Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB 2013 - 2017 (refreshed as at 20 October 2015) - Toi Te Ora ...

 
Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB 2013 - 2017 (refreshed as at 20 October 2015) - Toi Te Ora ...
Bay of Plenty and Lakes Rheumatic
      Fever Prevention Plan:

        Bay of Plenty DHB
           2013 – 2017

 (refreshed as at 20 October 2015)
                                     1
Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB 2013 - 2017 (refreshed as at 20 October 2015) - Toi Te Ora ...
“It is our attitude at the beginning of a difficult undertaking which, more than anything else,
                           will determine its successful outcome.”

                                       William James

                    (American psychologist, philosopher and physician)

                                                                                                  2
Foreword
In most of the developed world rheumatic fever is thought of as one of those diseases that
people used to get. Here in New Zealand it is still very much a problem. It is a particularly
cruel illness, often snatching away a child’s or teenager’s potential, just when they should be
gaining their confidence and independence. A complication of a seemingly minor throat
infection can lead to heart disease, disability and years of treatment. This scenario plays out
month after month; the number of cases still unacceptably high and unequally affecting
Māori, Pacific and deprived communities.

From 2009, Bay of Plenty and Lakes DHBs have led and funded a comprehensive approach
to reduce rheumatic fever, working closely with affected communities. As national
awareness of the issue grew, local initiatives have been absorbed into a national drive to
prevent rheumatic fever.

The additional focus and funding that has flowed from the national campaign, has had an
impact. Data on cases and their management has never been so complete. There is greater
awareness of rheumatic fever and its importance among professionals and communities,
established school-based services, a register of cases to make sure secondary cases are
prevented, and a core of dedicated staff and community leaders. Television advertising has
for the first time alerted the public right across the country to the issue. Efforts to address the
underlying determinants of this illness, in particular poor housing conditions, are now
benefiting from a clear health service focus, and cross agency approach.

Despite best endeavours, cases of acute rheumatic fever have continued to occur locally
and nationally, and rates have remained stubbornly high. There are, however, some
encouraging signs of change. The early part of 2015 saw a fall in rates of hospital
admissions, and preliminary evaluation of school based services at the national level,
showed modest effectiveness in preventing cases. The detailed findings are awaited, as are
the results of other research into rheumatic fever that have been commissioned as part of
the national programme.

The structure of a comprehensive approach to preventing rheumatic fever has at last been
put in place across NZ, and there are now belated, but welcome signs that a difference may
be emerging.

Continuing to accept a small but steady number of ill children every year is, as I said in the
foreword to the first version of this plan, not an option.

Now is not the time to lose our nerve. Rheumatic fever doesn’t happen in modern,
developed countries. It shouldn’t be happening here.

Dr Jim Miller

Medical Officer of Health

Chairperson

Lakes/BOP Rheumatic Fever Steering Group

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Bay of Plenty DHB Rheumatic Fever Prevention Plan (refreshed version) sign-off

This document has been reviewed and accepted as the refreshed Bay of Plenty DHB Rheumatic
Fever Prevention Plan from 1 January 2016 and beyond 30 June 2017.

 Name: Phil Cammish
 Chief Executive
 Bay of Plenty DHB
                                                   ___________________       20/10/2015
                                                   Signature

Name: Punohu McCausland

Chairperson, Maori Health Runanga

Bay of Plenty DHB

                                                  ____________________       20/10/2015

                                                  Signature

                                                                                       4
Table of Contents

Foreword .................................................................................................................... 3

Table of Contents ....................................................................................................... 5

Section 1: Overview of rheumatic fever in Bay Of Plenty and Lakes District Health
Boards (DHBs) ........................................................................................................... 9

   1.0 Background ................................................................................................................ 9

   1.1 Purpose of the plan .................................................................................................. 10

   1.2 BOP and Lakes DHBs – a shared approach ............................................................. 10

   1.3 Structure of the plan ................................................................................................. 10

   1.4 Commitment to reducing rheumatic fever in the BOP and Lakes DHBs .................... 11
      1.4.1. Target data......................................................................................................... 11

      1.4.2 Performance data................................................................................................ 12

   1.5 Stakeholder input and engagement .......................................................................... 12
      1.5.1 Local stakeholders input into original plan ........................................................... 12

      1.5.2 Consultation on the refreshed plan ...................................................................... 13

   1.6 Rheumatic fever champions ..................................................................................... 18
      1.6.1 Lakes DHB .......................................................................................................... 18

      1.6.2 BOPDHB ............................................................................................................. 18

      1.6.3 Future Governance provisions ............................................................................ 19

Section 2: Overarching actions to reduce the incidence of rheumatic fever in the
BOP and Lakes districts ........................................................................................... 20

   2.0 Overview of the prevention of ARF and RHD ............................................................ 20

   2.1 BOP and Lakes shared priorities 2013-2017 ............................................................ 21

Section 3: National Evaluation of School Based Throat Swabbing Programme ....... 22

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3.1 What does this mean for BOPDHB and the BOP school based sore throat swabbing
    programme? ................................................................................................................... 23

    3.2 Laboratory data ........................................................................................................ 24

    3.3 Root cause analysis data.......................................................................................... 26

Section 4: Investment to reduce ARF incidence and RHD ....................................... 30

    Section 4.0 Introduction .................................................................................................. 30

    4.1 BOPDHB resources committed to reducing rheumatic fever 2015/16 ....................... 30

    4.2 BOPDHB investment for 2016/17, including new initiatives ...................................... 32

    4.3 BOPDHB investment for 2017/18 and later out years to 2021/22 ............................. 34

    4.4 Co-benefits ............................................................................................................... 36
      4.4.1 Prevention, early assessment and treatment of skin infections............................ 36

      4.4.2 Respiratory infections in children ......................................................................... 36

      4.4.3 Enrolment and ongoing engagement with primary health care ............................ 36

    4.5 Re-designed Healthy Homes Initiative from January 2017 ........................................ 37

    4.6 Revamped Business as Usual sore throat management services in primary and
    community care .............................................................................................................. 38

Section 5: Actions to prevent the transmission of Group A streptococcal throat
infections .................................................................................................................. 40

    5.0 Introduction............................................................................................................... 40

    5.1. Housing ................................................................................................................... 40

    5.2 Improving general hygiene in education settings ...................................................... 46

    5.3 Reducing skin infections in schools, community and home settings.......................... 48

Section 6: Actions to treat Group A streptococcal throat infections quickly and
effectively ................................................................................................................. 51

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6.0 Introduction............................................................................................................... 51

    6.1 Throat swabbing programmes .................................................................................. 51

    6.2 Primary care and sore throat management guidelines .............................................. 54

    6.3 Awareness raising of sore throats, Rheumatic Fever and its presentations, and
    Rheumatic Heart Disease ............................................................................................... 57

Section 7 : Actions to facilitate the effective follow-up of identified rheumatic fever
cases ........................................................................................................................ 60

    7.0 Introduction............................................................................................................... 60

    7.1 Delivery and monitoring of prophylactic antibiotics .................................................... 60

    7.2 Notification of ARF cases to the Medical Officer of Health (MOH)............................. 64

    7.3. Review of cases to identify known risk factors and system failure points ................. 64

    7.4 Other actions to facilitate the effective follow-up of identified RF cases .................... 65

Section 8: Actions to facilitate the effective follow-up of patients with rheumatic heart
disease ..................................................................................................................... 66

    8.0 Introduction............................................................................................................... 66

    8.2     Interventions for patients who do not have established RHD ................................ 66

    8.2 Interventions for patients who do have established RHD .......................................... 67

Section 9: Action plan for 2015/16 and subsequent years ....................................... 68

    9.0 Introduction............................................................................................................... 68

Appendix 1 - Stakeholders ....................................................................................... 77

Appendix 2 – Logic model for Toi Te Ora Goal 1: Reduce childhood admissions from
ARF, respiratory and skin infections, each by 2/3rds in 5 years ............................... 78

Appendix 3 - Schools on Rheumatic Fever Throat Swabbing programme ............... 79

References ............................................................................................................... 86

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List of Abbreviations
ARF                     Acute Rheumatic Fever

BAU                     Business as Usual

BOP                     Bay of Plenty

BOPDHB                  Bay of Plenty District Health Board

BPS                     Better Public Services

CHW                     Community Health Worker

CME/CNE                 Continuing Medical Education/Continuing Nursing Education

CoBoP                   Collaboration Bay of Plenty

DNS                     District Nursing Service

EECA                    Energy Efficiency and Conservation Authority

EBOP                    Eastern Bay of Plenty

EBPHA                   Eastern Bay Primary Health Alliance

GAS                     Group A Streptococcus

GP                      General Practice / Practitioner

HNZ                     Housing New Zealand

ICD codes               International Classification of Disease codes

INR                     International Normalisation Ratio (for use of warfarin anticoagulant)

MoH                     Ministry of Health

MOH                     Medical Officer of Health

NHF                     National Heart Foundation

NMO Ltd                 Nga Mataapuna Oranga Primary Health Organisation

PHN                     Public Health Nurse

PHO                     Primary Health Organisation

PoPAG                   Population Health Professional Advisory Group

RAPHS                   Rotorua Area Primary Health Services

RHD                     Rheumatic Heart Disease

Toi Te Ora              Toi Te Ora – Public Health Service

WBOP                    Western Bay of Plenty

WBOPPHO                 Western Bay of Plenty Primary Health Organisation

WISH                    Whakatohea Iwi Social and Health Services

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Section 1: Overview of rheumatic fever in Bay Of Plenty and Lakes District
Health Boards (DHBs)

1.0 Background
Acute rheumatic fever (ARF) has been clearly recognised as a significant problem in New
Zealand which needs to be addressed. Bay of Plenty DHB (BOPDHB) and Lakes DHB
recognised ARF as a priority issue in 2008. In 2009 a joint steering group was established to
lead a range of DHB-funded initiatives to address rheumatic fever which are now operating
largely as business as usual. Ministry of Health (MoH) funded projects were introduced in
2012, with further MoH-funded programmes introduced in 2015.

The approach taken so far has been based firmly on the Heart Foundation rheumatic fever
guidelines, taking into account the local epidemiology and community wishes.

Programmes are now in place in the following areas:

   1. raising public awareness that ‘sore throats matter’
   2. continuing professional development for health professionals and Community Health
       Workers (CHWs)
   3. school-based throat swabbing campaigns, with linked activity in reducing skin
       diseases
   4. improved notification of new cases to the Medical Officer of Health (MOH)
   5. implementation of rapid-response clinics in medium-risk areas not covered by school-
       based programmes
   6. housing improvement and assistance to “live well together” to reduce structural and
       functional crowding
   7. improving case management, including development of a rheumatic fever register
       across Lakes and BOP DHBs
   8. enhanced surveillance and root-cause analysis of cases

A range of positive results have been demonstrated to date. These include raised
awareness of rheumatic fever in higher risk communities and the general public; increased
awareness of the sore throat guidelines among GPs; the establishment of a register in
BOPDHB district; school-based throat swabbing programmes in 30 decile 1-3 schools that
are operating to agreed protocols, having gained the support of local communities. To date
though, there is no clear evidence of a sustained trend to reduced rates of ARF in the BOP.

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1.1 Purpose of the plan
The purpose of this refreshed plan is firstly to enable BOPDHB, Lakes DHB and their partner
organisations to co-ordinate services and prioritise initiatives to achieve the national Better
Public Services (BPS) target to reduce the incidence of rheumatic fever by two thirds to 1.3
cases per 100,000 people by June 2017. The plan also signals the level of continuing
preventive services to be provided from 1 July 2017 until June 2022. The BOPDHB
refreshed plan goes beyond the reduction of ARF, by also focusing on minimizing the impact
of rheumatic heart disease (RHD) in the population served by BOP and Lakes DHBs through
coordinated secondary service provision. About 80% of children and young people develop
Rheumatic Heart Disease (RHD) following Acute Rheumatic Fever. A Maori man with RHD
lives 12 years and a Maori woman lives 17 years less than Maori without RHD. Acute
Rheumatic Fever’s long shadow is RHDi.

While some limited evidence is emerging nationally and locally on which services are most
likely to achieve the BPS target, it is likely that more evidence will be produced from
evaluations undertaken in the future. This refreshed plan therefore will need to be reviewed
regularly to ensure that practice is aligned to the most recent at hand.

1.2 BOP and Lakes DHBs – a shared approach
In order to achieve the Better Public Services target to reduce rheumatic fever, a shared
approach has been taken by BOP and Lakes DHBs, as there is significant regional work that
is common to both. This includes the development of a single rheumatic fever register,
awareness raising, clinical and peer support for the school-based programmes and
continuing professional development for health professionals.              There is a shared
commitment to continue to work together to meet this challenging target.

However, it is also recognised that in some areas, different approaches are warranted. This
is reflected in the development of two separate plans, one for Lakes DHB and one for
BOPDHB, which share a common overview but provide DHB-specific interventions.

1.3 Structure of the plan
The first two sections outline the shared approach taken by BOP and Lakes DHBs:

Section 1: Presents the background, purpose and structure of the plan. This is followed by a
commitment to reducing rheumatic fever, outlining stakeholder engagement and input into
the plan, and the role of the rheumatic fever champions.

Section 2: Summarises the overarching actions to reduce the incidence of rheumatic fever.

The following sections are BOPDHB specific:

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Section 3: This section looks at the national and local evidence and data for existing
interventions and their effectiveness.

Section 4: Investment in reducing rheumatic fever

Section 5: Actions to prevent the transmission of Group A streptococcal throat infections

Section 6: Actions to treat Group A streptococcal throat infections quickly and effectively

Section 7: Actions to facilitate the effective follow-up of identified rheumatic fever cases

Section 8: Actions to facilitate the effective follow-up of patients with rheumatic heart
disease

Appendices

1.4 Commitment to reducing rheumatic fever in the BOP and Lakes DHBs

1.4.1. Target data
Lakes and BOP DHBs are committed to reducing the incidence of rheumatic fever to levels
set by the Better Public Services targets. The specific targets for each DHB are summarised
in Tables 1 and 2 along with the National targets.ii

Table 1: Acute rheumatic fever initial hospitalisation target rates per year for Lakes and BOPDHBs (per 100,000
total population), 2012/13 to 2016/17

District Health Board       2009/10–     2012/13          2013/14     2014/15        2015 /16      2016/17
                            2011/12      Target:          Target:     Target:        Target:       Target:
                            Baseline     Remain      at   10%         40%            55%           2/3
                            rate         baseline level   reduction   reduction      reduction     reduction
                            (3-year                       from        from           from          from
                            average                       baseline    baseline       baseline      baseline
                            rate)                         level       level          level         level

Lakes                       7.8          7.8              7.0         4.7            3.5           2.6
Bay of Plenty               3.8          3.8              3.4         2.3            1.7           1.3
New Zealand                 4.0          4.0              3.6         2.4            1.8           1.3

Table 2: Acute rheumatic fever initial hospitalisation target numbers per year for Lakes and BOP DHBs (total
population), 2012/13 to 2016/17

District Health Board       2009/10–     2012/13          2013/14     2014/15        2015 /16      2016/17
                            2011/12                                                                Target:
                                         Target:          Target:     Target:        Target:
                            Baseline                                                               2/3 reduction
                                         Remain at        10%         40%            55%
                            numbers                                                                from baseline
                                         baseline level   reduction   reduction      reduction
                                                                                                   level
                            (3-year                       from        from           from
                            average                       baseline    baseline       baseline
                            rate)                         level       level          level

                                                                                                               11
Lakes                           8                8           7                5         4                  3

Bay of Plenty                   8                8           7                5         4                  3

New Zealand                    177              177         162             109         83                 62

1.4.2 Performance data
The actual performance against these targets for the years 2012/13, 2013/14 and 2014/15 is
shown in Table 3:
Table 3: Actual acute rheumatic fever hospitalisation rates and numbers per year for Lakes and BOP DHBs (total
population), 2012/13 to 2014/15 (data provided by Ministry of Health)

District Health Board                  2012/13 actual               2013/14 actual           2014/15 actual
                                 Rates       Numbers             Rates    Numbers      Rates       Numbers

Lakes                            6.8             7                3.9             4      5.8           6
Bay of Plenty                    3.3             7               4.6          10         3.2           7

New Zealand Total                4.0            179               3.9         175        3.0          135
New Zealand Maori               12.7                             10.6                    8.8
New Zealand Pacific             25.9                             31.6                   22.5

A brief summary of the demographics of the 44 cases of first episode AFRF notifications to
the Medical Officer of Health from 1 January 2010 to 30 September 2015 shows that:
        A total of 31 cases were in the eastern BOP and 13 in the western BOP
        A total of 21 cases came from geographical areas where full school-based throat
         swabbing programmes are currently in place, 18 resided in areas where there is
         reasonable access to current rapid response clinics, and 3 were in areas that are
         outside of sore throat management programmes other than routine general practice.
        Of the 44 cases, 39 were Maori, 3 Pacific, one NZE and one Unknown using the
         prioritised ethnicity classification system
         A total of 36 cases were aged 5-14, 4 were aged 15-19 and 4 were 20 years
         of age.
A fuller report with breakdown by Local Authority is appended as Appendix 4.

1.5 Stakeholder input and engagement

1.5.1 Local stakeholders input into original plan
Local stakeholders had input to the original plan primarily via the BOP and Lakes rheumatic
fever steering group, which has met quarterly since 2009. The steering group members
include representatives from BOPDHB and Lakes DHB Planning and Funding and paediatric

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teams, Toi Te Ora - Public Health Service (Toi Te Ora), Primary Health Organisations
including Eastern Bay PHA (EBPHA), Rotorua Area Primary Health Services (RAPHS), and
contracted providers Korowai Aroha, Whakatohea Iwi Social and Health Services (WISH),
Te Ika Whenua Hauora, Te Kaokao o Takapau, Ngati Awa Social and Health Services
(NASH) and Te Manu Toroa. Please refer to Appendix 1 for a full list of stakeholders.

Iwi/Māori input to the original plan was organised through the Lakes DHB Māori Health team,
BOPDHB Māori Health Planning and Funding team, and BOPDHB Regional Māori Health
Services.

The Pacific population is relatively small in the Bay of Plenty, which is reflected in the small
number of cases of ARF reported (fewer than one per annum on average). Input was
obtained through the BOP Pacific Advisory Group.

Experience has shown that driving change through community ownership requires active
engagement and participation of iwi, hapu and whānau.          Community presentations and
lengthy discussions preceded the establishment of each of the DHB-funded school-based
programmes.

Draft versions of this plan were sent to the rheumatic fever sector group – this is comprised
of the community health workers from each of the throat swabbing programmes in Opotiki,
Kawerau, Murupara, Taneatua, Whakatane and Tauranga in the BOP and Rotorua in Lakes.

1.5.2 Consultation on the refreshed plan
At the outset of the refreshment process, a BOP project group was established made up of
clinicians and Planning and Funding personnel to oversee the rewriting of the existing plan.
There was an early videoconference of Planning and Funding personnel from Northland,
Lakes, Tairawhiti and BOP DHBs to take key learnings on what has worked in each district.
Consultation has occurred with a variety of groups within the BOP to provide input into this
refreshed prevention plan, as well as attendance of key personnel at Ministry of Health-led
workshops and meetings.

The following is a summary of key points that have arisen for the consultation process.

1.5.2.1 BOP Pacific Advisory Group – 20 August 2015

The BOP Pacific Advisory Group is made up of Pacific community representatives and
BOPDHB personnel, and is coordinated by the Pacific Island Community (Tauranga) Trust,
the main provider of Pacific health services in the BOP. It provides a mechanism for the

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Pacific community to raise issues about the health of Pacific people across the BOPDHB
district, provide cultural advice to the DHB on the planning and delivery of health services,
and for the DHB to share information with the Pacific community on services or key
messages that have a significant impact on Pacific health.

The key items of feedback were:

      There is still a need for awareness raising within the Pacific community on acute
       rheumatic fever, and the links between sore throats and heart disease. The
       terminology of rheumatic fever is not necessarily recognisable for Pacific people,
       particular those who have lived in the Pacific Islands. Other terms that are more
       familiar to them should be used.
      There continue to be barriers to affordable, easily accessible primary health care
       services because of transport, waiting times, cost (particularly for over 12’s, practice
       debt, and perhaps most importantly, being able to get leave from work to attend in
       standard practice hours.
Possible solutions that were canvassed included:

      Having rheumatic fever/sore throats as a theme at one of their regular Po Talanoa
       evenings.
      Holding education sessions through the Tongan churches in Tauranga, particularly
       on those Sundays when a number of churches join for services.
      Community nurses to visit the Pacific language nests so they can talk to mothers in
       particular.

1.5.2.2 BOPDHB Maori Health Runanga – 9 September 2015

The Runanga has a Treaty relationship at the Governance level with the elected and
appointed Board, and have representatives from the 18 iwi of the BOPDHB district. This
consultation was the first of two, and designed to seek input into the initial thinking for the
refreshed plan.

The key items of feedback were:

      The Runanga sees strength in the current model of school-based throat swabbing
       and community awareness raising programmes being delivered by iwi-based hauora
       providers. The Community Health Workers in those services are seen as being well-
       connected to their communities, have built up a lot of expertise around rheumatic
       fever prevention and credibility with whanau. They advocated for a continuation of

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these services in conjunction with local general practice as a cornerstone of primary
       prevention services.
      There was comment from one representative that whanau were becoming blasé
       about throat swabbing. The service in her iwi’s rohe has been going for six years and
       whanau are still experiencing repeated sore throats positive for GAS. It was thought
       that the programme needs to be revitalised in this area. (This issue was followed up
       in the BOP Rheumatic fever Sector Group consultation meeting – see section
       1.5.2.3.)
      There were difficulties seen in getting landlords to meet the costs of home
       improvements such as insulation, heating and ventilation that were recommended by
       the Healthy Homes Initiative assessors. Opotiki was mentioned as a particular issue,
       where there is a landlord owning about 100 homes.
      While whanau had improved knowledge about rheumatic fever and what they needed
       to do to protect their tamariki/rangatahi, more should still be done.
      There needs to be better integration of common key messages to whanau delivered
       by all well child/primary/community health practitioners.
A second consultation meeting was held on 14 October where the draft refreshed plan was
presented (see 1.5.2.5.below).

1.5.2.3 BOP Rheumatic Fever Sector Group – 16 September

A consultation hui was held with eleven nurses and CHWs from all six providers of school-
based throat swabbing and community awareness raising providers in the BOP. Also
present were staff from Toi Te Ora and the BOPDHB Planning and Funding team.

The key items of feedback were:

      The community has a greater understanding of rheumatic fever but there was still
       work to do. Awareness is greater in those communities with longer term school-
       based throat swabbing programmes, and is greater amongst children than adults.
       Some confusion amongst parents and children between strep throat and rheumatic
       fever. “When we swab and treat for GAS throats, some get confused and think that
       we are treating rheumatic fever. Some call strep throat rheumatic fever.” The TV ads
       and other material featuring the Katoa twins help to make the links between sore
       throats and rheumatic fever.
      Following up on the comment from the Maori Health Runanga consultation, CHWs
       reported that some whanau are becoming hoha about sore throat management,

                                                                                         15
particularly where rangatahi have had several course of antibiotics. Can be hard to
    push the message, and maintain antibiotic adherence.
   The use of Blis probiotics in the research project in the eastern BOP seems to be
    having an impact, by extending the period between recurrences of positive swabs.
    Data supplied on the day showed that for six Kawerau programme schools, the
    proportion of children who had three or more GAS positive sore throats in a school
    year among all children that had at least one positive swab, reduced to 6.69% in the
    year to 11 September 2015 compared with 13.28% in the full 2013 year and 14.39%
    in the full 2014 year. [Blis product has been used in a non-rigorous way for those
    children with recurrent positive swabs and to support antibiotic adherence. This
    evidence is anecdotal only. A research study is being done on the use of Blis in a
    different population within the eastern BOP, and this work should give more robust
    findings.]
   Messaging about sore throat management and link to rheumatic fever needs to be
    provided by all services working with children e.g. Before School Check, Well Child
    Tamariki Ora, Public Health Nursing, Dental Therapists.
   The higher rate of cases amongst boys in the BOP was noted. Reasons offered
    included that it wasn’t “cool” for the older boys to report a sore throat. Ideas to
    improve messaging to boys included using their sports teams as a way to reach
    them.
   Programmes are most effective where the teachers/teacher aides are fully engaged
    and incorporate rheumatic fever work into the wider curriculum. Teachers with sore
    throats are routinely swabbed in most areas, which helps to set an example for
    children as well as limiting the spread of GAS infection.
   There are barriers to accessing primary care, particularly getting time off work/too
    busy at work for parents to take children to a clinic. Schools remain a key setting for
    this primary care.
   It was noted that swabbing at GPs (or pharmacies) are less in school holidays than in
    school term, even though families are advised to take their child to thee services
    before term break. Education is provided at organised school holiday programmes,
    particularly where the CHWs also work there.
   A lot of pressure is placed on the nurses/CHWs when a notified case of ARF occurs.
    Increased and external support for families and nurses/CHWs is then needed.
    However there are “positive” spin-offs in increasing the attention of teachers to this
    issue.

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   There are barriers to referring families to the Healthy Housing initiative. CHWs do not
       often get into the home of some high risk families - “get to the gate, the window, the
       door, but not beyond”. Nevertheless, CHWs know that they can accompany the
       home assessors if that will improve communication. Cost to the landlord/unwilling
       landlord is an issue, along with a fear that rents may be increased or tenancies
       terminated. Need to consider easier and more acceptable ways to offer the housing
       referrals.
1.5.2.4 General Practitioners in BOPDHB district – Survey Monkey questionnaire

A Survey Monkey questionnaire was distributed to all GPs in the BOPDHB district through
multiple mechanisms. Only 10 responses were received, so no meaningful conclusions
could be drawn from the survey. The key results were:

      All 10 respondents had easy access to sore throat management guidelines,
       algorithms or pathways. They accessed a variety of sources including Bay Navigator
       pathway for sore throat management; and Heart Foundation guidelines, either direct
       from the website or from a supplied A4 hard copy.

      All 10 respondents able to access patient/whanau health education materials.

      Nine out of 10 practices used practice nurse protocols for sore throat management.

      Only 3 practices treated patients empirically without taking a swab.

      Nine out of 10 practices treated without waiting for a swab result to be received and
       of those 9, seven ceased antibiotics treatment if swab was negative.

      Six out of 10 had active strategies for following up patients during the 10 day course
       for adherence.

      Seven practices ran drop-in clinics and 2 had extended or weekend hours.

1.5.2.5 BOPDHB Maori Health Runanga – 14 October 2015

This consultation was to take back to the Runanga how their earlier feedback had been
incorporated into the final refresh of the Plan. The Runanga were comfortable with the
changes made, and formally approved the final draft of the Plan at the meeting.

1.5.2.6 Ministry of Education

Informal consultation occurred with MoE members of the BOP Child and Youth Alliance at a
meeting on 2 October when a presentation was made on the refresh process. Discussion

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focussed on the political fallout in schools if/when school-based throat swabbing ceases.
The DHB has invested a lot of energy in promoting this programme with strong support from
schools, and it will need careful handling if/when this service is withdrawn.

1.6 Rheumatic fever champions
The BOP and Lakes rheumatic fever champions have been nominated by their respective
DHBs and all are members of the BOP and Lakes rheumatic fever steering group. One of
the key tasks of the champions is to act as the main point of contact for rheumatic fever
issues in each DHB. The Lakes and BOP DHBs Rheumatic Fever Champions will work
within the two DHBs and with equivalent champions across other DHBs, to drive and co-
ordinate actions in each DHB plan to achieve DHB targets.

1.6.1 Lakes DHB
Dr Johan Morreau (Community Paediatrician) and Dr Neil Poskitt (General Practitioner and
Clinical Leader of Child Health for RAPHS) are the rheumatic fever champions for Lakes
DHB. One of the key tasks of the champions is to act as the main point of contact for
rheumatic fever issues in Lakes. Dr Poskitt, in conjunction with RAPHS, has been key to the
development of the Rheumatic Fever Register. This provides the capability to audit current
rates, trends, adherence rates and review of patient care.

Elise Pope (rheumatic fever co-ordinator) is the champion for continuous monitoring and
performance of prophylaxis care, interlinking primary and secondary health care services
and assisting in the transition from child to adult care for rheumatic fever patients throughout
Lakes DHB.

1.6.2 BOPDHB
Dr John Malcolm (Paediatrician, Whakatane Hospital) and Pamela Barke (Nurse Leader
Regional Community Services) are the rheumatic fever champions for the BOPDHB. John’s
appointment provides paediatric medical oversight for programmes, and draws on his
considerable expertise and interest in rheumatic fever issues over many years.

Pamela Barke is the champion for monitoring performance of the delivery of Benzathine
Penicillin prophylaxis. This work is also linked to the steering group priority goals to develop
a regional rheumatic fever register and audit Bi-cillin delivery. The district nurses also
provide education and facilitate follow up care for patients with a diagnosis of acute
rheumatic fever and/or rheumatic heart disease (RHD).

                                                                                             18
1.6.3 Future Governance provisions
To date, the governance of the BOP Rheumatic Fever Prevention Plan has been through the
BOP and Lakes DHBs Rheumatic Fever Steering Group. This Group has included all the key
stakeholders, but at a senior clinical and portfolio manager, Planning and Funding level. This
group will continue to provide immediate oversight for the refreshed BOP Rheumatic Fever
Prevention Plan.

The BOPDHB is currently entering into early discussions on possible new governance
arrangements across the wider central government sector as part of strategic thinking to
better integrate the health and social sectors. This new governance body will include the
Ministries of Education and Social Development, and Te Puni Kokiri as a minimum. The role
of this new Governance Group is to provide strategic oversight of a range of intersectoral
activities, including most likely:

       Social Sector Trial sites in Whakatane and Kawerau;

       Community Response Forum;

       Better Public Service targets, including rheumatic fever prevention;

       BOPDHB’s Child and Youth Strategy, which is jointly signed off by MSD, MoE and
        BOPDHB;

       MBIE contract streamlining and accountability/audit processes.

Membership of the Governance Group will be at senior Executive levels in each
organisation.

It is important that BOPDHB ensures that governance arrangements for rheumatic fever
services align with Government expectations of closer health and social service co-design
for vulnerable families. There are likely to be considerable changes to the framework for
publicly-funded health and social services in the next few years.

The BOPDHB therefore undertakes to review governance arrangements for rheumatic
fever services on an annual basis.

                                                                                           19
Section 2: Overarching actions to reduce the incidence of rheumatic fever in
the BOP and Lakes districts

2.0 Overview of the prevention of ARF and RHD
The overarching goal for BOP and Lakes DHBs is to reduce the incidence of rheumatic fever
amongst the total population (but primarily Māori and Pacific peoples) by two thirds by June
2017. In order to achieve this, there are a number of critical prevention stages:

Primordial prevention: Broad social, economic and environmental initiatives undertaken to
                                                                ii
prevent or limit the impact of GAS infection in a population.        BOP and Lakes DHBs will
undertake interventions aimed at preventing the transmission of Group A streptococcal
throat infections in crowded housing situations through the continuation of the Healthy
Homes Initiative funded by the Ministry until 31 December 2016. DHBs have less direct
influence on child poverty and other social issues, but will work with local government and
other central governments agencies where possible, including through cross sector
programmes such as Children’s Action Team, Social Sector Trials and Whanau Ora, to
improve living standards for vulnerable children and young people.

Primary prevention: Reducing GAS transmission, acquisition, colonisation and carriage or
                                                                                       ii
treating GAS infection effectively to prevent the development of ARF in individuals.        BOP
and Lakes interventions will be aimed at school, community and primary health care level
through appropriate detection and management of GAS pharyngitis. Primary prevention also
includes community awareness raising initiatives and continuing professional development
for health professionals.

Secondary prevention: Administering regular prophylactic antibiotics to individuals who
have had an episode of ARF to prevent the development of RHD or to individuals who have
established RHD to prevent the progression of the disease.ii In the BOP and Lakes,
secondary prevention is closely linked to the implementation of a regional register, with
monitoring and auditing capabilities. Care pathways and Bi-cillin prophylaxis protocols are
also aimed at preventing further recurrence of ARF and RHD.

Tertiary prevention: Intervention in individuals with RHD to reduce symptoms and disability
and prevent premature death. BOP and Lakes DHBs acknowledge the need to ensure
excellent clinical follow up of patients with an existing diagnosis of ARF and RHD. The BOP
and Lakes rheumatic fever register operated by RAPHS will support this work.

                                                                                             20
2.1 BOP and Lakes shared priorities 2013-2017
There is significant regional work that is common to both DHBs to achieve the goal of
reducing rheumatic fever. Since 2009, efforts to address rheumatic fever have been led by
the Lakes/BOP Rheumatic Fever Steering Group. A multifaceted approach was adopted
including the revision of priorities from year to year, with a focus on primary, secondary and
to a lesser extent tertiary prevention. With the adoption of a challenging national target for
the reduction of rheumatic fever rates and confirmation that health is to take the lead across
sectors, primordial prevention will be a new and significant area of work. The steering group
agreed broad priorities for action across both DHBs from 2013 to 2017, these being:

      addressing the determinants of health, in particular poor housing conditions and
       crowding;
      establishment of a rheumatic fever register across BOP and Lakes districts;
      community awareness raising;
      continuing professional development for health professionals;
      easier access to primary care;
      ensuring the delivery of high quality school-based programmes in high risk areas to
       ensure that children have access to prompt treatment, to ensure that services are
       operating safely, and to contribute to national evaluations of effectiveness;
      meaningful monitoring – process and outcome evaluation.

                                                                                           21
Section 3: National Evaluation of School Based Throat Swabbing Programme

An interim evaluation of the sore throat management component of rheumatic fever
prevention plans was undertaken by the University of Otago/ESR in 2015. This evaluation
used national data as data sets for individual DHBs were too small to allow statistically
significant results. Key findings of the evaluation were:
      The effectiveness of the school based sore throat swabbing component of RFPPs is
       estimated to be about 17% nationally, with a range of between 0-42%. Counties
       Manakau DHB effectiveness was estimated to be about 30%, although this finding
       again was not statistically significant.
      The rate of ARF dropped significantly during the first six months of 2015 both in
       areas with and without school based sore throat swabbing programmes.
      The development of separate RFPPs by different high incidence DHBs has resulted
       in sore throat management programmes which have been implemented in different
       ways and at different times.
      Swabbing data demonstrate that the correct populations are being targetted
       (increased numbers of swabs in Maori and Pacific children, in both primary care and
       schools, and in socioeconomically deprived areas). The incidence of GAS-positive
       throat swabs has increased in all high incidence DHBs.
      In the Auckland region, the majority of ARF cases 2010-14 did not have a preceding
       throat swab.
      Economic analysis based on Counties Manakau DHB data suggest the school
       programmes are cost effective under WHO criteria but probably not cost effective
       based on PHARMAC's funding criteria. N.B. Various assumptions were made
       regarding the effectiveness of the programme and the costs of delivery, which may
       not be comparable to BOPDHB's school based programmes.
      Economic analysis based on this study report improvements are required to ensure
       the school component is cost effective.
      The relative contributions (effectiveness) of school based component and rapid
       response clinics could not be determined due to data collection issues.
      Sore throat programmes alone are unlikely to reduce the incidence of ARF
       sufficiently to enable DHBs to reach the RF target.

                                                                                       22
Further evaluations are to follow. Towards the end of 2015 a Litmus qualitiative evaluation is
to be published, and there will potentially be a comparative evaluation of rapid access clinics
versus school based services if data becomes available.

3.1 What does this mean for BOPDHB and the BOP school based sore throat
swabbing programme?
This interim evaluation has provided some useful insights. While unfortunately not achieving
statistical significance, there is encouragement that the programmes have been partially
successful in reducing the incidence of RF, and may be an important component of a DHB's
programme to achieve the RF target. In regards to BOPDHB, our population, and our school
based programme, there are some aspects which limit direct comparison between the
national evaluation and the potential effectiveness or cost effectiveness of the service in our
region.

The cost of delivering the school based programmes in BOPDHB is considered to be lower
than figures used in the interim evaluation:
         The total school rolls of the 29 schools in the programme is 4,551 as at July 2014.
          Based on an approximate 98% consent rate to throat swabbing, then there are 4,460
          children able to access the programme.
         The total cost of the school-based throat swabbing programme is $721,667 per
          annum, including the agreement prices for all providers, laboratory testing costs, and
          the costs of the nursing clinical assurance oversight.
         Therefore the costs per child per annum are $161.81 c.f. Counties-Manukau DHB
          costs used in the economic analysis of $200 per child per annum.

Further to the national evaluation, a local audit and evaluationiii on preliminary data reported
a non-statistically significant decrease in RF rates for Māori children (aged 5-14) in eastern
BOP intervention schools – Opotiki, Kawerau and Tuhoe programmes. In the pre-
intervention period from 2000 to 2010, Maori children aged 5-14 had a ARF rate of
128.7/100,000 (95%CI 60.6-177.4), and in the intervention period from 2011 to 2014, the
rate was 50.7/100,000 (95%CI 16.3-118.3). This data is to be updated for the 2014/15 year
and the inclusion of the Murupara programme. This unpublished audit and evaluation may
provide some broad indication that RF rates may be reducing in the Eastern BOP. However,
because of small numbers, we are unsure how robust this observation is and to what we
should attribute any changes.

                                                                                             23
The reduced costs of the BOPDHB school-based throat swabbing programme would have
an effect on the cost per QALY gained for the programme. The BOPDHB programme is also
not limited to solely the prevention of RF, with linked activities to reduce skin diseases and
highlight the importance of good hygiene practices.

It is appreciated that school based sore throat swabbing programmes are not likely to allow
DHBs to reach RF targets on their own, rather they are seen as a interim approach while
other initiatives increase primary care access. In BOPDHB school based programmes are
one component of the RFPP, with further initiatives detailed elswhere in this Plan.

When school based sore throat swabbing commenced in BOPDHB (in 2009), it was
acknowledged the programme would continue beyond the period funded by MOH.
Stakeholder and community engagement has shown us that the school based programmes
are valued and well received in communities, and act to increase awareness of RF and the
importance of sore throat management in whanau. The interim national evaluation of school
based sore throat programmes does not have a sufficient number of cases to demonstrate a
statistically significant effectiveness in reducing ARF, however it does suggest that the
programme is likely to reduce the number of cases, and act as a useful adjunct to the other
initiatives BOPDHB is employing in order to reach the BPS target of rheumatic fever
incidence reduction. It is interesting to note that an evaluation undertaken by Dr Janine
Stevens of Hawke’s Bay DHBs Say Ahh programme in Flaxmere, also recommended that
the programme should continue. While recognising the challenges in continuing the
programme, such as increasing costs due to increased service utilisation, concens about
over-use of antibiotics, and opportunity costs for other health service priorities, the
recommendation supported continuation of the programme unless conclusive evidence
showed that the programme’s benefits were less than these costsiv.

3.2 Laboratory data
Data supplied by Path Lab for Group A streptococcus swab tests from January 2010 to
September 2015 shows a steady increase in the number of swabs taken in:
     the school-based throat swabbing programme, as additional schools have been
        included;
       in general practice, as community awareness increases and health practitioners are
        more familiar with accepted best pactice;
       in hospital emergencency departments, as community awareness increases.

                                                                                           24
Positivity rates have trended downwards in general practice, with positivity rates being lower
        in the 2013 to 2015 to date period in comparison with the 2010 to 2011 period. Overall the
        percentage of swabs which tested positive taken in A&E was significantly higher than those
        taken in general practice, which in turn was higher than swabs from the school programme.
        That is likely to reflect the severity of symptoms in the people presenting to the different
        services.

        Table 4 shows the data from the school-based throat swabbing programme, general
        practice, and hospital emergency departments.

        Table 4: Path Lab data for GAS swab testing – BOPDHB district

   Year                  School-based                         General practice            Hospital Emergency Department
                 No of     No of +ve    Positivity    No of      No of +ve   Positivity    No of    No of +ve    Positivity
                swabs        swabs        rate       swabs        swabs          rate     swabs      swabs           rate
   2010          2,040        206        10.1%        7,095        1,336         18.8%      619       116            18.7%
   2011          5,954        600        10.1%        9,301        1,800         19.4%      664       138            20.8%
   2012          9,659        988        10.2%        6,017        1,732         28.8%      943       193            20.5%
   2013         13,734       1,300        9.5%       13,104        1,888         14.4%     1,123      211            18.8%
   2014         15,579       1,276        8.2%       16,422        2,031         12.4%     1,285      192            14.9%
2015 to Sept    10,224        987         9.7%       14,283        1,487         15.1%     1,093      169            15.5%
2010 to date    57,190       5,357        9.4%       66,222       10,274         15.5%     5,727      1,019          17.8%

        The following graphs present the same data for the general practice swab testing results.

                                                                                                                25
3.3 Root cause analysis data
The following flow diagrams showing the outcomes of the national and local system failure
analysis reports disclose that not much more than half of diagnosed cases of rheumatic
fever had any memory of a sore throat throat. Dr S Schulman noted this also as the ARF
programme in Baltimore, USA took effect. Of those that did note a sore throat, about a third
saw a health professional and were prescribed the right antibiotics, although strict adherence
to taking the antibiotics is not known. This supports that:
      reliance cannot be placed on sore throat management as a means to achieve a
       target of two-thirds reduction.
      Improvements can be made in the sore throat management pathway, which if
       achieved would potentiallly reduce the risk of acute rheumatic fever in children
       identified with sore throats.

                                                                                           26
   echocardiographic screening needs further consideration and the outcome of 2013
    Heart Foundation, MOH, Te Puni Kokiri and HRC funded evaluation research may
    have a bearing.

                                                                                27
Analysis of national system failure analysis reports 2014/15

                                             ± ⅔ completed course         ± ⅓ did not complete course
                                                                          (intervention: improved adherence education)

                                                                                                25   got right antibiotic

                                                                        31
                                                                     got antibiotics
                                                                                                6 did not get right antibiotic
                                                                                            (Intervention: more health
                                                                                              professional education)
                                               42
                                              saw a health
                                              professional
                                                                        11   did not get antibiotics
                                                                             (Intervention: more health professional education)
                        69
                      remembered
                   having a sore throat
                                               27    did not see a health professional
                                                    (Interventions: individual, whanau and community awareness raising/
                                                     improved access to primary care including
                                                     rapid response clinics)
127
systems failure
analysis reports
completed                                    58   did not remember having a sore throat
                                                   (Intervention: improving housing programme, echocardiographic screening?)

                                                                                                                                  28
Analysis of BOP case review forms 2014/15

                                                  Unknown if completed course?         did not complete course
                                                                             (intervention: improved adherence education)

                                                                                                        1   got right antibiotic

                                                                               1
                                                                            got antibiotics
                                                                                                        0 did not get right antibiotic
                                                                                                    (Intervention: more health
                                                                                                      professional education)
                                                      1
                                                    saw a health
                                                    professional
                                                  (recurrent case)
                                                                               0   did not get antibiotics
                                                                                    (Intervention: more health professional education)
                            3
                         remembered
                      having a sore throat
                  (includes recurrent case)
                                                      2   did not see a health professional
                                                           (Interventions: individual, whanau and community awareness raising/
                                                            improved access to primary care including
                                                            rapid response clinics)
7
(6 initial ARF and 1 recurrent)
Case review reports
completed                                         4   did not remember having a sore throat
                                                         (Intervention: improving housing programme, echocardiographic screening?)

                                                                                                                                         29
Section 4: Investment to reduce ARF incidence and RHD

Section 4.0 Introduction
This section outlines the service and funding decisions over the next few years. The overall
strategy is to make every effort to achieve the target by 30 June 2017, while keeping DHB
funding levels constant as the Ministry contribution decreases. From 2017/18 onwards, the
DHB funding levels may be able to be reduced, depending on outcomes against the national
and DHB target, and evidence of the most effective and cost-efficient services. The following
summary in Table 5 outlines budgets for the next three years and beyond.
Table 5: Summary of Budgets 2015/16 to 2017/18 and beyond

                                       2015/16      2016/17     2017/18 + out years

DHB funding (contracted)               851,551      825,423       836,520

MoH funding (contracted)               430,375       98,875            0

Additional MoH funding (not contracted) 100,000#    331,250+     183,743α

Total expenditure                    1,381,926     1,255,548   1,020,263

# MoH funding (not contracted) available in 2015/16 to be used for meeting costs of Tuhoe
programme for 6 mths ($65,000) and Rapid response clinic services delivered by NMO Ltd
($35,000)

+ MoH funding (not contracted) available in 2016/17 to be used for meeting costs of Tuhoe
programme for 12 months ($130,000), Healthy Homes programme coordination service
($40,000), revamped rapid response clinics ($135,123), and offset part of Ngati Awa
programme in Whakatane area ($26,127).

Α MoH funding (not contracted) available in 2017/18 to be used for meeting costs of Tuhoe
programme for 12 months ($130,000), and part of the revamped Business as Usual sore
throat management services within primary and community care ($53,743).

4.1 BOPDHB resources committed to reducing rheumatic fever 2015/16
The BOPDHB has planned for the following investment to be made in reducing rheumatic
fever in 2015/16 (GST exclusive). Most of this resource is already committed in provider
agreements – Table 6 refers.

                                                                                          30
Table 6: BOPDHB resources committed to reducing rheumatic fever 2015/16

                       Initiatives                        Cost $              Comment
  School-based throat swabbing programmes
  Opotiki-Whakatohea Iwi Social & Health(expires
  30/6/17)                                                126,171
  Kawerau - EBPHA (expires 30/6/17)                       118,945   #reassignment from Tuhoe
  Murupara - Te Ika Whenua Hauora (expires                44,902    Matauranga Trust to Tuhoe
  31/12/15)                                              130,000*   Hauora on 12 Oct 2015
  Tuhoe area# Tuhoe Hauora (expires 31/12/15)             75,713    *$65,000 from MoH to
  Tauranga area NMO Ltd (expires 30/6/16)               75,75,71    31/12/1531/12/15

  Community awareness raising
  Whakatane – NASH (expires 30/6/16)                      50,475

  Rapid response clinics
  EBPHA (expires 30/6/16)                                107,000
                                                                        All providers funded by
  WBOPPHO (expires 30/6/16)                              103,000
                                                                            MoH to 30/06/16
  NMO Ltd (expires 30/6/16)                               35,000

  Housing improvement initiatives
  Smart Energy Solutions Ltd (expires 30/6/16)          50,000
  Sustainability Options Ltd (expires 31/12/16)
  Tauranga Community Housing Trust (expires             77,687#     #Providers funded by MoH
  31/12/16)                                              77,688#    to 31/12/16 MoH 31 /12/1
  Laboratory testing
  Laboratory costs (Part of PathLab bulk funding
  agreement)                                            185,000     P

  Coordination and governance
  Additional funding to Toi Te Ora-Public Health          85,000
  Service through PV Schedule

  Clinical quality assurance of swabbing
  programmes
  EBPHA (expires 30/6/17) Funded by DHB to
  provide quality assurance across all school-based       40,936             Funded Ff.50
  throat swabbing programmes.                              404
  Funded by DHB through EBPHA to provide quality
  assurance across all throat swabbing programme.50
  Register ongoing costs
  Rotorua Area Primary Health Services (expires
                                                          14,000
  30/6/16)

  District nursing support
                                                          60,409
  BOPDNS through PV Schedule
  Total                                                 1,381,926                  .175

Footnote:
The table does not include investment where services are provided in kind. These include:
Planning and Funding portfolio manager, contracts management, finance and overhead costs; PHO
data analysis and evaluation costs; Paediatrics and Nursing contributions within Rh Fever Steering
group. Also Toi Te Ora - Public Health Services Medical Officer of Health time and Communicable
Diseases Nurse time in actual case management; costs within general practice, or routine District
Nursing Services Bi-cillin management programme. This footnote applies also to Tables 7 and 8.

                                                                                                  31
4.2 BOPDHB investment for 2016/17, including new initiatives
The BOPDHB’s strategy for the 2016/17 year is to make every reasonable endeavour to
achieve the target, maintaining services at current levels as much as possible within funding
constraints. The Ministry has reduced its funding from 2015/16 levels by $100,250. The DHB
will also reduce its investment into programmes by $26,128 while maintaining core services.

The intention is to continue funding the following programmes during the 2016/17 year at the
same level as in 2015/16.

   Opotiki, Kawerau, Murupara, Tuhoe and Tauranga South school-based throat swabbing
    programmes, considering any cost efficiencies that are practicable.
   The community awareness raising programme delivered by NASH in eastern BOP.
   Clinical quality assurance agreement with EBPHA.
   Coordination and governance through Toi Te Ora - Public Health Service
   Laboratory costs (ensuring that the block amount being paid currently aligns with the
    volume of swabs being sent to PathLab, so that the price per swab remains competitive)
   Register ongoing costs
   District nursing support for a Rheumatic Fever Coordinator
   BOPDHB third party funding for all housing projects across the BOP, including those
    specifically for rheumatic fever prevention whanau.
The DHB will continue to fund Ministry-initiated projects but with reduced funding and
changes to the service delivery model.
   Housing Insulation Initiative scheme, with the pathway, referral criteria and processes be
    streamlined from 1 January 2017, and be dependent on subsidy levels and criteria set by
    EECA and other third party funding contributions.
   A revamped Business as Usual primary and community-based service for rapid
    response assessment and treatment of sore throats.

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