15 September 2023
Rakau
[FYI request #23182 email]
Tēnā koe Martyn
Your request for Official Information, reference: HNZ00022778
Thank you for your email of 27 June 2023, asking for the following which has been
considered under the Of icial Information Act 1982 (the Act):
1. In light of recent guidance that ethnicity be considered in clinical prioritisation for treatment, I
request information from your policies/guidelines/similar relating to:
2. 1) If any patient-stated ethnicity can be questioned, disputed, or refused by clinical or
administrative staff in the healthcare process
3. 1a) if so, where the public can access that information. If it is not already publicly available I
request a copy of the relevant information.
4. 2) How unstated ethnicity is handled in clinical prioritisation, e.g. "None", "N/A", "Not
Stated", "Prefer not to say", "Refuse to state" etc
5. 2b) if this information exists, where the public can access that information. If it is not already
publicly available I request a copy of the relevant information
Response
We have published this information: See the documents here: https://www.tewhatuora.govt.nz/
publications/equity-adjustor-tool/
We are therefore refusing your request under section 18(d) of the Official Information Act on the
basis that the information is or will soon be publicly available.
Context for our work to pursue health equity
Work developing the tool to reduce inequity in access to planned care surgical services in Auckland
and some other parts of the Northern region was substantively undertaken before Te Whatu Ora
came into existence. It now sits within the context of the health reforms, and the requirement under
the Pae Ora (Healthy Futures) Act that we actively pursue health equity.
While equity is a particularly important concept in the health system – because all groups of people
care about their health – understanding and meeting the needs of different communities and groups
of people is a familiar challenge for organisations in all kinds of settings. This includes understanding
why services do or don’t work for some groups, what barriers prevent positive outcomes (including
how services are delivered), and how best to identify people who may need something different
Similarly, our legislation requires us to design, arrange and deliver services that achieve the Act’s
purpose, including to ‘achieve equity in health outcomes among New Zealand’s population groups,
including by striving to eliminate health disparities, in particular for Māori’. Furthermore, Te Whatu
Ora is required to act in accordance with the ‘health sector principles’, the first of which is that ‘the
health sector should be equitable, which includes ensuring Māori and other population groups:
(i)
have access to services in proportion to their health needs; and
(ii)
receive equitable levels of service; and
(iii)
achieve equitable health outcomes.
These expectations of our work, set by Parliament, are very clear, underpinning the very important
work we are required to do to achieve health equity.
Evidence of health inequities
The requirements and expectations noted above are not surprising when considering key health
statistics, which show some groups of people – particularly Māori, Pacific, people with disabilities
and those from high deprivation and rural areas – are not doing as well as others. Large
differences exist in health outcomes, including life expectancy. We note:
•
for evidence and data regarding people’s health, health equity and inequity at a national
level see the Health Quality and Safety Commission’s (HQSC) A Window on the Quality of
Aotearoa New Zealand’s Health 2019 – https://www.hqsc.govt.nz/resources/resource-
library/a-window-on-the-quality-of-aotearoa-new-zealands-health-care-2019-a-view-on-
maori-health-equity-2/ &
•
for evidence and data on the impact on health equity of where New Zealanders live see the
Geographic Classification for Health – https:/ journal.nzma.org.nz/journal-articles/defining-
rural-in-aotearoa-new-zealand-a-novel-geographic-classification-for-health-purposes
With respect to ethnicity, including its consideration as a prioritisation factor, it is important to note
that there remain significant dif erences in a range of health indicators – by ethnicity – even when
other factors like socioeconomic status, rurality or gender are taken into account. For example,
Māori living in the most wealthy (least deprived) areas stil have a life expectancy gap of more than
6 years when compared with non-Māori-non-Pacific people living in the same areas (it is also the
same gap seen in the most deprived areas). Si
milarly, for Māori living in urban areas, there is also
a life expectancy gap of more than 6 years compared to non-Māori-non-Pacific urban populations
(and the same gap is also seen in the most rural areas).
In other words, neither rurality nor deprivati
on level alone explain significant health inequities for
Māori. We also know that the causes of health inequity are complex and require diverse responses
and solutions embedded across the health system. One way to reduce inequity is the subject of
this letter: the application of criteria or tools that prioritise service delivery, with the aim of
improving the equity of health outcomes.
Comments on the Equity Adjustor Tool
Ultimately, when it comes to non-urgent care, the health system aims to treat people in a timely
way and not have them waiting longer than 4 months. Prioritisation, though, is an important tool
for managing the delivery of health services within our resources.
link to page 3
Prior to the establishment of Te Whatu Ora, work was undertaken over many years by District
Health Board (DHB) staff in the Auckland area to examine tools and approaches to reduce
inequities in health outcomes. This work led to the development of an Equity Adjustor Tool, which
takes several factors into account to help prioritise non-acute care (noting also that non-acute care
excludes cancer treatment, which is not subject to the adjustor tool).
Patients are first prioritised according to their clinical need and placed into a clinical category. The
equity tool is then used to help determine the order in which patients are booked for surgery within
each clinical category. Factors taken into consideration include the length of time someone has
been waiting, Māori or Pacific ethnicity, patients from low socio-economic areas and those living in
rural areas.
Like all prioritisation tools, we keep learning more as we go, which helps us improve and achieve
better and more equitable health outcomes.
1 In that regard, it’s important to note that some options
and design features mentioned in the documents released to you are not part of how the current
Equity Adjustor Tool is applied. For example, before the tool was adopted, for a short period
Māori and Pacific were moved up a clinical category for some services, with the intention of
addressing a disproportionate impact in wait times due to COVID-19 pressures. During the
development work, there was also consideration of whether expectations embodied in Te Tiriti
should be reflected through an additional prioritisation factor; this was not implemented
(recognising also the significance of the ethnicity criteria for Māori). When the tool was
implemented, there may also have been a small number of cases early in its application where the
tool resulted in patients being effectively shifted between clinical priority categories (not intended
by the tool); checks and balances are now in place to prevent this from occurring.
Given the ongoing importance of our work to achieve health equity, we are conducting an
evaluation of the tool and we have paused any further roll-out until this has been completed. This
will enable us to better understand how the tool has been used and monitored, the impact the tool
is having, identify what other approaches are being used in other areas, as well as inform our
pursuit of health equity for all groups of people.
Nāku iti noa, nā
Mark Shepherd
Regional Director, Hospital & Specialist Services
Northern Region
1 The implementation framework for this work in Auckland is included in the Te Whatu Ora | Health New Zealand’s
Planned Care Taskforce Reset and Restore Plan. This plan can be found at:
https://www.tewhatuora.govt.nz/publications/planned-care-taskforce-reset-and-restore-plan/
TeWhatuOra.govt.nz
Te Whatu Ora, PO Box 793,
Wel ington 6140, New Zealand
