More DHBs mull favouring Ma¯ori, Pacific patients
Covid-19 offers a ‘big-bang opportunity’ to reset our health system. DHBs are responding with plans to prioritise Māori and Pacific patients for elective surgery, writes Nicholas Jones.
Half the country’s district health boards could consider or have committed to prioritising Ma¯ori and Pacific patients for some elective surgeries, the Weekend Herald can reveal.
The changes are an effort to make sure those groups don’t fall further behind the Pa¯keha¯ majority as DHBs clear huge backlogs of planned procedures and surgeries, caused by the Covid-19 lockdown restrictions.
Capital & Coast and Hutt Valley DHBs, covering the Wellington region, recently confirmed Ma¯ori and
Pacific patients would be prioritised for surgeries.
Eight others are considering or have left the door open to similar changes, permanently or while surgery backlogs are cleared after Covid restrictions. They are Northland, Nelson Marlborough, Taranaki, Wairarapa, Southern, Bay of Plenty, MidCentral and Auckland.
No decisions have been made and how any prioritisation would work is being fine-tuned and will likely differ between DHBs and depend on the surgery needed.
The Counties Manukau, Waitemata¯, Hawke’s Bay and
Taira¯whiti boards didn’t directly answer when asked if they are or might consider such changes, or said it was too early to comment.
Currently, people accepted for treatment are given a priority ranking. For example, priority one patients are considered urgent and might be seen within two weeks, priority two may be seen within six to eight weeks, and priority three and non-urgent cases face a wait of months.
Capital & Coast and Hutt Valley DHBs say Ma¯ori and Pacific ethnicity will be used to help rank patients once they are already within a priority band, along with clinical urgency and wait time.
It is not to fix scheduling problems, the DHBs say, but rather to balance the fact those groups are less likely to access healthcare “and delays that may occur across the healthcare pathway from primary to secondary care”.
“We anticipate that our plans to increase planned surgery overall will offset our policy, meaning any impact on other patients would be minimal,” a spokesman said.
Studies and data from DHBs show Ma¯ori and Pacific people are less likely to be referred or accepted for treatment in the first place, and once in the system generally get less treatment.
“Our data shows Ma¯ori and Pasifika patients take longer to move from referral to listing for procedure and often have to present multiple times,” Auckland DHB chairman Pat Snedden wrote in a paper that is still being debated by the board.
“Our current system privileges some groups already. Ma¯ori and Pasifika are not in that group usually.”
It was a nondescript letter that would save his life. Waitemata¯ and Auckland DHBs invited Paumea Ferris and other Ma¯ori aged 55-74 to get a free check for swelling of the main blood vessel from the heart to lower body, an often symptom-less problem that can cause life-threatening rupture.
Ferris didn’t hesitate; his mother had an abdominal aortic aneurysm (often called AAA or triple A) repaired after it was found by chance during other treatment.
After his own ultrasound the technician returned to the room in tears.
“She said, ‘It’s tears of joy. . . it’s why I love my job — it’s not often you save someone’s life.’”
An AAA is enlargement of the aorta above a 30mm diameter. Ferris’ late mother had surgery at 53mm. His was a whopping 68mm.
“I was worried I wasn’t going to last another night, another day. I stopped the gym, I stopped the walk — I stopped everything.”
Within a few months he had surgery. Three years later and he’s back to walking 5km every day and talks happily of his grandsons, James, 3, and Liam, 2 — and the letter that allowed him to meet them.
“I am just lucky to be here with my family. I am just so grateful.”
Momentum for change
Decades-old health gaps between Ma¯ori and Pacific New Zealanders and the Pa¯keha¯ majority remain stubbornly large, despite work like the triple-A screening programme.
Half of Ma¯ori and Pacific deaths are potentially avoidable, compared to 23 per cent for non-Ma¯ori and nonPacific. Those study findings were a national travesty, a recent New Zealand Medical Journal editorial concluded, and should be on the computer screensavers of all planning staff in health organisations.
Eight of the country’s 20 DHBs have now responded by considering an unprecedented step to prioritise Ma¯ori and Pacific patients for certain elective surgeries, with another two confirming plans to do so.
“Our current system privileges some groups already. Ma¯ori and Pasifika are not in that group usually. It is important to be explicit about this. Covid gives us a big-bang opportunity to reset,” Auckland DHB chairman Pat Snedden wrote in an extraordinary document put to the board for debate.
“The waiting list work is about prioritisation, it isn’t that people will miss out, but it does change who gets up the queue earlier.”
Snedden’s paper was released soon after the Weekend Herald revealed the prioritisation discussions among the northern region DHBs — Auckland, Waitemata¯, Counties Manukau and Northland — a month ago, and things have moved fast since.
Capital & Coast and Hutt Valley DHBs — covering the greater Wellington region — revealed Ma¯ori and Pacific patients would be prioritised for surgeries.
Eight others are considering or have left the door open to similar changes, to be permanent or while surgery backlogs are cleared after Covid restrictions. They are: Nelson Marlborough, Taranaki, Wairarapa, Southern, Bay of Plenty, MidCentral, Northland and Auckland.
No decisions have been made and how any prioritisation would work is being fine-tuned and will likely differ between DHBs and the surgery needed.
Another four DHBs — Counties Manukau, Waitemata¯, Hawke’s Bay and Taira¯whiti — didn’t directly answer when asked if they are or might consider such changes, or said it was too early to comment.
Currently, people accepted for treatment are given a priority ranking. For example, priority one patients are considered urgent and might be seen within two weeks, priority two may be seen within six to eight weeks, and priority three and non-urgent cases face a wait of months.
Capital & Coast and Hutt Valley DHBs say Ma¯ori and Pacific ethnicity will be used to help rank patients once they’re already within a priority band, along with clinical urgency and wait time.
Doing so isn’t to fix scheduling problems, the DHBs say, but rather to balance the fact those groups are less likely to access healthcare “and delays that may occur across the healthcare pathway from primary to secondary care”.
“We anticipate that our plans to increase planned surgery overall will offset our policy, meaning any impact on other patients would be minimal,” a spokesman said.
Politicians react
A growing number of studies and reports show Ma¯ori and Pacific people are less likely to be referred or accepted for treatment in the first place, and once in the system generally get less treatment.
Auckland and Northland DHBs have attributed part of the problem to institutional racism, which is a term that describes how procedures or practices result in some groups being disadvantaged.
Last year a landmark report by the Health Quality and Safety Commission challenged health services to stamp out institutional racism that it says severely harms and kills Ma¯ori.
Its review gave a range of examples, including that specialist appointments have unacceptably long wait times and happen less often for Ma¯ori, who are also less likely to get certain treatment soon after admission.
The commission’s chairman, Professor Alan Merry, said of the report that, while broader social factors influence a person’s health, the findings suggested seeking healthcare doesn’t reduce inequities: “In fact, the results suggest the health system creates further disadvantage for Ma¯ori.”
Those systems aren’t always a hangover from another era. The national bowel cancer screening programme — which is halfway through its rollout — is widening health gaps because Ma¯ori and Pacific develop the disease earlier in life, and more are missed by screening from age 60 than Pa¯keha¯.
In his paper, Auckland DHB’s Snedden acknowledged how controversial prioritising Ma¯ori and Pacific would be — but said the fact our health system is designed to advantage the Pa¯keha¯ majority is also a trade-off, but one most people aren’t aware of.
“Our data shows Ma¯ori and Pasifika patients take longer to move from referral to listing for procedure and often have to present multiple times. . . we want our clinical assessment process to be intrinsically evidence-based and fair to our population within the resources available. But it hasn’t been, and we can’t avoid that.”
Most board members supported the change, but it was opposed by Ian Ward and Doug Armstrong, with the latter saying he supported initiatives like the AAA screening but “racebased” prioritisation of electives “is just anathema to me”.
Snedden agreed to Armstrong’s suggestion for him to refine the paper, and bring it back for more discussion (the next board meeting is July 1).
The issue has now turned political. Act Party leader David Seymour has been most outspoken, issuing a press release accusing DHBs of policies that “risk fuelling an election campaign of racial bickering”.
“How do you define Ma¯ori and Pasifika? What weight do DHBs place on race? Are they going to make sure every Ma¯ori and Pasifika person is treated before anyone else?” the Epsom MP asked.
“Any doctor can tell you that people of different ethnic backgrounds have far more in common than anything dividing them. We should treat all humans equally because it is our common humanity that unites us. Racial profiling can only divide.”
National is also opposed. Dr Shane Reti, the party’s Associate Health spokesman and MP for Whanga¯rei, where he worked as a GP before politics, said resources should be distributed based on need. Ma¯ori often had the highest need, and so services aimed at the most needy would help them too, he said. Inequalities also existed around age, gender, level of deprivation and geography.
“The reassuring part is if we look, for example, at life expectancy of Ma¯ori, non-Ma¯ori, the gap has started to narrow. . . but this is a long project over time.”
Reti has used annual reviews of DHBs by Parliament’s health committee to get data that shows how differently Ma¯ori can be treated. One example: Hawke’s Bay DHB confirmed an average of $181 pharmaceutical dollars spent on Ma¯ori in 2018/19, compared to $279 for nonMa¯ori.
“I don’t claim to be finding anything new. But I do claim to be getting contemporary evidence. . . and the fact I’m watching gives DHBs reason — I hope — to make sure they’re attending to it.”
Dr David Tipene-Leach, chair of Te Ora, the Ma¯ori Medical Practitioners Association, said using ethnicity to help prioritise patients was justified given “terrible” health inequities. Factoring in deprivation could make the reforms more palatable to some New Zealanders.
“People who live in decile 9, 10 communities [the most socioeconomically deprived] also have inequitable health outcomes. There is this aphorism in the Ma¯ori health field — if you get it right for Ma¯ori, you get it right for everybody.”
Health Minister David Clark said he’d made it clear to DHB chairs that improving equity was a priority for the Government, but decisions about prioritisation were for clinicians.
“I’m encouraged by the good work many DHBs are doing on this. Improved access to primary care drives better access to more advanced care and services and can reduce the need for hospitalisation.”
Who gets the ICU bed?
How to decide who gets treated first was a problem that became urgent when Covid-19 cases here climbed as hospitals in countries like Italy were overwhelmed, and intensive care beds given to those judged to have a reasonable chance of survival.
Kiwi intensivists saw the coming wave and began work with University of Otago academics on software to help decide who would get an ICU bed, if there weren’t enough for Covid patients.
For almost 20 years the “1000minds” software has been used to prioritise elective surgery, from cataract removal to hip replacement.
It works by first presenting patient vignettes to clinicians. In deciding who should be treated next, a set of criteria is worked out, and then weighted according to importance. This information is used by the software to create a score for real-life patients.
That score would then help a group of doctors decide who should get a bed, when there aren’t enough to go around (it would only be used for Covid-19 patients, and would aid, not make, the decision).
The sort of factors that would help score Covid patients included extremes of weight, age and chronic disease.
Ma¯ori and Pacific New Zealanders
I was worried I wasn’t going to last another night, another day. I stopped the gym, I stopped the walk — I stopped everything.
Paumea Ferris
suffer worse rates of chronic disease, obesity and other measures of poor health. Ensuring they weren’t therefore more likely to miss out was a focus of a working group that included an ethicist, a senior Ma¯ori advocate and Ma¯ori clinicians.
“As we decided the criteria for triage weighting it was obvious that some would disproportionately affect certain ethnicities, even though they were valid considerations as they directly affect survival chances,” said Dr Andrew Stapleton of the Australian and NZ Intensive Care Society.
“In partnership with our Ma¯ori advocate we therefore attempted to reduce the impact of individual factors within the tool: for example, not adding weighting for things like smoking or obesity unless they were at very high levels.”
Other mitigation efforts included adding “functional capacity” — meaning if someone is overweight but physically fit then the software takes that into consideration.
It was thought there were only two to three weeks before the Covid tool might be used, but since that likelihood has receded the consultation has been extended to include iwi, and the work is now with the Ministry of Health before sign-off.
Beating back Covid created another challenge; nationwide, about 153,000 surgeries and procedures, scans and specialist appointments need to be done to catch up from the lockdown disruption.
Snedden of Auckland DHB said the “big bang” opportunity to reset services after Covid-19 could start with prioritising certain patients for surgeries, but that wasn’t nearly enough. A new partnership with iwi had seen the greater Auckland DHBs delegate a big chunk of work (and funding) to Ma¯ori and Pacific communities
and health providers.
“DHBs have never before had this level of support on the ground and data,” Snedden, a former chief Crown negotiator in the Office of Treaty Settlements and chief executive of the Manaiakalani Education Trust, wrote in his paper. “We have found a new way of working. This is the enlargement of equity in action.”
Some of that action centred on a Covid testing station at the main Otara shopping centre and beside the SouthSeas health clinic, which has 10,000 patients, about 94 per cent of whom are Pacific and 3 per cent
Ma¯ori. The site was set up four weeks after others and only after lobbying from Pacific health leaders and organisations. Nearly 6000 people have been tested, and food parcels have also given out. It will run until the end of the month, with pressure on to keep it open through winter.
“We have a good Pacific group that are willing to work; they’ll just go in and deal with what they have, even without resources,” said Dr Maryann Heather, a GP at SouthSeas and senior lecturer of Pacific Health at the University of Auckland.
“I think you have to put more trust in your communities.”
Heather knows some people see the elective prioritisation changes as favouritism, but what she sees every day means she supports it.
“Our diabetes hasn’t changed in 10 years in Counties Manukau, stroke rates haven’t got any better. . .we really, really struggle to try and get [patients] into the system.
“People come in here in tears — they’re frustrated and don’t know why they got bumped off after waiting so long for cataract surgery; they don’t know why they can’t get bariatric surgery.”
Tens of millions of dollars are currently spent on treating late-stage complications like diabetes-related eye problems, amputations and dialysis. Intervening earlier could save the country money, Heather said.
“People are dying earlier than they should, and they are getting diseases earlier than everyone else in the population is getting them.”
‘Did not attend’ rates plummet
Bay of Plenty DHB’s chief operating officer Pete Chandler said it would increase surgery volumes for all patients, and was “exploring the appropriateness of prioritising selection of Ma¯ori patients for surgical treatment in some specialties in relation to our backlog recovery approach”. Data work was being done to find what areas had obvious disparities.
“One thing we have found is that of all our patients waiting longer than the fourmonth standard for surgery, a higher proportion of these patients are Ma¯ori and so this is something we want to put right,” Chandler said.
Some DHBs that aren’t considering adding ethnicity to the prioritisation process permanently have promised other steps. Waikato will identify Ma¯ori and Pacific patients whose treatment was delayed by Covid-19 and “ensure they are actively managed to move through the waiting list according to their acuity”. New referrals will be “streamlined”.
Health boards found the move to online appointments during lockdown slashed “did not attend” rates, which had been a stubborn problem, partly because of the cost of transport and finding childcare.
At Auckland DHB, DNA rates fell from 9 per cent to 3.9 per cent for Pacific, for example, and from 8.6 per cent to 3.9 per cent for Ma¯ori.
Waitemata¯ DHB — which says prioritising Ma¯ori and Pacific surgical patients “has not yet been considered” — will expand on work during Covid that saw mobile services reach people in their homes, marae and community. That would help boost primary care.
“Ma¯ori in the Waitemata¯ district
‘I’m just so grateful’
are more likely to suffer from gout than non-Ma¯ori but are less likely to regularly receive urate-lowering drugs.
“This is an example of an area where improved access to primary care could assist those who are missing out,” a spokesman said.
Ferris, who is Nga¯ti Porou, said the debate was a tricky one, but he supported anything that would improve access to healthcare.
He spoke to the Weekend Herald to raise awareness of abdominal aortic aneurysm.
The project that screened him tested 2500 others and found Ma¯ori are twice as likely to have an AAA as non-Ma¯ori. There are plans to widen screening to Pacific patients.
This month Ferris will turn 69, a year younger than his father was when he passed away. That’s something he’s thought about.
“Everyone from the sonographer through to the doctors and the nurses, they are all fantastic people.
“When this happened my daughter and my daughter-in-law were pregnant. . . I’m here, and I’m just so grateful. And I hope this can be done for many others.”
Our diabetes hasn’t changed in 10 years in Counties Manukau, stroke rates haven’t got any better. . . we really, really struggle to try and get [patients] into the system.
Maryann Heather, GP at SouthSeas