health & science

Tears and frustration over health equity gap

District Health Board members reacted with frustration, anger and tears, to a confronting presentation on the country’s inequitable health outcomes. Laura Walters reports on a scheme that was supposed to help Aotearoa’s poorest access healthcare, but has instead exacerbated the problem.

The Very Low Cost Access scheme was supposed to help the country’s most deprived people access primary healthcare, but those working in the financially constrained area say it’s contributing to the widening equity gap.

At the Capital and Coast District Health Board's monthly meeting on Wednesday, Porirua GP Bryan Betty gave a confronting presentation, which led to a heated discussion about the country’s inequity problem, the fear of normalisation, and the blunt realities facing New Zealand’s most deprived people.

What Betty calls an important discussion and “honest reaction” from the CCDHB board members comes as the country grapples with a widening equity gap.

But while inequity grows, DHBs feel hamstrung by funding constraints, which see them struggling just to keep their heads above water.

Betty’s presentation relied on data from 320,000 patients in the Capital & Coast DHB area, and it painted a clear picture of what deprivation and health inequity looks like in high needs areas across the country.

"These are our people, so for us, when I hear that we keep talking about putting money into it, that’s normalising of the fact that we’re expecting our community to be that sick, and die that quickly."

Betty’s practice, Porirua Union Health Service, has 8439 patients, of which 88.2 percent are considered high needs.

Porirua Union is a very low cost access scheme (VLCA) provider, which means it is a general practice that has voluntarily signed up to cap its patient fees.

Through the VLCA scheme, 277 practices across the country get extra funding in return for charging lower fees. It's open to practices with 50 percent or more high-needs patients. High needs is defined as Māori, Pacific, or quintile 5 on the deprivation index.

However, Betty made it clear the funding does not cover the resources needed to care for a patient population with such a high concentration of complex needs.

All of the VLCA practices Betty spoke about in the CCDHB area had a high proportion of people who were high needs (between 54 percent and 94 percent) and high numbers of Māori and/or Pacific patients.

While the VLCA scheme is based on cutting fees for people who cannot afford them, many patients still can't pay the capped fee of $7 - $15.

Porirua Union has accumulated $365,000 in debt over the past two years due to patients being unable to pay.

That meant the practice could not afford the manpower and resources it needed to deal with these complex needs, Betty said.

Damning statistics

Betty said his presentation was supposed to be frank and confronting.

“I was really worried we were losing sight, and normalising what was happening in a place like eastern Porirua. I became really, really concerned about that.

“We need to start to tell the story a bit more forcefully, about what’s actually going on.”

The data showed the burden that came with the concentration of patients with highly complex medical needs. These patients often have multiple conditions, and develop them at a younger age.

The population demographic skews younger for VLCA providers. “I’ll be blunt about it, this is the type of population distribution you see in the third world,” Betty said.

Rates of co-morbidity are particularly alarming, with these practices having five times the number of patients with seven different conditions or risk factors. When patients have more than one condition, the time and resources it takes to treat that patient rises exponentially.

The only condition to buck the trend is ‘frail elderly’. There were not a lot of older patients in these practices, Betty said.

“To be blunt about that, it’s because our patients don’t live as long."

The morning of the meeting, the GP had diagnosed a 22 year old with diabetes – “that means you’re 42 by the time your kidneys pack up or you have a heart attack”, he said.

Porirua Union had a high proportion of refugee patients, who always get a double appointment slot. Again, something not accounted for in the funding.

Meanwhile, extra time is spent advocating on patients' behalf to Housing New Zealand and Work and Income.

Time is also spent on the administrative work related to the high number of emergency department presentations and avoidable hospital admissions.

“We talk equity, we have to talk about differential funding… because the gap is so wide at this point," Betty said.

While the VLCA scheme was supposed to help the country’s most impoverished, it was actually contributing to the gap; a gap that had widened over the past 20 years, he said.

Board members watched, transfixed, as Betty ran through his graphs and slides.

Words like “compelling”, “confronting”, and “powerful” were used to describe data that proved unequivocally what many of them knew and experienced.

But some described the situation as “frustrating” and “aggravating”, in what became a frank and, at times, heated exchange.

‘Ana Coffey (Te Atiawa) said the board spoke a lot about equity, and rationing resources in order to put more money towards improving equity.

But it came down to who gave up money and power in order to make a difference.

“And I feel the frustration is that we sit here and it’s depressing, because it’s our communities. These are our people, so for us, when I hear that we keep talking about putting money into it, that’s normalising of the fact that we’re expecting our community to be that sick, and die that quickly,” Coffey said through tears.

“So, it’s not just about the fact that we don’t have enough money. It’s about the fact that my community, my people, are dying earlier….It is very depressing and I take it very personally, a lot of us do.”

The DHB's director of Māori health services Arawhetu Gray (Ngāti Kahungunu) used the opportunity to segue into presenting the DHB's newly signed off Māori Health Strategy to 2030, Taurite Ora.

The strategy outlines many of the same damning statistics, and points to the expected Māori population growth, but also lays out a clear and bold plan for improving equity to services and outcomes. It also places priority on maternal, child and youth health; and mental health and addictions.

"It’s been a long time, and we’re still here… We’re still here, the fight is still here," she said.

New Zealand's equity problem

The discussion at CCDHB’s October board meeting does not take place in a bubble.

New Zealand’s health equity is a topic of constant discussion, spurred on by a damning Waitangi Tribunal report and a similarly bleak Health and Disabilities System Review interim report.

At the same time as CCDHB were having its discussion on the 11th floor of the Wellington Regional Hospital, across town at the TSB Arena, the Ministry of Health was convening the second day of its annual forum. The focus was on equity.

While the sector is squarely focused on the problem, there is clear frustration over the limited capacity to deliver services due to a lack of funding.

During his speech to the forum on Tuesday, Health Minister David Clark spoke repeatedly about under-funding, neglect, and the amount of time it would take to build up the workforce, the facilities and the services needed to address the problem.

And earlier this month, he announced the sector-wide deficit for the 2019 financial year was $1.081 billion.

“We’re in a constrained funding environment, full stop, end of story."

Like all others, CCDHB is  feeling the pressure. In the 2020 financial year, it’s expected to post an agreed deficit of $15.9m.

Board member Kim Ngarimu (Ngāti Porou) said she found the situation “really quite aggravating”.

“It’s about the choices we make [as a board]. If improving equity is important to us, then we need to make hard choices about what we fund."

The DHB’s director of strategy, innovation and performance Rachel Haggerty pushed back, saying every new funding decision was made with an equity lens.

“We are turning a very large ship to focus in that way, but we make constant decisions in that way, and we have done so for the last three years. They’re not fast enough and they’re not big enough… but that’s how we have to continue."

Haggerty also referred to a scuppered plan to pump more funding into this area.

Health Minister David Clark speaks openly about the lack of funding and investment into the healthcare sector, and the flow-on impacts. Photo: Lynn Grieveson

In a statement to Newsroom CCDHB and Hutt Valley DHB joint chief executive Fionnagh Dougan said when the DHB was formulating its budget for the current financial year, it identified an opportunity to invest $3m into its ongoing equity work, but ultimately decided the additional investment was not currently feasible.

“In light of the financial pressures that we – like other DHBs – currently face, our focus is on meeting costs. This means additional investments – including this one – have not been prioritised at this point.”

Dougan said the DHB remained committed to investing in equity, with a focus on improving health outcomes for Māori, Pacific and lower socio-economic communities.

The country was at a junction, Betty said.

“We’re in a constrained funding environment, full stop, end of story."

But the major Health and Disability System Review also presented an opportunity to tackle the issue head on, if the Government and others made the most of the moment, he said.

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