A Health Care Perspective from Raukura Hauora O Tainui

• Raukura Hauora O Tainui – The Organisation
• Roles of Raukura Hauora O Tainui
• Health Area Priorities
• Relationships with Other Health Care Providers
• Moves Towards Managed / Integrated Care
• Integration of Maori Services Alongside Mainstream Services
• Main Barriers to Provision of Best Care
• The Impact of the Transitional Health Authority (THA) on Maori Health
• Maori Involvement in Coalition Health Policy
• Maori Health Commission
• The Role of Research Groups in Provision of Maori Health Care Services
• Success Stories
• Summary
  

Raukura Hauora O Tainui – The Organisation

The conception of Raukura Hauora O Tainui aims extends as far back as the 1930s, a period of high Maori mortality, when Princess Te Puea was instrumental in the construction of a hospital for Maori. The facility, Mahinarangi House, was, however, declared by the authorities of the day to be unsuitable for delivery of health services. It now occupies a central part of the Turangawaewae marae. The efforts of Princess Te Puea have been a driving force behind the organisation.

The next major step in health development occurred in 1983 when community health workers were established at Waahi marae. This was built on the concept of the "barefoot doctor", based on the Chinese approach involving a hierarchy of health practitioners including "barefoot doctors" working at grass roots level.

In 1991, Raukura opened its first primary medical clinic. The organisation has now grown to 42 people employing medical practitioners, nurses, community workers, and alcohol and drug service personnel.

The focus at Raukura Hauora O Tainui has been to move away from an institutionalised style of care and to a system bringing services to people in their own setting, for example through the clinics at Te Puea, Waahi and Raungaiti marae.

The clinics offer primary care services on an ongoing basis but over the last four years have sought to provide some specialist services by bringing various specialists on-site. This approach was prompted by a survey some years ago which showed that approximately one-half of referrals to Waikato Hospital were reaching the hospital system.

Paediatrics is a speciality area which has been delivered successfully in this way using a community paediatrician from Waikato Hospital. The emphasis is now on identifying other services for which there is a particular need and where skills can be brought to the people in a similar fashion.

Roles of Raukura Hauora O Tainui

A number of roles for Raukura Hauora O Tainui can be identified:

• direct provision of health services
• advocacy - provided on behalf of consumers
• innovation - one of the aims of Raukura Hauora O Tainui is to help to model Maori health frameworks at all levels, both policy and implementation
• traditional corporate functions
• identification of opportunities to enter into collaborative competent exchanges with other providers and to develop appropriate relationships for successful partnerships
• provision of objectives and direction for the delivery of care to those people registered with Raukura’s services.

Further, as a well established health care provider, Raukura Hauora O Tainui fulfils an important advisory role for other Maori providers. The group makes itself easily accessible to others; between 1993 and1995, it received 160 delegations, 75% of which were Maori groups. Raukura Hauora O Tainui has advised a large percentage of the Maori provider groups in the central North Island on a wide range of issues from processes involved in contracting general practitioner (GP) services, through to appropriate provider structures and business planning.

Other key Maori provider groups also play something of this advisory role. They include the Te Whanau O Waipareira Trust, Te Hau Ora O Te Tai Tokerau, Te Oranganui, Poutiri Rangiorapapa, and the Healthcare Aoteoroa group. The latter group is essentially a provider forum including a large number of the major Maori providers.

Health Area Priorities

Raukura Hauora O Tainui has identified the following nine health priority areas:

• diabetes
• skin diseases
• asthma
• mental health
• smoking
• alcohol and drugs
• glue ear
• hypertension
• child health.

Child health is a priority. Children under six years have received free care through Raukura Hauora O Tainui, independently of the recent introduction of free care nationally.

The focus on child health is grounded in the principle that a well child has more potential to be educated. In turn, a well educated child has greater opportunity for employment, and an employed individual has a greater opportunity to contribute to the development of the economy and, thus, to the overall well-being of the country.

Health issues for Maori are symptomatic of bigger issues for Maori and making gains in health will not necessarily improve the lot of Maori. There needs to be concerted developments on several fronts including education and employment, and health in the context of Maori development per se.

Relationships with Other Health Care Providers

Raukura Hauora O Tainui maintains relationships with a range of different providers.

The focus of relationships with providers has tended to be on primary support services. This emphasis has been on determining which support services Tainui clients need to access and who is in the best position to provide these services, based on expertise, facilities, etc. This has resulted in a number of relationships with crown health enterprises (CHEs) and other primary providers.

A strong strategic alliance with South Auckland Health focusses on identifying opportunities to collaborate and co-operate.

An alliance with community health services at Health Waikato allows both parties to combine their strengths to deliver services to local Maori communities, whether as marae-based services, services in community centres, entry into Kohanga Reo or Kura Kaupapa, or through other arrangements.

An example of this relationship is the provision of co-ordinated services into Rakaumanga Kura in Huntley West. Prior to this, the school could have had five to six different health professionals from different organisations entering it with no co-ordination of effort. Visiting professionals included public health nurses, Maori community health nurses, and representatives for mental health services, hearing testing services, etc. Teams have now been set up to provide a co-ordinated comprehensive programme.

Other key relationships are with selected chemists and laboratories who have agreed to work with Raukura Hauora O Tainui in a way that improves access for clients.

Moves Towards Managed / Integrated Care

There is a major move nationally towards developing managed or integrated care. Managed care comprises a number of different concepts. But largely, it is based on a variety of relationships, between purchaser and provider, between provider and consumer, and between providers.

The national focus tends to be on the relationship between funder and provider, emphasising budget-holding and cost management in provision of health services. The focus of Raukura Hauora O Tainui is on the consumer. With this perspective, relationships between different providers become extremely important.

Managed care is included within the strategic goals of Raukura but is not a high priority. Primary medical services currently provided are funded under the GMS, and Raukura Hauora O Tainui is not convinced that the current formulas for budget-holding provide adequate allowance for the risk associated with high risk clients.

The creation of positive relationships with other providers is seen as a more relevant area for attention than a move directly to budget-holding.

Integration of Maori Services Alongside Mainstream Services

There is a need for both Maori-for-Maori services and culturally safe mainstream services in order to provide choice for consumers. Thirtyfive thousand people used Raukura Hauora O Tainui clinics in 1996 simply because they exercised a choice which had not been previously available.

In many situations it is acceptable that similar services are provided in both mainstream and Maori-for-Maori settings. For example, traditional national plunket services sit alongside Tipu Ora national Maori child health services. There might be some duplication of costs, overhead structures and service delivery but this is not regarded as significant.

Raukura Hauora O Tainui focusses on individual preferences, allowing people to exercise their choice to be a consumer of Raukura Hauora O Tainui services and choose which of those services they wish to use.

Main Barriers to Provision of Best Care

A number of issues have been identified as barriers to provision of best care for Maori. Workforce issues relating to numbers of skilled workers available are an ongoing problem.

• The Vision 2020 bridging proposal at the Auckland Medical School which seeks to accelerate the increase in numbers of Maori qualified in medicine and allied health professions.
• Raukura Hauora O Tainui has been able to build a skill level in community health workers, matching workers to the functions they are able to perform. It is important that, while workers are not pushed beyond their capabilities, they still get an opportunity to expand their skills.
• A further barrier to progress in the development of Maori health services is the limited appropriate business skills available to support Maori health providers. Sound business skills and good information systems are needed for the management and delivery of services.
• Short term contracts of 12 – 15 months make it difficult for all provider groups, Maori and mainstream, to undertake those activities that deliver long term benefits and are an important element in provision of best care. Raukura Hauora O Tainui takes a medium to long term view in planning where possible and this is evidenced in a strong focus on preventive care.

Other barriers which have been identified include:

• institutional attitudes in the health system
• entrenched attitudes to "for Maori-by-Maori" services
• a focus on "culturally appropriate" services which are not easily defined; the preferred focus is on a "safe" service which Maori are able to enjoy using.

The Impact of the Transitional Health Authority (THA) on Maori Health

At this stage, the move to centralised funding is being viewed cautiously. The shift is seen as further change and there are difficulties inherent in this. The jury is still out on issues like advantages of a national versus a regional framework.

Community representation and a strong Maori voice are seen as important requirements.

There are possible positive outcomes of centralised purchasing including the need for Raukura Hauora O Tainui to deal with only one purchasing body. Raukura Hauora O Tainui is one of a few Maori provider groups outside the larger national providers offering services across regional health authority (RHA) boundaries. Raukura Hauora O Tainui has contracts with both Midland Health and North Health and the two purchasing agencies are very different organisations to deal with, varying in their Treaty principles amongst other things.

Despite some concerns, Raukura Hauora O Tainui aims to view the change in funding/purchasing structure as an opportunity. Most Maori have been supportive of the various changes, including the shift to an RHA structure, since the start of the health reforms under Simon Upton.

At the time of the first round of reforms in 1992, the agenda was not clear. The separation of purchaser and provider and the creation of a market-driven environment in the provision of health services led to some confusion.

The competitive nature of the structure impacted on integration. It created issues with respect to commercially sensitive information which parties were not willing to share. Established relationships had been based on goodwill and trust and the new approach involved recognising that there were some things that each party could not share. For success in an integrated structure, each party must respect the privacy issues of other parties.

However, the impact of competition has shifted over time; the initial mistrust has been replaced and Raukura Hauora O Tainui is now looking at new contracts which involve joint ventures with other providers for projects, particularly in the area of community-based education. Provider groups can compete on some contracts but also agree not to compete on certain contracts.

Maori Involvement in Coalition Health Policy

Maori representation on the Steering Committee on implementing the Coalition Agreement on Health consisted of Wayne McLean and Professor Mason Durie.

Generally Maori have a positive perspective on the health reforms; Maori have always viewed changes as opportunities. Many sectors have taken a more negative view of the changes associated with the health reforms. This highlighted the need to ensure that the gains made in the last three years in Maori health care are maintained.

Maori Health Commission

The new Maori Health Commission has been set up with the goal of making a positive contribution to reducing the disparities between the health status of Maori and non-Maori.

A first role for McLean as Chairman of the Commission for Maori Health will be to develop a pathway outlining how the Maori Health Commission should approach its task.

An early focus will be to identify which services for Maori are successful and why they are successful, and to learn from this experience. Another initial task will be to identify opportunities for working alongside key players in the health system, including the THA, Mental Health Commission, Ministry of Health, National Health Committee and other groups.

The Role of Research Groups in Provision of Maori Health Care Services

The research groups Te Pumanawa Hauora at Massey University and the Eru Pomare Research Centre, Victoria University of Wellington are very important for the development of evidence-based research in Maori Health.

There is some concern that Maori are over-researched in terms of health status and that there is no advantage to continually confirming the disparities between Maori and non-Maori. These centres have made a difference in that they have helped to create a climate where Maori support research in principle and the outcomes of research are used to shape the future for Maori.

The research groups also have a role in commenting on how the health system reforms can become more responsive to Maori health needs.

Success Stories

One of the signs of good progress in Maori health care is the growing number of many new Maori providers. Over 200 providers now contract with the THA for service provision.

Success in Raukura Hauora O Tainui services can be measured in a number of ways but one striking achievement is in response rates in preventive care. In recent evaluations, the cervical screening rate at its Templeview clinic was audited at 87% of all women registered with the clinic who fall within the targeted age bracket, and the immunisation rate at the Te Puea marae clinic was audited at 90% of all children registered with the clinic.

A target area for Raukura Hauora O Tainui clinics has been on various health screens including cervical screening and immunisation, well child checks, well woman checks, etc. These checks are impacting positively on late presentation, which is frequently noted as a problem with Maori clients in mainstream services.

The average visit rate for Maori presenting to a GP in New Zealand is about 2.5 times per annum compared to an average rate in New Zealand of over 4 times per annum, across all ages. A recent goal for Raukura Hauora O Tainui has been to determine how Maori utilisation relates to such items as cost, transport, service location, service delivery, etc. This determination has resulted in Raukura implementing a range of strategies aimed at improving utilisation of services by Maori. One outcome is that the utilisation rate at the Te Puea marae clinic, which has now been operating for two years, is moving closer to the national average.

Summary

Raukura Hauora O Tainui is an enthusiastic organisation with high energy levels. The group is confrontational when necessary although such an approach was required more in the early stages. The organisation is now better established with a credible track record. While it may now be regarded by some as "more reasonable", the passion is still there.

A considerable issue facing the health system, particularly in the CHE environment, is that people are tired of change. In eight years there have been several major changes including shifts from hospital boards to area health boards, the introduction of the funder/provider split, the establishment of CHEs, and the introduction of market-driven principles leading to competition. An ailing health system needs to be given a "human face" again.

Raukura Hauora O Tainui’s values are based around the "human face" and pursued with passion backed by performance.