This morning Newstalk ZB and the Herald revealed Te Whatu Ora - Health NZ has introduced an “Equity Adjustor Score”, which uses an algorithm to prioritise patients according to clinical priority, time spent on the waitlist, geographic location (isolated areas), deprivation level and ethnicity.
In the ethnicity category, Māori and Pacific are top of the list, while European New Zealanders and other ethnicities are lower-ranked.
That’s riled some surgeons, who in anonymous comments to Newstalk ZB slammed the policy as medically indefensible. However, the change has support among others as a vital step to finally reduce health gaps.
How long has this happened?
Using ethnicity to help decide which patients should be prioritised isn’t new - some DHBs did so when working through wait lists that were swollen by Covid-19 disruption.
That change was spearheaded by Auckland DHB, whose former chairman Pat Snedden said the disruption from Covid-19 represented a once-in-a-lifetime 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 a document put to the board in May 2020.
He acknowledged how controversial the step 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.
“Our data shows Māori 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.”
The paper had broad support, but some board members were opposed.
“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,” board member Doug 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.”
Many of the country’s other DHBs investigated or committed to using ethnicity as a factor when prioritising patients, the Herald later revealed, and that change was embedded into the system after DHBs were replaced by Te Whatu Ora, on July 1 last year.
What’s driven the reform
A growing number of studies and reports - including hospitals’ own data analysis - show Māori and Pacific people can be less likely to be referred or accepted for treatment in the first place, and once in the system generally get less treatment.
Health authorities attribute part of the problem to institutional racism, which is a term that describes how procedures or practices result in some groups being disadvantaged.
A landmark report by the Health Quality & Safety Commission (one of the country’s health watchdogs) in 2019 challenged services to stamp out institutional racism that it said severely harms and kills Māori. Its review gave a range of examples, including:
* Specialist appointments have unacceptably long wait times and happen less often for Māori.
* Inappropriate prescribing happens much more often for Māori, and Māori consistently rate the communication with hospital staff and doctors lower than other groups.
* The percentage of Māori getting an operation for a hip fracture on the day of or after admission steadily decreased since 2013, whereas the percentage for non-Māori steadily improved.
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 Māori.”
Other research includes a 2019 study that found about half of Māori and Pacific deaths are potentially avoidable, compared to 23 per cent for non-Māori and non-Pacific.
Those findings prompted an extraordinary editorial from the NZ Medical Journal, which said they should be on the computer screensavers of all planning staff in health organisations.
“The 7.0-7.4 year shortened life expectancy for Māori and 5.9-6.0 year for Pacific is a travesty and a lost opportunity within families, communities and Aotearoa,” the editorial authors said.
The Herald has reported on numerous other examples where Māori and Pacific suffer worse health outcomes, including in maternity and diabetes care. For example, researchers have found Māori are at much greater risk of losing a leg to diabetes, even after factors such as deprivation are taken into account.
Controversy grows along with wait lists
National and the Act Party are opposed to prioritisation by ethnicity, and spoke out against the changes when they were first made by DHBs.
However, the issue is now back in the headlines, in election year and amid community concern about worsening hospital delays.
Backlogs have hit record lengths, with over 90,000 people overdue for treatment or a specialist appointment.
The current position of health officials is that while improvements could happen earlier, dramatic reductions in wait list times won’t occur until “at least” 2025.
The situation has deteriorated since in May last year then-Health Minister Andrew Little announced a “high-powered” planned care taskforce, which delivered a report outlining how backlogs could be cleared.
The report - which was accepted by the Government - supported Te Whatu Ora’s approach that “once high clinical priority cases have been addressed, priority must be given to excessively long-waiting patients, with emphasis on the longest waiting Māori and Pacific patients.”
The taskforce found data that showed a disproportionate number of Māori and Pacific patients “waiting excessively long” for imaging scans (used to check for serious conditions including cancer) in some regions.
Another example: Māori and Pacific children suffered the most because current capacity in the paediatric oral health service can’t match demand, including for dentistry requiring sedation or general anaesthetic.
“There are numerous examples of inequities in many planned care services,” the taskforce concluded. “Initiatives must be put in place to resolve this.”
Another factor in what treatment somebody gets can be their address - so-called “postcode healthcare lottery”, where thresholds for treatment and surgeries can vary greatly by region.
For example, an ongoing Herald investigation has exposed how Southlanders are declined life-changing cataract surgery, which they would easily qualify for if they lived in greater Auckland or other regions.
This month Health Minister Dr Ayesha Verrall announced new groups of expert clinicians would be formed, and tasked with identifying regional variations, and then recommending how these can be reduced and eliminated.
The groups, called national clinical networks, would help bring in national standards of care, Verrall said, and would also be expected to close equity gaps, including by ethnicity.
In response, Act Party leader David Seymour said if Labour wanted to eliminate inequities “it would also get rid of the racial lottery, where patients face unfair differences in access to treatment based on their ethnicity.
“That means a needy patient can miss out due to their race, and a less needy patient can overtake them,” Seymour said.
“Pharmac [also] uses ethnicity criteria for some medicines and they’ve adopted a lower age threshold for Māori and Pasifika to get the flu vaccine.
“Labour’s changed the way GPs are subsidised to mean Māori and Pacific patients receive a larger subsidy than other people. Universities are using Māori and Pasifika quotas to allocate limited places in medical schools.”
National vows to scrap scheme
Te Whatu Ora Auckland interim district lead Dr Mike Shepherd this morning told Newstalk ZB’s Mike Hosking that Māori and Pacific patients might get perhaps one or two extra points out of about 100 because of their ethnicity. Clinical need was the main driver of a patient’s score, he said.
“Our people want to get out of bed every day and ensure that all of our population is getting the best health care possible and this is the part of that solution,” Shepherd said.
However, Seymour continued his attack on the policy, saying the other factors taken into account - clinical priority, time waiting, geographic location (isolated areas), and deprivation level - should be sufficient.
“The only possible effect of racial discrimination is to make sure a person in greater need waits longer for an operation and may die on a waiting list because they had the wrong ancestors,” Seymour said.
“A person who is in great clinical need, has waited a long time, lives far from major medical facilities, and is poor could be Māori, European, Pacific, Indian or Chinese, and they should all be treated equally.”
National health spokesperson Dr Shane Reti also reiterated his party’s opposition, saying prioritisation by ethnicity “is offensive, wrong and should halt immediately.
“The way to improve Māori and Pasifika health is through better housing, education and addressing the cost of living, not by disadvantaging others.”
That opposition was foreseen by Dr David Tipene-Leach, chair of Te Ora, the Māori Medical Practitioners Association.
In 2020 he told the Herald that using ethnicity to help prioritise patients was justified given “terrible” health inequities, but factoring in deprivation could make the reforms more palatable to some New Zealanders.
“People who live in decile 9, 10 communities [the most socio-economically deprived] also have inequitable health outcomes. There is this aphorism in the Māori health field - if you get it right for Māori, you get it right for everybody.”
Nicholas Jones is an investigative reporter at the New Zealand Herald. He won the best individual investigation and best social issues reporter categories at the 2023 Voyager Media Awards.