An overview of DHB-funded health services for older people in New Zealand. Current situation and future need.
Abstract: Older people, especially that portion aged over 85 years, are intensive users of healthcare resources, experiencing high rates and prevalence of chronic illness, disability and co-morbidity compared to other age demographic groups in the population. As the number of 'older old' people rises in the immediate future, the demand on health resources will be increasingly pressured and acute. An overview of publicly funded health and disability support services for older people in New Zealand over the life of the Health of Older People Strategy (2002-2010) is provided to inform physiotherapists of the platform that now exists to support and further develop health service models to assist in ensuring today's 'baby-boomers' experience a positive and healthy older age. Murdoch F. (2010): An overview of DHB-funded health services for older people in New Zealand. Current situation and future need. New Zealand Journal of Physiotherapy 38(3) 113-119.
Article Type: Report
Subject: Health care industry (Analysis)
Aged (Health aspects)
Chronic diseases (Analysis)
Chronic diseases (Prevention)
Author: Murdoch, Fiona
Pub Date: 11/01/2010
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: Nov, 2010 Source Volume: 38 Source Issue: 3
Topic: Computer Subject: Health care industry
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 263880355
Full Text: INTRODUCTION

Like the inevitability of paying taxes, we know that for each one of us it will be true that:

* We will grow old.

* We will be healthier than previous generations so we will live longer.

* There will be fewer health professionals / support workers available to look after us in our old age.

* Our preference will be to stay in our own home rather than move to an institution.

* Our children / next-of-kin may live and work in another town / overseas.

* If we live past 90 we may be one of the 40.4% of 90-94 years olds that has dementia (New Zealand Guidelines Group 2004).

The first cohort of the 'Baby Boomer Generation' has already hit the 65 year old mark and, as health consumers, are a very different breed from the postwar older population now in their eighties. What does this mean for health services overall, and how will physiotherapy respond to the changing service models that will be required in a resource-constrained health environment and the rising demand for service provision?

With universal entitlement to superannuation at age 65 years, no-fault accident insurance through the Accident Compensation Corporation, a publicly funded health system that offers an excellent standard of free emergency and acute care, as well as legislation that limits how much older people have to contribute towards the cost of long-term residential care, it could be said that today's older population is relatively well serviced in terms of access to health services. All indicators on the international stage point to older people in New Zealand, on the whole, doing much better than their counterparts across the world. In contrast, New Zealand's greatest health inequalities are demonstrated in the younger population 0-15 years (New Zealand Ministry of Health 2010a).

So why do we need to continue to keep older people as a key target population for health dollars?

The Impact of Volume

New Zealanders are frequently reminded of the increasing financial, healthcare, and social care burden created by the growing proportion of the over 65 population. The key word here is 'proportion'. The ageing population refers not so much to an unusual growth in the number of older people, but that growth in this sector of the population is not balanced by a corresponding increase in the younger population; with the number of births per capita in New Zealand declining over the recent decades (Pool et al 2005) thereby leading to an 'ageing' population.

The New Zealand Treasury in 2007 predicted the following changes in population by 2021:

* Baby Boomers will be over 75 years.

* There will be more people over 65 years than those under 15 years.

* Primary expenditure of public money will be on superannuation and health.

* The average age of entry to residential care will be 90 years old.

* Residential care for older people will be hospital level, end of life care.

It is clear that this demographic change will have a significant impact on how health services for older people will need to be structured and delivered in both the short and medium term (2011-2021) and in the long-term by 2051 when the population of people aged 65 years and over will double. Table 1 shows that the increase in percentages is not the same for all age groupings.

Older people, especially that portion aged over 85 years, are intensive users of healthcare resources, experiencing high rates and prevalence of chronic illness, disability and co-morbidity compared to other age demographic groups in the population. As the number of older people rises in the future, with an expected increase in life expectancy, the demand on publicly funded health resources will be increasingly pressured and acute. Therefore, the proportion of Vote Health dollars allocated to services for older people will need to increase, simply to cope with demand (Table 2).

In addition, the health workforce will not keep pace with the growing demand for life-sustaining interventions for frailer, older people with increasingly complex health needs characterised by co-morbidity and decreasing functional independence (Pawar et al 2009). The Ministry of Health has predicted a shortfall of 23,000 in the regular health workforce by 2021 (New Zealand Ministry of Health 2006).

Community-based disability support services face a double potential risk from this demographic change. At the same time as the change reduces the supply of informal carers and increases the amount of formal care that will be required, it significantly reduces the formal workforce pool. The informal family carers and the formal support workers are from the same demographic pool. The quality of the workforce pool is also being affected. In a high employment market, people who are 'work ready' with residual skills can easily get higher paying jobs with better conditions than community service agencies can currently offer. Those that have very few skills tend to be what is left for an industry that cannot compete in such a market (Molony 2005).

The Strategic Context

These factors, namely, that older people are the main consumers of health care and disability support, that the number of older people is increasing exponentially, and that older people require input from multiple specialities and disciplines, meant that a single unambiguous and coordinated approach for older people to access services was required.

The New Zealand Positive Ageing Strategy (New Zealand Government 2001) was released in 2001 by the Office for Senior Citizens and promoted engagement of all agencies impacting on the lives of older New Zealanders, including (but not limited to) Work and Income, District Health Boards, District Councils, Sport and Recreation New Zealand, Statistics New Zealand, and the State Services Commission; to "achieve the vision of a society where people can age positively" by "directing our collective efforts towards achieving identified positive ageing goals."

Goal Two of this strategy provided the platform for the Health of Older People Strategy: "Health equitable, timely, affordable and accessible health services for older people" (see Appendix One).

The Health of Older People Strategy (2002 2010) required development of models of care for services to older people that responded to the eight objectives (see Appendix Two); identifying areas where change was essential if the vision was to be achieved.

The development of these health services also needed to be aligned to the broader service and population-based strategies such as the New Zealand Health and Disability Strategies, the Mori Health Strategy (He Korowai Oranga), the Primary Health Care Strategy, Mental Health Strategy, the Pacific Health and Disability Action Plan, the New Zealand Palliative Care Strategy and the Cancer Control Strategy.

The primary aim of the Health of Older People Strategy was to develop an integrated approach to health and disability support services that was responsive to older peoples' varied and changing needs outside of acute episodes of care. This approach, the integrated continuum of care, means that an older person is able to access needed services at the right time, in the right place and from the right provider. Providers work closely together, and, where appropriate, with families, whanau and carers.

The key elements of an integrated approach are:

* Services are older-person focused.

* The wellness model is promoted.

* Services are coordinated and responsive to needs.

* Family, whanau and carer needs are also considered, where appropriate.

* There is information sharing and a smooth transition between services.

* Planning and funding arrangements support integration.

Performance indicators were identified that included:

* Decreased length of stay in acute services.

* Decreased presentations to emergency departments.

* Decreased volume of avoidable admissions.

* Decreased utilisation of home-based support services.

* Delayed entry to long-term residential care.

* Lower levels of client disability on exit from services.

This approach was not expected to reduce the amount of expenditure overall given the rate of growth of the older population, but it was expected to be able to contain the rate of expenditure to within population-based funding levels.

Health of Older People Disability Support Services

Health Services for Older People are funded in the main, but not exclusively, by District Health Boards (DHBs), with funding for specialist Assessment, Treatment and Rehabilitation services (AT&R), and long-term disability support services for people 65 years and over (and people aged 50-64 who have older age-related health needs) devolved from the Ministry of Health to DHBs on 1 October 2003. Disability-related equipment is funded through the Ministry of Health (via ENABLE NZ www.enable.org.nz or Accessable www.accessable.co.nz) in Auckland and Northern regions; and DHB provider arm services deliver personal-health related services (episodic or short-term services related to an acute event or exacerbation). Of note is that accepted ACC-claimants requiring services following accidental injury are excluded from accessing DHB-funded disability support services

The Health of Older People strategy targeted the gaps in the continuum of care that occurred when an older person ended an acute episode of care and when they finally needed long-term institutional support. The consultation process around the Health of Older People strategy highlighted that older people wanted to be able to stay at home, preferably dying at home; they wanted the number of times they were assessed reduced to one or two key points in their healthcare; and they wanted more support to maintain their independence.

DHBs set off down a path of developing and revamping a range of services to fill this gap. The challenges were, and still are, many. These include funding silos, funding constraints, competing DHB priorities, national inconsistency in both price and service provision, changes in government and strategic targets, workforce availability, incomplete models of care, as well as the failure of health information and payment systems to keep pace with the required changes. The issues needing to be resolved include:

* Stability and sustainability.

* Service gaps.

* High worker turnover.

* Inappropriate or duplication of services.

* Quality and safety.

* Cost blowouts.

* Dependency.

Sustainability

As a potential user of these services, the reader will be interested in the question of whether health services for older people are able to keep pace with the growth in demand within the funding and workforce constraints being experienced by all DHBs. Most DHBs will be aiming to simply manage the rate of growth in demand while at the same time extending their 'menu' of community-based services to provide alternatives and support shorter lengths of stay during acute episodes.

Delayed entry to long-term care is the primary target of most long-term DHB-funded disability support services for older people, as approximately 75% of a DHB's Health of Older People budget is spent on long-term age-related residential care. Delaying entry to long-term care is achieved by way of either increasing the range of community-based support services available to support 'ageing-in-place' thereby reducing demand for institutional care; increasing access to earlier intervention for acute need and reducing the rate of functional decline (for example, through the development of acute stroke units, or faster access to elective surgery in tertiary services); or by restricting access through modifying eligibility criteria for services, such as increasing the age of eligibility.

There is already debate on the age of retirement in New Zealand and elsewhere. Eligibility for Health of Older People services is linked to the age of retirement--65 years--if this goes up does that mean that the age of access to services for Health of Older People will also rise? Probably, but that will not have a large impact on the expenditure on these services as the majority of older people using Health of Older People services are aged 75 years or older.

The potentially politically suicidal options for governments to consider are those such as increasing the contributions from older people towards the cost of their care, or reducing input if the older person has family / next of kin / wh nau to provide informal care regardless of proximity. Community debate and consensus would need to be achieved in relation to these latter options.

District Health Boards of New Zealand (2010) co-ordinate a national Health of Older People Steering Group which has representation from all DHBs and comes together regularly to provide a sector group through which DHBs can coordinate their activities at a national level on selected issues impacting on the sustainability of services for Health of Older People. The Steering Group monitors the effectiveness and efficiency of DHB-funded services that exist now, and those that may be developed in the future to meet identified gaps. Key priorities are efficient funding of long-term care, national consistency in the purchase of home-based support services, service models for long-term support of people with high and complex care, and service models to support the expected increasing prevalence of dementia in our community.

A Ministry of Health consultation document 'Care and Support in the Community' reported in the collated feedback from DHBs and other stakeholders that: "Individual DHBs have taken different areas of focus in service development. The scope and pace of development so far has largely depended on the relative priority that a DHB has placed on funding older people's services against all other health priorities. DHBs recognise they need to take account of the flow-on effects to other services (that is, primary, secondary and residential care) before decisions are made" (Ministry of Health 2007).

Significant developments to date have generally focused on services for people with high/complex needs and on one or more of the following areas:

* Single point of entry to health and disability services.

* Needs assessment and service co-ordination.

* The use of multidisciplinary teams, including nurses, social workers and other health professionals.

* Case management / care co-ordination for people with high / complex needs.

* Flexible and responsive packages of care with rehabilitative / restorative focus.

Many DHBs identified that service development is a slow process because it takes a long time to consult with the community, to implement changes and to adapt the infrastructure.

Most DHBs considered it important that time and energy went into building relationships with stakeholders to ensure genuine buy-in to both the need for change and to adopt new ways of working. It was also seen as critical that shifts in attitudes and public expectations occurred alongside service changes if changes were to succeed in the longer term (Ministry of Health New Zealand 2007).

While the answers to the question of sustainability are not immediately evident, there are a number of projects that have had, at their core, the need to ensure sustainability of service delivery for a growing older population. A recently released report entitled 'Aged Residential Care Service Review' (Grant Thornton New Zealand Ltd 2010) discussed sustainability issues for long-term residential services. The ASPIRE Trial earlier looked at the sustainability of three different aging-in-place service models (Parsons et al 2006) and these models have formed the basis for a number of service developments around New Zealand.

New health strategies have emerged to manage the consequences of uncertain sustainability of health services when there is cost-shifting to other sectors, for example, 'The New Zealand Carers Strategy' (New Zealand Ministry of Social Development 2008). Jorgensen (2009) highlighted the increasing carer burden experienced by informal caregivers of ageing partners, parents, siblings, and even older children (in the case of adults with intellectual disability now experiencing age-related morbidity).

The development of casemix models for both home-based support services and long-term residential care services will allow for consistent planning and funding decisions in relation to the sustainability of these services. The current national implementation of a new support needs assessment tool for older people (the interRAI Minimum Data Set Home Care and Contact Assessment tools (New Zealand Guidelines Group 2003)) will provide aggregated local, regional and national data that will inform the development of casemix funding models and ensure that services are developed that meet identified needs. Such data being collected in a nationally consistent manner (New Zealand Ministry of Health 2009) will inform the Ministry of Health where there are gaps in service options and where sustainability of services is an issue to be concerned about.

Identified Service Gaps

Service development in DHBs initially focused mostly on services for people with high / complex needs, and gaps were identified in the current range of health promotion (for example, activities such as promotion of physical fitness and good nutrition) and disease prevention services (for example, early detection and intervention) available for older people in New Zealand. The population-based HEHA Strategy (New Zealand Ministry of Health 2003) that aimed to increase physical activity, improve nutrition and decrease obesity targeted the younger Maori and Pacific population and specifically excluded initiatives targeting older people.

Primary Health Organisations will have an important role in providing health promotion and disease prevention services for older people in future, as well as case co-ordination of those with complex needs using a range of community services.

Primary Health Organisations' links with community-based services are generally underdeveloped at present, although the regional focus being driven through the twelve 'Better Sooner More Convenient' business cases (New Zealand Ministry of Health 2010b) promises better interfaces between primary health care, medical and surgical specialist services, community-based health services, mental health services, environmental support services, short-term home support services and population health services to prevent service duplication and unnecessary wasting of scarce resources.

Specific business case objectives will be of interest to physiotherapists as networks of Primary Care Organisations seek to align General Practice with community services (such as Non-Government Organisations providing home-based support services) and DHB District Nursing and Allied Health services in 'cluster models' grouped around General Practices to service geographical areas, and promote service integration.

Publicly funded socialisation services (for example, shopping services, befriending services, community access services) are limited but demand is high. These services have been identified as effective in managing the boredom, isolation and loneliness that beset older people leading to health issues such as self-neglect, depression and suicide (Chal 2004).

Service gaps have also been identified related to delays in older people being assessed by specialist assessors or delays in funding decisions being made about environmental needs. These delays can result in older people not getting timely access to the equipment and support they need in order to live at home, and this can delay their rehabilitation, and precipitate entry to higher levels of care. The Ministry of Health Disability Support Services Directorate held meetings with clinicians in June 2010 to consider and discuss ways of managing the demand and clinical practice for the safety of older people in the future. Possible solutions covered themes such as better targeting of services, training, changing procurement practices by DHBs, and modifying access criteria (New Zealand Ministry of Health 2010c).

A significant gap in most Health of Older People services is the lack of focus on outcome measurement and long-term service effectiveness. Implementing these changes with a sector where historical purchasing models have focused on inputs and outputs rather than outcomes has been a priority for DHBs. Nearly all DHBs have established, or are investigating service changes, that involve restorative approaches for people with medium to high and very high / complex levels of need. Some are looking at extending such approaches to people with low levels of need.

DHBs and providers generally accept that 'restorative' approaches are more a philosophy than a defined set of services. The main aim of the restorative approach to service provision is to assist the person to be in control and to regain, maintain and increase function.

Restorative approaches do not provide the level of specialist rehabilitation required of inpatient and tertiary rehabilitation services, but instead aim to support the philosophy in the provision of 'transitional' services or long-term care. Service specifications also require the use of multidisciplinary or interdisciplinary teams, including health professionals (for example, nurses, allied health) and non-regulated support workers to provide co-ordinated care; however, the health professional input is expected to be more consultative, providing workforce training, and developing restorative care plans, rather than providing hands-on specialist treatment interventions.

Restorative services develop integrated 'packages' of services to include different combinations of rehabilitation, activities and support services that are flexible and responsive to individual needs. Goal setting, measurement and review are challenging areas for many non-specialist services and physiotherapists can play a key role in this area.

Informal carers (for example, family members) are an integral part of supporting older people to live at home, and are a key element in the continuum of care. Issues related to the lack of adequate support, training and information for informal carers are a recognised gap and are becoming more of a priority for some DHBs.

Future needs

The increasing prevalence of dementia in the older population will pose significant challenges for health professionals and service funders. Specialist rehabilitation services, which are becoming increasingly pressured, often exclude people with dementia where the patient's cognitive and learning difficulties may lead to assumptions that there is no benefit to be gained from rehabilitation approaches. However the pressure on funding for Health of Older People services to purchase community support services for the growing number of people with dementia behoves health professionals to research and develop rehabilitation interventions that will make a difference for this sector of the population, and their informal caregivers.

The most dramatic rate of growth in the older population will be for those sectors of the population that are now experiencing better health for longer, specifically older people from M ori and Pasifika communities. Services either need to be specifically developed for particular ethnic groups or be flexible enough to respond to the needs of other cultures.

There is need for improvement around so-called 'transition points' between services, particularly where older people are moving between acute care or residential care and the community. An increasing trend of shorter length of stay and shorter inpatient rehabilitation in acute care, and of rapid discharge to the community is highlighted. This trend does not allow for the longer recovery time that many older people require, and increases risk of readmission to acute care because of insufficient rehabilitation.

Services along each 'transition' point of a continuum of care for older people should:

* Contribute to a broad population health approach to improving health outcomes by working collaboratively with other service providers.

* Ensure that service users have their health and disability support needs fully assessed and appropriate services are provided.

* Prevent or delay the onset or development of increasing levels of disability / disease.

* Reduce the need for people with complex medical, psychiatric, cognitive, functional and / or social needs to be admitted to hospital or residential facilities.

* Maintain and restore physical and psychological health necessary for independent living and functional independence.

* Improve service user satisfaction with access to and provision of the services.

* Support the development of best-practice services for people with complex medical, psychiatric, cognitive, functional and / or social needs across all delivery settings.

CONCLUSION

While DHBs cannot ignore the increasing proportion of their 'older-old' population who will require increasing health and community support services as they become more frail, the health targets that DHBs are currently required to meet do not specifically target this population. Managing acute demand is the focus of health targets rather than managing long-term support for increasing morbidity and complexity in the older population.

DHBs are continually faced with increasing funding pressures, with the targeted investments in Health of Older People services seen over the past few years under the Health of Older People strategy now being refocused to questions about disinvestment where expected service outcomes are not being delivered, or where service duplication is evident.

Effective and efficient services for Health of Older People would demonstrate client and family outcomes along with a stable and competent workforce. Characteristics of such services include (Jacobs S, 2007):

* Informal carers are involved and supported.

* The client's needs are assessed and influence service and support plan.

* The client's support is co-ordinated / care managed.

* Public information supports the approach.

* Services are responsive and flexible.

* All parties receive all information needed for support plan to be developed and implemented.

* The client's goals are assessed, set and aimed for in service plan.

* The older people's health workforce feels valued.

* The workforce is trained and assisted to develop required competencies.

* The heath and disability workforce is adequately remunerated.

* The services are cost-effective.

* Funding supports flexible packages of care.

* Funding supports workforce training and supervision.

The future risk of DHBs disinvesting from such services due to poor service outcomes can be lessened by specialist input such as physiotherapy guiding service providers in appropriate service interventions and client outcome measurement of rehabilitation and restorative approaches. Allied health service models that support integrated continuums of care for the 'younger-old' and the 'older-old' will be key in managing the interfaces between the various transition points on that continuum.

Appendix One: Positive Ageing Strategy Goals

1. Income--secure and adequate income for older people

2. Health--equitable, timely, affordable and accessible health services for older people

3. Housing--affordable and appropriate housing options for older people

4. Transport--affordable and accessible transport options for older people

5. Ageing in the Community--older people feel safe and secure and can age in the community

6. Cultural Diversity--a range of culturally appropriate services allows choices for older people

7. Rural Services--older people living in rural communities are not disadvantaged when accessing services

8. Positive Attitudes--people of all ages have positive attitudes to ageing and older people

9. Employment Opportunities--elimination of ageism and the promotion of flexible work options

10. Opportunities for Personal Growth and Participation --increasing opportunities for personal growth and community participation

Appendix Two: Health of Older People Strategy Objectives

1. Older people, their families and whanau are able to make well-informed choices about options for healthy living, health care and/or disability support needs.

2. Policy and service planning will support quality health and disability support programmes integrated around the needs of older people.

3. Funding and service delivery will promote timely access to quality integrated health- and disability support services for older people, family, whanauand carers.

4. The health and disability support needs of older Maori and their whanau will be met by appropriate, integrated health care and disability support services.

5. Population-based health initiatives and programmes will promote health and wellbeing in older age.

6. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

7. Admission to general hospital services will be integrated with any community-based care and support that an older person requires.

8. Older people with high and complex health and disability support needs will have access to flexible, timely and coordinated services and living options that take account of family and whanau carer for people who are disabled.

Appendix Three: Health of Older People Service descriptions (DSS funding)

SERVICES SPECIFICALLY FOR ADULTS ELIGIBLE FOR DHB FUNDED SUPPORT SERVICES

1. INFORMATION, EDUCATION AND Advocacy

Service information, education and advisory services to inform people and their families / whanau / care-givers about available services and facilitate access to services e.g. Disability Information Advisory Service (DIAS)

Advocacy and Elder Abuse prevention services--information, advice and advocacy services

Carer advice and advocacy services and support specifically for people caring for adults needing assessment, service coordination, care management, treatment, rehabilitation or long-term support.

2. ASSESSMENT AND SERVICE COORDINATION_

Integrated assessment--proactive screening and early intervention by a key worker, Needs Assessment Service Coordination (NASC), Coordination Of Services for the Elderly (COSE), Older People Assessment Team (OPAT) or other assessment agency, referral to specialist assessment as appropriate and coordination of specialist assessments.

Care planning and management tailored to the service user's level of need, to ensure that they get the level and combination of services they need. May be done by a key worker, NASC, COSE, OPAT or other service provider.

3. INTERMEDIATE CARE

Intermediate care--services designed to facilitate the transition from hospital to home, and / or from medical dependence to functional independence, where the objectives of care are not primarily medical, the patient's discharge destination is anticipated and a clinical outcome of recovery (or restoration of health) is desired. May be delivered in non-acute facilities or at home, and may be overseen by geriatric and / or specialist rehabilitation staff, or by GP and primary care team.

4. SPECIALIST SERVICES

Specialist services for older people--assessment, treatment and rehabilitation services for older people with multiple or complex health or disability support needs, in community or hospital settings. Includes specialist services for dementia, short-term management of people with challenging behaviour and a palliative approach for progressive conditions.

5 LONG-TERM SUPPORT

Long--term support packages developed from a mixture of services listed below to suit specific conditions / needs. Support for independence services aimed at enabling people to retain their independence and live in their own homes are listed below. These services may be combined into specific packages for people with high/complex needs or with low level needs:

* Home help--help with household activities (e.g. meal preparation, shopping, laundry, cleaning)

* Personal care--help with bathing, dressing, medication oversight (checking the person is taking medication at home) etc. May be at different levels, for people with low level needs or those with high/complex needs

* Meals--meals on wheels or otherwise provided

* Night care--sleepovers, 'dinner bed and breakfast' services, night sitters--short-term services either at home or in facilities to provide care at night

* Day care--social/recreational programmes to provide respite/carer support. Not primarily rehabilitative. Includes dementia services

* Respite care--short-term residential or home-based service for people with carers

* Carer support--short-term residential or home-based service to substitute for carer

* Socialisation services--befriending and other measures to prevent/reduce social isolation and depression.

* Residential care--for people with a need for permanent residential care

--Rest home

--Long-stay hospital

--Specialist (secure) dementia unit (rest home level)

--Specialist hospital (psychogeriatric.)

RECOMMENDED READING

Clinical Training Agency. (2003). Disability workforce analysis report. www.moh.govt.nz/moh.nsf/

Cornwall J, Davey JA. (2004). Impact of population ageing in New Zealand on the demand for health and disability support services and workforce implications. New Zealand Institute for Research on Ageing and Health Services Research Centre, Victoria University, Wellington.

New Zealand Guidelines Group (2003). Assessment processes for older people. www.nzgg.org.nz

New Zealand Institute of Research on Ageing (2005, updated 2008). Bibliography of New Zealand population ageing research. www.victoria.ac.nz/nzira

New Zealand Ministry of Health (2004). Specialist health services for older people. District Health Board of New Zealand and Accident Corporation Commission. www.moh.govt.nz

Pool I, Baxendine S, Cheung J, Coombs, N, Dharmalingum A, Jackson G, Katzengellenbogen JM, Sceats J, Cooper J. (2009). Restructuring and hospital care--sub-national trends, differentials, and their impacts in New Zealand from 1981. Monograph Series Population Studies Centre, the University of Waikato. www.waikato.ac.nz/wfass/populationstudiescentre

Selected articles on allied health workforce and allied health service models located at http://www.rosalieboyce.com.au/readings.html

REFERENCES

Chal J. (2004). An evaluation of befriending services in New Zealand. Uniservices Auckland Limited.

District Health Boards of New Zealand. (2010). www.dhbnz.org.nz [Accessed: 10 February 2010]

Grant Thornton New Zealand Ltd. (2010). Aged residential care service review. Report for District Health Boards New Zealand and New Zealand Aged Care Association

Jacobs S. (May 2007) Personal communication: models of care and service development--restorative approaches for older people.

Jorgensen D, Parsons M, Jacobs S. (2009). The experience of informal caregivers in New Zealand. Published Report for Carers New Zealand and Auckland University.

Molony S. (2005). Home support purchase and contracting models. Unpublished report for Central Region District Health Boards.

Ministry of Health (2007). Care and support in the community summary of collated feedback. Unpublished report from the Health of Older People Directorate.

New Zealand Government. (2001). New Zealand positive ageing strategy. Office of Senior Citizens www.osc.govt.nz/positive ageing-strategy

New Zealand Guidelines Group. (2004). Guidelines for the support and management of people with dementia. www.nzgg.org.nz

New Zealand Guidelines Group. (2003). Assessment processes for older people. www.nzgg.org.nz

New Zealand Ministry of Health. (2010a).The best start in life: achieving effective action on child health and wellbeing: a report to the Minister of Health. Health Advisory Committee. www.phac.health.govt.nz

New Zealand Ministry of Health. (2010b). Equipment and modification workshops; final summarised report. Disability Support Services Directorate. www.moh.govt.nz

New Zealand Ministry of Health (2010c). Primary care strategy. www.moh.govt.nz

New Zealand Ministry of Health. (2009). InterRAI national DHB project implementation plan. Population Health Directorate. www.moh.govt.nz

New Zealand Ministry of Health. (2007). Care and support in the community for older people in New Zealand: summary of feedback. Health of Older People Directorate. www.moh.govt.nz

New Zealand Ministry of Health. (2006). Health workforce development: an overview. www.moh.govt.nz

New Zealand Ministry of Health (2003). Healthy eating and healthy action oranga kai- oranga pumau: a strategic framework. www. moh.govt.nz

New Zealand Ministry of Social Development. (2008). The New Zealand carers strategy and 5-year action plan. www.msd.govt.nz

New Zealand Treasury (2003) Unpublished presentation to the guideline for specialist health services for older people technical advisory group

Parsons M, Anderson C, Senior H, Chen X, Kerse N, Brown P, Jacobs S, Jorgensen D, Kilpatrick J (2006). ASPIRE (Assessment of services promoting independence and recovery in elders): published report for the Ministry of Health, University of Auckland, Auckland Uniservices Limited.

Pawar S, Amey J, Sceats J. (2009). A perfect storm: ageing patients and an ageing workforce in regional New Zealand. Paper presented to Population Association of New Zealand conference, Wellington.

Pool I (2008) Population ageing in New Zealand, Public Sector, 31(3):12-14

Statistics New Zealand (2000) www.stats.govt.nz

Fiona Murdoch MHSc; PGDipPhys (Neurosciences); DipPhys MNZSP

Portfolio Manager--Health of Older People and Disability Support Services

ADDRESS FOR CORRESPONDENCE

Fiona Murdoch, Planning and Funding--Waikato DHB, PO Box 934 Hamilton. Phone +64 7 834 3646, Mobile +64 21 856 748, Fax +64 7 839 4327. Email: fiona.murdoch@waikatodhb.health.nz
Table 1: Projected New Zealand population at ages 65, 75+ and 85+
years from 2011 to 2051 as a percentage of the total population
(Statistics New Zealand 2000)

Age (years)   2011  2016  2021  2026  2031  2036  2041  2046  2051

65+           13.7  15.8  17.9  20.3  22.6  24.3  25.2  25.4  25.5
75+            6.3   6.9   7.8   9.3  10.8  12.6  14.1  15.0  15.3
85+            1.9   2.2   2.4   2.7   3.2   4.1   4.8   5.7   6.3

Table 2: Projected expenditure on older people as a
percentage of Vote Health (New Zealand Treasury 2003)

                          2002     2011     2021

>74yrs and <85 yrs          16%     16%     17.7%
>85 yrs                   9.9%    12.9%      15%
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