Par

tner

ship

s &

Co

llab

ora

tio

n

Pac

ific

co

mm

un

itie

s, t

he

hea

lth

sec

tor

and

oth

er

key

agen

cies

wo

rk

effe

ctiv

ely

tog

eth

erto

p

rom

ote

and

su

pp

ort

h

ealt

han

dw

ellb

ein

g t

o P

acif

ic c

om

mu

nit

ies.

Tar

get

:L

et’s

Bea

t D

iab

etes

pla

n a

lign

sw

ith

th

e H

ealt

hy

Cit

y C

har

ter

Spe

cific

dia

bete

spr

even

tion

obje

ctiv

es i

nclu

ded

as p

art

of t

he T

omor

row

’sM

anuk

au T

e O

ra O

Man

ukau

/Man

ukau

the

Hea

lthy

City

Out

com

e G

roup

revi

ewof

the

Hea

lthy

Citi

es C

hart

er.

Ann

ual a

ctio

npl

ans

deve

lope

dw

hich

foc

us o

n di

abet

es a

nd h

ow e

very

heal

thpr

ovid

erw

ill e

ndor

se a

nd im

plem

ent t

he id

entif

ied

actio

ns.

Dat

abas

e of

all

prov

ider

s an

d gr

oups

wor

king

in t

he d

iabe

tes

field

acc

essi

ble

to c

omm

unity

gro

ups

as a

mea

nsof

net

wor

king

and

deve

lopi

ngw

orki

ngpa

rtne

rshi

ps.

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ific

prov

ider

s an

d pa

rtne

rs i

nclu

ded

in w

eb-b

ased

inf

orm

atio

n lin

ked

to

Let’s

Bea

t Dia

bete

s w

ebsi

te.

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toco

l fo

r in

form

atio

n sh

arin

g de

velo

ped

to e

nsur

e th

at b

oth

prim

ary

and

seco

ndar

y ca

re p

rovi

ders

hav

eac

cess

to r

elev

ant i

nfor

mat

ion.

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ific

chur

ches

and

hea

lthpr

omot

ion

expl

ore

oppo

rtun

ities

to

wor

k to

geth

erto

pr

omot

e an

d de

liver

he

alth

an

d ph

ysic

al

activ

ity

prog

ram

mes

to

th

eco

mm

uniti

es, w

ith th

e vi

ew to

bec

omin

ga

key

setti

ng fo

r se

rvic

e pr

ovis

ion.

Tom

orro

w’s

Man

ukau

T

e O

ra

O

Man

ukau

/Man

ukau

th

e H

ealth

y C

ityO

utco

me

Gro

up, C

MD

HB

, pro

vide

rs

Go

al:

Ed

uca

tio

n &

Em

pow

erm

ent

Pac

ific

co

mm

un

itie

s ar

e kn

ow

led

gea

ble

and

in

form

ed

abo

ut

dia

bet

es,

its

risk

fact

ors

, h

ow

to

p

reve

nt

it,

and

h

ow

tom

anag

e it

.

Tar

get

: B

y20

08 a

mea

sura

ble

incr

ease

inp

reve

nti

on

kn

ow

led

ge

in c

hild

ren

, ad

ult

san

d o

lder

ad

ult

s.

Com

mun

ity-w

ide,

cul

tura

llyap

prop

riate

dia

bete

saw

aren

ess

and

educ

atio

npr

ogra

mm

es fa

cilit

ated

com

mun

ityw

ide.

Chu

rche

s an

dch

urch

gro

ups

H

omes

P

re-s

choo

ls a

nd e

arly

chi

ldho

od c

entr

es

W

orkp

lace

s

Vill

age

mee

tings

E

x-S

tude

nts

Ass

ocia

tions

Eth

nic-

spec

ific

spok

espe

rson

sw

ork

with

th

e he

alth

pr

omot

ion

sect

or

and

Auc

klan

d P

ublic

Hea

lth R

esou

rce

Ser

vice

(A

RP

HS

) to

edu

cate

and

inf

orm

Hea

lth

prom

otio

n se

ctor

, et

hnic

-sp

ecifi

c sp

okes

pers

ons,

he

alth

prom

otio

n se

ctor

, A

RP

HS

, M

inis

try

ofP

acifi

c Is

land

s A

ffairs

(M

PIA

), M

inis

try

of H

ealth

(M

oH),

Chu

rche

s, C

MD

HB

,he

alth

pro

vide

rs

26F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Pac

ific

com

mun

ities

on

diab

etes

and

on

a re

gula

r ba

sis

via

Pac

ific

radi

o an

d ne

wsp

aper

s.

Pos

itive

diab

etes

rol

e m

odel

s an

d st

orie

s ar

e co

llate

d an

ddi

strib

uted

aspa

rtof

edu

catio

n an

d em

pow

erm

ent.

Dia

bete

san

d di

abet

es-r

elat

edin

form

atio

n re

view

ed a

nd t

rans

late

din

toth

edi

ffere

nt P

acifi

c la

ngua

ges,

and

dis

trib

uted

thro

ugh

Pac

ific

netw

orks

Eth

nic-

spec

ific

guid

elin

es

for

man

agin

g di

abet

es

for

Pac

ific

peop

les

deve

lope

d. T

hey

incl

ude:

A d

iabe

tes

focu

sed

clin

ic

Hea

lthpr

omot

ion

T

rain

ing

man

uals

Rec

ogni

sed

trai

ning

pro

vide

rs

Pac

ific

chur

ches

and

hea

lthpr

omot

ion

expl

ore

oppo

rtun

ities

to

wor

k to

geth

erto

pr

omot

e an

d de

liver

he

alth

an

d ph

ysic

al

activ

ity

prog

ram

mes

to

th

eco

mm

uniti

es, w

ith th

e vi

ew to

bec

omin

ga

key

setti

ng fo

r se

rvic

e pr

ovis

ion.

Go

al:

Hea

lth

y,A

ctiv

eC

om

mu

nit

ies

Pac

ific

co

mm

un

itie

s ar

e h

ealt

hy,

ac

tive

and

vib

ran

tco

mm

un

itie

s.

Tar

get

: B

y 20

08 a

mea

sura

ble

in

crea

sein

hea

lth

yea

tin

g

and

ac

tive

lif

esty

les

by

Pac

ific

peo

ple

s in

Co

un

ties

Man

uka

u.

Pac

ific

com

mun

ityor

gani

satio

ns a

nd g

roup

sw

ork

with

AR

PH

S to

dev

elop

and

impl

emen

t cu

ltura

llyap

prop

riate

nut

ritio

ngu

idel

ines

tha

t pr

omot

e an

d su

ppor

the

alth

yea

ting.

The

se o

rgan

isat

ions

and

gro

ups

incl

ude:

Chu

rche

s an

dch

urch

gro

ups

H

omes

P

re-s

choo

l and

ear

ly c

hild

hood

edu

catio

n ce

ntre

s

Wor

kpla

ces

V

illag

em

eetin

gs

Ex-

Stu

dent

sA

ssoc

iatio

ns

Com

mun

ity o

rgan

isat

ions

and

grou

ps s

uppo

rted

by

heal

thpr

omot

ion

sect

or t

ode

velo

p an

dim

plem

ent

phys

ical

activ

itypr

ogra

mm

es

that

ar

e cu

ltura

llyap

prop

riate

and

age

-spe

cific

.

AR

PH

S,

Pac

ific

com

mun

ities

, he

alth

prom

otio

n se

ctor

Go

al:

Wo

rkfo

rce

Dev

elo

pm

ent

‘By

Pac

ific

fo

r P

acif

ic’

wo

rkfo

rce

dev

elo

pm

ent.

Pac

ific

co

mm

un

itie

s an

dC

MD

HB

sup

port

s an

d re

sour

ces

the

deve

lopm

ent

and

ongo

ing

deve

lopm

ent

of q

ualif

ied

Pac

ific

wor

kers

in

the

diab

etes

fie

ld,

incl

udin

g nu

rses

, do

ctor

s,C

MD

HB

, pro

vide

rs, M

anuk

au In

stitu

te

of T

echn

olog

y(M

IT)

27F

INA

L P

LA

N 0

2 F

ebru

ary

2005

CM

DH

Bw

ork

to

in

crea

se t

he

nu

mb

er o

f q

ual

ifie

dw

ork

ers

in t

he

dia

bet

es f

ield

tod

eliv

er t

o P

acif

ic c

om

mu

nit

ies.

Tar

get

:

Th

e n

um

ber

o

f P

acif

ic

nu

rses

,d

oct

ors

and

com

mu

nit

y w

ork

ers

wo

rkin

gin

Co

un

ties

Man

uka

u d

ou

ble

s b

y 20

10.

diet

icia

ns, c

omm

unity

wor

kers

and

oth

er n

eces

sary

prof

essi

ons.

Go

al:

Eva

luat

ion

Eva

luat

ion

id

enti

fies

su

cces

sfu

l st

rate

gie

san

d

sup

po

rts

a le

arn

ing

fr

amew

ork

th

atsu

pp

ort

s fu

nct

ion

alan

d

effe

ctiv

ep

artn

ersh

ips

and

act

ivit

ies.

Tar

get

: E

valu

atio

n f

ram

ewo

rk s

et u

pb

yJu

ly 2

005

Pac

ific

com

mun

ities

, M

anuk

au C

ity C

ounc

il(M

CC

) an

d C

MD

HB

wor

kw

ith t

heS

choo

l of

Pop

ulat

ion

Hea

lth(U

oA–S

oPH

) to

dev

elop

a fr

amew

ork

for

proc

ess

and

outc

omes

eva

luat

ion

of t

he a

gree

dac

tion

plan

s,w

ith t

he k

ey o

bjec

tive

bein

g to

sup

port

a le

arni

ng fr

amew

ork

and

effe

ctiv

e su

stai

nabl

e pa

rtne

rshi

ps.

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ific

com

mun

ities

, M

CC

, C

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oA-S

oPH

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e W

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ce

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lth

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e W

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Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

ers

Go

al:

Par

tner

ship

s

To

mo

rro

w’s

M

anu

kau

/Te

Ora

OM

anu

kau

/Man

uka

u

the

Hea

lth

yC

ity

Ou

tco

me

Gro

up

, w

ith

sup

po

rt

fro

mC

MD

HB

an

d

AR

PH

Sw

ork

effe

ctiv

ely

tog

eth

er t

o a

dvo

cate

for

init

iati

ves

wit

hin

thei

r o

wn

wo

rkp

lace

s th

at

pro

mo

te

and

sup

po

rt h

ealt

hy,

act

ive

lifes

tyle

s.

Tar

get

: B

yD

ecem

ber

2004

su

pp

ort

in

pri

nci

ple

fr

om

T

om

orr

ow

’s

Man

uka

u/T

eO

ra O

Man

uka

u/M

anu

kau

th

e H

ealt

hy

Cit

yO

utc

om

e G

rou

p.

Tom

orro

w’s

Man

ukau

T

e O

ra

O

Man

ukau

/Man

ukau

th

e H

ealth

y C

ityO

utco

me

Gro

up a

nd A

RP

HS

form

ally

agr

eeto

wor

k to

geth

er t

o ad

voca

tefo

rin

itiat

ives

with

in th

eir

own

wor

kpla

ce th

at p

rom

ote

and

supp

ort h

ealth

y, a

ctiv

elif

esty

les.

Tom

orro

w’s

Man

ukau

/Te

Ora

O

M

anuk

au/M

anuk

au

the

Hea

lthy

City

Out

com

e G

roup

, CM

DH

B, A

RP

HS

28F

INA

L P

LA

N 0

2 F

ebru

ary

2005

29F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Go

al:

Hea

lth

y, A

ctiv

e W

ork

pla

ces

To

mo

rro

w’s

M

anu

kau

/Te

Ora

O

M

anu

kau

/Man

uka

u

the

Hea

lth

y C

ity

Ou

tco

me

Gro

up

m

emb

ers

imp

lem

ent

init

iati

ves

wit

hin

th

e w

ork

pla

ce

that

p

rom

ote

an

d

sup

po

rt

hea

lth

y,

acti

ve

lifes

tyle

s.

Tar

get

: B

y Ju

ly 2

005

form

al a

gre

emen

t b

y in

div

idu

al

mem

ber

s o

f T

om

orr

ow

’s

Man

uka

u/T

e O

ra O

Man

uka

u/M

anu

kau

th

e H

ealt

hy

Cit

y to

in

tro

du

ce

hea

lth

y w

ork

pla

ce

po

licie

s,

wh

ere

they

d

o

no

t al

read

y ex

ist.

Tom

orro

w’s

M

anuk

au/T

e O

ra

O

Man

ukau

/Man

ukau

th

e H

ealth

y C

ity

Out

com

e G

roup

, with

sup

port

from

CM

DH

B a

nd A

RP

HS

wor

k to

geth

er to

in

trod

uce

initi

ativ

es w

ithin

thei

r ow

n w

orkp

lace

s th

at p

rom

ote

and

supp

ort

heal

thy,

act

ive

lifes

tyle

s.

Thi

s in

itiat

ive

is r

olle

d ou

t to

sim

ilar

inte

rsec

tora

l w

orki

ng g

roup

s in

the

P

apak

ura

and

Fra

nklin

Dis

tric

ts,

and

all

cent

ral

and

loca

l go

vern

men

t ag

enci

es in

Cou

ntie

s M

anuk

au.

In c

olla

bora

tion

with

the

Foo

d in

dust

ry A

ccor

d A

ctio

n A

rea,

the

foo

d in

dust

ry i

s en

cour

aged

and

sup

port

ed t

o in

trod

uce

heal

thy

eatin

g ac

tive

livin

g po

licie

s in

to it

s w

orkp

lace

s.

Tom

orro

w’s

M

anuk

au

Te

Ora

O

M

anuk

au/M

anuk

au

the

Hea

lthy

City

O

utco

me

Gro

up, A

RP

HS

Go

al:

Eva

luat

ion

Eva

luat

ion

o

f th

e ac

tivi

ty

will

b

e u

nd

erta

ken

w

ith

th

e o

bje

ctiv

e o

f id

enti

fyin

g

succ

essf

ul

hea

lth

y w

ork

pla

ce

pra

ctic

es a

nd

su

pp

ort

ing

lea

rnin

g a

cro

ss

org

anis

atio

ns.

Tar

get

:

By

July

20

05

an

eval

uat

ion

fr

amew

ork

is

in p

lace

wh

ich

will

su

pp

ort

p

roce

ss a

nd

ou

tco

me

eval

uat

ion

.

Tom

orro

w’s

M

anuk

au/T

e O

ra

O

Man

ukau

/Man

ukau

th

e H

ealth

y C

ity

Out

com

e G

roup

, C

MD

HB

an

d A

PH

RS

, w

orks

w

ith

the

Uni

vers

ity

of

Auc

klan

d S

choo

l of

P

opul

atio

n H

ealth

(U

oA

– S

oPH

) to

de

velo

p a

fram

ewor

k fo

r pr

oces

s an

d ou

tcom

es e

valu

atio

n of

the

agr

eed

actio

n pl

ans,

with

the

obje

ctiv

e of

sup

port

a le

arni

ng fr

amew

ork

and

an e

ffect

ive

sust

aina

ble

part

ners

hip.

Tom

orro

w’s

M

anuk

au/T

e O

ra

O

Man

ukau

/Man

ukau

th

e H

ealth

y C

ity

Out

com

e G

roup

, C

MD

HB

, A

RP

HS

, U

oA-

SoP

H

2. Promoting Behaviour Change Through Social

Marketing

Context

Beating obesity and diabetes will require a change in norms – of government, industry,community, family and individuals. Changing norms means changing environmentsand behaviour. The scale of change required will not occur without a substantialinvestment in the information and knowledge environment for all people in Counties Manukau.

Effective social marketing involves consistent messages reinforced in different waysand received from multiple trusted sources. In Counties Manukau that could meanmessages from sources such as kaumatua, church leaders, doctors, health workers, the local council and the media. The changes being promoted must also be relevant,practical, and achievable and deliver value when accomplished.

New Zealand experience shows that well constructed social marketing programmes are an effective and critical part of broad public health programmes. Examples includethe stop smoking campaigns, seatbelts, drink driving, and mental healthdestigmatisation. However, the obesity and diabetes message is far more complexthan these examples, and the difficulties are amplified by those most at risk being hard to reach through traditional social marketing avenues. The social marketing strategyfor Let’s Beat Diabetes will need to recognise these complexities and need to have suitable messages for different audiences and communities of interest. Ongoingevaluation of social marketing is required to assess whether it is being effective in changing knowledge, attitudes and behaviour.

A number of organisations have indicated their interest in supporting a broader social marketing strategy, including Manukau City Council (MCC) and the Food Group. Thereare also existing social marketing programmes by Sport and Recreation New Zealand(SPARC), the Heart Foundation and the Auckland Regional Public Health Service (ARPHS) which support healthy eating and/or active living. A marketing strategy tosupport the national Healthy Eating Healthy Action Framework is also being developed.It is prudent that Counties Manukau’s Let’s Beat Diabetes plan’s social marketingprogramme aligns with existing programmes.

Marketing is not just about selling an idea or service, effective marketing is based ondeveloping an intimate understanding of and relationship with, the customer so that thedesign of products and services meet customer needs and wants – and deliver value.

Programme Design

The social marketing programme design has a number of components to it:

1. The branding: The publicising and positioning the Let’s Beat Diabetes plan itself.The plan must develop a profile and be understood by community and health sectorleaders. We can not expect a broader audience to understand the detail of theplan, but the core concepts and key action strands should be known. The plan also needs to develop an emotional response and to represent hope and the ‘can-do’ Counties Manukau attitude. In response to these needs, it is proposed to develop an identity and profile for the plan that resonates with the Counties Manukaucommunity.



2. The social marketing programme: A comprehensive and integrated programme that runs for five years with the objective of changing knowledge, attitudes and behaviour towards nutrition and physical activity.

The plan will require support from market research to better understand the profile and issues for the Counties Manukau population. A professionally designed and executed marketing/information strategy will developed with alignment to activity by Health Promotion, Primary Care-based Prevention, Schools, Well Child and support from other sectors such as industry and local government.

A programme of evaluation is required to identify the impact of the strategy and provide direction for future developments.

The social marketing strategy must also fulfil the function of understanding the needs and wants of the people of Counties Manukau so that substantive issues such as health service design and access can be based on what the people want. This feedback process will guide service developments across all action areas of the Let’s Beat Diabetes plan.

FIN

AL

PL

AN

02

Feb

ruar

y 20

05

Act

ion

Pla

n

A w

ho

le s

yste

m c

om

mu

nic

atio

ns

pro

gra

mm

e ch

ang

es p

eop

le’s

beh

avio

ur.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

Th

eL

et’s

B

eat

Dia

bet

es

pla

nb

eco

mes

a m

oti

vati

on

al c

all

to a

ctio

n f

or

com

mu

nit

ies

and

o

rgan

isat

ion

sin

Co

un

ties

Man

uka

u.

Tar

get

: F

ebru

ary

– Ju

ly20

05 t

he

pla

n i

s m

arke

ted

acr

oss

ou

r co

mm

un

itie

s.

An

iden

tity

and

mar

ketin

g pl

an

for

the

Let’s

Bea

t D

iabe

tes

plan

its

elf

is

deve

lope

d an

d im

plem

ente

d.

Sum

mar

y ve

rsio

nsof

the

pla

n ar

ede

velo

ped

and

dist

ribut

ed,

alon

g w

ithpr

esen

tatio

nsan

d su

ppor

tive

med

ia

to

deve

lop

good

unde

rsta

ndin

g an

dsu

ppor

t fo

r th

e pl

an f

rom

lea

ders

ins

ide

Cou

ntie

s M

anuk

au a

nd a

t a

natio

nal

leve

l.

The

pla

n id

entit

y an

dpr

esen

tatio

n m

ust

be r

elev

ant

to a

nd m

otiv

atio

nal

for

Mao

ri an

d P

acifi

c pe

ople

s.

Cou

ntie

s M

anuk

au

Dis

tric

t H

ealth

Boa

rd (

CM

DH

B)

Go

al:

Aw

ell

dev

elo

ped

so

cial

mar

keti

ng

stra

teg

y is

su

stai

ned

ove

r fi

veye

ars

and

inte

gra

ted

wit

h w

ider

pla

no

bje

ctiv

es.

Kn

ow

led

ge,

at

titu

des

and

b

ehav

iou

rch

ang

es

as

a re

sult

o

f a

five

-yea

rco

mp

reh

ensi

ve

soci

al

mar

keti

ng

pro

gra

mm

e.

The

go

vern

ance

gr

oup

deve

lops

a

com

mer

cial

re

latio

nshi

pw

ithsu

rvey

/eva

luat

ion

and

com

mun

icat

ion

prof

essi

onal

s to

de

vise

,de

velo

p,im

plem

ent a

nd e

valu

ate

a co

mpr

ehen

sive

five

-yea

r so

cial

mar

ketin

g st

rate

gy.

Tar

get

s:

S

eco

nd

h

alf

2005

th

e m

edia

asp

ect

of

the

soci

al m

arke

tin

g p

rog

ram

me

beg

ins.

Mea

sura

ble

ch

ang

e in

kn

ow

led

ge

atti

tud

es a

nd

beh

avio

ur

(act

ual

mea

sure

sye

t to

be

dev

elo

ped

).

A g

over

nanc

egr

oup

is s

et u

p to

gui

de t

he d

evel

opm

ent

of a

soc

ial m

arke

ting

prog

ram

me

that

is

lin

ked

with

th

e br

oade

r st

rate

gies

of

th

e Le

t’s

Bea

tD

iabe

tes

plan

,is

res

pons

ive

to n

eeds

of

Mao

ri an

d P

acifi

c pe

ople

san

d al

igns

with

the

natio

nalH

ealth

y E

atin

g H

ealth

y A

ctio

n st

rate

gies

.

The

str

ateg

y in

clud

es th

e fo

llow

ing

com

pone

nts:

Sur

veys

to

crea

te a

bas

elin

e an

d to

inf

orm

the

dev

elop

men

t of

a f

ive

year

soc

ial m

arke

ting

stra

tegy

.

Str

ateg

y im

plem

ente

dw

ithsu

ppor

t fr

om

mul

tiple

or

gani

satio

ns

and

whi

ch is

inte

grat

edw

ith o

ther

com

pone

nts

of th

e br

oade

r pl

an.

Ong

oing

eval

uatio

n un

dert

aken

to

in

form

an

d im

prov

e pr

ogra

mm

ede

sign

.

CM

DH

B,

MC

C,

Min

istr

yof

H

ealth

(MoH

),

SP

AR

C,

PH

AR

MA

C,

Foo

d gr

oup,

P

rimar

y H

ealth

O

rgan

isat

ions

(PH

Os)

, N

on-G

over

nmen

tO

rgan

isat

ions

(N

GO

s)

Go

al:

H

ealt

h

serv

ices

im

pro

ve

thei

rp

erfo

rman

ce

thro

ug

h

hav

ing

b

ette

rkn

ow

led

ge

of

pat

ien

t n

eed

s an

d is

sues

.

Tar

get

:

By

Oct

ob

er20

06

init

ial

surv

eyco

mp

lete

d.

Sur

vey

on s

ocia

l mar

ketin

g is

sues

als

o se

ek a

n un

ders

tand

ing

of w

ider

heal

thse

rvic

e is

sues

and

are

used

to

info

rm d

ecis

ions

on

serv

ice

desi

gnac

ross

the

Ten

Act

ion

area

s of

the

Let’s

Bea

t Dia

bete

s pl

an.

Soc

ial m

arke

ting

prov

ider

, CM

DH

B

32

3. Changing Urban Design to Support Healthy, Active

Lifestyles

Context

Urban design influences the physical environment (such as road and parks), the service environment (such as shops and public transport) and the social environment (such as social cohesion and community safety) (Kawachi I, 2003). Urban environments also impact on ourlifestyle choices and decisions, and subsequently our health and risk of disease. A key issue for the health sector is to ensure urban design in Counties Manukau encourages and supports physical activity, and provides access to medical facilities.

In recent decades, the predominant urban residential design globally, as well as in Counties Manukau has been towards suburban, car-based living. This suburban lifestyle brought largersections and low density living which has been considered desirable. There have also beendownsides with traffic jams, social isolation, poor public transport, community safety concerns,poor access to many service amenities (except by car) and less opportunity for daily physical activity.

There is good evidence to show that good urban design can increase physical activity.Germany and the Netherlands have implemented a wide range of policies over the past two decades that have simultaneously encouraged walking and cycling while dramatically loweringpedestrian and bicyclist fatalities and injuries and keeping auto use at only half the Americanlevel (Pucher J, 2003). Urban environments also impact on community life, which influencesperceptions of safety, leading to concerns over children walking to school or walking andjogging for exercise.

Changing urban design is difficult because of the expensive and permanent nature of basic infrastructure. It is also very slow.

A number of initiatives are already under way. Manukau City Council (MCC) and otherstakeholders are supportive of the priorities identified in the Auckland Regional Growth Strategy and the Urban Design Protocols which will address active transport provision, injury preventionmeasures and availability of public transport in city and urban design. Healthy urban designconcepts also encourage ‘liveable cities that support social wellbeing, quality of life and culturalidentities’, which is one of the key government outcomes in the sustainable cities component of the national Sustainable Development Programme of Action. Manukau City along withInfrastructure Auckland has invested in the development of cycle-ways across the district aspart of the cycling/walking strategy.

Programme Design

MCC is demonstrating healthy urban design concepts in the Flat Bush development. Flat Bush will be a new town of more than 40,000 people. The development will not be another sprawling suburb, but is being designed to be a ‘town’, with a town centre, extensive parkland, cycleways, local shopping centres and green fingers of protected stream-ways running through theresidential areas. MCC also intends to introduce urban design concepts that support moreactive, connected and healthy communities as it redevelops the various urban hubs and town centres in the district. Introducing these new concepts in the urban hubs represents new



design priorities for MCC and reflects their commitments to healthy city and sustainable city ideals.

CMDHB and Auckland Regional Public Health Service (ARPHS) will work in partnership with MCC, providing health advice and expertise, where required for urban design planning.

Act

ion

Pla

n

Th

e u

rban

en

viro

nm

ent

in C

ou

nti

esM

anu

kau

su

pp

ort

s in

crea

sed

ph

ysic

al a

ctiv

ity

leve

lsan

d im

pro

ved

so

cial

co

hes

ion

.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

S

ust

ain

able

ap

pro

ach

es

to

sup

po

rtin

gh

ealt

hy

urb

an

des

ign

ar

e d

evel

op

ed

and

imp

lem

ente

d

in

par

tner

ship

wit

h

Man

uka

u

Cit

yC

ou

nci

l (M

CC

), P

apak

ura

Dis

tric

t C

ou

nci

l (P

DC

) an

d F

ran

klin

Dis

trci

t C

ou

nci

l (F

DC

).

Tar

get

:

By

2005

C

MD

HB

an

d

MC

C

sig

n

the

Min

istr

y fo

r th

e E

nvi

ron

men

t sp

on

sore

d

Urb

anD

esig

n p

roto

col,

wh

ich

is

a co

mp

on

ent

of

the

Su

stai

nab

le C

itie

s n

atio

nal

stra

teg

ic in

itia

tive

.

MC

C a

ndC

MD

HB

sig

n th

eM

inis

try

for

the

Env

ironm

ent

spon

sore

dur

ban

desi

gn p

roto

col,

whi

ch i

s co

mpo

nent

of

the

Sus

tain

able

Citi

esin

itiat

ive.

CM

DH

B s

uppo

rts

MC

C,

FD

C a

ndP

DC

in

anal

ysis

and

plan

ning

proc

esse

s to

im

plem

ent

urba

n de

sign

whi

ch

prom

otes

he

alth

ylif

esty

les

and

acce

ssib

le h

ealth

ser

vice

s.

MC

C, C

MD

HB

, AR

PH

S, P

DC

, FD

C

Go

al:

F

lat

Bu

sh

dev

elo

pm

ent

wit

h

imp

rove

dh

ealt

hy

des

ign

co

nce

pts

co

ntr

ibu

tes

to i

ncr

ease

dp

hys

ical

act

ivit

y o

f re

sid

ents

.

Tar

get

E

nh

ance

d

safe

wal

kin

g

and

cy

clin

go

pp

ort

un

itie

s ar

e in

tro

du

ced

in

to

Fla

t B

ush

dev

elo

pm

ent.

MC

C d

evel

ops

over

all d

esig

nco

ncep

ts a

nd p

rovi

des

publ

icam

eniti

esw

hich

sup

port

hea

lthy

urba

nde

sign

in F

latB

ush.

MC

C d

evel

ops

spec

ifica

tions

for

priv

ate

deve

lope

rsw

hich

ensu

reth

at t

he h

ealth

y ur

ban

desi

gn c

once

pts

are

take

n up

in

com

mer

cial

deve

lopm

ents

thro

ugho

ut th

e F

lat B

ush

area

.

CM

DH

B

prov

ides

M

CC

, P

DC

an

d F

DC

with

a re

view

of

the

inte

rnat

iona

l lite

ratu

re a

s it

rela

tes

to h

ealth

yur

ban

envi

ronm

ents

.

CM

DH

Bw

orks

with

MC

C t

o de

velo

pa

plan

for

the

hea

lth f

acili

tyan

dse

rvic

e in

fras

truc

ture

for

the

Fla

t Bus

h de

velo

pmen

t.

MC

C, A

RP

HS

, CM

DH

B, P

DC

, FD

C

Go

al:

In

crea

sed

p

hys

ical

ac

tivi

ty

leve

ls

and

soci

al

coh

esio

n

are

sup

po

rted

by

the

red

evel

op

men

t o

f ex

isti

ng

urb

an h

ub

s an

d t

ow

nce

ntr

es.

Tar

get

: D

etai

led

rev

iew

an

d r

edev

elo

pm

ent

pla

ns

for

at

leas

to

ne

urb

an

hu

b

in

a lo

w

soci

o-

As

Cou

ncils

unde

rtak

e re

deve

lopm

ent

activ

ities

for

exi

stin

g ur

ban

infr

astr

uctu

re,

the

appr

oach

will

be g

uide

d by

new

prio

ritie

sfo

r ur

ban

desi

gns

whi

ch in

crea

se p

hysi

cal a

ctiv

ityan

d so

cial

coh

esio

n.

CM

DH

Bw

ill a

dvoc

ate

to M

CC

, P

DC

and

FD

C o

n a

case

by

case

basi

s to

pro

vide

evi

denc

e an

d an

alys

is th

at w

ill s

uppo

rthe

alth

yur

ban

desi

gn,

whi

chin

clud

es a

dequ

ate

and

acce

ssib

le c

omm

unity

hea

lth

MC

C, F

DC

, PD

C, C

MD

HB

, AR

PH

S

35F

INA

L P

LA

N 0

2 F

ebru

ary

2005

36F

INA

L P

LA

N 0

2 F

ebru

ary

2005

eco

no

mic

are

a.

faci

litie

s,

publ

ic

open

sp

ace

and

com

mun

ity

faci

litie

s,

safe

ty

and

incr

ease

d op

port

uniti

es fo

r ph

ysic

al a

ctiv

ity.

Go

al:

MC

C a

nd

CM

DH

B s

up

po

rt h

ealt

hy

urb

an

des

ign

th

rou

gh

p

lan

nin

g,

imp

lem

enta

tio

n

and

ev

alu

atio

n

par

tner

ship

s in

F

lat

Bu

sh

dev

elo

pm

ent.

Tar

get

:

By

July

20

05

ther

e is

ag

reem

ent

for

eval

uat

ion

fo

r th

e F

lat

Bu

sh d

evel

op

men

t w

ith

th

e U

niv

ersi

ty

of

Au

ckla

nd

S

cho

ol

of

Po

pu

lati

on

H

ealt

h (

Uo

A-S

oP

H)

CM

DH

B,

MC

C a

nd t

he U

nive

rsity

of

Auc

klan

d S

choo

l of

Pop

ulat

ion

Hea

lth (

UoA

–SoP

H)

wor

k to

dev

elop

an

eval

uatio

n fr

amew

ork

for

the

Fla

t Bus

h de

velo

pmen

t and

ong

oing

urb

an r

edes

ign

initi

ativ

es.

MC

C,

FD

C,

PD

C,

CM

DH

B,

AR

PH

S,

UoA

S

oPH

4. Supporting a Healthy Environment Through a Food

Industry Accord

Context

Changes to the food environment have been a major contributor to the current obesity epidemic (Critser G, 2003) The food environment during pregnancy, childhood, adolescence and adult life all contributes to health and can cause disease. The food environment also amplifies the issues of disparity in diabetes rates in our society. Generally, people who have high incomes eat food that is higher in nutrients and lower in fats and carbohydrates. People who have low incomes tend to eat low-cost high-fat/high-sugar/high-salt take-away foods more often than is considered ‘healthy’. Children from families with lower incomes are also less likely to eat a proper breakfast at home and a nutritious lunch at school (FAO/WHO Expert Consultation,2003; Barnfather D, 2004; Ministry of Health, 2003).

The current ‘obesogenic’ food environment is a global issue, with governments from manycountries and international agencies like the World Health Organisation looking at how to makechanges to protect populations from poor diets. Strategies being investigated includeregulation of aspects of food industry behaviour and more collaborative approaches with industry seeking voluntary changes to commercial behaviour.

Industry itself has identified that its customers are seeking healthier food and that there is an obligation for responsible corporates to work with health agencies to develop an overall healthier food environment to reduce population obesity and subsequent disease.

Representatives of major food producers and retailers in New Zealand signed the Food Industry Accord in September 2004, which commits the signatories to supporting the Ministry ofHealth’s Healthy Eating Healthy Action Framework, and recommends that a pilot of theAccord’s activities is instigated in the Auckland Region (New Zealand Food Industry Accord2004). Counties Manukau Distrcit Health Board (CMDHB) and representatives of the foodindustry have agreed to collaborate to undertake a ‘demonstration pilot’ of the Food Industry Accord in Counties Manukau.

Programme Design

The Counties Manukau food industry ‘demonstration pilot’ represents a number of major foodorganisations working together with the health sector for a common health objective.

The initial component of programme design is to develop a set of trusting and functionalrelationships, which acknowledge the unique nature of the collaboration and identify ways to deliver real improvements to the food environment.

A collaborative working group will be set up which includes representatives from industry,CMDHB, the Auckland Regional Public Health Service (ARPHS) and Manukau City Council (MCC) in the first instance. Others groups may join at a later date.

The food industry has identified a number of Action Areas it is interested in supporting, namely: Community Leadership and Action; Social Marketing; Food Accord; Schools; and VulnerableFamilies



Specific practical activities will be developed in each of these areas. As the relationships and programmes mature, it would be expected that a wider range of food industry partners would join the collaborative group.

It is proposed that the food industry group be represented on the wider governance group for the Let’s Beat Diabetes plan.

Evaluation of the strategies will need to be undertaken for process and outcomes to ensure that all parties are informed of performance and value issues associated with the collaboration. The objective is to develop a learning environment which supports continuous quality improvement methodology and measures the effectiveness of this new partnership.

FIN

AL

PL

AN

02

Feb

ruar

y 20

05

Act

ion

Pla

n

Th

e fo

od

en

viro

nm

ent

in C

ou

nti

es M

anu

kau

ch

ang

es t

o in

crea

se h

ealt

hy

foo

d a

vaila

bili

ty a

nd

co

nsu

mp

tio

np

arti

cula

rly

for

fam

ilies

wit

h lo

w in

com

es a

nd

hig

h r

isk

of

dia

bet

es.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

Th

e fo

od

in

du

stry

an

d c

om

mu

nit

ies

of

inte

rest

wo

rk e

ffec

tive

ly t

og

eth

er t

o d

esig

n a

nd

del

iver

ob

esit

y-re

du

cin

g s

trat

egie

s.

Tar

get

: B

y 20

07 t

he

Fo

od

Gro

up

will

hav

e sh

ow

nth

at e

ffec

tive

co

llab

ora

tive

act

ivit

ies

can

occ

ur

and

oth

er D

istr

ict

Hea

lth

Bo

ard

sw

ill s

eek

to j

oin

the

Fo

od

Ind

ust

ryA

cco

rd in

itia

tive

s.

CM

DH

B,

AR

PH

S,

MC

C a

ndth

e F

ood

Gro

up f

orm

aw

orki

nggr

oup

that

will

lea

dth

e ‘F

ood

Indu

stry

’ act

ivity

are

a of

the

Let’s

Bea

t Dia

bete

spl

an.

Foo

d in

dust

ryre

pres

enta

tion

is i

nclu

ded

on t

heLe

t’s B

eat

Dia

bete

s G

over

nanc

eG

roup

.

CM

DH

B, F

ood

Gro

up, A

RP

HS

, MC

C

Go

al:

Th

e av

erag

e p

er c

apit

a en

erg

y in

take

of

the

Co

un

ties

Man

uka

u p

op

ula

tio

nd

ecre

ases

as

a re

sult

of

the

Fo

od

Ind

ust

ryA

cco

rd in

itia

tive

s.

Tar

get

: B

yJu

ly 2

005

spec

ific

str

ateg

ies

to b

ed

evel

op

ed i

n e

ach

of

the

five

id

enti

fied

act

ion

area

s (t

arg

et t

o b

e u

pd

ated

at t

hat

sta

ge)

.

The

food

wor

king

gro

up im

plem

ents

pra

ctic

al s

trat

egie

s in

the

area

s of

:

C

omm

unity

Lead

ersh

ip

Soc

ialM

arke

ting

F

ood

Acc

ord

S

choo

ls

Vul

nera

ble

Fam

ilies

The

se s

trat

egie

s ar

e to

be

deve

lope

d an

dim

plem

ente

din

a c

olla

bora

tive

man

ner.

At

the

time

of w

ritin

g th

e de

velo

pmen

t of

the

spe

cific

str

ateg

ies

is a

t a

very

early

stag

e an

dw

ill b

e co

mpl

eted

dur

ing

the

first

six

mon

ths

of 2

005.

Foo

d G

roup

, MC

C, C

MD

HB

, AR

PH

S,

Go

al:

E

valu

atio

n

of

the

foo

d

ind

ust

ryre

lati

on

ship

an

d

acti

vity

d

evel

op

s an

den

viro

nm

ent

of

tru

st

and

o

ng

oin

g

evid

ence

-b

ased

ac

tivi

ties

to

im

pro

ve

the

foo

den

viro

nm

ent.

Tar

get

: B

y Ju

ly 2

005

an e

valu

atio

n f

ram

ewo

rk is

in

pla

cew

hic

hw

ill s

up

po

rt p

roce

ssan

d o

utc

om

eev

alu

atio

n.

The

food

wor

king

grou

pw

orks

with

the

Uni

vers

ity o

f Auc

klan

d S

choo

lof P

opul

atio

nH

ealth

(U

oA –

SoP

H)

to d

evel

op a

fra

mew

ork

for

proc

ess

and

outc

ome

eval

uatio

nof

the

agr

eed

actio

n pl

ans

with

the

obj

ectiv

e of

sup

port

ing

a le

arni

ng f

ram

ewor

kan

d an

effe

ctiv

e su

stai

nabl

e re

latio

nshi

p.

CM

DH

B, F

ood

Gro

up, U

oA -

SoP

H

39

5. Strengthening Health Promotion Co-ordination and

Activity

Context

Health promotion in Counties Manukau is a small sector with many providers and multiplefunders. The diversity of providers is a strength, with organisations establishing strong relationships with their local communities to deliver well targeted programmes. Many providers deliver population based services as well as personal health services such as health education.

The health promotion environment is also somewhat fragmented, with low levels ofcommunication between funders leading to poor alignment of funding streams and strategic objectives. Health promotion funders include Ministry of Health (MoH), Counties ManukauDistrict Health Board (CMDHB), Manukau City Council (MCC) and Primary HealthOrganisations (PHOs). Providers operate in an environment where there is often limitedknowledge of each other’s activities and there is not a long term view about capacity development across the sector.

There is a history of broad collaboration associated with Te Ora O Manukau/Manukau theHealth City and more recently the Tomorrow’s Manukau Health and Wellbeing Outcome Group,which provides an umbrella forum for health and social service organisations. At a morespecific level, CODA (Community Organisations working together) has acted as a network forhealth promotion organisations with an interest in diabetes.

Recently PHOs have begun to receive funding for health promotion and the Counties Manukau PHOs have agreed to a charter that will see coordination of health promotion activity acrossPHOs.

Maori and Pacific communities would like to see the strengthening of health promotionproviders and programmes that work within a cultural framework of ‘by Maori for Maori’ and ‘byPacific for Pacific’. The Pacific communities also support ethnic-specific programmes within the broader Pacific community, especially church-based programmes.

The development of effective health promotion programmes for Asian and new settler communities is a challenge given the range of languages, cultures and community structureshealth promoters must work within.

The overall health sector expenditure in health promotion is low despite good evidence from multiple sources that investment in effective health promotion delivers good returns compared to other parts of the health sector.

Programme Design

The programme design is a direct response to the issues raised by health promotion providersand community leaders at a series of workshops, hui and fono held in Counties Manukau. They include:

Funder Alignment: the need to ensure there is communication and strategic alignment between funders as it applies to programme priorities and design, and also to long-termviews about building the capacity of the health promotion sector.



Workforce Capacity: the need to identify the workforce development requirements for health promotion providers, and put in place a sustainable system to develop a new heath promotion workforce and grow the skills in the existing workforce.

Communications & Resources: the need to review the quality, accessibility and suitability of resources being used by health promotion providers as they relate to diabetes prevention and management; and to develop new resources as required, and ensure all providers are aware of existing resources.

Networking & Aligned Activity: the need to develop an effective process for networking health promotion providers so there is a forum for raising and resolving common issues, aligning programmes and communicating with one voice to funders. It is important to maintain communication between the PHO services and other health promotion providers.

Health promotion needs to fulfill a role of being the glue that holds many parts of the plan together, which can only be achieved through improved provider capacity and whole system coordination. Let’s Beat Diabetes will strengthen health promotion providers, support existing partnerships and create new ones to encourage more effective cross sector activity.

The sector acknowledges that all actions must be culturally responsive to the needs and aspirations of Maori, Pacific peoples, Asians and other ethnic groups. To this end ethnic groups and communities of interest will be involved in all aspects of design, development, implementation and evaluation, including strengthening of programmes that work within a cultural framework of ‘by Maori for Maori’ and ‘by Pacific for Pacific’.

Act

ion

Pla

n A v

ibra

nt,

ski

lled

an

d c

o-o

per

ativ

e h

ealt

h p

rom

oti

on

sec

tor

that

wo

rks

effe

ctiv

ely

wit

h a

ll g

rou

ps

and

in a

ll se

ttin

gs

to r

edu

ce t

he

inci

den

ce a

nd

imp

act

of

dia

bet

es a

nd

hea

lth

ineq

ual

itie

s.A

ll ac

tions

mus

t be

cultu

rally

res

pons

ive

to th

e ne

eds

and

aspi

ratio

ns o

f Mao

ri, P

acifi

c pe

ople

s, A

sian

s an

d ot

her

ethn

ic g

roup

s. T

o th

is e

nd, M

aori,

P

acifi

c pe

ople

s, A

sian

s an

d ot

her

ethn

ics

grou

ps w

ill b

e in

volv

ed in

all

face

ts o

f des

ign,

dev

elop

men

t and

impl

emen

tatio

n.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

ers

Go

al:

Fu

nd

er A

lign

men

t

A

mo

rep

rod

uct

ive

and

su

stai

nab

leen

viro

nm

ent

for

effe

ctiv

eh

ealt

h p

rom

oti

on

is

crea

ted

th

rou

gh

b

ette

r co

llab

ora

tio

nb

etw

een

fu

nd

ing

ag

enci

es.

Tar

get

:

Fu

nd

er

agre

emen

t o

n

Let

’s

Bea

td

iab

etes

fu

nd

ing

in

itia

tive

s fo

r h

ealt

hp

rom

oti

on

by

May

200

5.

Hea

lth P

rom

otio

n fu

nder

san

d ot

her

rele

vant

org

anis

atio

ns m

eet

at l

east

tw

ice

aye

ar a

s a

grou

p to

dis

cuss

issu

es, p

erfo

rman

ce,s

trat

egie

s, p

rogr

amm

e de

sign

and

fund

ing

allo

catio

ns in

ord

er t

o de

velo

p an

alig

ned

and

effic

ient

fun

ding

fra

mew

ork

for

all h

ealth

pro

mot

ion

prov

ider

s in

Cou

ntie

s M

anuk

au.

CM

DH

B d

evel

ops

its f

undi

ng s

trat

egie

s fo

rLe

t’s B

eat

Dia

bete

s in

col

labo

ratio

nw

ith o

ther

fun

ders

to

iden

tify

syne

rgie

s,re

duce

ove

rlap

and

ensu

re f

unds

are

use

def

ficie

ntly

.

A c

ross

fund

erpl

an is

dev

elop

ed fo

r Le

t’s B

eat D

iabe

tes

that

incl

udes

budg

ets

and

serv

ice

obje

ctiv

es.

CM

DH

B, M

oH, S

PA

RC

, MC

C, P

HO

s

Go

al:

Par

tner

ship

s

CO

DA

and

th

e P

HO

H

ealt

h

Pro

mo

tio

nW

ork

ing

Gro

up

wo

rk e

ffec

tive

ly t

og

eth

er t

o

ove

rsee

to

im

ple

men

tati

on

of

this

pla

n o

fac

tio

n

in

colla

bo

rati

on

wit

h

MC

C

and

To

mo

rro

w’s

M

anu

kau

/Te

Ora

O

M

anu

kau

/Man

uka

u t

he

Hea

lth

y C

ity

Ou

tco

me

Gro

up

.

Tar

get

: C

on

trac

t to

su

pp

ort

h

ealt

hp

rom

oti

on

cap

acit

y in

pla

ce b

y Ju

ne

2005

.

The

CO

DA

hea

lthpr

omot

ion

foru

m a

nd P

HO

HP

WG

wor

k to

geth

er t

o ov

erse

e th

esu

cces

sful

im

plem

enta

tion

of t

his

plan

of

actio

n, i

n co

llabo

ratio

nw

ith T

omor

row

’sM

anuk

au/T

e O

ra O

Man

ukau

/Man

ukau

the

Hea

lthy

City

Out

com

e G

roup

,

CM

DH

B e

xplo

res

oppo

rtun

ities

for

a h

ealth

pro

mot

ion

prov

ider

to

take

a m

ore

activ

e ro

le

to

supp

ort

the

netw

orki

ngan

dad

min

istr

atio

n re

quire

d fo

r th

e pa

rtne

rshi

pap

proa

ch a

nd th

e ca

paci

ty b

uild

ing

aspe

cts

of th

e pl

an.

A r

epre

sent

ativ

e fr

om th

e he

alth

pro

mot

ion

part

ners

hip

grou

p si

ts o

n th

e Le

t’s B

eat

Dia

bete

sG

over

nanc

e G

roup

.

Dia

bete

s P

roje

cts

Tru

st,

CO

DA

, P

HO

H

PW

G,T

omor

row

’s M

anuk

au/T

e O

ra O

Man

ukau

/Man

ukau

th

e H

ealth

yC

ityO

utco

me

Gro

up, A

RP

HS

CM

DH

B

Go

al:

Wo

rkfo

rce

Cap

acit

y

Hea

lth

Pro

mo

tio

nw

ork

forc

e is

div

erse

an

dh

igh

ly

skill

ed,

and

p

rovi

des

ef

fect

ive,

Con

sulta

tion

and

need

s as

sess

men

t –

iden

tify

a nu

mbe

r of

rol

es t

hat

peop

lepe

rfor

m in

heal

th p

rom

otio

n an

des

tabl

ish

wha

t ty

pe o

f sk

ills

thes

e ro

les

need

and

Dia

bete

s P

roje

cts

Tru

st,

CO

DA

, P

HO

H

PW

G,T

omor

row

’s M

anuk

au/T

e O

ra O

42F

INA

L P

LA

N 0

2 F

ebru

ary

2005

cult

ura

lly

resp

on

sive

h

ealt

h

pro

mo

tio

n

top

eop

le f

rom

all

eth

nic

gro

up

s.

Tar

get

: C

on

trac

t to

su

pp

ort

h

ealt

hp

rom

oti

on

cap

acit

y in

pla

ce b

y Ju

ne

2005

.

whe

ther

peo

ple

have

or

can

easi

lyga

in th

ese

skill

s.

Cur

ricul

um –

iden

tify

or d

evel

op a

cur

ricul

umfo

r ea

ch o

f the

se r

oles

.

Tra

inin

g –

sour

ce t

rain

ing

for

each

of

thes

e ro

les

incl

udin

g tr

aini

ng t

hat

allo

ws

peop

le to

mov

e be

twee

n ro

les

of d

iffer

ent s

kill

leve

ls a

nd tr

aini

ng to

mai

ntai

n sk

ills.

Adv

ocat

e to

ens

ure

that

fun

ding

is a

vaila

ble

for

peop

le t

o at

tend

tra

inin

g.D

evel

opex

istin

g he

alth

pr

omot

ion

educ

atio

n pr

ogra

mm

es

to

acco

mm

odat

eLe

t’s

Bea

tD

iabe

tes

wor

kfor

ceco

mpe

tenc

ies.

Rec

ogni

tion

– en

sure

that

peo

ple

who

und

erta

ketr

aini

ngre

ceiv

ere

cogn

ition

of t

his

trai

ning

from

em

ploy

ers

such

as D

HB

s, P

HO

s an

d N

GO

s

Spe

cial

ist

skill

s –

reco

gnis

e th

at m

ost

orga

nisa

tions

will

not

be

able

to

empl

oype

ople

with

all

spec

ialis

t sk

ills.

E

nsur

e pe

ople

with

spe

cial

ski

lls a

re k

now

n ab

out

and

avai

labl

eto

pro

vide

adv

ice.

Spe

cial

ist

skill

s m

ayin

clud

e cu

ltura

l sk

ills

for

wor

king

with

Mao

ri, P

acifi

c pe

ople

san

dot

her

ethn

ic g

roup

s, e

valu

atio

n, I

T,

and

med

ia s

kills

etc

.

Man

ukau

/Man

ukau

th

e H

ealth

yC

ityO

utco

me

Gro

up, A

RP

HS

, CM

DH

B

Go

al:

Net

wo

rkin

g &

Alig

nm

ent

Hea

lth

Pro

mo

tio

n e

nvi

ron

men

t an

d a

ctiv

ity

is

co-o

rdin

ated

an

d

focu

sed

,w

ork

ing

tow

ard

s a

shar

edvi

sio

n.

Tar

get

:

Co

ntr

act

to

sup

po

rth

ealt

hp

rom

oti

on

cap

acit

y in

pla

ce b

y Ju

ne

2005

.

Web

site

– d

evel

op a

nd m

aint

ain

aw

ebsi

tew

here

gro

ups

can

shar

e in

form

atio

non

activ

ities

an

d ev

ents

, tr

aini

ng

oppo

rtun

ities

, hu

man

an

dph

ysic

al

reso

urce

s,re

sear

ch i

nfor

mat

ion

etc.

Li

nk t

o T

omor

row

’s M

anuk

auan

dot

her

agen

cies

web

site

s w

here

appr

opria

te.

Mee

tings

–

esta

blis

h a

min

imum

nu

mbe

rof

fo

rum

s th

at

mee

t th

e ne

eds

ofor

gani

satio

ns (

qual

ity f

orum

s, in

form

atio

n sh

arin

g)w

orki

ngin

the

fie

ld a

nd e

nsur

eth

at t

hey

are

run

effe

ctiv

ely

and

thei

r de

cisi

ons

are

diss

emin

ated

to

all

inte

rest

edpa

rtie

s.B

uild

ing

trus

t be

twee

n or

gani

satio

ns –

fos

ter

co-o

pera

tion

betw

een

orga

nisa

tions

byen

surin

g in

divi

dual

s ca

nm

eet

and

wor

k to

geth

er a

nd d

evel

opin

ga

set

ofm

utua

llyag

reed

gro

und

rule

s.

Key

coo

rdin

ator

s –

iden

tify

a nu

mbe

r of

indi

vidu

als

who

can

act

as

key

peop

le f

orho

ldin

g an

d sh

arin

g in

form

atio

n in

spe

cific

top

ic a

reas

(e.

g. s

choo

ls/y

outh

, M

arae

, ph

ysic

al a

ctiv

ity, G

P, e

tc).

Dia

bete

s P

roje

cts

Tru

st,

CO

DA

, P

HO

H

PW

G,T

omor

row

’s M

anuk

au/T

e O

ra O

Man

ukau

/Man

ukau

th

e H

ealth

yC

ityO

utco

me

Gro

up,

AR

PH

S,

Hea

lthpr

ovid

ers,

CM

DH

B

43F

INA

L P

LA

N 0

2 F

ebru

ary

2005

44F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Go

al:

Co

mm

un

icat

ion

& R

eso

urc

es

Key

mes

sag

es a

rou

nd

dia

bet

es p

reve

nti

on

to

b

e ev

iden

ce

bas

ed

and

ef

fect

ivel

y an

d

con

sist

entl

y d

isse

min

ated

.

Tar

get

:Co

ntr

act

to s

up

po

rt h

ealt

h p

rom

oti

on

ca

pac

ity

in p

lace

by

Jun

e 20

05.

Key

mes

sage

s–

deve

lop

a gr

oup

that

can

ide

ntify

and

upd

ate

key

mes

sage

s fo

r di

abet

es r

elat

ed h

ealth

pro

mot

ion

for

the

regi

on.

Ens

ure

that

the

se m

essa

ges

are

diss

emin

ated

to th

ose

who

will

use

them

.

Res

ourc

es –

iden

tify

or f

und

and

deve

lop

a ra

nge

of a

ppro

pria

te (

pref

erab

ly lo

cally

de

velo

ped

or e

valu

ated

) re

sour

ces

that

inc

lude

the

key

mes

sage

s.

Ens

ure

thes

e re

sour

ces

are

used

by

effe

ctiv

e di

ssem

inat

ion

and

havi

ng a

reg

iste

r of

res

ourc

es.

Oth

er s

ecto

rs –

ens

ure

that

the

str

ateg

ies

and

activ

ity o

f th

e he

alth

pro

mot

ion

sect

or is

com

mun

icat

ed to

oth

er a

reas

of t

he h

ealth

sec

tor

(prim

ary

and

seco

ndar

y ca

re)

and

othe

r re

leva

nt s

ecto

rs th

roug

h ke

y id

entif

ied

cont

acts

.

CM

DH

B,

Spe

cial

ists

, P

HO

s,

Non

-G

over

nmen

t O

rgan

isat

ions

(N

GO

s),

MoH

, C

OD

A,

AR

PH

S,

Dia

bete

s A

uckl

and

6. Enhancing Well Child Services to Reduce Childhood

Obesity

Context

‘A life-course perspective is essential for the prevention and control of non-communicablediseases. This approach starts with maternal health and prenatal nutrition, pregnancyoutcomes, exclusive breastfeeding for six months, and child and adolescent health; reacheschildren at schools, adults at worksites and other settings, and the elderly; and encourages a healthy diet and regular physical activity from youth into old age’ (WHO, 2004).

The World Health Organisation’s (WHO) Global Strategy on Diet, Physical Activity andHealth acknowledges the importance of a life course approach in beating chronicdiseases like diabetes. A life course approach starts with maternal health and thecritical early years of life. An increasing body of evidence now supports the impactmaternal nutrition and child nutrition and physical activity have on a person’s healththroughout life (Barnfather D, 2004).

The importance of the health of our young children has been echoed in hui and fonoundertaken as part of the Let’s Beat Diabetes planning process. Maori and Pacific peoples have given clear guidance that the strategy must focus strongly on the newgeneration and place more effort on protecting children from obesity and subsequentdisease. Recent statistics show that 31 percent of New Zealand children areoverweight or obese; 62 percent of Pacific children overweight or obese; and 41percent of Maori children overweight or obese. Childhood obesity can lead to earlyonset of diabetes and is a strong predictor of adult obesity.

While international and local communities call for health services to address chronicdisease throughout the life course, there is little national policy or service provision targeting good nutrition and physical activity in the early years - breastfeeding being theexception. There is also a need to improve identification and management ofgestational diabetes.

The Let’s Beat Diabetes consultation process has also identified community concernsabout how best to support ‘at-risk’ families. Many of these families have multipleproblems, and providing appropriate nutrition for their children is beyond their reach.Health services on their own are limited in what they can do to support children insituations where the family is dysfunctional or has very limited resources.

Programme Design

The objective of this action area is to develop an environment in which parents havethe knowledge and opportunity to provide appropriate nutrition and physical activity for their young children. There is an opportunity to enhance the current maternity and WellChild frameworks to support a life course approach to diabetes prevention. There is also an opportunity to forge new partnerships with the Ministry of Social Developmentto better identify and support vulnerable families.

To achieve the desired changes in service provision, it is proposed that a district-widenational pilot programme is developed which, due to its broad and cross-sectoralimplications, includes the Ministry of Health (MoH), Ministry of Social Development(MSD), Counties Manukau District Health Board (CMDHB) and service providers in the



planning and development phases. The pilot would seek to achieve four key outcomes:

Enhancement of Maternity and Well Child frameworks to facilitate greater family uptake of appropriate nutrition and physical activity in the early years, and throughout childhood.

Improved capabilities of Well Child services to assess children with developing obesity risks, and provide more intensive support or referral were required.

Develop a cross-sectoral approach to identification of, and support for, vulnerable families. Increase the ability of maternity and Well Child providers to identify vulnerable families and refer for support services.

Develop a broader strategic framework for reducing childhood obesity, which may include an extension of Well Child support systems into the school environment.

Implementation of the proposed service enhancements would not take place until the roll out of the current update to the Well Child service framework is completed, which is expected in late 2005. Implementation of the enhanced Well Child framework may require greater CMDHB control over the Well Child funding stream than is currently the case.

47F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Act

ion

Pla

n

Ch

ildre

n b

egin

th

eir

lives

in a

n e

nvi

ron

men

t th

at s

up

po

rts

life

lon

g h

ealt

h.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

s A

ctio

n L

ead

er

Go

al:

Su

stai

nab

le s

tru

ctu

res

are

set

up

to

su

pp

ort

new

ear

ly y

ear’

s se

rvic

es.

Tar

get

: B

y 20

05 a

gre

emen

t fo

r d

etai

led

p

ilot

stru

ctu

re a

nd

ou

tco

mes

.

Dev

elop

an

agre

emen

t be

twee

n C

MD

HB

, M

oH,

and

MS

D t

o tr

ial

enha

nced

M

ater

nity

and

Wel

l C

hild

fra

mew

orks

in

Cou

ntie

s M

anuk

au i

n a

dist

rict-

leve

l pi

lot.

Dev

elop

a g

over

nanc

e st

ruct

ure

for

the

pilo

t pro

gram

me.

CM

DH

B, M

oH, M

SD

Go

al:

Ob

esit

y in

yo

un

g c

hild

ren

red

uce

s d

ue

to

imp

rove

d

nu

trit

ion

an

d

ph

ysic

al

acti

vity

.

Tar

get

:

By

2006

en

han

ced

ed

uca

tio

n

op

erat

ion

al.

By

2010

th

e ri

se i

n c

hild

ob

esit

y w

ill h

ave

sto

pp

ed.

Dev

elop

a s

et o

f le

arni

ng o

bjec

tives

and

a c

urric

ulum

to

cove

r bo

th a

nten

atal

an

d ea

rly y

ears

act

iviti

es t

hat

goes

bey

ond

the

curr

ent

supp

ort

for

brea

st

feed

ing.

C

urric

ulum

cov

ers

know

ledg

e an

d be

havi

our

chan

ge t

echn

ique

s to

su

ppor

t cha

nged

atti

tude

s to

chi

ldho

od o

besi

ty.

Intr

oduc

e th

e le

arni

ng o

bjec

tives

and

cur

ricul

um in

to th

e se

rvic

e sp

ecifi

catio

ns

of m

ater

nity

and

Wel

l Chi

ld p

rovi

ders

. D

evel

op s

uppo

rtin

g re

sour

ces.

Tra

in s

ervi

ce p

rovi

ders

in th

e ne

w c

urric

ulum

and

del

iver

enh

ance

d se

rvic

es.

CM

DH

B,

Wel

l C

hild

pro

vide

rs,

Man

ukau

In

stitu

te o

f Tec

hnol

ogy

(MIT

), M

oH

Go

al:

Vu

lner

able

fam

ilies

will

be

able

to

b

rin

g u

p h

ealt

hy

child

ren

.

Tar

get

: B

y 20

06 n

ew r

efer

ral m

ech

anis

ms

in p

lace

.

Sup

port

tra

inin

g an

d de

velo

pmen

t pr

oces

ses

to e

nabl

e m

ater

nity

and

Wel

l C

hild

pr

ovid

ers

to

accu

rate

ly

asse

ss

and

iden

tify

fam

ilies

in

vu

lner

able

si

tuat

ions

, w

ho a

re u

nabl

e to

pro

vide

an

appr

opria

te n

utrit

ion

envi

ronm

ent

for

thei

r ch

ildre

n.

Dev

elop

exp

licit

proc

esse

s fo

r m

ater

nity

and

Wel

l C

hild

pro

vide

rs t

o re

fer

vuln

erab

le fa

mili

es to

MS

D-li

nked

ser

vice

s fo

r su

ppor

t and

rec

over

y.

Mai

ntai

n co

llabo

rativ

e he

alth

/wel

fare

su

ppor

t fo

r fa

mily

re

silie

ncy

and

Chi

ld

Hea

lth

outc

omes

.

CM

DH

B, W

ell C

hild

pro

vide

rs, M

IT, M

oH

Go

al:

C

hild

o

bes

ity

is

iden

tifi

ed

and

re

spo

nd

ed

to

in

an

evid

ence

-bas

ed

man

ner

.

Tar

get

: A

ll o

bes

e ch

ildre

n p

re f

ive

are

iden

tifi

ed

and

p

aren

ts

pro

vid

ed

wit

h

advi

ce o

n a

pp

rop

riat

e re

spo

nse

.

Sup

port

trai

ning

and

dev

elop

men

t pro

cess

es to

ena

ble

Wel

l Chi

ld p

rovi

ders

to

accu

rate

ly a

sses

s an

d id

entif

y ch

ildre

n at

ris

k of

obe

sity

or

who

are

alre

ady

obes

e an

d w

hose

hea

lth m

ay b

e co

mpr

omis

ed.

Dev

elop

spe

cial

ist s

uppo

rt a

nd r

efer

ral s

ervi

ces

to e

nabl

e W

ell C

hild

pro

vide

rs

to

prov

ide

mor

e in

tens

ive

supp

ort

for

high

ris

k ch

ildre

n an

d re

ferr

al

to

spec

ialis

t ser

vice

s if

nece

ssar

y.

CM

DH

B, W

ell C

hild

pro

vide

rs, M

IT, M

oH

Go

al:

S

ervi

ce

con

tin

uit

y is

d

evel

op

ed

Dev

elop

a m

ore

stra

tegi

c co

ncep

tual

vie

w o

f W

ell C

hild

ser

vice

s fo

r C

ount

ies

CM

DH

B,

MoH

, M

SD

, M

inis

try

of

48F

INA

L P

LA

N 0

2 F

ebru

ary

2005

bet

wee

n W

ell

Ch

ild a

nd

‘h

ealt

hy

sch

oo

l’ se

rvic

es.

Tar

get

:

By

July

20

05

sco

pin

g

revi

ew

com

ple

te

wit

h

reco

mm

end

atio

ns

for

furt

her

act

ion

.

Man

ukau

in th

e fu

ture

, whi

ch s

ees

the

stru

ctur

ed p

roce

ss o

f Wel

l Chi

ld a

ctiv

ity

flow

thr

ough

int

o pr

imar

y sc

hool

Hea

lth P

rom

otin

g S

choo

ls f

ram

ewor

ks a

nd

on i

nto

a W

ell

Tee

n co

ncep

t th

at c

ould

em

erge

fro

m t

he c

urre

nt Y

ear

9 as

sess

men

ts a

nd ‘

Nut

ritio

n E

xerc

ise

and

Wei

ght’

prog

ram

me

with

in t

he A

im

Hi c

lust

er o

f low

dec

ile s

econ

dary

sch

ools

.

Thi

s m

ore

stra

tegi

c vi

ew o

f a

‘Wel

l C

hild

to

Wel

l T

een’

fra

mew

ork

coul

d be

de

velo

ped

as a

pilo

t in

par

tner

ship

with

the

Min

istr

y of

Edu

catio

n an

d M

SD

to

mee

t the

pol

icy

obje

ctiv

es o

f hea

lth, w

elfa

re a

nd e

duca

tion.

Edu

catio

n

Go

al:

A c

on

tin

uo

us

lear

nin

g a

nd

qu

alit

y im

pro

vem

ent

envi

ron

men

t en

cou

rag

e im

pro

ved

pro

vid

er e

ffec

tive

nes

s.

Tar

get

: E

valu

atio

n f

ram

ewo

rk d

evel

op

ed

by

July

200

5.

Wor

k w

ith th

e U

nive

rsity

of A

uckl

and

Sch

ool o

f Pop

ulat

ion

Hea

lth (

UoA

-SoP

H)

to d

evel

op a

fram

ewor

k fo

r ev

alua

tion

of th

e W

ell C

hild

initi

ativ

e.

Ong

oing

pr

oces

s an

d ou

tcom

e ev

alua

tion

unde

rtak

en,

desi

gned

to

fo

ster

qu

ality

impr

ovem

ent c

ycle

s.

UoA

-SO

PH

, C

MD

HB

, W

ell

Chi

ld

prov

ider

s, M

IT, M

oH

7. Developing a Schools Accord to Ensure Children

Are ‘Fit, Healthy and Ready to Learn’

Context

The school environment is important for the health of our growing children. Childrenspend up to thirteen years in school. What they learn during these formative years will influence their choices and decisions in later life. Also, the nutrition and physical activity environment at school directly affects children’s health and predisposition for chronic diseases, like diabetes, later in life. Children’s levels of physical activity during school years are dropping and children are eating more energy dense foods, leading toobesity (Barnfather D, 2004). In 2002, 30 percent of all New Zealand children were overweight or obese. A recent survey of Year 9 pupils in AIMHI secondary schools inCounties Manukau showed that in excess of 30 percent are already obese.

Many schools within Counties Manukau have challenging educational environmentsand relatively low levels of financial support from their communities. Schools are underpressure to meet academic outcomes. A number of observers have noted that schoolsplace less emphasis on physical activity now than they have in the past in order todevote more time to academic learning.

The benefits of improving the health environment in schools are not only health-related.There is an emerging body of evidence linking physical activity and good nutrition witheducational attainment, the most recent being The Learning Connection: The Value ofImproving Nutrition and Physical Activity in Our Schools report. The report documentsthat the rise in poor nutrition and inactivity is adversely affecting academic achievementand increasing financial pressures on schools. It is in the school’s interest to support ahealth promoting environment.

The importance of health in schools has recently been noted by a new Governmentpolicy that primary schools will be expected to provide students with one hour of physical activity a week.

Many schools will require increased levels of support if they are to reorient themselvesto address the obesity epidemic and actively create healthy environments, including skills, programmes, resources and community support. Many schools have said theyprefer to operate comprehensive or integrated programmes which have a whole-school approach, reflect each school’s unique situation and look at student health in a holisticmanner.

Currently there are a number of organisations and providers that support healthy schools but in general they work in only a small number of schools and lack sector-wide coordination or long term goals. There are a number of advice-only programmes,where-as schools have indicated they want on-the-ground practical help. The KidsFirstpublic nursing service is one of the few health-based services delivered across allprimary schools. A comprehensive approach to school health is being supported in asmall number of high needs secondary schools through the Nutrition Exercise andWeight (NEW) programme.

Despite the issues with fragmented providers, there is a platform of skills andprogrammes that can grow to provide more substantial support for schools. Primary Health Organisation (PHO)-based health promotion services have recognised that theymay have a role in the schools environment. The Food Group has indicated its interest



in activities associated with the schools environment. Schools themselves are taking a stronger interest in their health promoting role.

Consistent approaches to achieving best practice in schools are required, as well as better feedback on which programmes are achieving the desired outcomes.

Programme Design

The fundamental requirement of programme design is to create a vision and a framework that enables schools and service providers to work in a more coordinated and effective way. The programme design seeks to develop a collaborative approach that includes teachers, principals, trustees and the health and physical activity sectors. A sustainable governance structure is required that can provide a direction that all parties own.

A set of realistic goals need to be developed that contribute to reducing the obesity epidemic but are also achievable. Some proposed goals are outlined in this paper. A number of these actions can be started immediately with existing services and resources.

In order to achieve a far reaching change in school environments the existing level of support and general activity may not be enough. A more thorough review of the programmes and resources required to achieve the fit and healthy schools goals may be needed.

Existing service providers should be encouraged and supported where their programmes are well accepted and effective. It is proposed that the various services on offer are presented to trustees and principals as a consolidated menu of services, which schools can choose from to help them meet their objectives.

Early childhood education, primary schools and secondary schools have different needs and dynamics. Strategies need to look at each of these sectors separately.

Act

ion

Pla

ns

Ear

ly C

hild

ho

od

Ed

uca

tio

n

Sch

oo

ls a

re a

n e

nvi

ron

men

t th

at p

rote

cts

agai

nst

ob

esit

y.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

By

2010

Co

un

ties

Man

uka

u e

arly

child

ho

od

edu

cati

on

lead

s th

e co

un

try

in t

hei

r co

mm

itm

ent

to

sup

po

rtin

gh

ealt

hy

eati

ng

an

d a

ctiv

e liv

ing

.

Tar

get

:

By

2010

10

0%

of

earl

y le

arn

ing

envi

ron

men

ts h

ave

aud

ited

eff

ecti

ve h

ealt

hy

eati

ng

acti

ve li

vin

g p

olic

ies.

Adi

stric

t go

vern

ance

gro

up i

s es

tabl

ishe

d th

at i

nclu

des

early

chi

ldho

oded

ucat

ion

staf

f, pa

rent

s an

d he

alth

sec

tor

togu

ide

wor

kas

sess

ing

need

s fo

rea

rly c

hild

hood

, fiv

e ye

ar g

oals

and

rec

omm

ende

d pr

ogra

mm

es.

A r

epre

sent

ativ

e fr

om th

e gr

oup

sits

on

the

Let’s

Bea

t Dia

bete

sG

over

nanc

eG

roup

.

Cou

ntie

sM

anuk

au

Dis

tric

t H

ealth

Boa

rd(C

MD

HB

),

Min

istr

yof

E

duca

tion

(MoE

),

Man

ukau

C

ity

Cou

ncil

(MC

C),

Ear

lyC

hild

hood

Cen

tres

(E

CE

), K

ohan

ga R

eo

Go

al:

Ph

ysic

al a

ctiv

ity

By

2010

ob

esit

y g

row

th i

n c

hild

ren

has

sto

pp

edan

d is

red

uci

ng

.

Tar

get

:

By

2010

10

0%

of

earl

y le

arn

ing

envi

ron

men

ts h

ave

aud

ited

eff

ecti

ve h

ealt

hy

eati

ng

acti

ve li

vin

g p

olic

ies.

Spo

rt a

nd R

ecre

atio

n N

ew Z

eala

nd (

SP

AR

C),

sup

port

edby

the

edu

catio

nan

d he

alth

sec

tors

, im

plem

ents

its

Kiw

iba

by,

Kiw

i to

ddle

r an

d K

iwi

pre-

scho

ol p

rogr

amm

es in

EC

Es

in C

ount

ies

Man

ukau

. T

his

incl

udes

Koh

anga

Reo

and

Pac

ific

EC

Es.

Str

ateg

ies

are

inve

stig

ated

tha

t le

vera

ge c

ultu

ral k

now

ledg

e an

d pr

actic

ein

Koh

anga

Reo

and

Pac

ific

EC

Es

to s

uppo

rt h

ealth

yap

proa

ches

to

phys

ical

activ

ity.

SP

AR

C,

heal

th

sect

or,

EC

Es,

N

on-

Gov

ernm

ent O

rgan

isat

ions

(N

GO

s)

Go

al:

Nu

trit

ion

By

2010

ob

esit

y g

row

th i

n c

hild

ren

has

sto

pp

edan

d is

red

uci

ng

.

Tar

get

:

By

2010

10

0%

of

earl

y le

arn

ing

envi

ron

men

ts h

ave

aud

ited

eff

ecti

ve h

ealt

hy

eati

ng

acti

ve li

vin

g p

olic

ies.

Auc

klan

d R

egio

nal

Pub

lic

Hea

lthS

ervi

ce

(AR

PH

S)

supp

orts

S

PA

RC

’sef

fort

s by

pr

ovid

ing

nutr

ition

al

info

rmat

ion

and

supp

ort

to

the

EC

Es

inC

ount

ies

Man

ukau

.T

his

incl

udes

Koh

anga

Reo

and

Pac

ific

EC

Es.

Str

ateg

ies

are

inve

stig

ated

tha

t le

vera

ge c

ultu

ral k

now

ledg

e an

d pr

actic

ein

Koh

anga

Reo

and

Pac

ific

EC

Es

to s

uppo

rt h

ealth

y ap

proa

ches

to n

utrit

ion.

AR

PH

S, N

GO

s, S

PA

RC

Go

al:

Eva

luat

ion

Eva

luat

ion

su

pp

ort

s a

lear

nin

g

fram

ewo

rk

and

sup

po

rts

esta

blis

hm

ent

of

bes

t p

ract

ice

in e

arly

lear

nin

g c

entr

es.

SP

AR

C e

valu

ates

its

prog

ram

mes

.S

PA

RC

, CM

DH

B, U

oA-S

oPH

51F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Tar

get

: E

valu

atio

n f

ram

ewo

rk s

et u

p b

y Ju

ly 2

005.

SP

AR

Cw

orks

with

C

MD

HB

an

d th

e U

nive

rsity

of

A

uckl

and-

Sch

ool

ofP

opul

atio

n H

ealth

(U

oA–S

oPH

) to

dev

elop

a f

ram

ewor

k fo

r pr

oces

s an

dou

tcom

es e

valu

atio

n of

the

agre

ed a

ctio

n pl

ans.

Pri

mar

y S

cho

ols

Pri

mar

y sc

ho

ols

are

an

en

viro

nm

ent

that

pro

tect

sag

ain

st o

bes

ity.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

B

y 20

10 C

ou

nti

es M

anu

kau

sch

oo

ls l

ead

th

e co

un

try

in

thei

r co

mm

itm

ent

to

sup

po

rtin

gh

ealt

hy

eati

ng

an

d a

ctiv

e liv

ing

.

Su

gg

este

d t

arg

ets:

By

2008

:10

0%

of

pri

mar

ysc

ho

ols

p

rovi

de

1 h

ou

rex

erci

se p

er w

eek.

By

2010

:90

% o

f p

rim

ary

sch

oo

ls p

rovi

de

30 m

inu

tes

exer

cise

a d

ay.

100%

of

sch

oo

ls h

ave

aud

ited

hea

lth

y m

enu

can

teen

s.

A

repr

esen

tativ

e go

vern

ance

gr

oup

is

esta

blis

hed

(incl

udes

st

uden

ts,

teac

hers

, pr

inci

pals

, tr

uste

es

and

heal

th/

activ

ity

prov

ider

s)

to

guid

eas

sess

men

t of

nee

d in

prim

ary

scho

ols,

ide

ntify

the

fiv

eye

argo

als

and

reco

mm

end

prog

ram

mes

.

A r

epre

sent

ativ

e fr

om th

e gr

oup

sits

on

the

Let’s

Bea

t Dia

bete

sG

over

nanc

eG

roup

.

Kid

z F

irst,

CM

DH

B,

Sch

ools

, N

GO

s, M

OE

,A

RP

HS

, MC

C

Go

al:

Res

ou

rces

are

ava

ilab

le t

o a

chie

ve g

oal

s.

Tar

get

: B

yJu

ly 2

005,

rev

iew

com

ple

ted

.

A r

evie

w i

s un

dert

aken

loo

king

at

wha

t le

vels

of

inpu

t, pr

ogra

mm

e de

sign

san

d re

sour

ces

will

be

requ

ired

to a

chie

ve th

e id

entif

ied

goal

s.

The

rep

ort w

illgu

ide

the

actio

n pl

an.

Sch

ools

gov

erna

nce

grou

p, C

MD

HB

Go

als:

S

cho

ols

are

su

pp

ort

ed t

o d

evel

op

hea

lth

yen

viro

nm

ents

.

Tar

get

:A

ll sc

ho

ols

are

per

son

ally

co

nta

cted

and

serv

ices

on

off

er p

rese

nte

d d

uri

ng

200

5.

The

re is

impr

oved

co-

ordi

natio

n of

pro

gram

mes

am

ongs

tpr

ovid

ers

to m

ake

it ea

sier

for

prin

cipa

ls t

o un

ders

tand

wha

t su

ppor

t se

rvic

es a

re a

vaila

ble

to

assi

st th

em to

ach

ieve

the

iden

tifie

d go

als.

Prin

cipa

ls a

re in

form

ed a

bout

the

supp

ort s

ervi

ces

and

reso

urce

s av

aila

ble.

The

re

is

proa

ctiv

e co

mm

unic

atio

nw

ith

all

scho

ols

abou

t th

e ne

ed

to

CM

DH

B,

SP

AR

C,

PH

Os,

Min

istr

yof

Hea

lth(M

oH),

NG

Os

52F

INA

L P

LA

N 0

2 F

ebru

ary

2005

addr

ess

obes

ity a

nd th

e su

ppor

t ser

vice

s on

offe

r.

Go

al:

Eva

luat

ion

Go

al:

Eva

luat

ion

su

pp

ort

s a

lear

nin

g f

ram

ewo

rkan

d

sup

po

rts

esta

blis

hm

ent

of

bes

t p

ract

ice

in

pri

mar

y sc

ho

ols

.

Tar

get

: E

valu

atio

n f

ram

ewo

rk s

et u

p b

y Ju

ly 2

005.

Sch

ools

gov

erna

nce

grou

p, S

PA

RC

and

CM

DH

B w

ork

with

the

Uni

vers

ityof

Auc

klan

d-S

choo

l of

Pop

ulat

ion

Hea

lth (

UoA

–SoP

H)

to d

evel

op a

fra

mew

ork

for

proc

ess

and

outc

omes

eval

uatio

n of

the

agr

eed

actio

n pl

ans,

with

the

key

obje

ctiv

e be

ing

to

supp

ort

a le

arni

ng

fram

ewor

k an

d ef

fect

ive

sust

aina

ble

part

ners

hips

.

Sch

ools

go

vern

ance

gr

oup,

U

oA-S

oPH

,C

MD

HB

, SP

AR

C

Sec

on

dar

y S

cho

ols

Sec

on

dar

y sc

ho

ols

are

an

en

viro

nm

ent

that

pro

tect

s ag

ain

st o

bes

ity.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

By

2010

C

ou

nti

es

Man

uka

use

con

dar

ysc

ho

ols

lea

dth

e co

un

try

in t

hei

r co

mm

itm

ent

to

hea

lth

y ea

tin

g a

nd

act

ive

livin

g.

Su

gg

este

d t

arg

ets:

By

2010

:80

% o

f se

con

dar

y sc

ho

ols

pro

vid

e 30

min

ute

sex

erci

se a

day

.10

0% o

f sc

ho

ols

hav

eau

dit

ed h

ealt

hy

men

uca

nte

ens.

A

repr

esen

tativ

e go

vern

ance

gr

oup

is

esta

blis

hed

(incl

udes

st

uden

ts,

teac

hers

, pr

inci

pals

, tr

uste

es

and

heal

th/

activ

ity

prov

ider

s)

to

guid

eas

sess

men

t of

nee

d in

prim

ary

scho

ols,

ide

ntify

the

fiv

eye

argo

als

and

reco

mm

end

prog

ram

mes

.

A r

epre

sent

ativ

e fr

om th

e gr

oup

sits

on

the

Let’s

Bea

t Dia

bete

sG

over

nanc

eG

roup

.

CM

DH

B, s

choo

ls, M

oE, A

RP

HS

, NG

Os

Go

al:

Res

ou

rces

are

ava

ilab

le t

o a

chie

ve g

oal

s.

Tar

get

: B

yJu

ly 2

005,

rev

iew

com

ple

ted

.

A r

evie

w i

s un

dert

aken

loo

king

at

wha

t le

vels

of

inpu

t, pr

ogra

mm

e de

sign

san

d re

sour

ces

will

be

requ

ired

to a

chie

ve th

e id

entif

ied

goal

s.

The

rep

ort w

illgu

ide

the

actio

n pl

an.

Sch

ools

gro

up, C

MD

HB

Go

als:

S

cho

ols

are

su

pp

ort

ed t

o d

evel

op

hea

lth

yen

viro

nm

ents

.

Tar

get

:A

ll sc

ho

ols

are

per

son

ally

co

nta

cted

and

serv

ices

on

off

er p

rese

nte

d d

uri

ng

200

5.

The

re is

impr

oved

co-

ordi

natio

n of

pro

gram

mes

am

ongs

tpr

ovid

ers

to m

ake

it ea

sier

for

prin

cipa

ls t

o un

ders

tand

wha

t su

ppor

t se

rvic

es a

re a

vaila

ble

to

assi

st th

em to

ach

ieve

the

iden

tifie

d go

als.

Prin

cipa

ls a

re in

form

ed a

bout

the

supp

ort s

ervi

ces

and

reso

urce

s av

aila

ble.

CM

DH

B, S

PA

RC

, PH

Os,

MoH

, NG

Os

53F

INA

L P

LA

N 0

2 F

ebru

ary

2005

54F

INA

L P

LA

N 0

2 F

ebru

ary

2005

The

re

is

proa

ctiv

e co

mm

unic

atio

n w

ith

all

scho

ols

abou

t th

e ne

ed

to

addr

ess

obes

ity a

nd th

e su

ppor

t ser

vice

s on

offe

r.

Go

al:

Sch

oo

ls s

erve

on

ly d

iet

dri

nks

an

d w

ater

.

Tar

get

: B

y 20

06,

90%

die

t d

rin

ks a

nd

wat

er t

arg

et

ach

ieve

d.

Sch

ools

are

enc

oura

ged

to r

educ

e th

e av

aila

bilit

y of

hig

h ca

rboh

ydra

te

drin

ks o

n sc

hool

gro

unds

. S

choo

ls, A

RP

HS

, Foo

d G

roup

, CM

DH

B

Go

al:

Stu

den

ts t

ake

up

lea

der

ship

ro

les

wit

hin

th

eir

sch

oo

ls

to

sup

po

rt

hea

lth

y ea

tin

g

acti

ve

livin

g.

Tar

get

: S

tud

ent-

led

act

ivis

m b

egin

s d

uri

ng

200

6.

Stu

dent

-led

activ

ism

in

the

area

of

fit a

nd h

ealth

y sc

hool

s is

enc

oura

ged

and

reso

urce

s ar

e m

ade

avai

labl

e to

sup

port

app

ropr

iate

stu

dent

act

iviti

es.

Sch

ools

gov

erna

nce

grou

p

Go

al:

E

valu

atio

n

of

inte

rven

tio

ns

at

the

AIM

HI

sch

oo

ls

pro

vid

es

gu

idan

ce

for

on

go

ing

h

igh

sc

ho

ol s

trat

egie

s.

Tar

get

:

Pre

limin

ary

resu

lts

of

NE

W

eval

uat

ion

co

mp

lete

d b

y en

d o

f 20

06,

wit

h d

ecis

ion

s m

ade

abo

ut

on

go

ing

pro

gra

mm

e d

esig

n.

A f

urt

her

eva

luat

ion

of

sch

oo

ls i

nte

rven

tio

ns

will

b

e u

nd

erta

ken

by

Uo

A-S

oP

H,

wh

ich

wit

h r

esu

lts

avai

lab

le in

200

7/08

.

The

ex

istin

g N

EW

pr

ogra

mm

e,

a co

mpo

nent

of

th

e A

IMH

I H

ealth

y C

omm

unity

Sch

ools

ini

tiativ

e, d

eliv

ered

in

asso

ciat

ion

with

the

Dia

bete

s P

roje

cts

Tru

st,

is s

uppo

rted

as

a pi

lot

prog

ram

me

- w

ith i

ts o

wn

eval

uatio

n co

mpo

nent

.

The

U

nive

rsity

of

A

uckl

and

Sch

ool

of

Pop

ulat

ion

Hea

lth

(UoA

-SoP

H)

seco

ndar

y sc

hool

in

terv

entio

n an

d ev

alua

tion

is

also

su

ppor

ted

and

syne

rgie

s de

velo

ped

betw

een

the

two

prog

ram

mes

.

Bot

h se

ts o

f ev

alua

tion

resu

lts w

ould

be

used

to

guid

e on

goin

g pr

ogra

mm

e de

sign

, im

plem

enta

tion

and

inve

stm

ent

in

seco

ndar

y sc

hool

-bas

ed

prog

ram

mes

.

AIM

HI

scho

ols,

D

iabe

tes

Pro

ject

s T

rust

, U

oA-S

oPH

, CM

DH

B, M

oE

8. Supporting Primary Care-Based Prevention and

Early Intervention

Context

A large number of government policies call on primary health care to make a greatercontribution to the health of populations, to work with families, and to focus on chronic disease prevention and management (NZ Health Strategy, NZ Primary Health CareStrategy, He Korowai Oranga, The Pacific Health and Disability Action Plan). (Ministry of Health 2000; 2001; 2002).

Primary Health Organisations (PHOs) have been set up and new funding streams are now available to support chronic disease prevention and management. However, thereis also a lack of clear evidence about exactly how PHOs and General Practitioner (GP)teams can go about preventing disease in a cost effective way. Prevention anddisease management programmes challenge the primary care sector to define new relationships with patients and new roles and responsibilities within primary careteams.

Counties Manukau District Health Board (CMDHB) and the primary care sector haveinvested considerable resources over the past five years developing the Chronic CareManagement programme (CCM), which supports community-based structuredmanagement of people with advanced and complicated diabetes. The CCM projectinvolves collaborations between CMDHB and PHOs. CCM delivers training programmes for GP teams, information technology support and incentive payments toGPs. It is one of New Zealand’s most sophisticated disease management initiatives,and provides a strong platform for further collaborative activities between CMDHB and the PHOs.

Developing primary care initiatives that focus on disease prevention and managementwill need sound evidence and be achievable in the busy practice environment. TheCCM experience has identified that significant training, support and strong projectmanagement is required to bring about changes in the general practice environmentand that even small changes can take considerable time to introduce. PHOs haveshown a willingness to become more involved in disease prevention activities.

Primary care involvement in, and support for, broader social marketing programmes is essential to change population behaviour. There is an increasing body of evidenceabout the role for primary care in providing brief intervention advice on behaviour change and support for improved education to support the “expert patient” andimproved self management. General practice is the key environment for the earlyidentification of risk factors and screening to identify diabetes. New Zealand has published national guidelines for the screening for and management of diabetes. Thefact that the major health sector costs from complications of diabetes are heartdisease, especially in the early stages of disease progression, suggests that peoplewith diabetes should also be proactively managed in terms of their cardiovascular risk. PHO funding streams allow for significant flexibility for primary care based healthpromotion and disease prevention activities – especially targeting high risk groups.

Programme Design

The following four initiatives have been identified in collaboration with the primary caresector. They are based on supporting evidence that they will have a positive impact,



they are achievable, they fit together to support improved overall system capacity in primary care, and they link into the broader Let’s Beat Diabetes plan:

To provide consistent and persuasive information to ‘at risk’ people to support lifestyle change;

To improve identification of people who have diabetes at an earlier stage of their disease progression; (New Zealand Guidelines Group 2003)

To improve the level of education given to newly-diagnosed diabetics to support improved self management of diabetes and of their cardiovascular risk; and

To trial a new approach to disease management in which the primary care team works with the whole family of a person with diabetes, to support better health for the whole family/whole whanau approach (links with He Korowai Oranga).

These programmes will require collaborative leadership across CMDHB and PHOs. They will also require investment in training and development of primary care teams and in the community outreach medical and nursing specialist service at Middlemore Hospital.

Information Technology (IT) infrastructure will be required to support activities. The projects will require CMDHB project management and clinical expertise and well as PHO-led operational management. Evaluation will also be a key component of the activity, and will inform how the programmes develop, particularly the family group practice trial.

Act

ion

Pla

n

Pri

mar

y h

ealt

h c

are

pro

acti

vely

an

d p

rofi

cien

tly

wo

rks

wit

h p

atie

nts

an

d t

hei

r fa

mili

es

to r

edu

ce d

iab

etes

ris

k an

d im

pro

ve d

isea

se m

anag

emen

t.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

P

atie

nts

at

ten

din

g

GP

te

ams

pro

acti

vely

re

ceiv

e in

form

atio

n

and

cou

nse

llin

g t

o s

up

po

rt h

ealt

hy

eati

ng

an

dac

tive

livi

ng

.

Tar

get

: 7

0% o

f at

ris

k p

atie

nts

att

end

ing

GP

s re

ceiv

e a

‘do

se’

of

pra

ctic

al

hea

lth

info

rmat

ion

ab

ou

tlif

esty

lew

hic

h a

lign

sw

ith

the

soci

al m

arke

tin

g s

trat

egy.

GP

te

ams

are

trai

ned

in

evid

ence

-bas

ed

appr

oach

es

to

effe

ctiv

e br

ief

inte

rven

tion

coun

selli

ng.

GP

team

sar

e in

volv

ed in

and

info

rmed

of t

he s

ocia

l mar

ketin

gpr

ogra

mm

ean

d ar

e aw

are

of t

heir

role

in

supp

ort

of t

he d

esire

d be

havi

our

chan

geou

tcom

es.

GP

tea

ms

are

prov

ided

with

res

ourc

es a

nd t

ools

(e.

g. c

ompu

ter-

base

dad

vice

/pro

mpt

s an

d pa

tient

reso

urce

s) to

und

erta

ke b

rief i

nter

vent

ions

.

Fun

ding

sys

tem

s ar

e de

velo

ped

to s

uppo

rt G

P t

eam

abi

lity

to d

eliv

erbr

ief

inte

rven

tion

coun

selli

ng.

P

rogr

amm

es

rolle

d ou

t w

itha

best

pr

actic

efr

amew

ork.

PH

Os,

C

MD

HB

, ho

spita

l se

rvic

es,

RN

ZC

GP

Go

al:

P

eop

le

at

risk

o

f d

iab

etes

ar

esc

reen

ed i

n a

tim

ely

man

ner

in

acc

ord

ance

wit

h N

ewZ

eala

nd

gu

idel

ines

.

Tar

get

:B

y 20

10

80%

of

pra

ctic

es

are

effe

ctiv

ely

and

sys

tem

atic

ally

scr

een

ing

for

dia

bet

es a

sd

escr

ibed

in

th

e N

ewZ

eala

nd

Gu

idel

ine

for

the

Ass

essm

ent

and

Man

agem

ent

of

Car

dio

vasc

ula

r R

isk.

CM

DH

Bw

orks

with

PH

Os

to a

ssis

t up

take

of

IT b

ased

dec

isio

n su

ppor

tto

ols

and

man

agem

ent

prot

ocol

s,w

hich

wou

ld f

acili

tate

accu

rate

, ev

iden

ce-

base

d sc

reen

ing

and

follo

wup

act

iviti

es.

Rol

l out

of

scre

enin

g is

alig

ned

with

bro

ader

sys

tem

rev

iew

to

ensu

re t

here

is c

apac

ity to

pro

vide

effe

ctiv

e fo

llow

up

activ

ities

.

CM

DH

B, P

HO

s, H

ealth

Alli

ance

Go

al:

All

new

ly

dia

gn

ose

d

peo

ple

wit

hd

iab

etes

par

tici

pat

e in

qu

alit

y ed

uca

tio

n a

nd

lear

nin

g

to

sup

po

rt

effe

ctiv

e se

lfm

anag

emen

t o

f th

e co

nd

itio

n.

Tar

get

: B

y 20

10 8

0% o

f p

eop

le d

iag

no

sed

wit

h

dia

bet

es

rece

ive

an

enh

ance

ded

uca

tio

n

fro

m

a h

ealt

h

pro

fess

ion

alw

ho

has

rec

eive

dac

cred

ited

tra

inin

g.

Dev

elop

accr

edite

d tr

aini

ng p

rogr

amm

es fo

r pr

imar

y ca

re te

ams

for

diab

etes

educ

atio

n an

dsu

ppor

t fo

r se

lf m

anag

emen

t.

It is

like

ly s

uch

a pr

ogra

mm

eco

uld

be p

rovi

ded

by M

IT, r

esul

ting

in a

form

al q

ualif

icat

ion.

Sup

port

GP

tea

ms

to u

nder

take

tra

inin

g an

d de

velo

pmen

t (t

here

will

bea

need

for

con

sist

ency

acro

ssth

e tr

aini

ng b

ut d

iffer

ent

team

mem

bers

will

requ

ire d

iffer

ent t

rain

ing

mod

ules

).

Col

labo

rate

with

Wai

tem

ata

Dis

tric

t H

ealth

Boa

rd i

n th

e de

velo

pmen

t of

PH

Os,

MIT

, CM

DH

B, W

hitio

ra

Dia

bete

s S

ervi

ce, W

aite

mat

a D

istr

ict

Hea

lth B

oard

57F

INA

L P

LA

N 0

2 F

ebru

ary

2005

58F

INA

L P

LA

N 0

2 F

ebru

ary

2005

reso

urce

s an

d be

st p

ract

ice

mod

els

for

self

man

agem

ent

Intr

oduc

e ‘a

ccre

dite

d’ e

duca

tion/

self

lear

ning

pro

cess

int

o no

rmal

GP

-tea

m

activ

ity.

Rol

l out

trai

ning

pro

gram

mes

acr

oss

GP

team

s.

Go

al:

GP

tea

ms

wo

rk w

ith

wh

ole

fam

ilies

to

b

ette

r su

pp

ort

peo

ple

wit

h d

iab

etes

an

d t

o

hel

p f

amili

es s

tay

hea

lth

y.

Tar

get

:

By

2008

th

e tr

ial

of

new

‘f

amily

g

rou

p’ a

pp

roac

h c

om

ple

ted

an

d e

valu

ated

.

Dev

elop

det

aile

d ev

iden

ce a

nd p

rogr

amm

e de

sign

for

a s

econ

d P

hase

of

the

Chr

onic

C

are

Man

agem

ent

prog

ram

me,

w

hich

su

ppor

ts

GP

te

ams

wor

king

m

ore

clos

ely

with

th

e fa

mili

es

of

peop

le

with

di

abet

es.

The

pr

ogra

mm

e w

ould

inv

olve

a t

rail

with

a l

imite

d nu

mbe

r of

GP

pra

ctic

es

beco

min

g in

volv

ed in

the

new

pro

gram

me,

with

form

al e

valu

atio

n.

Whi

le p

rimar

y ca

re b

ased

, th

e tr

ial

may

hav

e lin

ks t

o th

e ‘fa

mili

es’

actio

n ar

ea o

f Le

t’s B

eat

Dia

bete

s, w

hich

aim

s to

sup

port

vul

nera

ble

fam

ilies

to

mak

e he

alth

y ch

oice

s.

The

pr

ogra

mm

e de

sign

w

ould

in

volv

e tw

o st

ages

of

ac

tivity

; fir

stly

to

de

term

ine

whe

ther

the

app

roac

h is

effe

ctiv

e, a

nd s

econ

dly

to t

est

if it

is

effe

ctiv

e in

an

aver

age

gene

ral p

ract

ice

situ

atio

n.

The

tria

l obj

ectiv

es a

re t

o im

prov

e di

seas

e m

anag

emen

t fo

r th

e pe

rson

with

di

abet

es a

nd a

lso

to id

entif

y an

d re

duce

ris

k fa

ctor

s fo

r th

e fa

mily

mem

bers

.

PH

Os,

RN

ZC

GP

, CC

RE

P, C

MD

HB

9. Enabling Vulnerable Families to Make Healthy

Choices

Context

Many families in Counties Manukau find it very difficult to live healthy lives.

Some families are able to change their behaviour to support a family member who hasdiabetes or to reduce the risk of getting diabetes, but for some families there are somany other difficulties in their lives, making healthy choices is not an option.

Counties Manukau has a high proportion of families that are in difficulty or are‘vulnerable’ and may not be far from a crisis. Vulnerable families may have low incomes through unemployment or low-wage jobs, be new immigrants, have relationship difficulties, suffer from domestic violence or crime, or simply become isolated in their community. It is these vulnerable families, for whom a healthy lifestyleis a low priority, who are most at risk of diabetes. Disease then adds to their difficulties. It is a vicious circle.

Many of the strategies in the Let’s Beat Diabetes plan make it easier for families to make healthy choices (Community Leadership, Well Child, Schools, Social Marketing, Health Promotion, Primary Care-based Prevention), but these strategies on their ownare unlikely to work for vulnerable families. Action is required to help those families most ‘at risk’. Many organisations and agencies support vulnerable families but morefocus is needed on how they work together to support healthy living and self management of disease. A new level of collaboration is required across governmentagencies at policy and funding levels and across providers at operational levels to provide well targeted support for families.

Over the past year, there has been a major government focus on improved support forvulnerable families. This has been reflected in a number of budget initiatives throughthe Ministry of Social Development (MSD), including:

Working for families package – increased number of social support entitlements for working families, such as childcare subsidies, accommodation supplements andreturn to work support.

Family Start expansion – expansion of service aimed at families with very youngchildren who have the greatest needs. It provides early help to improve outcomesfor children by providing intensive cross-government support to parents (coming into Manukau in 2005).

Pacific family violence – funding has been made available to begin implementationof education and awareness programmes as part of the Framework for PreventingFamily Violence in Pacific Communities.

Social workers in schools expansion – social workers in schools supportparticipating families to achieve improvements in their children’s educational, healthand social outcomes as well as improvements in parenting and management ofhousehold resources.

There are also many existing family focused programmes supported by MSD, including: Strengthening Families, Heartlands, Youth Interagency Project, TeenageParents Project, Enhanced case management for people on a sickness benefit andinvalids benefit and Youth Transitions.


MSD has also set up a new service called Family and Community Services (FACS).The FACS’s role is to support government and non government organisations inworking collaboratively to strengthen family support services and make them more effective for families. There is a strong focus on prevention and early intervention.Some of the action areas for FACS include:

The development of a detailed web-based national social services directory that enables social agencies to accurately refer to other support organisations

The Strategies for Kids/Information for Parents (SKIP) programme which aims toprovide positive patenting skills and resources for parents and caregivers ofchildren aged from one to five

A number of programmes which aim at prevention and early intervention of familyviolence

Local services mapping – a framework for determining how services provided by central government, local government and local agencies can be managed to better meet local needs

There are opportunities for the health sector to more effectively interface with the MSDsuite of services to enable families to live healthier lives and better manage disease.

Programme Design

It is proposed MSD take the lead in the development of activities to support families to make healthy choices. MSD has responsibility for Government policy and servicedelivery in many areas of social support, such as Work and Income and FACS. It alsohas links with many other organisations and a history of working closely with the healthsector and local government in Counties Manukau. As noted above, there are a number of new service initiatives and funding streams based in MSD, which candirectly support vulnerable families.

The approach will need to create a sustainable collaboration between health andwelfare at a policy and design level and also at the level of implementation, which would be accomplished through the development of an MSD-led working group. Thisworking group could emerge from one of the existing interagency groups, such as Strengthening Families.

The broad aim is to develop the health sector’s ability to identify vulnerable families and to refer those families to the most appropriate point for ongoing support, and then towork with those support organisations in a co-coordinated manner. For MSD services,there is an opportunity to be involved with families at a point of vulnerability - asopposed to crisis – where families may be more amenable to early intervention. Thereis also opportunity for MSD to better achieve its policy goals such as return-to-work,reduction in disparities and reduction in family violence if it is working with the healthsector.

A number of the programmes will emerge once the working group has beenestablished, however, some areas that have been identified where collaborativeprogrammes should be developed.

Aligning an enhanced Well Child programme (the focuses more strongly onchildhood nutrition) with Strengthening Families and the expanded Family Start



programme to provide improved assessment and referral processes for vulnerable families

Strengthening vulnerable families, within the context of their community, to make healthy choices for themselves and their children

Alignment of the primary care family group intervention trial with family group focused welfare support

Supporting accurate and appropriate referral from health services to welfare support agencies.

Ensuring the local area mapping service programme is undertaken in relation to the health welfare interface and the needs of chronic disease prevention and management.

Act

ion

Pla

n

Vu

lner

able

fam

ilies

are

ab

le t

o m

ake

hea

lth

y ch

oic

es.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

A

g

ove

rnan

ce

stru

ctu

resu

pp

ort

sco

llab

ora

tio

n

bet

wee

n

hea

lth

an

dw

elfa

rese

cto

rs t

o b

ette

r su

pp

ort

vu

lner

able

fam

ilies

.

Tar

get

:

By

Ap

ril

2005

wo

rkin

gg

rou

pis

fun

ctio

nin

g e

ffec

tive

ly.

MS

D b

ecom

es a

mem

ber

of t

he o

vera

ll go

vern

ance

gro

up o

f th

e Le

t’sB

eat D

iabe

tes

plan

.

Aw

orki

ng

grou

p is

se

t up

un

der

MS

D

guid

ance

th

at

beco

mes

ale

ader

ship

hu

b fo

r in

tegr

atin

g he

alth

an

dw

elfa

re

activ

ities

to

be

tter

addr

ess

the

heal

th n

eeds

of v

ulne

rabl

e fa

mili

es a

s th

ey r

elat

e to

chr

onic

dise

ase.

It

is

likel

y th

is

grou

pw

illbe

an

ex

tens

ion

of

the

curr

ent

Str

engt

heni

ngF

amili

es in

tera

genc

y gr

oup.

The

gr

oup

will

ne

ed

to

iden

tify

whe

re

ther

e ar

eop

port

uniti

esfo

rap

plic

atio

n of

rec

ent

budg

etan

d se

rvic

e in

itiat

ives

to

supp

ort

the

fam

ilyfo

cuse

d ap

proa

ch to

obe

sity

prev

entio

nan

d di

seas

e m

anag

emen

t.

MS

D, C

ount

ies

Man

ukau

Dis

tric

tH

ealth

Boa

rd (

CM

DH

B)

Go

al:

All

child

ren

re

ceiv

ead

equ

ate

and

app

rop

riat

e n

utr

itio

n d

uri

ng

th

e cr

itic

al e

arly

year

s o

f lif

e.

Tar

get

: B

yJu

ly20

06 E

nh

ance

d W

ell C

hild

an

dac

com

pan

yin

gw

elfa

resu

pp

ort

sar

eim

ple

men

ted

.

Wel

l C

hild

pr

ovid

ers

rece

ive

trai

ning

/cap

acity

de

velo

pmen

t to

en

able

impr

oved

iden

tific

atio

n of

fam

ily v

ulne

rabi

lity,

whe

n th

ere

is e

vide

nce

ofpo

or n

utrit

ion

in 0

-5ye

ar o

lds

(thi

s in

clud

es o

besi

ty a

sw

ell

as u

nder

nutr

ition

).

Cle

arly

defin

ed r

efer

ral p

athw

ays

to s

ocia

l sup

port

age

ncie

s an

don

goin

gpr

oces

ses

of c

olla

bora

tive

supp

ort

are

iden

tifie

d an

d de

velo

ped

with

the

Str

engt

heni

ngF

amili

es in

tera

genc

y gr

oup.

CM

DH

B

Go

al:

Fam

ilies

ar

e ab

le

to

mak

e h

ealt

hy

nu

trit

ion

ch

oic

es

for

them

selv

esan

d

thei

rch

ildre

n.

Tar

get

: T

he

per

cen

tag

e o

f ch

ildre

n n

ot

eati

ng

bre

akfa

st a

t h

om

e b

efo

re s

cho

ol

red

uce

s b

y50

% b

y 20

10.

MS

D-li

nked

se

rvic

es

join

with

he

alth

prov

ider

s to

su

ppor

t im

prov

eded

ucat

ion

of p

aren

ts o

n ap

prop

riate

nut

ritio

n fo

r ad

ults

and

chi

ldre

n.

The

re i

s m

ore

use

mad

e of

ent

itlem

ent

revi

ews

whe

reit

appe

ars

that

heal

thy

choi

ces

are

not b

eing

mad

e du

e to

fina

ncia

l con

stra

ints

.

The

re i

s su

ppor

t fo

r a

broa

d st

rate

gy t

hat

enco

urag

es c

hild

ren

to e

atbr

eakf

ast a

t hom

e be

fore

sch

ool.

The

re

is

a re

view

of

th

e F

ood

in

Sch

ools

pr

ogra

mm

e in

C

ount

ies

Man

ukau

asa

com

pone

nt

of

the

broa

der

child

nu

triti

on

stra

tegi

cap

proa

ch.

MS

D

62F

INA

L P

LA

N 0

2 F

ebru

ary

2005

63F

INA

L P

LA

N 0

2 F

ebru

ary

2005

Go

al:

Im

pro

ved

wh

ole

sys

tem

ap

pro

ach

es t

o

pre

ven

tio

n

and

ea

rly

inte

rven

tio

n

are

dev

elo

ped

.

Tar

get

:

By

2008

H

ealt

h

and

w

elfa

re

fam

ily

gro

up

inte

rven

tio

n t

rial

co

mp

lete

d.

The

prim

ary

care

bas

ed t

rial

of f

amily

gro

up i

nter

vent

ions

als

o in

clud

es

expl

icit

linka

ge

with

w

hole

fa

mily

ba

sed

appr

oach

es

from

w

elfa

re

agen

cies

. T

he t

rial w

ill b

e ab

le t

o id

entif

y th

e va

lue

of t

his

cros

s ag

ency

w

hole

fam

ily a

ppro

ach

for

wor

king

with

hig

h ris

k fa

mili

es.

Wel

fare

age

ncie

s ne

ed to

be

invo

lved

in d

evel

opm

ent o

f the

tria

l des

ign.

CM

DH

B

Go

al:

In

crea

se e

ffec

tive

su

pp

ort

fo

r fa

mili

es

thro

ug

h

app

rop

riat

e re

ferr

al

bet

wee

n

hea

lth

an

d w

elfa

re a

gen

cies

.

Tar

get

:

By

July

20

05

nat

ion

al

dir

ecto

ry

is

up

dat

ed a

nd

mar

kete

d t

o h

ealt

h s

ervi

ces.

Rev

iew

the

app

licab

ility

of

the

Fam

ily a

nd C

omm

unity

Ser

vice

s w

eb

base

d na

tiona

l se

rvic

es d

irect

ory

as a

cor

e to

ol f

or u

se i

n su

ppor

ting

appr

opria

te

refe

rral

be

twee

n he

alth

an

d w

elfa

re

agen

cies

. E

nhan

cem

ents

cou

ld i

mpr

ove

the

usef

ulne

ss o

f th

e di

rect

ory

for

heal

th

prov

ider

s.

Mar

ket u

se o

f the

nat

iona

l dire

ctor

y to

hea

lth s

ervi

ces.

MS

D

Go

al:

T

her

e is

a

clea

r lo

ng

te

rm

stra

teg

y id

enti

fied

fo

r se

rvic

e st

ruct

ure

s th

at w

ill m

ost

ap

pro

pri

atel

y m

eet

the

nee

ds

of

the

Co

un

ties

M

anu

kau

po

pu

lati

on

.

Tar

get

: P

apak

ura

ser

vice

map

pin

g c

om

ple

te

by

the

end

of

2005

.

The

Loc

al S

ervi

ces

map

ping

initi

ativ

e by

FA

CS

will

exp

licitl

y fo

cus

on th

e ne

eds

of t

he h

ealth

/wel

fare

/edu

catio

n in

terf

ace

in r

elat

ion

to v

ulne

rabl

e fa

mili

es a

nd d

evel

op a

long

term

str

ateg

y fo

r se

rvic

e de

velo

pmen

t.

MS

D

10.Improving Service Integration and Care for

Advanced Disease

Context

The Let’s Beat Diabetes plan has a strong focus on stopping diabetes through whole-society strategies. It also supports primary care to have a greater capacity to preventdiabetes, identify diabetes early, and support lifestyle change to slow or stop diseaseprogression. However, many people already have advanced diabetes and will continueto get serious complications from diabetes despite better prevention.

For most people with diabetes, the disease gets steadily worse over time. The averagetime from diagnosis to death for diabetes for Europeans is approximately 22 years, Pacific peoples approximately 20 years, and Maori approximately 18 years (Ministry ofHealth, 2002). The complications from diabetes include heart disease, kidney failure,stroke, blindness and ulceration/amputation of lower limbs. The disease leads to suffering for the patient and also cost for the health sector. In 2003, diabetes-relatedcost for the top 20 diabetes patients at Counties Manukau District Health Board’s(CMDHB) inpatient and outpatient service was $77,000 to $170,000 per patient (Thomas E, 2004). The average cost of clinic-based haemodialysis is $45,000 a year.

There is very good evidence that best practice health interventions and lifestyle changecan make a significant difference to the outcomes of people who have diabetes,including people with advanced diabetes with serious complications (UKPDS, 1975 - 204).

A number of initiatives have been introduced at a national, regional and district level tosupport more effective care and treatment for people with diabetes, including:

National level

Get Checked - a national programme, where General Practitioners (GPs) are paid$40 to provide a recall and check-up for people with diabetes – and to provide datafor a national database. (There is currently a review of the electronic support for theGet Checked programme).

Care Plus - a national funding initiative that provides GP teams with $200 a year toprovide extra care for people with chronic disease. It can be applied to supportstructured care for people with diabetes.

National Diabetes Guidelines – The New Zealand Guidelines Group publishedevidence based best practice guidelines for the management of Type 2 Diabetes inDecember 2003, including a view on Maori and Pacific perspectives onmanagement.

Electronic decision support tools – the Ministry of Health has funded the publishingof the guidelines within an electronic decision support environment. The guidelineswill be embedded in the Predict decision support tool and are expected to bereleased in early 2005.

Regional level

Dialysis review – a regional review of dialysis services, access criteria and demandmanagement strategies is currently underway in collaboration between theWaitemata, Auckland and Counties Manukau District Health Boards (DHBs).


Chronic disease strategy review – there is currently an analysis of the approachesto chronic disease management being taken by the four northern DHBs, looking at areas of convergence and divergence in approaches and at the risks and opportunities associated with the current approaches, with a view to developing more effective regional collaboration.

Activities of other DHBs – Auckland DHB is working with Primary Health Organisations(PHOs) to provide enhanced primary-care-based services for people with advanceddiabetes, similar to services provided under the Chronic Care Management (CCM) programme. Waitemata DHB is focusing on improving PHO-based retinal screeningand intensive education post diagnosis to support improved self management.Waitemata has also introduced a practice based quality and learning cycle – based broadly on the Institute of Healthcare Improvement’s ‘Collaborative Model for AchievingBreakthrough Improvement.’ The learning programme is delivered in partnership withthe Royal New Zealand College of General Practice (RNZCGP). Across the threeAuckland DHBs, similar frameworks to diabetes management are emerging, all involving defined levels of care intensity, with associated expectation of serviceresponse.

District level

Chronic Care management - Counties Manukau has for the past five years beendeveloping and implementing the CCM programme, which aims to provide qualitymanagement of diabetes within the primary care environment. CCM involvestraining and development for practice teams, increased levels of nurse-basedsupport, structured care and an Information Technology (IT) system that supports GP decisions and provides reports on how patients are responding. CCM alsoprovides GPs with extra funding to carry out the structured care activities and itreduces the financial barriers for people to access GPs.

Retinal Screening – In 2003 the Counties Manukau Diabetes Advisory Group(CMDAG) commissioned a review was undertake to develop improved co-ordination, clinical pathways and capacity development for diabetes retinal screening services. The recommendations of that review are now beingimplemented.

Gestational diabetes – A project is currently under way to provide better integrationbetween hospital and primary care services to support women with diabetes tohave healthy babies and to provide better follow up of women with gestational diabetes.

Community pharmacy – a strategy is being developed to improve the contribution pharmacists make to the management of chronic disease through providing adviceto practice teams and through enhanced counseling services for patients on correctuse of medicines and improving adherence to medication regimes.

As the above list of existing and emerging activities show, there is no shortage of newprogrammes and review processes in the treatment and management of diabetes. Themajor issue for improving diabetes outcomes is the effective uptake of best practiceprocesses in the general practice environment and the co-ordination of services across primary and secondary care. There are few practices which are currently working atthe level of identifying and managing diabetes in a manner which meets the national guidelines.

The CCM programme has recently released information which shows that whilst the early adopter practices were making a significant change in outcomes due to taking upthe CCM structured care approach, late adopter practices are not making the same



impact, despite financial incentives and considerable IT support. This outcome illustrates the difficulties in introducing chronic disease based programmes that require culture and systems change into the general practice environment. In other words, some of the major impacts on patient outcomes for diabetes are not patient characteristics or programme design but provider characteristics and capacity.

Progress is not being held back by a lack of ideas, but the need for effective implementation.

Programme Design

The objective of the programme design is to develop robust and sustainable systems that support broad primary care uptake of best practice care and improved integration with secondary care. Achieving this improved uptake of innovations requires a multifaceted change management programme, with strong governance, management (including knowledge management) and clinical leadership, as well as investment in workforce capacity and the use of innovative funding mechanisms.

The proposals outlined below are wide ranging and will challenge existing roles and relationships, however, this type of systems approach is required if the sector is to take on the changes required to effectively manage diabetes and other chronic diseases. The programme design supports:

Developing an improved framework for delivering care and organising integration

Creating an improved governance and management framework for diabetes care

Developing improved medical and nursing clinical leadership and a centre of excellence for whole system diabetes management

Creating an explicit learning collaboration to support innovation adoption, which includes general practice and secondary care

Building a sustainable and professionalised education courses/qualifications for the educational aspects of chronic disease management

Bringing various IT developments together to create a unified system

Defining a funding structure that incentivises outcomes as well as inputs

Building process and outcome evaluation to support whole system learning.

Act

ion

Pla

n

Peo

ple

wit

h d

iab

etes

are

man

aged

acc

ord

ing

to

the

New

Zea

lan

d b

est

pra

ctic

e g

uid

elin

es.

Lo

ng

-ter

m g

oal

s an

d t

arg

ets

Act

ion

sA

ctio

n L

ead

er

Go

al:

Dia

bet

es m

anag

emen

t ac

tivi

ties

are

imp

lem

ente

d

effe

ctiv

ely

in

a co

nsi

sten

tfr

amew

ork

acr

oss

pri

mar

yan

d s

eco

nd

ary

care

.

Tar

get

:B

y 20

05

fram

ewo

rk

for

care

agre

ed.

An

orga

nisi

ng f

ram

ewor

k fo

r di

abet

es c

ross

-sec

tor

man

agem

ent

is d

evel

oped

and

endo

rsed

tha

t lin

ks t

o th

e N

Z G

uide

lines

,is

sup

port

edby

fund

ing

fram

ewor

ks a

nd i

sco

ngru

ent

with

oth

er D

HB

sin

the

Auc

klan

d re

gion

. Alig

nw

ith r

etin

al s

cree

ning

pro

ject

,di

alys

is r

evie

w, g

esta

tiona

l dia

bete

s re

view

, nat

iona

l dev

elop

men

ts.

An

outli

ne o

f co

re a

ctiv

ities

to

be u

nder

take

n is

dev

elop

ed(w

ith u

sefu

l re

fere

nce

toW

aite

mat

a D

HB

wor

k)

in

part

ners

hip

betw

een

DH

B

and

PH

Os.

Rol

es

and

resp

onsi

bilit

ies

of v

ario

us s

ecto

r pa

rtne

rs a

re c

larif

ied.

Fun

ding

and

sup

port

mec

hani

sms

are

deve

lope

d,w

ith p

rogr

amm

e of

impl

emen

tatio

n.

CM

DH

B, P

HO

s, W

hitio

ra, W

DH

B

Go

al:

Dia

bet

es

go

vern

ance

st

ruct

ure

ssu

pp

ort

a

wh

ole

sy

stem

view

an

dm

anag

emen

t.

Tar

get

:

New

go

vern

ance

st

ruct

ure

in

pla

ce b

y Ju

ly20

05.

The

cur

rent

str

uctu

re a

nd t

erm

s of

ref

eren

ce o

f th

e D

iabe

tes

Adv

isor

y G

roup

and

the

Chr

onic

Car

e M

anag

emen

t G

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re d

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nd im

plem

ente

d.

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s

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stai

nab

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earn

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en

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nm

ent

is

crea

ted

wh

ich

su

pp

ort

s u

pta

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fse

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e in

no

vati

on

s in

p

rim

ary

and

se

con

dar

y ca

re.

Tar

get

:

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ial

lear

nin

g

colla

bo

rati

veb

egin

s Ju

ly 2

005,

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ns

for

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mo

nth

s.

30%

of

GP

s h

ave

par

tici

pat

ed in

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arn

ing

colla

bo

rati

on

by

2010

.

CM

DH

B,

PH

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and

the

RN

ZC

GP

set

up

anap

proa

ch t

o le

arni

ng a

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gst

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linic

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ical

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g an

d di

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rtis

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rogr

amm

e co

nten

t le

ader

ship

and

capa

city

dev

elop

men

t for

the

wid

er s

ecto

r.

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tiora

, CM

DH

B

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L P

LA

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ebru

ary

2005

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get

: R

evie

w o

f W

hit

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ro

le c

om

ple

te

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ril 2

005.

Allo

cate

mor

e sp

ecia

list

time

for

non

clin

ical

act

iviti

es f

or d

evel

opm

ent

of b

road

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ogra

mm

e de

sign

and

qual

ity r

evie

w,a

long

with

trai

ning

and

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lopm

ent f

or p

rimar

yca

re.

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ure

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tiora

team

has

deve

lopm

enta

l sup

port

to b

uild

and

mai

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n ce

ntre

of

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llenc

e st

atus

.

Go

al:

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e p

rim

ary

care

wo

rkfo

rce

has

th

esk

ills

and

kn

ow

led

ge

to

sup

po

rt

self

man

agem

ent

and

ad

her

ence

str

ateg

ies.

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get

: T

her

e is

a

form

alco

urs

e/q

ual

ific

atio

n f

or

up

skill

ing

pra

ctic

e n

urs

es i

n s

elf

man

agem

ent

edu

cati

on

fo

r th

e 20

06 y

ear.

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elop

a s

trat

egic

rel

atio

nshi

pw

ith M

anuk

au I

nstit

ute

of T

echn

olog

y (M

IT).

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port

su

stai

nabl

e co

urse

s to

pr

ovid

e ne

wgr

adua

tes

with

in

-dem

and

skill

s,

such

as

com

mun

ity

heal

thw

orke

r an

d pr

actic

e nu

rse,

an

d pr

ovid

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cour

ses

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ting

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ary

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actit

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rs

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man

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stin

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d qu

alifi

catio

ns f

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ours

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nder

take

.

30%

of

pra

ctic

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urs

es h

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bee

n t

hro

ug

hth

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y20

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ol. T

each

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acy

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to

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and

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em

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t sk

ills

and

to

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le

join

t G

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harm

acy

activ

ities

fo

r in

crea

sing

med

icat

ion

com

plia

nce

rate

s.

CM

DH

B, M

IT, W

hitio

ra, P

HO

s

Go

al:

Th

e in

form

atio

n

envi

ron

men

tsu

pp

ort

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fici

ent

bes

t p

ract

ice

man

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ent

of

dia

bet

es.

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get

:

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gra

ted

p

rim

ary

/sec

on

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yd

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etes

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syst

em

op

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al

by

July

2006

.

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exi

stin

g st

rate

gy o

f co

mpl

etin

g V

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on I

I of

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CC

M s

oftw

are

is s

uppo

rted

alon

gw

ith s

usta

ined

roll

out o

f the

pro

gram

me.

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pro

posa

l to

rede

velo

p th

e C

CM

sof

twar

e co

mpo

nent

sto

sup

port

man

agem

ent

ofC

are

Plu

s pa

tient

s is

sup

port

ed,

allo

win

gG

Ps

not

enro

lled

in C

CM

to

gain

ben

efits

of

usin

g IT

tool

s th

at e

ncou

rage

a st

ruct

ured

car

e en

viro

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t.

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emen

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in

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supp

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with

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re i

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the

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to

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ther

it

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d al

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with

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ata

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port

inte

grat

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with

ret

inal

scre

enin

g da

taba

ses.

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re

is

supp

ort

for

the

WD

HB

-fun

ded

deve

lopm

ent

of

a se

cond

ary

care

ca

rdio

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ular

/dia

bete

s di

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e m

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ould

eve

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llyal

ign

with

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prim

ary

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bas

ed C

CM

dat

abas

e to

cre

ate

a fu

ll m

anag

emen

t sys

tem

.

CM

DH

B,

PH

Os,

W

hitio

ra,

MO

H,

WD

HB

, AD

HB

Go

al:

Dia

bet

es

fun

din

g

sup

po

rts

real

chan

ges

in p

atie

nt

ou

tco

mes

.

Tar

get

: T

he

bal

ance

d

fun

din

g

tria

l is

com

ple

ted

by

Dec

emb

er b

y20

07.

The

fund

ing

envi

ronm

ent f

or p

rimar

y ca

re a

ctiv

ityin

dia

bete

s m

anag

emen

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refo

rmed

to p

rovi

dea

bala

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of f

unds

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inp

ut a

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d to

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entiv

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omes

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ch a

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e ch

ange

s in

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cal i

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.g. H

bA1c

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A

tria

l is

un

dert

aken

whe

re

the

curr

ent

situ

atio

n of

fu

ndin

g ba

sed

on

inpu

ts

is

CM

DH

B, P

HO

s

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INA

L P

LA

N 0

2 F

ebru

ary

2005

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LA

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2 F

ebru

ary

2005

com

pare

d w

ith a

bal

ance

d fu

ndin

g st

rate

gy w

here

the

re is

a s

plit

of in

cent

ives

acr

oss

inpu

ts a

nd o

utco

mes

.

Go

al:

Eva

luat

ion

p

rovi

des

ev

iden

ce

of

effe

ctiv

enes

s o

f in

vest

men

t in

sy

stem

ca

pac

ity

The

Cen

tre

for

Clin

ical

Res

earc

h an

d E

ffect

ive

Pra

ctic

e (C

CR

EP

) de

velo

ps a

pro

cess

an

d ou

tcom

e ev

alua

tion

fram

ewor

k fo

r th

e ab

ove

stra

tegi

es

and

links

w

ith

the

RN

ZC

GP

in s

uppo

rtin

g a

plan

-do-

stud

y-ac

t qua

lity

cycl

e am

ongs

t gen

eral

pra

ctic

e.

CC

RE

P, R

NZ

CG

P, C

MD

HB

, SoP

H

Enablers

Let’s Beat Diabetes is not only about diabetes prevention and management, but aboutthe types of changes society and the health sector need to make to better prevent and manage a number of chronic diseases, most obviously heart disease.

The change required challenges how the many different parts of the health sectoroperate, particularly the role of the District Health Board. The plan is divided into theTen Action Areas. However, there are many cross cutting themes, capacity andsystems issues that require proactive management to create an environment that inconducive to change. Some of these will require DHB management; others willemerge as the plan’s development process continues.

1. Consumer involvement

There is currently no well supported consumer forum to support consumer consultationabout issues of service design and quality. There are some existing consumer groups,one of these could be supported and expanded or a new group developed. Theconsumer group should include people from various ethnicities and stages of diabetesprogression. The group should also receive training and development in effectiveadvocacy. There may be an opportunity to more effectively use existing communityvehicles and networks, such as community boards, to support consumer involvement.

2. Maori and Pacific peoples

The priority placed on Maori and Pacific diabetes outcomes means that there needs tobe a special focus through the plan to ensure that Maori and Pacific health needs arebeing met in all Ten Action Areas. There needs to be separate stand-alone plans forMaori and Pacific peoples that pull together all aspects of the broader Let’s BeatDiabetes plan into one document to provide focused communication about the plan for Maori and Pacific communities. The strategies designed to assist Maori and Pacific peoples are outlined below:

Community Action Fund: This fund will enable Maori and Pacific communityorganisations, marae and churches to apply for funding to support activities which prevent diabetes and support people with diabetes.

Focus on marae/kura: The Maori leadership strategy supports the development ofmarae and kura as health promoting environments through knowledge, cultural lore and activities.

Focus on churches: The Pacific leadership strategy supports the development ofmulti-ethnic strategy that is responsive to each of the Pacific peoples and enables Pacific churches to support the physical as well as spiritual health of their congregation.

Cultural training (professionalise in primary care): The professionalisation of upgrading skills within primary care will enable greater uptake of training in cultural issues and safety.

Health Promotion capacity: Maori and Pacific health promotion providers willreceive more support for capacity development and more opportunity forprogramme developments, plus more effective links with mainstream providers.

Family/whanau focus to work: The core family focus to the strategy aligns with the national He Korowai Oranga (Maori Health Strategy) and Pacific Health and


Disability Action plan. The family focus is illustrated in the Vulnerable Familiesstrategy and in the ‘family group’ trial of the Prevention Focused Primary Carestrategy.

Targeted social marketing: The social marketing programme will target Maori andPacific peoples in an encouraging environment and provide practical information onlifestyle change.

Evaluation of outcomes for Maori and Pacific peoples: The evaluation frameworkwill develop special considerations for process and outcomes issues for Maori and Pacific peoples, utilise Maori and Pacific researchers and include communities inprocess.

3. Funding Environment

One of the key functions of CMDHB in creating a supportive environment for Let’s BeatDiabetes is to provide resources for action and to realign existing resources under itscontrol and influence resources under the control of other organisations. Fundingactivities required to support the plan include:

Aligned Health Promotion Funding: CMDHB will work with other funding organisations in the health promotion area to gain greater synergy between fund allocation in terms of programme design, target group and capacity building in thesector.

Sustained upstream funding: CMDHB will provide an estimate about a level offunding that will be allocated to the Let’s Beat Diabetes strategy for a period of five years, so that there is security from the health sector and confidence from non-health partners that diabetes is a priority area and CMDHB is committed tosustained action for the five years of the plan.

Balanced primary care input/outcome incentives: The funding for activities within the primary care environment will be reviewed to see if improved outcomes can beachieved by a balanced funding strategy across inputs and outcomes – as opposedto purely funding inputs as is currently the case.

Allocation to evaluation: A proportion of the overall investment in Let’s BeatDiabetes will be set aside for evaluation.

Seeking matched funding with other agencies: Where possible CMDHB will seekmatched funding or resource input from other agencies in new areas of activitywhere there is cross agency jurisdiction and interest in order to maximise societal investment in diabetes prevention. This may include sponsorship in some areas.

Support for specific strategies and the Community Action Fund: Funds will be allocated to support specific strategies outlined in the Let’s Beat Diabetes plan andthere will also be a general fund which will allocate small grants to community organisations to support diabetes prevention programmes that work within aparadigm of cultural strength and community empowerment.

4. Learning Environment

Let’s Beat Diabetes proposes strategies that expand health sector activity and society efforts into challenging new areas of activity. The plan will not succeed unless thereare strong evaluation and learning frameworks to support continual reassessment andfine turning of activities and to know whether the plan is having the desired impact.

Overall evaluation – continuous quality improvement: It is proposed that CMDHB develop a partnership with the University of Auckland School of Population Health


(UoA-SoPH) and Counties Manukau communities to develop an evaluationframework that sits across the entire 10 strands of the plan and the governanceprocess. The evaluation would be designed to measure outcomes but to also support a process of learning through a continuous quality improvement cycle.

PDSA cycle – Breakthrough Collaboration: Approaches will be made to GPs,PHOs and the Royal New Zealand College of General Practice to implement a series of action learning cycles (based loosely on the IHI Breakthrough Collaborations) to support uptake of innovations by GPs and to better understandthe blockages to innovation adoption.

Workforce development – education and self management: A major issue for primary care and to some extend in secondary care is the need for there to beimproved expertise in patient education, motivational interviewing and support for self management. This requirement applies to all chronic disease, not justdiabetes. There needs to be a move to a proper professionalised course based inan education institute that can access education funding streams, provide new skills to a wider range of health professionals, deliver a recognised qualification andcreate a common language and approach to help foster a new paradigm in the management of chronic disease. There is also a need to enhance training opportunities for a broad range of community workers so they are better able tocontribute to community wellness and chronic disease management.

Mangere schools evaluation: The UoA research project into the impact of healthinterventions at secondary schools should be supported as it provides an opportunity to accurately quantify the impact and outcomes of such interventions and build an evidence base for ongoing investment in schools programmes.

5. Sustainable Governance

The development of a sustainable governance structure will require a strong andinclusive initial structure, powerful links to the action areas, the delivery of value for participating organisations and individuals and good administration support:

Overarching governance model: The overarching governance group for Let’s BeatDiabetes will guide the plan implementation. The group will have representationfrom all Ten Action Areas, plus key partnership organisations, community leaders,clinical experts and consumers.

Links to Tomorrow’s Manukau: The governance group will link with the Health andWellbeing sub committee of the Tomorrow’s Manukau group to ensure that the partnership and information flow with Manukau City Council (MCC) and other key government agencies is maintained.

Leadership Hubs for each area: Each of the Ten Action Areas will have its own leadership hub or group. The make-up of each hub will differ as each will havedifferent requirements. For example, the Food Group will differ from the Well Childgroup. Different organisations will lead each area. For example, Ministry of SocialDevelopment will lead the Vulnerable Families area, whereas Manukau City Council will lead the Urban Design area. The ‘action leader’ approach is similar tothat used in the Tomorrow’s Manukau plan.

Administration support: CMDHB will support resources and networks to provideoverall administrative co-ordination of the various work streams.


6. Organisational Development

The development of appropriate and trained workforce may be the single mostimportant factor for enabling primary care to meet the challenge of improved chronicdisease management. Workforce development must be a priority. Health programmes also require strong professional leadership. It is proposed that the Whitiora DiabetesService is supported to maintain a centre of excellence status with regards to wholesystem diabetes management. CMDHB will also have to look to its own capacity inorder to support Let’s Beat Diabetes. It is proposed that enabling cross-sector learningcould be a central pillar to the DHB role:

Workforce – new workforce and training in primary care: Modeling has shown that there is likely to be a substantial demand for practice nurses and community healthworkers as primary care changes to support improvements in chronic diseasemanagement. There will also be requirements for proportionally more dieticians, psychologists, nurse practitioners, nurse specialists, social workers, pharmacists as part of the primary care team but these are likely to be provided by existing marketplace mechanisms. Indications are that there will be shortages in practice nurses and community workers unless proactive activity is undertaken to develop an increased workforce.

There is also a need to professionalise the upskilling of the existing primary careteams (discussed under the ‘Learning Environment’ heading).

Workforce – constraints within secondary care: If the current increase in dialysis continues there is a high likelihood that the existing global shortage ofnephrologists will become an acute issue in terms of quality and capacity. Forwardplanning is required across the entire area of demand and service capacity for dialysis.

Whitiora centre of excellence – clinical leadership: Middlemore Whitiora DiabetesService currently provides the clinical base and centre of excellence that has drivenmuch of the capacity increase across primary care, through training, advice andsupport for nursing and medical practitioners. The Whitiora team is under considerable pressure from clinical workloads and needs to be able to retain astrong strategic role in broad guidance across clinical issues and whole system capacity and processes as they relate to best practice care for people withdiabetes.

Let’s Beat Diabetes creates greater demand for centre-of-excellence medical,nursing and health psychologist leadership. Investment in increased medicalspecialist time devoted to system-wide clinical leadership and ongoing developmentof nursing staff in their nurse specialist roles is required to implement the system improvements outlined in the plan.

DHB co-ordination and system change model: Let’s Beat Diabetes challenges therole of the DHB in system change. How much is CMDHB a hands-off policy/funding organisation and to what extent does it become involved in themanagement of programmes and change processes? CMDHB is already involvedat quite a detailed level with broad whole system processes, like the CCM programme. While there will be leadership from many organisations andcommunities with the plan implementation, there will still have to be a core administrative heart across the wider process – and this role legitimately falls to the DHB as it has the requisite administrative, management, policy and strategic skillsand the governance mandate.

It is suggested that CMDHB focus its attention strong on the whole system learningrequirements of the plan. The plan will not work with a purely top down command and


control structure. A network based learning environment will need to be encouragedwhich is supported with robust proven, learning processes and with regularperformance information from the evaluation process.

In this manner, CMDHB will develop a core competency in directing and encouraging learning and innovation adoption within the health environment, which will be importantto its ongoing effectiveness as a leadership organisation.

7. Information Systems

There are many powerful information systems tools to support clinical decisions,patient administration and performance measurement. At present there are a numberof unlinked systems that have the potential to become better aligned/linked/integratedto form a complete system of clinical management support for people with diabetes:

CCM Version II/CCM Care Plus/ Ministry guidelines in Predict: Complete thedevelopment of the CCM Version II plan to make the CCM tools more useful and user friendly, update the CCM tools to support the clinical and administrative tasks associated with the Care Plus disease management activities and include the new guideline-based decision support tools in the CCM suite of tools.

Screening – CV/diabetes: Provide general practice with the ability to undertakedecision-support-assisted screening for CV risk and diabetes according to the NewZealand guidelines. There may have to be a dual approach. The preferredapproach of embedding the screening tools and activity within the CCM suite of tools, and the contingency plan for those GPs who appear unlikely to take up CCM of supporting web based screening and risk assessment decision support tools.The objective is to maximise the penetration of screening and introduce general practice to the use of decision support tools to assist clinical activities.

Get Checked – annual check database: The national data system that supports theDiabetes Get Checked programme should be aligned, or at least linked, with the CCM system to allow for simplified user data entry and reporting.

WDHB secondary care module: Waitemata District Health Board is investing in thedevelopment of a secondary care based clinical support system and database for diabetes and cardiovascular disease. This system is being designed to fit with theCCM system to create a wider whole clinical system for primary and secondary care management of CV and diabetes. Counties Manukau needs to maintain close links with the development of the Waitemata system to see where the synergies liewith Counties Manukau secondary care needs and that issues of integration withthe existing CCM system are managed from the user perspective.

Advice only support for brief interventions and self management counseling andresources on line: A scoping study should be undertaken as to the practicality and value of the CCM platform being used to support brief intervention counseling and patient education via on-line evidence-based advice for practice staff and theprovision of online education resources.


Part III

Implementation


Executive Summary

Let’s Beat Diabetes presents an implementation challenge due to its breadth,complexity and cross sectoral approach. The need to reduce the risk factors fordiabetes, slow disease progression and increase the quality of life for people withdiabetes requires a response that encompasses whole-society action across the lifecourse.

The implementation process must develop a community partnership that can create an‘atmosphere of leadership’ that permeates local government, industry, the health sector and the population itself. The ‘newness’ of this project means implementation mustsupport an explicit learning framework and strong feedback loops.

A governance structure is proposed that includes a broad stakeholder governancegroup that meets as a forum twice a year to provide overall guidance for the projectand feedback from the broader society, a steering group made up of key action leadersthat meets monthly and leadership hubs for each of the Ten Action Areas.

Counties Manukau District Health Board (CMDHB) will provide support for a project management team that coordinates the overall implementation process through thegovernance and steering groups and provides links across the various health sectoractions.

The project management team will need to work closely with each of the partnerorganisations to ensure Let’s Beat Diabetes is aligned to their strategic objectives and that the plan and implementation continue to deliver value to stakeholders and thereby maintains their commitment.

The implementation process includes an establishment phase for the first six months of2005 when the governance and management structures are set up, detailedprogrammes designed in each of the Ten Action Areas, targets and key performanceindicators set, reporting and evaluation mechanisms set up, and funding committed.

Implementation will be phased with most programme activity beginning from July 2005,but with some programmes scheduled to begin a year later to enable more detaileddesign and to manage the workload and complexity of the project, and a small number of programmes beginning earlier to ensure momentum is maintained from the planning during 2004.

There are a number of significant risks with the project associated with its breadth and complexity and the need for effective community and organisational partnership processes. These risks are mitigated to some extent by the community commitmentshown to date, the strong interagency relationships in Counties Manukau, and the skills CMDHB, Manukau City Council (MCC), and other agencies have developed inimplementing community based programmes.

It is noted that the implementation plan does not include a discussion on fundingissues. These will be included in a separate ‘business case’ document.


Scoping the task

The Challenge

Implementing Let’s Beat Diabetes represents a huge challenge for the health sectorand for the wider Counties Manukau society. Reducing the risk factors for diabetesrequires us to change some of the core components of our modern environment andlifestyle. Treating diabetes effectively needs health sector reorientation from its historicacute care model to a chronic care model, which requires a paradigm shift in roles,relationships and skill sets.

As the WHO has noted: ‘In developed countries, the epidemiological shift in diseaseburden from acute to chronic diseases over the past 50 years has rendered acute care models of health service delivery inadequate to address the health needs of thepopulation’ (WHO, 2003)

Our immediate challenge is diabetes - but to beat diabetes we must address head-onthe current inability of society and our health sector to respond effectively to chronicdisease.

These deep structural issues must be manifest in both programme design and inimplementation.

Implementation challenges inherent in the programme design

Let’s Beat Diabetes describes a set of Ten Action Areas that, when implemented,will have a material impact on obesity, diabetes and other chronic diseases, suchas cardiovascular disease. The 10 areas are wide in scope and emphasise awhole society approach and the need for sustained commitment over time by government agencies, industry and communities.

Let’s Beat Diabetes is committed to the principles of partnership, participation andprotection permeating all aspects of design and delivery, specifically in its relationship with Maori and more generally as a guiding philosophy for meaningfulcivic leadership.

Let’s Beat Diabetes notes the importance of community ownership and the use ofculture to embed sustainable change in our society.

Let’s Beat Diabetes is a plan for the Counties Manukau district (not just a health plan) and as such has a different and far more complex dynamic in terms ofgovernance and operational management than a normal sector-specific strategicplan.

Let’s Beat Diabetes is new. It is moving into new ground for a district health board in New Zealand, forging new partnerships and designing and implementing new programmes. Some programmes are being developed in areas where there is notconclusive evidence of effectiveness, therefore a strong learning and evaluation framework is required.

In some areas Let’s Beat Diabetes programmes cannot be implemented without a fundamental change to the traditional skill sets, organisational capacity andaccountabilities of parts of the health sector.


Let’s Beat Diabetes will require significant financial investment from multiplefunders.

Let’s Beat Diabetes is aiming for integration of campaigns at the district level, withconsistent branding, messages and resources. Achieving this will require influenceover the focus of national agencies,

Required outcomes

Let’s Beat Diabetes must stop people getting diabetes, slow the disease progressionand increase the quality of life for people with diabetes.

Achieving this vision will require:

Changes to the environment and behaviour at all stages in a person’s life

A reduction in the proportion and number of people who are overweight and obese

Early identification of disease

Best practice approaches to disease management

Improved self management and adherence to treatment

A more supportive family and community environment for people with diabetes.

Necessary system characteristics

Atmosphereof leadership

Services

Learning

People ofCountiesManukau

RiskEnvironment

CommunityPartnershipGovernance

The graphic above is an attempt to provide a fundamental picture of the systemcharacteristics required to meet the outcomes of Let’s Beat Diabetes.

To achieve real change requires a groundswell of understanding and commitment –and a common direction. This is described as an ‘atmosphere of leadership’ in thegraphic. The atmosphere of leadership and an understanding of direction shouldpermeate health service providers, communities, industry and local government.


The atmosphere of leadership will take on a life of its own, as all successful societalchanges do, but in the early stages it will require spark and fuel – and this is the role ofthe community partnership governance.

Activities to change the risk environment (both behavioural and environmental risk) and the service environment will be more effective if the population is not a passive recipient, but an active participant in shaping the sorts of changes required.

Finally, there are no ‘off-the-shelf’ models for beating diabetes. There is evidence frommultiple sources to help plan the journey, but central to success will be the ability of allparties to learn fast about what is working and what is not. This new knowledge needsto be shared at a local level and also to be fed back to the community partnershipleadership in order to shape the overall plan.

The implementation plan attempts to influence all of the necessary system characteristics.


Implementation structure and process

Programme shape and implementation phasing

The Gantt chart above describes the basic shape of the Let’s Beat Diabetes plan. Thefirst six months of 2005 are an establishment phase in which district governance structures are put in place and the project team set up. There is intensive detailed programme design. A small number of CMDHB-funded initiatives begin in order to maintain momentum from 2004 planning.

From 01 July 2005, sustainable funding becomes available for the programme. Thesecond half of 2005 sees a number of programmes (Phase I programmes)implemented with programme design work continuing for Phase II programmes.

The programme design and implementation is divided into two phases to manage theworkload, complexity and to align with other external programmes and activity. Thefirst wave of programmes will create a more conducive environment for those that follow later in the year.

The evaluation process will be ongoing from mid 2005, supporting a continuous qualityimprovement process and rich learning environment, however, it is proposed that thereis a major milestone report at the end of year three to review progress and support any adjustments that are required over the final two years of the project.

It is proposed that a substantive planning process is undertaken in year five to developstrategic directions for the next five years.


Developing community partnership governance

Community Governance Group

Overall guidance from communitypartners

PartnershipSteering Group

Urban design

Social

marketing

Schools

Integration

Primary care Community

leadership

Food

Well child

Vulnerable

families

Health

promotion

Governance

Meets 4 times ayear – districtownership (linksto Tomorrow’sManukau)

Steering Group

Monthly –leadership fromaction areas andproject team

Leadership hubs

Explicit leadershipstructures foreach of the 10 action areas

DHB roles

The DHB willprovide adminsupport to thegovernance andsteering groups.

It will also providea projectmanagementteam to providecore managementsupport for thewholeprogramme. Theprojectmanagementteam will supportthe 10 actionareas to varyingdegrees,depending on need andprogrammecharacteristics

Projectmanagement

team

The graphic above describes the overall governance and leadership structure for Let’sBeat Diabetes. There has been much discussion and debate over the most effectiveformat for community partnership governance. There is a tension between having an effective and focused leadership group to drive the project forward and the need forbroad community membership and guidance for the project.

There is also a tension between wanting community governance to retain guidance forthe plan as a ‘whole’ but also to maximise the ability of the various parts to be actionorientated, not held back by bureaucracy and to learn from each other without a hierarchical system of control. Conversely, if governance groups do not have anypower or influence, participants soon lose commitment to the process.

Underlying the governance structure is a commitment to open governance andcommunity empowerment, with documentation from meetings available on the Let’sBeat Diabetes website.

The proposed governance structure is an attempt to navigate through these issues.

The structure has three key levels.

i. Community Governance Group: This group will own the plan and provide overall high level leadership and guidance for its implementation. The group will representthe key organisational and community stakeholders. It will be quite large (e.g. 30 members) and would meet in a forum situation twice a year (or more often if required) to receive reports on progress, provide feedback from the community andpartner organizations, and provide guidance on issues.


ii. Partnership Steering Group: The Partnership Steering Group provides operational leadership and co-ordination for the plan implementation. The group will be madeup of leaders from the action areas, CMDHB project team members, and identifiedenthusiasts and experts. Consumer representatives may also with to participate inthe steering group on particular issues. It is anticipated the steering group will meet monthly. The steering group will also develop reports for Tomorrow’s Manukau TeOra O Manukau/Manukau the Healthy City Outcome Group to ensure that thepartnership and information flow with Manukau City Council (MCC) and other key district organisations is maintained.

iii. Leadership hubs: Leadership hubs will be established for each of the ten action areas. The hubs will vary considerably from area to area. In some cases it may bea specific new working group, in others it may be a new accountability for an existing group. Composition will differ to fit the functional needs of the programmes.Efforts will be made to develop stable individual leadership within each action area so that a consistent team develops at the steering group level. Efforts will be madeto support non-DHB leadership in many of the action areas to reflect the whole society approach. Functional networking across the action areas will beencouraged.

Supporting effective project management

The governance structure must be supported by effective project management. Thebreadth and complexity of Let’s Beat Diabetes creates new challenges andaccountabilities across the societal response and across the health sector.

It is proposed that a dedicated project support team is located in CMDHB and would befunded by CMDHB.

The role of the project support team would be to provide administrative and projectsupport for the governance, steering and action areas. It would also deliver expertise and programme design skills for the overall project and to lead and co-ordinate CMDHB’s commitment to the project. The project team would also be responsible foroverall performance reporting and would provide links back into CMDHB funder andprovider operations.

The project team will require management and clinical leadership, with support for the complex co-ordination task.

Alignment and commitment

A critical success factor in creating the ‘atmosphere of leadership’ necessary to beatdiabetes is the ongoing commitment from multiple organisations. CMDHB acknowledges that it will provide the greatest component of resource andadministrative support for the programme but other organisations must also commit or the plan will fail.

In order for organisations to commit, the plan must align with their directions anddeliver strategic and operational value. If Let’s Beat Diabetes ceases to deliverperceived value to stakeholders, they will disengage. All organisations have a differentview of what constitutes value, and sustainable partnerships will require continuallyassessing what value is being delivered for all stakeholders and modifying activity where necessary.


The CDHB project team must develop a set of relationships which are not ‘one size fits all’ but which encompass an in-depth understanding of the needs of key partners in terms of their requirements of partnership, their ability to participate, outcomes that are valuable and meaningful for them, and effective means of communication for theirorganisation.

A key early point for alignment and commitment will be in constituting the make-up of the partnership steering group, leadership groups for each of the Ten Action Areas,and in the detailed programme design and resource commitment.

Outlined below are the Ten Action Areas and the Enablers and some indications of potential organisations involved in each of the areas. The CMDHB project team willoffer administrative and project support for all Ten Action Areas, but the level and typeof support will vary considerably depending on need and function. A number of theaction areas may be provided administrative and project support by partner organisations.

Action Area Organisational leadership1. Community Leadership & Action Church and marae

Community organisationsTomorrow’s Manukau organisationsCMDHB, ARPHS, PHOs

2. Social Marketing CMDHB, SPARC, Pharmac, MCC, ARPHS, MOH, NGOs 3. Urban Design MCC, CMDHB, ARPHS, Housing4. Food Industry Food industry, CMDHB, ARPHS5. Health Promotion CODA group, CMDHB, Diabetes Projects Trust, NGOs,

PHOs, ARPHS, DPT6. Well-Child CMDHB, Plunket, MOH, NGOs, Kidz First, PHOs 7. Schools CMDHB, MOE, MCC, Trustees, Principals, SPARC, NGOs,

food industry, Kidz First8. Primary Care (Chronic Care

Management)CMDHB, PHOs, RNZCGP, Whitiora, NGOs

9. Vulnerable Families MSD (Work and Income, Family and Community Services),NGOs, CMDHB, Plunket,

10.Service integration CMDHB, Chronic Care Management, Whitiora, PHOsEnablersConsumer Consumers, NGOsMaori Marae, Kura, NGOs, CMDHB, PHOsPacific peoples Churches, NGOs, ethnic leadership groups, CMDHB, PHOsFunding Environment CMDHB, MOH, SPARC, MCC, PHOs, Pharmac, MOE, UoALearning Environment CMDHB, UoA, RNZCGP, CCREP, MIT, other DHBsGovernance CMDHB funder and provider, local govt (x3), reps of 10

action areas, Maori, Pacific, Asian communities,consumers, national agencies, evaluation, clinical reps

Organisational Development CMDHB, MIT, NGOs, Whitiora, PHOs, Kidz firstInformation Technology CMDHB, PHOs, MOH, other DHBs, IT providers

Design, performance and learning

Programme design work during 2005 will require detailed development of each of the Ten Action Areas, many of which require cross organisational planning.

Some of the projects are relatively straight forward. Others will require significantdetailed technical design. The CMDHB Let’s Beat Diabetes project team will need to


provide technical support and guidance for programme design in a number of areas,with specialist skills being seconded into support roles as required.

The development of the programmes should link closely to the learning systems andperformance measures for Let’s Beat Diabetes.

It is important that the leadership groups for each of the Ten Action Areas develop their own targets and performance measures. Top down goals and measures may work ina single organisational structure, but since Let’s Beat Diabetes works with crossorganisational collaborations, goals and measures must be owned by all parties.

The leadership groups for each of the Ten Action Areas will be expected to provide a set of goals and Key Performance Indicators by April 2005 and these will beconsolidated into a document that outlines goals and measures for the entire Let’s BeatDiabetes programme.

The evaluation process can help to develop ways of measuring whether processes areeffective and outcomes are being achieved. It is much more effective to develop theseevaluation measures at the point of design, rather than add them on later. Theevaluation plan is expected to be completed by May 2005. The evaluation approach is that of supporting Continuous Quality Improvement across the Let’s Beat DiabetesAction Areas. The evaluators will have to be familiar with each of the Ten Action Areasto determine how they can best add value and learning outcomes for each area as well as for the wider plan.

The enabler areas will be supported through the CMDHB project team and throughsome existing support structures within the CMDHB environment (e.g. workforce development, information systems, Maori and Pacific services).

Branding and developing the plan as an entity

One of the core aspects of the atmosphere of leadership is to develop the Let’s BeatDiabetes plan as part of the Counties Manukau cultural landscape. The plan itselfneeds a positioning and marketing strategy – which is a different issue to the social marketing strategy about diabetes.

One of the early tasks in the implementation process will be to develop a branding andmarketing strategy for the plan.

The plan needs to have a recognisable image and identify and to represent a set ofgoals that all parts of Counties Manukau wish to contribute to. It must be set up for longevity and to be around in a recognisable form in five years time.

The branding strategy will need to appeal to key communities, such as Maori andPacific people, as well as to industry and other government agencies. It will also needto be able to align with government strategies, such as the national Healthy Eating Healthy Action Framework.


Risk management

There are risks inherent in the Let’s Beat Diabetes programme design andimplementation.

The programme design is broad, complex and ambitious, and relies to a considerableextent on the motivation and goodwill of partner organisations and communities to join the health sector in fighting obesity and diabetes. The implementation of a plan of thisnature has not been tried by a DHB before. In many ways CMDHB is running ahead ofgovernment policy and MOH guidelines in the scale and scope of the Let’s BeatDiabetes plan, and hence there may not be a great deal of guidance and supportiveprocesses at a national level.

The positive balance to the inherent risk is that the response to date to the Let’s BeatDiabetes planning process has shown the depth of commitment in Counties Manukauto beat diabetes and the strong history of functional interagency relationships providesa platform to build from. The timing feels ‘right’ in terms of a conducive Counties Manukau environment.

CMDHB has excellent skills in community partnering and project management and hasindicated that it will provide sustained resources to support Let’s Beat Diabetes over afive year period. Given the trends in obesity and diabetes, it is likely that thegovernment will provide support to the programme and will highlight it as an exemplarfor other DHBs to follow.

Further details of risks and mitigating strategies are outlined below.

Risks Descriptions Mitigation

Poor external ownership Failure of organisational commitment to governance structure and action arealeadership

Significant effort has gone intoplanning phase to align organisations (commitmentthrough summit)This will be firmed up intospecific commitment duringQ1&2 of 2005

Poor internal ownership Failure of internal support, alignmentwithin DHB funder and provider arms(other priorities)

High level support from EMTand the Board, and alignmentof goals across diabetes planand broader system and clinical outcomes

Swamped by complexity Project team is unable to deliver on timedue to size and scope of project, designcomplexity and operational complexity

Maintain high skill level in coreteam, fund access to specific experts when required, phaseactivity, review regularly

Evaporation of interest Internal and external interest evaporatesat multiple levels (governance and operational)

Maintain pace of change,include strong learningframework in programmedesign and evaluation,highlight achievements (andachievers) and provide positivefeedback across the broaderchange programme (a sense of campaign)

Slow wins Lack of tangible results leads to loss ofmomentum.

Structure programmes withexplicit early wins, identify andpublicise KPIs, and celebrateprocess as well as outcome


achievementsCapacity and skill lack Change management, programme design

and implementation skills lacking leads to stalled programmes. Risk especially inprimary care sector given extent ofchange

Early identification ofskill/capacity lack andinvestment is skilldevelopment. Present andreinforce as top priority

Inconsistent fundingenvironment

Funding environment changes from yearto year leading to sector uncertaintyabout commitment

CMDHB Board agrees to committed and stable fundingstream. CMDHB fundssupported by resources fromother sources. Ongoingengagement of key funders


Establishment phase and developmental

phase activities

The set of graphics below outline the key tasks for the establishment phase (first six months of 2005) and the developmental phase (July 2005 – June 2006) of Let’s BeatDiabetes.

The set of tasks is broken up into governance and management tasks and the activityareas themselves.

Governance, project support and establishment

ID Task NameQ1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06

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

12

Develop detailed programme designfor 10 action areas to inform phasingissues for project management andfunding requirements.

2

1 Governance

Identify key partners and set upStakeholder Governance Group

11

10

9

8

7

6

4

3Develop leadership structures for eachof the 10 action areas

Build operational steering group fromkey leaders form 10 areas

Project support

Appoint staff to LBD project teamwithin CMDHBClarify roles and accountabilities withexisting DHB structures

5Review existing governance structuresand align with LBD structures

Programme design andperformanceIdentify targets and KPIs with 10action areas

Ensure targets and KPIs are reflectedin partner organisation strategic andoperational plans

15

14

13 Communications and relationships

Presentation of diabetes plan to keypartner organisations

Evaluation and learning

Develop overarching evaluationframework, aligned to CQI learningprocess and identified keyperformance indicators

18

17

Implement evaluation

Maintain open process ofcommunication and learning throughLet’s Beat Diabetes web site, whichwill include core information about allprojects and evaluation

16


Action Area tasks



1 Community leadership

2Set up community fund and developworkforce programmes for Tomorrow’sManukau organisations

3Community fund operational andorganisations implementing healthworkforce plans

4 Social marketing

5

Launch Let’s Beat Diabetes,communicate plan to district, developcontract relationship with professionalpartner to deliver social marketingprogramme

6 Begin social marketing programme

7 Urban design

8

CMDHB to work with Manukau City tosupport healthy urban design in FlatBush and redevelopments of existingurban hubs

9 Integrated Health Promotion

10

Revitalise district health promotion co-ordination through improved supportfor CODA group and links to HPOs.Develop plan of action.

11Implement contracts for capacitybuilding, co-ordination and resourcedevelopment for health promotion

Develop enhanced programmes to achieve targets and implement

12




1 Healthier food supply

2Develop and implement strategies toimprove food supply with food industrypartners

3 Enhancing Well Child Services

12

11

Undertake training and developresources

Implement new programmes5

4

Primary care based prevention

Programme design activity aroundbrief interventions, post diagnosiseducation and family intervention trial.

14

13Workforce development programmesimplemented

Implement enhanced brief interventionprogramme (linked to socialmarketing), improved post diagnosispatient education (expert patient) andfamily group intervention trial.

15Encourage primary care based diabetes screening as per the NZ guidelines

9

8

7

Development of governance structureand set of agreed targets for schoolsand support providers. Identifyresource requirements to meet targets.

Support expansion of NEWprogramme to align with UoA healthschools research

Develop enhanced programmes to achieve targets and implement

Improve co-ordination and marketingof existing programmes to preschools,Kura and primary schools

10

6 Healthy schools




8

3

2

1Integrated care for advanceddiabetes

Build whole disease managementcentre of excellence at WhitioraMiddlemore Diabetes Centre

Work with PHOs to define clearexpectations of diabetes management from point of diagnosis and requiredsupport systems

Work with RNZCGP to developcollaborative learning process for innovation adoption amongst GPs

Improve co-ordination of qualityenhancement programmes such asretinal screening, gestationaldiabetes, foot care, dialysis review,Get Checked for strategic guidance ofprogramme development

4

6

Improve linkages to social services for people with diabetes to ensure theyare receiving correct entitlements andsupport for remaining in employment

7

Work with MIT to develop recognisededucation courses that provide support the new skill sets – in both newgraduates and upgrading existingworkforce – for chronic disease management

5

Support development of enhanced primary care capacity throughincreased access to communitypharmacy, dietitian, psychologist,social worker and community workerexpertise in primary and secondary care.


References

Barnfather D (2004). "Childhood Obesity Prevention Programmes in Auckland."

Counties Manukau District Health Board (2002). "Healthy Futures: A Strategic Plan for Counties Manukau District Health Board."

Counties Manukau District Health Board (2004). "Survey of Year 9 pupils at Aim Hi Schools."

Critser G (2003). Fat Land: How Americans became the fattest people in the world, Allen LaneThe Penguin Press.

FAO/WHO Expert Consultation (2003). Diet, nutrition and the prevention of chronic diseases:Report of a joint WHO/FAO expert consultation, Geneva 28 January- 1 February 2002. Geneva,WHO.

Homer J, J. A., Seville D, et al (2004). The CDC's Diabetes Systems Modeling Project: Developing a New Tool for Chronic Disease Prevention and Control. Atlanta, Centre for DiseaseControl: 10.

Kawachi I (2003). Promoting Physical Activity and Health by Urban Design.

Lindsay A (2003). Diabetes Rates by Census Area Unit in Counties Manukau.

Ministry of Health (2000). "The New Zealand Health Strategy."

Ministry of Health (2001). "The Primary Health Care Strategy."

Ministry of Health (2002). "He Korowai Oranga - Maori Health Strategy."

Ministry of Health (2002). "Modeling Diabetes: Forecasts to 2011."

Ministry of Health (2002). Modeling Diabetes: Forecasts to 2011.

Ministry of Health (2002). "The Pacific Health and Disability Action Plan."

Ministry of Health (2003). "Healthy Eating - Healthy Action: A strategic Framework."

Ministry of Health (2003). "NZ Food, NZ Children. Findings of the 2002 National Children'sNutrition Survey."

Ministry of Health (2003). "A Snapshot of Health, Provisional Results of 202/03 New ZealandHealth Survey."

New Zealand Food Industry Accord (2004).

New Zealand Guidelines Group (2003). Management of Type 2 Diabetes, Ministry of Health.

PriceWaterhouseCoopers (2001). "Type 2 Diabetes. Managing for Better Health Outcomes."

Pucher J, D. L. (2003). "Promoting Safe Walking and Cycling to Improve Public Health: LessonsFrom the Netherlands and Germany." American Journal of Public Health 93.

Ratanjee (2004). Personal communication.


Thomas E (2004). The Management of Diabetes at Counties Manukau District Health Board from the Time of Diagnosis.

UKPDS (1975 - 204).

WHO (2004). Global strategy on diet, physical activity and health.


Documents

LET’S BEAT DIABETES - Counties Manukau Health · LET’S BEAT DIABETES A Five Year Plan to Prevent and Manage Type 2 Diabetes in Counties Manukau FINAL PLAN Endorsed by the …