Auckland DHB members have debated prioritising Māori and Pacific patients for some elective surgeries after chairman Pat Snedden said disruption from Covid-19 represents a "Big Bang" opportunity to reset an unfair health system.
"Our current system privileges some groups already. Māori 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," Snedden wrote in an extraordinary document put to the board today.
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The release of the document and discussion at today's meeting comes after the Weekend Herald revealed the talks around prioritising of Māori and Pacific patients for some non-urgent procedures.
A number of studies and reports show Māori 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 DHB's own data shows Māori and Pacific patients take longer after referral to have a procedure confirmed.
People accepted for specialist treatment are often given a priority ranking. For example, priority one patients 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.
"Suppose we began our new approach with a special focus on referred patients who are Māori and Pasifika with ethnic specific interventions where the judgment of our clinicians supports this making a difference?" Snedden wrote in his paper to the board.
"What if we decided that over a 12-month test period we would seek to make the clinical pathway to treatment more visible, faster and more supported for these citizens by intervening early to improve their life course outcomes?
"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."
Snedden is aware of how controversial prioritising some groups of patients would be - but said the fact our health system is designed to advantage the Pākehā majority is also a trade-off, but one most people aren't aware of.
"Making a trade-off in another direction explicit is important, and this is where the discomfort lies. Framing it as a zero-sum game however makes it unnecessarily a binary situation," he wrote. "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 to address known inequities and improve outcomes."
Snedden told a Zoom meeting of the board today that if adopted, the paper aimed to act as an early point for discussion, and to ultimately give backing to the DHB executive team as they worked through possible changes.
"We have to be brave. The point of laying this out is to give a sense that this isn't reckless, but a mature approach to addressing issues that we all know exist."
The paper had broad support, including from members Michelle Atkinson, Zoe Brownlie, Michael Quirke and Bernie O'Donnell. However, members Doug Armstrong and Ian Ward said they didn't support prioritising treatment based on ethnicity.
"I absolutely, completely disagree with having a prioritisation system into electives, or indeed anything that we do that is race-based. That is just anathema to me," Armstrong told the meeting.
"I am all for clinicians adopting a more holistic view when they do prioritise people [and] we can advance things by support. The majority of the national population would not support any racial-based prioritisation for elective surgery, or indeed any of the health provision that we make."
Snedden said he wanted full board support and agreed to Armstrong's suggestion for him to refine the paper, and bring it back to another meeting in two weeks.
The equity work can be linked to a Waitangi Tribunal claim that found multiple Treaty breaches and a decades-long failure by the Crown to change health services to stop Māori disadvantage. The Crown acknowledged no real improvement in 20 years.
The tribunal's urgent recommendations included an investigation into the underfunding of Māori health providers, and Māori health leaders have long called for funding and responsibility for services to be taken from "mainstream" organisations like DHBs and be led by Māori.
A big step in that direction came when Waikato, Counties Manukau, Auckland, Waitematā and Northland DHBs set-up a Northern Iwi/DHB Partnership Board, signed off by Health Minister David Clark in March.
The northern region DHBs have delegated a big chunk of work and powers to the new entity, including overseeing resource allocation and investments made "for the purpose of achieving Māori health outcomes and advancing Māori wellbeing".
An early example is a regional incident management team set up by DHBs to respond to the Covid-19 pandemic. It met the iwi partnership board and approved funding to Māori health providers.
That allowed Māori communities to make decisions about health services, Snedden noted in his paper.
"The effect has been to reduce the risk of infection for Māori to levels at or below the levels achieved for all other communities and to have some of the highest testing rates. This has never previously occurred.
"DHBs have never before had this level of support on the ground and data about the Māori populations. The net outcome has been a significant public health safety net supported by Māori interests to protect their people. We have found a new way of working. This is the enlargement of equity in action."
A similar "ethnic specific" way of working with Pacific communities had also been exceptionally successful, Snedden said, and allowing appointments to be done online had slashed the "did not attend" rates, which had been a stubborn problem, partly because of the cost of transport and finding childcare.
Those results raised expectations for lessons learned in the midst of a pandemic to be used more permanently and widely.
"Within six weeks we have discovered in real time and under extreme pressure the power of a regional, delegated iwi/DHB decision-making model."
Snedden said the "Big Bang" reset of services after Covid-19 could start with prioritising certain patients for surgeries, but that wasn't nearly enough.
"We know that there are elective surgical inequities and they need to be managed but this area of disadvantage is small compared to the magnitude of inequities generated by the social determinants of health, barriers to primary care access, later diagnosis, attrition across clinical pathways and necessary comorbidity management. These latter areas have got to be our focus, but the surgical wait list issues can be the leverage for the real action on these."
Nationwide about 153,000 surgeries and procedures, radiology scans and specialist appointments need to be done to catch up from the Covid-19 disruption - a backlog DHBs aim to clear in 18 months.
The northern region DHBs are at different stages of looking at how prioritising patients might work, and solutions might vary.
Dr Rawiri McKree Jansen, co-leader of Te Rōpū Whakakaupapa Urutā, a national pandemic group formed by Māori medical and health experts, told the Herald it was the perfect time for DHBs to "share power and authentically partner with Māori".
"Taking an evidence-based approach to the resumption of services is necessary, and wherever required, Māori access to diagnosis and treatment prioritised to ensure that the backlog of treatment does not see Māori at the bottom of the list."
Snedden is a former chief Crown negotiator in the Office of Treaty Settlements and is chief executive of the Manaiakalani Education Trust, which works with low decile schools in Tāmaki.
He was awarded the NZ Order of Merit for services to education and Māori and under his leadership Auckland DHB has led efforts to address inequity, including fast-tracking eligible Māori and Pacific job candidates to the interview stage, and identifying institutional racism as a major reason for poor Māori health.
Last year a landmark report by the Health Quality & Safety Commission challenged health services to stamp out institutional racism it says severely harms and kills Māori.
Its review gave a range of examples, including that specialist appointments have unacceptably long wait times and happen less often for Māori, who were also less likely to get certain treatment soon after admission. Pacific and Māori patients consistently rate the communication with hospital staff and doctors lower than other groups.
A special edition of the NZ Medical Journal recently highlighted the fact half of Māori and Pacific deaths in New Zealand are potentially avoidable, compared to 23 per cent for non-Māori and non-Pacific people - saying this was a "travesty and a lost opportunity within families, communities and Aotearoa".