National Health Committee. An Overview of Laboratory Services in New Zealand

Transcription

1 National Health Committee An Overview of Laboratory Services in New Zealand March 2015

2 National Health Committee (NHC) The National Health Committee (NHC) is an independent statutory body charged with prioritising new and existing health technologies and making recommendations to the Minister of Health. It was reformed in 2011 to establish evaluation systems that would provide the New Zealand people and the health sector with greater value for money invested in health. The NHC Executive is the secretariat that supports the Committee. The NHC Executive s primary objective is to provide the Committee with sufficient information for it to make decisions regarding prioritisation and reprioritisation of interventions and services. They do this through a range of evidencebased products chosen according to the nature of the decision required and timeframe within which decisions need to be made. The New Zealand Government has asked that all new diagnostic and treatment (non-pharmaceutical) services, and significant expansions of existing services, are to be referred to the NHC. In August 2011 the NHC was appointed with new Terms of Reference and a mandate to establish the capacity to assess new and existing health technologies. Its objectives (under Section 4.2 of its Terms of Reference include contributing to improved value for money and fiscal sustainability in the health and disability sector by: providing timely advice and recommendations about relative cost-effectiveness based on the best available evidence; providing advice and recommendations which influence the behaviour of decision makers including clinicians and other health professionals; providing advice and recommendations which are reflected in resource allocation at national, regional and local levels; and contributing to tangible reductions in the use of ineffective interventions and improved targeting to those most likely to benefit. In order to achieve its objectives under Section 4.2 and to achieve Value for Money, the NHC has adopted a framework of four assessment domains Clinical Safety & Effectiveness; Economic; Societal & Ethical; and Feasibility of Adoption in order that assessments cover the range of potential considerations and that the recommendations made are reasonable. It is intended that the research questions asked will fall across these domains to ensure that when the Committee comes to apply its decision-making criteria, it has a balanced range of information available to it. When the NHC is setting those questions they will have the decision-making criteria in mind. The 11 decision-making criteria will assist in the determination of the NHC work programme and in the appraisal and prioritisation of assessments. Page 2

3 Contents 1 Introduction 4 2 Organisation of laboratory services in New Zealand Provision by DHB Funding Workforce Information systems 9 3 Emerging technologies 12 4 New Zealand service developments and issues National strategy the National Laboratory Round Table Funding models Revision of the community laboratory schedule 14 References 16 National Health Committee (NHC) and Executive 18 Disclaimer 18 Page 3

4 1 Introduction This document is intended to provide the National Health Committee (NHC) with an overview of clinical laboratory testing in New Zealand in order to inform decisions about whether to undertake further work in the area. Consideration of clinical laboratory testing as an entity for analysis is a horizontal approach that cuts across more sequential analytical approaches such as by models of care. Laboratory testing plays a critical role in clinical decision making providing clinicians with information that expedites disease prevention, diagnosis, and treatment. Laboratory tests also underpin disease screening for risk factors, determination of disease severity, recovery likelihood, therapeutic selection, monitoring and investigation of adverse outcomes. At the population health level clinical laboratories are critical in the identification of hospital acquired infections, identifying antimicrobial resistance patterns, and in the control of infectious disease outbreaks and exposures to toxic substances. Evidence-based medicine is driving more effective and cost effective laboratory testing. Laboratory testing is incorporated into clinical practice guidelines to assist both clinicians and patients in decision making. Laboratory testing is one of several important indicators for assessing quality of care particularly for New Zealand health targets such as reducing the incidence of rheumatic fever. All laboratories in Australasia must participate in recognised quality assurance activities and receive formal accreditation to ensure doctors and patients can be confident that test results are reliable. (1) Pathologists are the medical specialists who have leadership in the diagnosis and monitoring of diseases utilising laboratory tests. The place of laboratory testing in clinical pathways of care is defined by the pathology discipline providing oversight of the particular test concerned. At present, pathology practice has nine different areas of activity relating either to the methods used or the types of disease that they investigate. These are: (2) 1. anatomical pathology, the study of organs and tissues to determine disease causes and effects 2. forensic pathology, the subspecialty of pathology that focuses on medico-legal investigations of sudden or unexpected death 3. chemical pathology, the diagnosis and management of disease by the analysis of chemicals present in body fluids and tissues 4. genetic pathology contributes to the multidisciplinary range of skills required within pathology services to aid in the diagnosis, management and treatment of patients with disorders arising from genomic mutations 5. haematology encompasses both clinical and laboratory aspects of primary disorders of the blood as well as how other diseases affect the blood. Haematology includes as a sub-discipline blood banking 6. immunopathology provides expert diagnostic support for patients with immune disorders and for the clinicians, educators, and scientists involved in their care Page 4

5 7. microbiology, involves the use of laboratory techniques to diagnose infectious diseases, recommend antibiotic therapy and to advise, correlate, coordinate and educate clinicians regarding aspects of the pathogenesis, epidemiology, prevention and management of infection 8. general pathology involves all aspects of pathology. It deals with the diagnosis and management of disease by use of every component of laboratory medicine and every diagnostic technique, including examination of the patient. General pathologists have a very broad understanding of the pathophysiology of disease, the diagnostic value of individual tests and also of the laboratory and its workings 9. clinical pathology a clinical pathologist is familiar with the major aspects of the clinical branches of laboratory medicine. They are usually trained in chemical pathology, microbiology, haematology and blood banking, though not in as much detail as subspecialists in each field. Page 5

6 2 Organisation of laboratory services in New Zealand The models of laboratory test provision vary greatly by region, making classification of testing results by primary (community), secondary, tertiary and quaternary (e.g. tests sent to international centres of excellence) problematic because in some regions: a single laboratory provides all services in that region community laboratories provide tests at hospital outpatient clinics hospital laboratories undertake some community testing. Currently the laboratory market in New Zealand is highly concentrated, with two market participants dominating around 75 per cent of the total market: Healthscope Ltd, which owns Northland Pathology, LabTests Auckland, and Southern Community Laboratories, and has 45 per cent of the community referred market Sonic Healthcare, which owns Diagnostic Medlab, Medlab Central and part owns T-Lab and Aotea Pathology, and has 31 per cent of the community referred market Pathology Associates Ltd, which owns Pathlab Waikato, Pathlab Bay of Plenty and a joint venture with Diagnostic Rotorua, and has 15 per cent of the community referred market. (3) 2.1 Provision by DHB Table 1 sets out current arrangements for community and hospital referred testing by DHB. (4) Page 6

7 Table 1: Current arrangements for community and hospital referred testing, by DHB DHB Community referred tests provided by Hospital referred tests provided by Northland Healthscope (Northland Pathology) Northland DHB Waitemata Auckland Counties Manukau 85% Healthscope (Lab Tests Auckland), 15% Sonic (Diagnostic MedLab Ltd) 90% Healthscope (Lab Tests Auckland), 10% Sonic (Diagnostic Medlab Ltd) 85% Healthscope (Lab Tests Auckland), 15% Sonic (Diagnostic Medlab Ltd) Waitemata DHB LabPlus the Auckland DHB hospital laboratory Counties Manukau DHB Bay of Plenty Pathology Associates (Pathlab BOP Ltd) Pathology Associates (Pathlab BOP Ltd) Waikato Pathology Associates (Pathlab Waikato) Waikato DHB Lakes Rotorua: Pathology Associates joint with DHB (Diagnostic Rotorua), Taupo: Healthscope SCL Pathology Associates joint with DHB (Diagnostic Rotorua) Tairawhiti Sonic joint with DHB (TLab) Sonic joint with DHB (TLab) Taranaki Medlab Taranaki (independent laboratory provider) Taranaki DHB Whanganui Sonic (Medlab Central) Sonic (Medlab Central) Hawkes Bay Healthscope (Southern Community Labs) Hawkes Bay DHB MidCentral Sonic (Medlab Central) Sonic (Medlab Central) Wairarapa Sonic (Medlab Central) Sonic (Medlab Central) Hutt Valley Joint Sonic (45%) and Abano (55%) (Aotea Pathology) Capital & Coast Joint Sonic (45%) and Abano (55%) (Aotea Pathology) Nelson Marlborough Healthscope (SCL) Hutt Valley DHB Capital & Coast DHB Healthscope (SCL) West Coast DHB, Healthscope (SCL) West Coast DHB Canterbury 95% Healthscope (SCL), 5% DHB (Canterbury laboratory) Canterbury Health the Canterbury DHB laboratory South Canterbury Healthscope (SCL) Healthscope (SCL) Otago Southland Healthscope (SCL) Healthscope (SCL) Page 7

8 All hospital laboratory tests are funded out of DHB baseline funding. Individual hospital laboratories have discretion as to the range of tests offered. There is considerable variation between hospital laboratories in the range of tests available, particularly for novel, expensive and tertiary level tests. Unlike the community laboratory schedule there is no national uniformity to DHB hospital laboratories for test ordering business rules, and no national consistency in the manner by which hospital laboratory expenditure is controlled. The national reference medical testing centre Crown research institute, Environmental Science and Research (ESR), undertakes a small volume of referred diagnostic tests, e.g. for HIV/AIDS. The health component of ESR s funding is by contract with the Ministry of Health. The Ministry has therefore instructed ESR to recover the costs of any referred diagnostic testing from the patient s DHB of domicile. 2.2 Funding The bulk of diagnostic laboratory services are publicly funded. All community laboratory tests are bulk funded (versus fee-for-service) via a laboratory test schedule, updated in 2013 on a contractual basis with laboratory providers (see Table 1) that involves a joint risk share model for laboratory (5, 6) expenditure exceeding a predefined threshold. A very small proportion of community laboratory tests are non-publicly funded and are paid for by patients. Reasons include tests for non-new Zealand residents, insurance assessment or for a small number of previous schedule tests not found to meet the threshold for public funding by expert advisory groups. Historically community laboratory testing was funded on a fee-for-service basis. The New Zealand Health Information Service (NZHIS) estimated that community laboratory testing accounted for about $220 million per year for the years 2004 to From 1994 to 2001 the fee-for-service for schedule tests was not increasing at the same rate as that of the commensurate Vote Health adjustor for DHBs, i.e. 8.5 percent annually (Brown et al, 2003). Volume increase led to laboratory funding requirements increasing at a rate of 6 percent annually over that time. (7) Under the fee-for-service model, an incentive for laboratories to encourage testing may have existed. (8) Other drivers for increased testing included an ageing population, increased day surgery and early discharges from hospitals, increased monitoring of new medicines and medico-legal pressure on the medical profession to ensure high quality care, government priorities (including a focus on primary health, earlier diagnosis and intervention) and national screening programmes. 1 An opportunity to reform the market arose in 2003 with the devolution of laboratory service funding to individual DHBs, and the shift to risk share based bulk funding completed subsequent to the 2006 contract renewals. 1 Steele R and select RCPA members, 2009 Draft RCPA response 7 April 2009 Page 8

9 The most recent reliable estimate of spend on pathology services in New Zealand as provided by the National Health Board, Funding and Monitoring team (17 May 2011) is set out in Table 2 and Table 3. Table 2: Overall laboratory services spend Year Total health care spend Total laboratory services spend Publicly funded Privately funded Percentage of total health care spend 2008/09 $19.3 billion $345 million $309 million $36 million 1.8% 2009/10 $20.5 billion $353 million $308 million $45 million 1.7% Source: National Health Board, Funding and Monitoring team (17 May 2011) Of the total laboratory services spend, 63% relates to community testing (Table 3). Table 3: Community laboratory service spend Spend on community tests $222 million $214 million $216 million $223 million Community test volumes 23.2 million 22.8 million 23.7 million 24.2 million Average community tests per capita Average spend on community tests per capita $54 $51 $51 $52 Source: National Health Board, Funding and Monitoring team (17 May 2011) 2.3 Workforce Both the New Zealand Medical Laboratory Workers Union Recruitment and Retention Survey 2011 (9) and the Royal Colleges of Pathologists of Australasia (10) have identified significant challenges to the training, recruitment, retention and in-service education of diagnostic laboratory staff in New Zealand. 2.4 Information systems e-ordering and clinical decision tools Anecdotal communications suggest successful past innovations in both paper based and electronic test ordering are not being applied in a consistent manner nationally. These include: providing the test cost next to the check box on the ordering form flagging tests which by virtue of expense, difficulty of collection and/or difficulty or result consultation should be discussed with a pathologist prior to ordering either as a recommendation or as a business rule. Page 9

10 Automated alerts (flags) are increasingly being used in patient management systems to identify laboratory tests requiring clinical review. This approach has the potential to enhance patient safety both in terms of timely clinician notification and by complementing manual review of test results. Anecdotally some clinicians are replacing test orderer review of laboratory results, relying solely on automated systems to determine test significance. This is of concern as professional responsibility and legal liability arising from the review and utilisation of test results lies ultimately with the clinician ordering the test. No automated alert system has 100 per cent sensitivity and specificity for identifying clinically significant tests. In addition determining whether a test result requires further action requires an understanding of the patient s clinical context and in concert with other diagnostic information, a level of sophistication of analysis that automated alert tools are unable to perform. If all tests ordered are not reviewed on a regular basis by the primary clinician for the patient concerned within the context of the patient s history and evolving clinical status, the quality of care for that patient will be sub-optimal. Clinical decision tools applied in the context of electronic patient records and access to all test results via laboratory data repositories have the potential to prevent unnecessary ordering of tests, e.g. where an appropriate test has already been performed in the recent past The laboratory warehouse and laboratory repositories Since the shift to bulk funding risk share agreements in 2006 for community laboratories there has been a marked decline in the quality of information provided to the national laboratory data warehouse which had previously been a robust source of aggregated test payment information. Bulk funding resulted in a loss of DHB incentive to collect the high quality laboratory test information required to manage the pre-2006 fee-for-service test remuneration model operating in some DHBs. There are currently regional laboratory repositories that hold all publicly-funded laboratory test results for an area, e.g. TestSafe for Northland and Auckland metro DHBs, and TestSafe South, serving Canterbury, South Canterbury and the West Coast DHB. The remainder of New Zealand lacks regional laboratory repositories. TestSafe and TestSafe South enable clinical access to all publiclyfunded laboratory tests within the region served, but not nationally. Any authorised repository user is able to access all publicly-funded tests for a particular patient in a particular region regardless of what laboratory performed the test. In the UK, the NHS Carter report estimated that 25% of pathology tests were unnecessary. (11) Without regional repositories that can be nationally accessed, it is impossible to determine the extent to which the Carter report findings might be applicable in New Zealand. For example tracking test ordering at the individual patient level, particularly in regions where patient care frequently crosses DHB geographical boundaries, is problematic. The priority 1 recommendation (need to act immediately) of the joint Wairarapa, Hutt Valley and Capital Coast DHB Laboratory Services Strategy (the 3 DHB strategy, (3) 28 August 2013) was the need to implement a (laboratory) data repository that is accessible by all with its proven clinical and financial benefits as soon as possible. The 3 DHB strategy working group regarded a repository as Page 10

11 critical for primary and secondary integration, for reduction in patient harm, reduction in waste through duplicated testing and needs to happen much faster than currently planned. The National Health IT update 2013/2014 (12) identifies regional laboratory data repositories as a critical requirement under the themes of common clinical information, common clinical results, clinical workstation and clinical data repository. There has to date been no attempt to retrospectively update current generation repositories in which tests have unique identifiers with previous generations of non-correlational free text databases or paper-based record systems. Anecdotally this is of particular concern to clinical genetics testing where a number of very expensive once in a lifetime tests are in fact being performed several times on the same client. Clinicians wishing to obtain clinically significant time series laboratory information, e.g. for managing chronic conditions, are similarly challenged. In a letter to the Ministry dated 9 July 2012 the Auckland & Regional Quality Assurance Group expressed concerns arising from misinterpretation of cumulative laboratory results from multiple providers as a consequence of information system anomalies including unique identifier codes (such as Logical Observation Identifiers Names and Codes (LOINC) 2 and the electronic test messaging systems (in particular General Practitioners Patient Management Systems (GP PMSs) and to a lesser extent the Éclair (hospital) and TestSafe (regional repository systems)). 2 Page 11

12 3 Emerging technologies The current round of laboratory re-contracting will result in successful tendering laboratories procuring upgraded test platforms viable for the duration of the new contract and capable of performing the next generation of molecular tests, e.g. for tumour markers such as Epidermal Growth Factor Receptor (EGFR). Emerging challenges to funders that may arise include: the introduction of novel tests particularly for treatment modalities such as genomics where appropriate test ordering is integral to the downstream genomic modalities for treatment, e.g. cancer marker testing, downstream targeted cancer chemotherapy and integration of pathology/ clinical cancer staging. Issues would include determining the level of clinical seniority at which test ordering authority would lie the number and location of laboratories offering non-schedule tests on a test-by-test basis and/or test category case-by-case basis and/or a region-by-region basis. There is, for example, the potential for a proliferation of laboratories capable of undertaking genomic testing. Page 12

13 4 New Zealand service developments and issues 4.1 National strategy the National Laboratory Round Table In May 2013, the Ministry of Health published a draft strategic framework for diagnostic laboratory services based on recommendations of a key laboratory stakeholder, National Laboratory Round Table, chaired by the Ministry s Chief Medical Officer. (13) This publication is a first step to a strategic response that seeks integration of pathology and laboratory services into a collaborative, wellconnected network guided by the NZ Triple Aim high level outcomes: 1. health services are clinically integrated, more convenient and people-centred 2. New Zealanders are healthier and more independent 3. future sustainability of the health system is assured. Enabling clinical treatment and care to be delivered in a safe, effective and timely manner by increasing efficiency and integration is a key strategy recommendation. In addition gains in efficiency and integration are likely to be achieved by using laboratory information for: commissioning of health services for populations making investment decisions in new health technologies ensuring that systems, processes and practices are in place to assess the quality of laboratory and pathology information. Key enablers flagged by the strategy include: a virtual national laboratory system and community information system linked into a shared patient record professionally and operationally agreed national adopted processes for introduction of new testing, including molecular biology/sequencing timely and managed introduction of new methods and technology reducing duplication of service development/laboratory function clinical ordering and diagnostic practice consistent with best practice guidelines clarification of national, regional, local services (e.g. national reference services, national diagnostic services, regional diagnostic services, and local diagnostic services) and ensuring their seamless integration recognising that laboratory information is a critical resource to support clinical treatment and care, and for the planning and integration of health systems for a population as a whole laboratory and pathology services are part of a suite of integrated providers, i.e. they cannot be seen as a standalone cost centre in the health system. Page 13

14 4.2 Funding models Given the dominance of the Healthscope and Sonic groups in the provision of community laboratory services, further provider consolidation might eliminate any semblance of competition given the already considerable externalities in the laboratory market and may lead to provider collusion. Since Pathology Associates or Taranaki Medlab are unlikely to provide sufficient competition due to their limited access to capital, the Commerce Commission has consequently refused mergers of the dominating market participants, particularly given the lessons of the merger between Diagnostic and Medlab to form DML in the early 2000s. Perceptions of savings to be made of approximately $50 million noted in the Ministerial Review Group (MRG) (14) may have already been realised in the 2006 round of community laboratory contracting, with a move to three major providers (Pathology Associates, Healthscope and Sonic) and the shift from schedule based purchasing to a bulk funded service level agreement approach. The perception that the Australian based multinational companies Healthscope and Sonic have considerable profit margins may no longer be true given the savings yielded in the 2006 re-contracting process. 4.3 Revision of the community laboratory schedule A review of publicly-funded laboratory tests led by a Laboratory Schedule Review Group, chaired by Sarah Prentice, General Manager of the Northern Region Authority, and involving other specialist subgroups, was completed in October (15) The project was overseen by the DHB Shared Services Agency. The aim of the laboratory schedule review project was to develop a consistent list of tests that are available and funded across DHBs. Laboratory tests that were regarded as obsolete or clinically inappropriate have been removed or, in some cases, superseded with newer tests. Guidelines for the appropriate ordering of selected tests were also developed. Over 50 referral guidelines were developed as part of this process. The tests in the new laboratory schedule have been categorised into two groups, termed Tier 1 and Tier 2. Tier 1 tests are core tests that any medical practitioner with a current practising certificate may order. Tier 2 tests are considered to be specialist tests whereby the referrer needs appropriate vocational registration or credentialing to order the test. The test guidelines do not override established local care pathways or guidelines that represent local consensus. It would be hoped, however, that local clinical pathways are consistent with these guidelines, and will be used to inform and supplement these. In order to provide maximum benefit, the review group accepts the need to move to an electronic platform integrated into practice management software. The Ministry of Health is currently Page 14

15 undertaking a programme of work to code the tests for this purpose. Until such time as electronic ordering of laboratory tests is in place, the test list and guidelines will be able to be used as a manual point of reference. The review group was not able to review tests ordered by nurse practitioners who work within individual scopes of practice. Similarly, while it is understood that community dieticians working in a hospital setting order tests under a specialist team, tests ordered by independent community dieticians were not able to be reviewed. As part of the review process, each subgroup looked in detail at the tests able to be ordered by lead maternity carers (LMCs), and the revised test list identified recommendations to DHBs. As per the current process, tests ordered by health professionals not identified in the Schedule should continue to be managed by local agreement. The test list and guidelines provide recommendations to DHBs, and until such time as e-referral systems are in place, DHBs are likely to focus on certain tests in the first instance. Coupled with this, and the fact that the vast majority of tests ordered by clinicians are likely to be core (Tier 1) tests, and/or within the clinician s vocational scope of practice as a Tier 2 test, the impact of the test list is likely to be small. The majority of the guidelines were developed from guidelines already in place in individual DHBs, and all DHBs can now benefit from these. Page 15

16 References 1. Wolcott A, Schwartz A, Goodman C. Laboratory Medicine: A National Status Report. Prepared for: Division of Laboratory Systems, Centers for Diease Control and Prevention, USA by the Lewin Group, Australasia TRCoPo. Position Statement: The Role of the Pathologist (Extended Version) 2013 [cited 14 February 2014]. Available from: 47fe-93fd-2b26cd7b4a17/The-Role-of-the-Pathologist.aspx;.htm. 3. Sub Regional Laboratory Group. Laboratory Services Strategy. Wairarapa Hutt and Capital and Coast District Health Boards, Canterbury District Health Board. Canterbury Laboratory Service Level Alliance Report. A Whole Systems Approach to Laboratory Services. Canterbury: Canterbury District Health Board, 2011 (updated 2013). 5. Biopsy Solutions. Bioby Solutions Services Provided [cited 11 February 2014]. Available from: 6. LabTests. Restricted Test Form [cited 11 February 2014]. Available from: 7. Brown CCL. A Response to Reinhard Pauls Paper: Options for Reform of Diagnostic Laboratory Services Markets Pauls R. Options for Reform of Diagnostic Laboratory Services Markets, Confidential Discussion Paper Prepared for District Health Boards New Zealand (Inc) by Simon Terry Associates Ltd 8 April New Zealand Medical Laboratory Workers Union. The New Zealand Medical Laboratory Workforce Getting Closer to the Edge?. The Lab Report. 2011;54: Royal College of Pathologists of Australasia. Pathologists Launch First Social Media Campaign to Highlight a Serious Message. NZDoctor [Internet]. 28 November 2012 [cited 11 February 2014]. Available from: Chaired by Lord Carter of Coles. Report of the Second Phase of the Review of NHS Pathology Services in England [cited August 2012]. Available from: H_ Ministry of Health. National Health It Plan Update 2013/ [cited 14 February 2014]. Available from: nov13%20-%202.pdf. 13. Ministry of Health. A Strategic Framework for the Pathology and Laboratory Services Sector Available from: Page 16

17 14. Ministry of Health. Meeting the Challenge: Enhancing Sustainability and the Patient and Consumer Experience within the Current Legislative Framework for Health and Disability Services in New Zealand. Report of the Ministerial Review Group 2009 [cited 11 February 2014]:[51 p.]. Available from: DHB Shared Services. Laboratory Schedule Review Project 2013 [cited 14 February 2014]. Available from: Review-Project.aspx. Page 17

18 National Health Committee (NHC) and Executive The National Health Committee (NHC) is an independent statutory body which provides advice to the New Zealand Minister of Health. It was reformed in 2011 to establish evaluation systems that would provide the New Zealand people and health sector with greater value for the money invested in health. The NHC Executive are the secretariat that supports the Committee. The NHC Executive s primary objective is to provide the Committee with sufficient information for them to make recommendations regarding prioritisation and reprioritisation of interventions. They do this through a range of evidence-based reports tailored to the nature of the decision required and timeframe within which decisions need to be made. Citation: National Health Committee An Overview of Laboratory Services in New Zealand. Wellington: National Health Committee. Published in March 2015 by the National Health Committee PO Box 5013, Wellington, New Zealand ISBN (online) HP 5954 This document is available on the National Health Committee s website: Disclaimer The information provided in this report is intended to provide general information to clinicians, health and disability service providers and the public, and is not intended to address specific circumstances of any particular individual or entity. All reasonable measures have been taken to ensure the quality and accuracy of the information provided. If you find any information that you believe may be inaccurate, please to NHC_Info@nhc.govt.nz. The National Health Committee is an independent committee established by the Minister of Health. The information in this report is the work of the National Health Committee and does not necessarily represent the views of the Ministry of Health. The National Health Committee makes no warranty, expressed or implied, nor assumes any legal liability or responsibility for the accuracy, correctness, completeness or use of any information provided. Nothing contained in this report shall be relied on as a promise or representation by the New Zealand government or the National Health Committee. The contents of this report should not be construed as legal or professional advice and specific advice from qualified professional people should be sought before undertaking any action following information in this report. Any reference to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute an endorsement or recommendation by the New Zealand government or the National Health Committee. Page 18