The new Government is shaking things up in health, the NewsWire team reports. On this page:

Part I: News: Porirua clinic feeling squeezed

Part II: Backgrounder – Less is More

Part III: Feature – Concerns for Highest-Need Groups

Part IV: Faces Behind the News – Health Care In the ‘Burbs

Part V: Editorial – A Broken System

Heat goes on GP clinic amid staffing crisis

David Isaia: Give clinic a chance.

BRENDA COTTINGHAM reports on difficult times for a local health provider.

A STAFFING CRISIS at Porirua’s Pacific Health Service has led to a call to shift patients to another practice.

The  Cannons Creek service is meeting with the director of Pacific health Taima Fagaloa at Capital & Coast District Health Board (DHB) to battle out its future after a public meeting at Mungavin Hall this week.

Pacific Health Service chairman David Isaia says the service has been in dialogue with the DHB and been told it has breached its contract by not having the clinic open from Mondays to Fridays.

The clinic, owned by Pacific Health Service, opened in April 2009 and GP Dr Minnie Strickland left middle of September, with Dr Katherine Stone, a locum from Tawa, now filling in for three days and a week.

Mr Isaia says the DHB’s plans are for the clinic to come under Porirua Union & Community Health Service in premises nearby.

The chairman says that the DHB has not given them a chance. More than 600 people have registered with the clinic since it opened.

Mr Isaia says there is concern from the community and the staff.

The clinic has a Fiji-trained doctor, Uiliano Tanielu, working in a support role but not licensed to practise in New Zealand.

The manager of Pacific health service, Eleni Masone, is not available for comment but told NewsWire earlier that she had put forward an application for the Serau project with the Ministry of Health.

Community health meeting at Cannons Creek, Porirua.

The ministry‘s department in charge of Pacific health put Serau in place as part of a Pacific Provider and Workforce Development Fund Programme of Action for 2009/10 to 2011/12.

The term Serau is originally the Fijian word for “brightness” and stands as a metaphor for a brighter way forward for the future of Pacific providers and the Pacific health and disability workforce, according to the ministry.

The programme provides $7.4 million worth of funding. About $4 million will be spent on Focus One, which the Ministry explains as “getting Pacific people with the right skills in the right places“.

Focus One has been split up into five steps in order to achieve the overall goal of increasing the Pacific health workforce.

Young people at Auckland, Wellington and Canterbury secondary schools are encouraged to take up science in Year 11, 12 and 13, so that later on they can train for the health workforce.   They will then be expected to train the next generation of young people.

The remaining $3.4 million will be used for Focus Two – sustainable Pacific providers, with the goal of strengthening Pacific health providers to ensure they deliver quality services.

The fourth step will be to evaluate benefits and diffuse learnings to Pacific providers.

No longer being devolved to the DHBs, the fund will be managed by the Ministry of Health itself.

The 265,974 people of Pacific origin living in New Zealand come from more than 22 different Pacific groups, the biggest being Samoa, Tonga, Fiji, Tuvalu, Cook Island, Niue and Tokelau.

Pacific people are still more exposed to risk factors leading to poor health and experience more barriers to accessing health services than other population groups.

Less is more in our highest-cost state sector

National’s plans for health hinge on its mantra “sooner, better and more convenient”.  The pressure is on the sector to focus more tightly on fewer tasks. SABRINA DANKEL outlines the new demands.

SINCE THE the change of government in last year’s election, the 10 health targets set by the former Labour government have been narrowed down to six.

The National government quickly showed it was aiming to reduce bureaucracy – and especially waiting hours for patients.

THE JAB: Immunisation rates must be raised. Photo: CDC

The health targets that went into effect from July 1, 2009 were:
shorter stays in emergency departments;
improved access to elective surgery;   shorter waits for cancer treatment;  increased immunisation;
better help for smokers to quit;
better diabetes and cardiovascular services.

Health Minister Tony Ryall announced in October that services duplicated by the 21 District Health Boards (DHBs) would partly be undertaken by a newly established National Health Board.

The idea emerged out of a report by a Ministerial Review Group called by Mr Ryall. Its report, Meeting the Challenge, was released on 31 July.

Also called the “Horn Report”, after Dr Murray Horn, group chairperson, it recommends how quality and performance of New Zealand’s public health system can be improved.

The group included New Zealand health sector leaders, clinicians and managers, and recommended more than 170 options to reduce bureaucracy and improve value.

The group advised on productivity, infrastructure and spending.

Establishing a National Health Board (NHB) to supervise the $9.7 billion that the 21 District Health Boards spend each year on hospital and primary health care was a key recommendation.

The NHB is now in place, overseeing IT, payroll, procurement and logistics, with the aim of savings of up to $700 million in the health sector – and a loss of 500 jobs.

According to Mr Ryall, the NHB, a unit within the ministry, is incurring a one-off set-up cost of $5 million to $10 million.

A number of 400 people of the ministry’s 1475 staff members will move to the NHB, while 180 people will lose their jobs.

The remaining 320 job cuts are intended to come from DHBs over time as more cooperation takes place.

Shorter stays in emergency departments: Ninety-five per cent of patients will be admitted, discharged or transferred from an emergency department within six hours

How progress is being measured: DHBs provide information on the time and number of patients waiting in emergency departments.

November 22 progress: The target has been reached already by eight of the 21 DHBs (West Coast, Wairarapa, Whanganui, Nelson Marlborough, Southland, South Canterbury, Tairawhiti, Taranaki)

Improved access to elective surgery: An average of 4000 discharges per year is the aimed.

How progress is being measured: A target number of policy funded, case-mix included and elective discharges in a surgical speciality is set by the DHBs and the National Minimum Data Set will provide data.

November 22 progress: The target has already been reached by 12 of the 21 DHBs (Auckland, Waikato, Nelson Marlborough, Waitemata, Wairarapa, Canterbury, Tairawhiti, MidCentral, Northland, Lakes, Southland, Capital & Coast)

Shorter waits for cancer treatment: People needing radiation treatment on waiting lists for not longer than six weeks by the end of July 2010 and four weeks by December 2010.

How progress is being measured: Data collected by the Ministry of Health from all DHBs.

November 22 progress: The target has already been reached by 18 of the 21 DHBs (Northland, Waitemata, Auckland, Counties Manukau, Waikato, Lakes, Bay of Plenty, Tairawhiti, Hawke’s Bay, Taranaki, Whanganui, Capital & Coast, Hutt Valley, Wairarapa, West Coast, South Canterbury, Otago, Southland)

Increased immunisation: The target is reached when 85% of two-year-olds are fully immunised (goal set for July 2010, 90% by July 2011 and 95% by July 2012).

How progress is being measured: The National Immunisation Register measures changes in immunisation coverage.

Progress in coverage of Maori and Pacific Island people is key as they have the highest rates of vaccine-preventable diseases.

November 22 progress: The target has already been reached by 10 of the 21 DHBs (South Canterbury, Hawke’s Bay, Southland, Wairarapa, Capital & Coast, Whanganui, Hutt Valley, Nelson Marlborough, Otago, Taranaki)

Better help for smokers to quit: Advice and help to quit for 80% of hospitalised smokers will be provided by July 2010, for 90% by 2011 and for 95% by July 2012. The PHO Performance

Programme will introduce a similar target for primary health care from July 2010 or earlier.

How progress is being measured: Information about treatment offered to smokers will be captured.

November 22 progress: The target has already been reached by one DHB (Wairarapa)

Better diabetes and cardiovascular services: The percentage of people with diabetes who attend free annual check and who have satisfactory or better diabetes management will be increased, as well as the number of people who have had their CVD risk assessed in the last five years.

How progress is being measured: Evidence-based guidelines for the assessment and management of cardiovascular risk and type 2 diabetes indicate the progress in reaching the targets.

Steady progress was reported but data collection has been uneven across DHBs.

National’s targets contain some similarities with Labour’s but include reductions in expectations in some areas and enhancements in others.

The percentage rate set as a target for the country’s immunisation coverage was decreased from 95% under Labour to 85%.

Labour set the target waiting time for cancer treatment for eight weeks; National reduced it by two weeks.

Other targets deal with the same issues but work from a different perspective. For example, Labour’s target to deal with the health risks of smoking was to “reduce the harm caused by tobacco”, while National aims to improve support services for smokers to quit.

Latest target achievement data are here. Most would agree, though, that it’s too soon to conclude whether there’s evidence of more efficiency so far.

Help for people with highest risk?

Māori and Pacific people die younger and have higher rates of chronic diseases, with cardiovascular disease and cancer being the principal causes of death.

Māori are more likely to have a functional disability requiring assistance than non-Māori and factors like nutrition and living conditions have an impact on Māori and Pacific health.

Factors affecting Pacific peoples’ health include:

• Living conditions: 27% of Pacific peoples live in severe hardship (compared with 8% of the total population) and are less likely to own their own homes and more likely to live in overcrowded households (26% compared to 55% of the total population)
• Employment: the Pacific unemployment rate is nearly twice the national rate
• Utilisation of  services: primary and preventive health care services are under-utilised by Pacific peoples.

Māori health is affected by factors such as:

• Smoking: Māori teenagers and adults are about twice as likely as non-Māori teenagers and adults to smoke tobacco
• Alcohol and drug use: Māori show potentially hazardous drinking patterns one and a half times more often than non-Māori, the number of Māori who regularly smoke marijuana is almost three times as high as the number of non-Māori who regularly smoke marijuana.

Non-Māori have a longer life expectancy than Māori (statistics show that in 2001 life expectancy at birth was 69 years for Māori males and 77 years for non-Māori males and 73 years for Māori females and 82 years for non-Māori females) .

One attempt by the Ministry of Health to improve Pacific Health is Serau: Pacific Provider and Workforce Development Fund Programme of Action 2009/10 to 2011/12.

The ministry this month introduced the 2009/10 MPDS Annual Plan Māori Provider Development Scheme to guide its own and the DHBs’ funding and purchasing decisions.

The main aim is to improve the health sector’s performance, to strengthen the health workforce and to support the development and delivery of effective health services to Māori.

Also introduced this year was Ka Tika Ka Ora – The Māori Health Provider , to bring together the ministry’s and DHBs’ plans to support the Māori health sector financially.

Aims are to strengthen whānau capabilities, establish collaborative relationships between state agencies in relation to whānau services, and improve cost-effectiveness and value for money.

The taskforce is considering feedback received last month on its discussion document, and will report to the minister in January 2010.

Short-term gains for long-term losses?

 PENELOPE SCOTT finds tightening of the Government’s health spend under National is raising fears about the fate of services targeting those most in need.

According to Minister of Health Tony Ryall (pictured), bureaucracy, waiting times and deterioration in some services frustrate the public. In his view, the system has not shown any growth or improvement in services despite having had large amounts of money invested in it.

Mr Ryall says: “The National government is determined to turn this situation around. The government wants our public health service to deliver better, sooner, more convenient care for all New Zealanders. We want reduced waiting times, better individual experiences for patients and their families, improved quality and performance, and a more trusted and motivated health workforce.”

Cuts to employees have already been made. In the next 20 months 185 jobs look set to be cut – most of them in Wellington. More than 300 district health board posts in the next five years are also to be cut.

Funding cuts of $37 million this year in primary health and health promotion services targeting specific health conditions are shown in post-Budget Treasury documents.

These include the diabetes Let’s Get Checked budget (down by $4.8 million), $3 million cut from the cardiovascular disease budget; mental health has also had funding cut.

Although Mr Ryall has said any savings made in the health sector will be reinvested in health, this will not be specifically aimed towards prevention or promotion of health to minority groups.

Health Care Aotearoa research analyst Tania Forrest says Maori and Pacific access to health will be greatly reduced.

“While Maori and Pacific people represent the highest statistics for conditions such as diabetes and cardiovascular disease, they are not accessing health care until the last minute,” she says.

A study released this year by Health Research Council, ACC and the Ministry of Health indicated the deterrents are distance, money and poor experience – being looked down on or disrespected.

Although both ethnic groups access mainstream healthcare, the cost and cultural fit of the organisation mean many prefer care specific to their own ethnic group rather than that of the mainstream.

“To walk into a plush medical centre and be told that you haven’t paid your fees – it’s not a welcoming environment for a lot of people who generally experience a lot of disabilities or health conditions and generally find it hard to get to health care,” Ms Forrest says.

Changes to a scheme providing “very low cost access” are the first indication that the people to miss out first and the most will be high health-need population, Ms Forrest says.

She says: “The National government is actually going to cut and has cut already … so people that were on diabetes programmes, cardiovascular and smoking cessation programmes are going to probably see them go, not so much because the programmes themselves will be completely deleted but the services that were actually providing them [will no longer be viable].”

Community-driven Maori and Pacific services that have made health care more accessible appear likely to be taken over by bigger entities.

Other cuts to community-based health care, such as promotion of cervical smear tests and mobile clinics at supermarkets, will also impact on these ethnic groups.

Outreach to these groups is important because they tend only to seek help themselves once they are really ill, says Ms Forrest.

“So that is what a lot of these community services were doing and we will see them slowly go … They will disappear, not all of them, but a lot of them will.”

For Health Care Aotearoa, the main national advocate for community providers of primary health care, she thinks the future is bleak.

“If the providers are not surviving then we don’t have a membership. We will have to relook at the way we deliver our advocacy work.”

The former Labour government had as one of its goals “to create a health system that makes a real contribution to reducing inequalities between the health status of Maori and Pacific peoples, and other New Zealanders”.

Labour’s health spokesperson Ruth Dyson points to the thrust of changes as short-term gains for long-term losses.

“In the last 12 months there has been a move from health promotion, disease prevention investment through to a short-term, ‘runs on the board’ political outcome,” she says.

The waiting times reduction will come at the cost of other investment really needed in the community, according to Ms Dyson.

She says some community health workers have already lost their jobs in areas of health promotion, diabetes checks and other areas important for Maori and Pacific communities.

Wellington Hospital social worker Joy Devilles is one who does not see the change in policy having a dramatic effect.

She says a complete range of ethnicities comes in to the hospital for mainstream help.

“We see many of the clients as well as migrants, refugees, HIV service clients.”

Although some find barriers to accessing health care, she says generally people feel comfortable coming in, “especially in social work as we do a lot of training in cultural competence in our practice”.

Above and beyond the call of duty, Pasifika style

By CARL SUURMOND

WHILE POLITICIANS debate the future of health care in New Zealand, Tongan-born Violani Wills (left) goes well beyond her official role to help the Pacific community in Wellington.

Mrs Wills works for Pacific Health Services in Strathmore as a nurse, community worker, educator and respected member of the Pacific community.

She has decades of experience working within the New Zealand health system, many of those years at Newtown Hospital. In 1970, she became one of the first charge nurses and midwives of Pacific Island origin in New Zealand.

After she retired in 1998, she was awarded the New Zealand Order of Merit for services to nursing and the Pacific Islands community.

“I was charge nurse at the hospital for the neonatal unit for 26 years and as a midwife as well.  I know most of the babies that went through the hospital that are Pacific Island,” she says.

To get results within the Pacific community, she says, people need to be educated about how to deal with wider social issues: “You can’t look after their health without looking after the other things.”

Mrs Wills adds: “If you start with a small number of people, if you educate them, then they’re the ones who will go and educate others or bring more patients here.”

She says the Pacific Health Service team, who are from Tonga, Tuvalu and Samoa, encourage people to bring in others from their communities to receive care.

“I don’t think we would ever be able to do our work properly if we did not know our community,” Mrs Wills says.

There were 20 Tongan patients when she first started five years ago at the health service. That number increased to at least 120 after the first six months.

job represented a return to health care after her “retirement”.

An incorporated society, the service comes under the wing of government-funded South East and City Primary Health Organisation (SECPHO), and works from a medical centre in a residential area of Strathmore.

The centre includes a general practice, mobile nursing unit and community services.

Mrs Wills starts her working day at least half an hour earlier than she is required to, as she uses her own time to organise appointments for patients.

“When I come here there’s no one here, I can do my ringing.  I can prepare the things for when the doctor comes to cut down on unnecessary waiting.

“What was last done? And what needs to be done?  That’s really going above my job, but [I do it] because I know it is quicker and we can get another patient through.”

Besides taking on administration, she also advises some of the patients on how to manage the challenges of daily life. This might include guidance with everyday household tasks, like cooking or grocery shopping.

For many people from the Pacific Islands, moving to New Zealand often means confronting cultural differences, which arise from different values.

In the islands it is common to go straight to hospital to receive health care, whereas in New Zealand an appointment with a GP is the first step. For newcomers it takes time to get used to the system.

Mrs Wills explains a major difference: “Prioritise is not a word which would ever be in our language.”

She says the reason lies in the tradition of reciprocating, because the practice is to help someone who has helped you in the past.

“You can’t lose face … so reciprocating is a problem. It’s nice, but what I’m trying to teach my people reciprocating can be done face to face by being there for that person.”

Having more insight into medical backgrounds of patients, her educational role includes making sure that when patients needing small medication or prescriptions leave the Wellington area they still receive their health care.

Answering “yes” to a question doesn’t mean a patient understands what is being asked, says Mrs Wills.

She has to be especially sensitive about how she deals with patients on the phone, otherwise some people might feel they cannot call, or they may put down the phone if they get a negative reaction.

At other times, when patients on the phone misunderstand a question, Mrs Wills also plays the role of interpreter to overcome language barriers. “It’s changing attitude by education, but education with an understanding.”

Healthy living is about more than just health, it is also about housing, environment, cost, communication, education and lifestyles in general, Mr Tafau says.

The idea of PHOs is to help those with the greatest needs, he says: “Traditionally that’s your Maori, Pacific and low-income families.”

A broken system crying out to be fixed

NewsWire editorial-writer RUBY ARMSTRONG-KOOY lays it on the line: The latest reforms to health are starting from a very low base.

THE NEW ZEALAND health system is sick. In fact, the health system has been sick for a long time and is showing few signs of recovery. Unfortunately, no one seems to know how to cure it.

Surely a functioning health system is one that provides well for all the people. Not just the people with money, not just the people who speak the right language, not just the people who fit nicely into the mainstream of society. A functioning health system needs to work for everyone.

Whichever way you look at it, the New Zealand health system is failing to do this. Despite programmes and funding put in place over the last decade, Maori and Pacific Islanders in New Zealand are not being served adequately by the system.

Maori and Pacific Islanders are dying younger than Pakeha. They have higher rates of chronic diseases and disability. Yet they still have less access to mainstream health services.

Barriers such as language, money and cultural understanding have been blamed for the disparities in health care access in New Zealand, barriers that must be overcome as soon as possible.

Some community-based health services are breaking down these barriers. There are health workers who understand the people and the cultures. There are people who use this knowledge in the communities to educate and work with the people who need help.

The bad news is, these valuable services which actually work for Maori and Pacific Islanders are at risk from the National government’s health reforms. Services that reach out into communities are in danger of being chewed up and spat out by the new, more centralised system.

Not all of National’s planned changes to health are harbingers of doom and their rationale is easy enough to understand. The Government wants to cut down the number of functions which are currently being duplicated by individual health boards and PHOs such as human resources management, IT, payroll and capital purchasing.

It’s hard to argue with the need to cut spending on health while New Zealand is still dealing with the financial mess left by the recession. A desire to make savings by cutting down bureaucracy is laudable, especially if the savings will be put towards patient care, as National says they will.

To this end, National has introduced the National Health Board which will reduce paperwork and organisational overlap and provide direction.

A serious danger of this centralisation is that the services which cater for our most vulnerable communities, and the organisations which provide these services, may be merged so deeply into larger, more “efficient” organisations that they disappear completely. The south of the south Island, for example, is on track towards one giant, merged primary health care organisation to serve the entire area.

How will crucial decisions for communities be made if the ability to make local decisions has been removed through cutting the services and people who work within the communities?

Who will support those who do not access mainstream healthcare when all that’s left is mainstream health care?

It’s good to hear that eight out of 21 DHBs have reached the target of shorter stays in emergency departments. It’s heartening to know that ten DHBs have achieved higher rates of immunisation.

However, it’s deeply concerning that amid all the talk of funding and targets, little is being said about what more will be done on a practical level to promote health care and prevention in the most at-risk groups and communities. And unless something is done soon to make a difference to Maori and Pacific Island health issues, all of New Zealand will pay the price.

We will pay the price when our hospitals are full of people with diseases that could have been prevented if they had better access to health care. We will pay the price when people are too sick to work and provide for their families. We will pay the price when people cannot contribute to our society.

Maori and Pacific Island health issues cannot be addressed without looking at the context and taking a wider approach that deals with living conditions, unemployment and education. Until these are dealt with as a whole, they will perpetuate the cycles of poverty, hardship and sickness.

The most effective health services for Maori and Pacific Islanders who have poor access to health care are those embedded in communities, those that understand and work around cultural differences. These are the services at risk from the reforms.

Tellingly, the Maori Party has moved to head off the threat by urgently seeking a special basket of funds for Whanau Ora, or care of all the family by Maori providers of a wide range of services. National has, so far, acquiesced and let the idea advance to a consultation phase.

Regardless of what the reforms bring, as long as the success of the system continues to be measured by targets rather than improved lives in our diverse communities, the system will continue to let down some of the people who need it most.