Stuff, 23 June 2023

Debate has broken out about the use of an “equity adjuster” to use alongside clinical need in deciding access to waitlisted health interventions, such as elective surgery.

I was an elected member of the Auckland District Health Board when, shortly after the board convened in early 2020, our Chair, Pat Snedden, challenged us about the issue of ethnic inequalities in health outcomes and access to health care. What could we, as a major DHB, do about this? We debated this long and hard and eventually, perhaps as an interim measure, this resulted in some patients being bumped up the waiting list. Far more useful and defensible in my view was the introduction of “navigators” to help Māori and Pacific patients through a complex system faced by many professional and personal barriers.

At the time I opposed the initiative on the following grounds:

• The data did not seem to support the need. For example, I worked out from 17 service directorate waiting lists that, except for one or two directorates, Māori and Pacific patients had waiting times somewhere between 20% below and 20% above other patients. 
• You don’t want to mess with objective clinical criteria. This has been a hard-won system from the 1990s designed to remove subjectivity and arbitrariness from waitlist decisions.
• If you wanted to pick up on disadvantage, more inclusive than ethnicity would be socio-economic position – such place of residence – as a bit of a broader catchall.
• The danger that, if taken the wrong way, this initiative might be taken as a signal to other groups that the public system is not for them and they start to migrate wholesale to the private sector.
• That the DHB was excessively hospital-focused and that we were dealing with the endpoint in a pipeline that starts with basic failures in primary care, which is where we should start.
• Finally, although this was not necessarily an explicit and practical suggestion at the time, health inequalities start well outside the health system and we need to tackle those head-on as well.

So this is not just about hospital waiting lists, it is about issues of inequality and legitimacy in health more broadly and goes to the heart of our political and decision-making system. How is it possible to be still living in a mature, modern social democracy in which there are such striking differences in life expectancy between key ethnic groups? Starting with waitlists is, perhaps, understandable from the point of view of our excessively hospital-focussed system, but it does not get anywhere near to the bottom of it.

It is estimated that maybe 20% of differences in health outcomes are due to health and medical care. So, if we want to reduce inequalities between ethnic groups, we should be looking at factors like housing, income, education, alcohol, smoking, diet, injury and so on. This does not let the health system “off the hook”, but it does bring home that fundamentally we have to look at wider social and economic policy.

The greatest disappointment in this area is the failure to intervene in key areas like alcohol and diet. All anybody has to say is “nanny state” and the argument seems to be lost, and yet we are up against a “nanny” food and beverage industry that is beguiling us with a diet that is almost certain in most cases to lead to poorer health outcomes. It is striking that even corporates and conservative politicians are starting to lend weight to this argument: thus the UK president of Danone a major food corporate urges taxes on unhealthy foods, and a former UK Conservative Prime Minister, William Hague, argues that we should be treating our ultra-processed salt- and sugar-laden diet as we have tobacco.  

But the health system does have a major role to play, particularly for disadvantaged groups. In particular, as we would hope it is well established that people who are registered with a family doctor are less likely to die of causes of death that are amenable medical treatment. And yet, one of the most striking items of information I witnessed on the ADHB was the very high proportion of Māori and Pacific children who ended up in hospital despite suffering from conditions that were treatable in primary care. Furthermore, we hear Middlemore urging people not turn up to the emergency department with minor conditions.

In other words, we have a problem in the organisation, funding, and access of our community and primary care health services: far too many of our most disadvantaged groups are just not getting the care that would prevent hospital admissions and extend their healthful lives.

The debate on an “equity adjuster” for hospital waiting lists may have been divisive, but if it encourages a fulsome and evidence-based debate on what we should be doing about health inequalities, then some good may come of it.

Peter Davis, Emeritus Professor of Population Health and Social Science at the University of Auckland, and former elected member to the Auckland District Health Board.