New Zealand Healthcare Summit 2013

Performance criteria and improving quality - A Whanau Ora Approach

I am delighted to be with you at the 2013 New Zealand Healthcare Summit.  

There is nothing closer to my heart than thinking about performance criteria to improve Maori health outcomes.  

As such it was pleasing to receive your letter advising me that Maori healthcare provision is a key issue for this event.   Pleasing in particular because from looking through your programme it wasn’t immediately obvious that this was the case.  

My assumption, therefore, is that the drive to confront Maori health inequalities has become so embedded in our national psyche that it is universally understood that all of us play a part.

The concept of the national psyche has been brought home to us over these last few weeks with the heart-wrenching, knife-edge drama played out on the high seas in a battle of two supersized waka hourua.

We watched in horror as our catamaran came so close to capsize. We shouted in disbelief as perched on match point, one race was void at the forty minute mark because the clock had run out.   We all became a little sailing-smart as we made judgements on the wind limits. Collectively we learnt to lean like Dean.

But the experience was much more than a contest between two super-yachts.   Over the ordeal we appreciated the role of tacticians analysing the variables of wind and tide. We realised the critical impact of technology and of course overnight we evolved into financial advisors, assessing the scope of investment behind our team.

However, by far the most enduring take-out for me, was the way in which we played the game.  The calm composure under crisis, the collective force of individuals united to give their all and ultimately their courage to persevere through adversity and defeat has been inspirational.

So what does the pursuit of the Auld Cup have to do with fixing Maori health inequalities?

I am arguing it has everything to do with success.

The determination to back ourselves. The application of values, strategy and technology is needed now more than ever to improve Maori health equity.

Newly released findings from Health Loss in New Zealand: a report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006-2016, have reinforced that higher health losses occur for Maori right across the board. The leading contributors to this Maori health loss include coronary heart disease, diabetes, lung cancer and chronic obstructive pulmonary disease.

The research also shows us that differential access to services exist for Maori. Barriers to access can include the cost of services, health service location and slower navigation through the pathways of care.

The on-going indicators of health loss and the continuing effects of these barriers to access are but symptomatic of a far deeper and more invasive problem in our health care.

I’m talking about the word so feared in our society that in the debating chamber it is described as an unparliamentary word – a word for which you must withdraw and apologise.

I’m talking about racism.

A University of Otago and Ministry of Health study published in 2011 found that controlling for other socio-economic variables, experience of racial discrimination was linked to a range of negative health outcomes and risk factors. These findings were consistent with international findings on the links between racism and poor health outcomes.

Over the years, the findings have been conclusive.  Maori receive fewer referrals and diagnostic tests, and less effective treatment plans from their doctors than do non-Maori patients.  It goes further.  Maori are interviewed for less time and are offered far fewer opportunities for treatment.  They are prescribed fewer secondary services such as physiotherapy, chiropractors and rehabilitation. and worst of all in too many cases Maori are either blamed for their plight or the professionals treat them in such a way as to presume they have a natural inclination towards the various illness.

So to put it bluntly, we are in a situation where we have to come from behind on the upwind leg to make a difference for Maori in healthcare provision.

Firstly we need to have the data to navigate the way forward.

Ethnicity data is a key element in our flight path. If we have high quality ethnicity data available we can track health trends by ethnicity and effectively monitor the health system’s performance to improve Maori health outcomes and achieve health equity.

One of my on-going frustrations is when health providers fail to report disaggregated information for Maori and Pasifika peoples as part of performance monitoring and the wider accountability arrangements for improving health outcomes for all population groups.   Without the data, how can we know the difference we need to make?

The Ministry of Health, in collaboration with Waitemata DHB, has therefore funded the development of the Primary Care Ethnicity Data Toolkit. In essence, it provides a framework to practices to assess the quality of their ethnicity data, their systems for data collection, and their recording and output processes. The tool also provides possible quality improvement activities following the audit process.  Implementation of the toolkit was made a deliverable within each DHB’s Maori Health Plan for 2013/14 – so I am greatly looking forward to seeing the impact in years to come.

Secondly, we need a skilled health workforce health sector to ensure Maori receive health services from a system that is consistent in its processes, connected, and working towards common goals.

To address the effects of racism on Maori health outcomes we need to promote and establish cultural competency and effective communication between health professionals and Maori and their whanau.

A 2010 Ministry of Health literature review on cultural competency has shown that ethnic differences in medical management are apparent in primary care, tertiary cardiac interventions, and cancer care. The good news, however, is that what the findings also tell us is that health inequities are modifiable, and that more culturally competent health practices may achieve more equitable health care and health outcomes.

I’m delighted with the impact that appears to have been achieved with the multimedia Foundation Course in Cultural Competency that went online in June last year.  Since its launch over 6000 users have accessed the tool, to up-skill on how they can make a difference to outcomes.

So, with the data and skills dealt to, the next step is in the plans.

The annual DHB Maori Health Plan is a fundamental document that outlines each DHB’s efforts to improve Maori health and reduce the health disparities.  

The plans must address fifteen health indicators across nine key health areas and what activities they will set to meet the targets. DHBs are also able to create their own local indicators based on the specific health needs of their Maori populations. So I would expect, for example, that DHBs with high rates of rheumatic fever or Sudden Unexpected Death in Infancy would give these priority.

The Maori Health Plan creates a level of accountability for DHBs to reduce Maori health inequities.  The goal now is to build on this foundation by reinforcing monitoring processes and linking planned activities to performance reporting.

I would hope that all of us agree that we need every measure in place to lift our performance – and the race is on to identify, set and meet performance targets that will do that.

But what will be the x factor – the cutting edge technology – that will bring all these plans, strategies and skills together to bring us home?

This is where I come to Whanau Ora.

The difference we need to see is all about whanau – it is about all of us – families, providers and government agencies working together to enable whanau to connect with one another; build their capability and develop leadership.  Their own solutions for their own issues.  

It is about being self-managing – backing themselves; creating their own pathways forward.

One of the most exciting reports I have seen from the Ministry of Health (and it takes a lot for me to get excited!) was the quarterly report ending March 2013 which shows that general practices operating in Whanau Ora collectives continue to outperform practices within the general national sample. Of particular note are the increased achievement rates for smoking cessation support, flu vaccinations and cardiovascular risk assessment.

You might just think these trends are due to a particular programme or initiative but I believe it is all about a change in attitude,  a commitment to transformation.

For a start it’s about believing in the power of the people to make the difference they need to.  

Health literacy is an essential component, to assist whanau to obtain, process and understand health information and services in order to make appropriate health decisions.  Health literacy is also about health professionals giving clear and appropriate messages. Being user-friendly.

One of the statistics that worries me is that Maori in the 16-24 year age groups have the poorest health literacy compared to the rest of the population. This is particularly concerning as over half of the Maori population was less than 25 years of age at the 2006 census.  Surely our greatest challenge is to think, collectively, how we are going to support these young people to become the healthy, strong leaders of tomorrow we will need.

Finally, one of the key issues I believe this Healthcare Summit will address is the cost benefit analysis of sustainable healthcare.

Without putting too fine a point on it, the higher burden of disease experienced by Maori also creates a burden of cost to the health system in relation to hospitalisations, the cost of health services for morbidity and the provision of intervention services for the major health conditions contributing to the high rates of Maori morbidity and mortality.

By collectively working to reduce Maori health inequalities we also reduce the burden of cost to the health system.

In the wake of the trans-atlantic adventure on the high seas, it is timely to reconsider where we as a nation, place our priorities.   What is the magic formula that grabs our attention, that unites us in a common goal keeping us absorbed right to the finishing line?

I don’t believe our compulsion to tune in was motivated by a sudden nautical interest.  Sure it was about a desire to win, the quest for victory.  But it was also about our common goal to come together as the underdog, to fight our way forward, and to do it with integrity and faith.

It would be such an incredible day in our history if we could all apply those same learning’s to the quest to improve the health care of our indigenous people as truly a race for life.  

It is only through a collective effort that we can create health equity for Maori.

We can’t solve problems and deliver solutions by working on our own. We all need to be connected and supporting each other on this journey.   I welcome all of you here to the opportunity to make that difference.