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- Introduction
- Barriers to Provision of Best Care for Maori
- Areas of Successful Progress in Maori Health
- Priority Areas in Maori Health
- Maori for Maori Services Alongside Culturally Safe Mainstream Services
- Integration of Services
- Key Working Relationships for the Crown Health Enterprise
- Transitional Health Authority
- The Role of Research Groups in Provision of Maori Health Care Services
Introduction
The strategic outlook from the time that South Auckland Health became a crown health enterprise (CHE) was to provide effective and appropriate services within the purchasers’ contractual requirements.
But there has been a very recent fundamental change in the CHE’s strategic direction. Now the CHE aims to contribute to community health by shifting the strategic focus from simple contract fulfilment to working with the purchaser to effectively identify health needs. The community served by South Auckland Health is the fastest growing in New Zealand and is extremely diverse, both economically and ethnically.
A further strategic aim is to work to improve effectiveness with available resources.
Barriers to Provision of Best Care for Maori
Short Term Focus
The goal when the Regional Health Authorities (RHAs) were first established was to match Maori health status to that of other New Zealanders. The intention was that after this goal was achieved, Maori health could begin targeting special areas. The major reason for lack of success has been short term focus in the RHAs and limited budgets.
Output Oriented Purchasing
Output oriented purchasing which fails to acknowledge additional funding requirements for minority ethnic groups is a further barrier to best care for Maori.
The CHE is dictated to by purchaser requirements. Purchasing is highly output oriented, relating to numbers of admissions and procedures.
As a result, the CHE’s contribution to improving or making a difference to Maori health statistics is dictated in a lot of respects by purchaser demands. Maori or Pacific Island people are not assigned a specific number of procedures. The CHE must meet a raw number demand with no use of priority weighting.
Purchasers’ demands do not reflect Maori needs at all well but there are areas within the purchasing agencies that are trying very hard to do this.
The barrier for the purchasers lies in Treasury-driven formulas. Formulas are based on a clinical case-mix; Treasury are seeking clinical outputs, for example a certain number of hip replacements, with numbers calculated on population-based funding.
Funding to the CHE reflects the percentage of the total population in CHE region. Unless the minority ethnic population percentages are higher than the national average for the whole RHA region, no additional funding for ethnic minorities is available from Treasury. South Auckland and the far north have the highest per capita Maori population in New Zealand. But the percentage of Maori in the population of the entire North Health Region is within the national average. As a result, Treasury funding reflects no special weighting for Maori in these areas.
The percentage of Pacific Island people in the North Health Region is above the national average and, therefore, there is a slightly higher weighting but the amount is questionable.
Additional funding is required for these Maori and Pacific Island groups as they are below the national average in health and they have support requirements relating to language and social needs. Diagnostic and clinical support time spent on these patients is higher than the national average because of these contributing factors. But the South Auckland CHE, which has the highest per capita numbers of every ethnic group in New Zealand, receives no more funding than, for example, Timaru Hospital which deals with few minority group patients.
The Transitional Health Authority (THA) divisions are very much aware of the problem and fight for further funding but the ongoing problem rests in Treasury-driven formulas.
Ministry of Health and Treasury Control
A further barrier to best care for Maori lies with the Ministry of Health infrastructure and an apparent inability to deal with the real issues. Wikaira believes that projects must involve the right Treasury input. "At the end of the day, the Treasurer has the last say. The Ministry of Health needs to speak the language of the Treasurer because the Treasurer holds the power."
The Ministry of Maori Development/Te Puni Kokiri assists by advising on how submissions for funding should be put together and plays an important role because it has the opportunity to "learn Treasury language."
Maori health is still not given a high enough priority. Paper policy is not adequately translated into reality; there is always reversion back to clinical outputs and short term strategies.
Shortage of Maori Health Professionals
A shortage of Maori health professionals is yet another barrier to improvements in Maori health. In 1991 only 2.7% of registered nurses and 0.7% of registered medical practitioners in New Zealand identified themselves as Maori.
South Auckland Health is a strong supporter of the Auckland Medical School Vision 2020 project which aims to increase numbers of Maori doctors and associated health professionals.
The proposal involves a preparation course to provide the skills and experience needed to study at undergraduate level. Participants then go on to the Auckland Medical School or into allied health fields such as physiotherapy, radiography, etc. The proposal is based on information from abroad where the health status of ethnic minorities has increased by increasing the numbers of their health professionals. The approach has been proven to work in North America and elsewhere.
Vision 2020 is an example of a long term strategy with a finite endpoint to encourage numbers of medically qualified Maori to reach such a "critical mass."
Maori have mentors in law and numbers of Maori qualified in law are beyond what could be regarded as the ideal "critical mass". The availability of Maori lawyers has impacted in a number of areas, for example in Treaty negotiations, and the number of Maori lawyers is likely to stay high because the role models are there and the momentum exists to maintain that number.
The aim of the Vision 2020 project is to create the same momentum in the training of Maori health professionals.
With appropriate progress, the Maori health industry should ultimately disappear; over the next ten to twenty years Maori health managerial positions should not exist because there should not be issues specifically associated with Maori health.
Areas of Successful Progress in Maori Health
An example of success at an operational level is the Te Whanau Atawhai support group for Maori which was started at Auckland Hospital. Wikaira was brought to South Auckland to initiate the same programme. All Maori patients are identified through admission lists. They are visited within 12 hours of admission by someone from the unit who determines their needs, completes a cultural assessment and relates as a key worker to the management of that patient’s stay up to and beyond discharge.
Success at a managerial level at the South Auckland CHE can be seen in the extent of Maori involvement at board level.
One Maori representative sits on the Board of Directors and three Maori sit on the Clinical Board which has 12 members including Rea Wikaira, Professor Colin Mantell and Dr Wendy Walker, Clinical Director of Paediatrics. No other CHE has that level of Maori involvement.
Further, Wikaira reports to the Chief Executive at South Auckland Health. Managers of Maori health who report to middle management are regarded as filling no more than a token role, the reporting structure reflecting the amount of attention being paid to Maori health issues.
A common feature of all working initiatives at South Auckland Health is that Maori are genuinely involved and are genuinely supported.
Support for Maori issues in the South Auckland CHE comes from the Board of Directors, the Chief Executive and the executive management. Maori are represented at a managerial level and the support and willingness to work towards improved care for Maori is there, is authentic and is ongoing.
Support at a strategic level means that differences can be made throughout the whole organisation in the area of policy development and service delivery. For example, a strategic alliance has been in place for around 18 months with Raukura Hauora o Tainui to exchange information and look for joint or separate opportunities.
One joint opportunity that has been trialled for around nine months is a primary care service operated by Raukura Hauora o Tainui alongside the A&E service at Middlemore Hospital. The service can take the overflow of emergencies which can be appropriately dealt with at a primary care level. People are offered the option to use the service in lieu of waiting for A&E services and some clients will now go directly to the Tainui service.
Raukura Hauora o Tainui carry the risk for the clinic; client fees are charged although some clients claim they cannot pay. The service is currently funded through GMS although there are efforts underway to pressure North Health to fund the service more appropriately, for example through a budget-holding arrangement.
The service has been extremely useful, particularly with the current bed shortage crisis. It provides the A&E department with an option which otherwise would not be available.
At this stage it is unclear whether the service will continue; more trial work is required. Eventually a move off-site is likely but the current arrangement will continue while significant numbers of people continue to present at the hospital.
A further aim of the primary care service was to create a shift in thinking from attending an A&E clinic to attending a primary care unit when appropriate. There are a number of reasons why people access an emergency department as a first point for care. One is an economic issue; people haven’t enough money or perceive that they haven’t enough money to go to a general practitioner (GP). There are also cultural perception issues. For example, Pacific Island people traditionally do not have GP services and will attend a hospital for any illness when in the Pacific Islands. People from some other ethnic groups approach a hospital for care as they perceive this to be appropriate when outside their own country.
In the longer term, South Auckland Health aims to have more strategically placed access points for people.
Priority Areas in Maori Health
Diabetes sits out head and shoulders above anything else as the priority area. Diabetes-related illness is a primary area of focus and concern. Fifty percent of Maori and Pacific Island medical admissions have a diabetes basis including late-presentation peripheral disorders, ischaemic heart disease, respiratory conditions, and circulatory conditions compounded by smoking and dietary issues.
There has been good progress in this research area through work with the Auckland Medical School and the South Auckland Diabetes project.
Other priority areas include child health generally and certain specific areas in child health such as asthma, respiratory disease, communicable disease, etc. Concern relates to high acute presentation with these conditions.
Advances have been made with asthma because of technology and improved medications but these need to continue.
Communicable diseases, for example meningococcal diseases and rheumatic fever, will be an ongoing issue with Maori where contributing factors such as living in extended groups and lower socio-economic conditions are common. Rheumatic fever accounts for 35% of paediatric admissions at South Auckland Health.
Maori for Maori Services Alongside Culturally Safe Mainstream Services
Not all Maori will access Maori for Maori services so there is a need for both Maori for Maori services and culturally safe, skilled mainstream services.
The main issues for a CHE providing culturally safe services are in providing:
- appropriate access at an appropriate time, ie before late presentation
- a skilled clinical work force and support expertise.
The clinical expertise of staff at South Auckland Health is superb. Support skills will be assisted by a planned cultural skills modular training programme. This is part of a more businesslike approach to patient focus with patient representatives etc, supporting patients and recognising that clinical care makes up only a part of the total care in the hospital. An holistic approach covering diagnostic, clinical, social, spiritual and cultural considerations is a powerful approach whereas a focus on one of these elements separate from the whole has a weaker outcome.
Were there no resource issue, all mainstream services would be mirrored in Maori for Maori services; any lesser service is a compromise from the ideal. The reality of resources’ issues means that complete duplication of services is not possible, particularly in the secondary care area.
Justification of Maori for Maori services at secondary and tertiary care levels would demand close evaluation. At one level, there would need to be a decision as to whether such funds, if available, were better invested in those services or elsewhere, for example in improved primary care services.
Integration of Services
South Auckland Health is currently investigating the option of service integration at the new SuperClinics, opened recently to manage all South Auckland Health day patients and out patients. South Auckland Health is looking to have other health providers co-located on-site at the SuperClinics including pharmacy services, integrated GP clinics, etc. There is an opportunity for Raukura Hauora o Tainui to establish a GP service jointly with other GP providers.
There needs to be a bigger investment in the primary health area for integration of services to work effectively. If primary health issues are addressed, this should lead to down-sizing of secondary care services in 10 to 20 years’ time. Strategic thinking at present should centre around something smaller than a 700-bed hospital, possibly aiming at modular hospitals. SuperClinics are the beginning of such an approach. The focus will be on primary intervention versus initial presentation at institutions, with secondary care centred on disease and trauma management.
South Auckland Health is working with the independent practice associations (IPAs) in developing integrated care projects that will meet the THA’s purchasing strategies.
Key Working Relationships for the Crown Health Enterprise
South Auckland Health has a close relationship with the Manukau City Council. Sir Barry Curtis and the Counties-Manukau Health Council are supportive of CHE activities in the community and this relationship is important to the development of integrated services.
Working with other Maori development groups is the key to success in Maori health but in some cases priorities have been elsewhere. For example, there is an option for activity with the Te Whanau o Waipareira Trust but none is underway at this stage.
The Manukau Urban Maori Authority (MUMA) is the Trust’s equivalent in the CHE region but no real working relationship between the CHE and MUMA has been established. MUMA has a broad area of focus and CHE activity has been a low priority.
Another key priority is to work with regional GPs through ongoing relationships with IPAs. Integration options are being evaluated and the groups are exchanging information which will soon involve electronic data exchange.
Transitional Health Authority
A major issue arising from the centralisation of purchasing in Wellington is the risk of poor knowledge of the local needs throughout the rest of the country.
In Maori health, the RHAs succeeded in achieving what they set out to achieve because they knew their local areas, consulted with the local communities and made decisions based on information, not on hysteria and politics.
The RHAs consulted in the community, formulated a database of that information and analysed it in order to set priorities including provider development, areas for investment, etc. All four RHAs did this well in Maori health and good ground work has been completed in purchasing. The RHAs have developed a critical mass of Maori with skills and expertise. The only downside was that they could have done a lot better with better resources.
It is hoped that this activity will continue with the Transitional Health Authority. There would be considerable concern if key personnel and information disappeared with the RHAs. The shift to centralised purchasing will be acceptable provided it maintains the gains which the RHAs have made.
The shift to a Transitional Health Authority may also make a difference by giving the purchasers more direct access to the corridors of power to vocalise issues, for example around Treasury formulas (see above). There is cautious optimism that the situation will improve as a result provided that local representatives on the Transitional Health Authority board will fight for local issues.
The Role of Research Groups in Provision of Maori Health Care Services
Health research centres provide good strategic information which has some applicability at a strategic level but no real application on a day to day basis.
South Auckland Health’s involvement in research into Maori health is mainly in conjunction with the Auckland Medical School. South Auckland is focussed on short, medium and long term research which will have an effect in South Auckland. Research needs to be specific to the South Auckland area as the population mix is totally different to anywhere else.
South Auckland Health is very supportive of tangible projects like Vision 2020, which aims to increase numbers of Maori qualified in medicine and allied health professions, and the Sudden Infant Death Syndrome (SIDS) project which has been under way for five years under Dr David Tipene-Leach and Rereteti Haretuku, and which provides ongoing training and service delivery.
Dr David Simmons’ work in diabetes is another example of applicable research; South Auckland Health has a direct link to the research findings and is able to react to information and to strategise and plan accordingly.
